Dr. Gs Hard Medicine
Photos by Slobodan Dimitrov
It was 10 a.m. on a weekday in early March, and the emergency room at Harbor-UCLA Medical Center was already full. Dr. Tom Garthwaite weaved through without pausing. He seemed unaware of the new arrivals milling around in clusters and sitting on the floor. He glanced at 20 others lined up near the front of the crowded room to sign in and breezed past the man slumped against a wall, his jacket pulled over his head.
No one recognized the 55-year-old Garthwaite, and its probably a good thing for him. As director of L.A. Countys health department, he is responsible for the long waits which can drag on for hours and even days at some county-run hospitals, delays so long that doctors complain patients are dying. Since arriving on the job 16 months ago, hes undertaken unpopular, but what he insists are vital steps to fixing L.A. Countys collapsing health-care system. Hes done away with 16 clinics, closed two hospitals and in June plans to begin laying off another 4,000 doctors, nurses and health-care workers.
Along the way, hes overcome steep political opposition on the county Board of Supervisors and silenced all but a few of the usual advocates for health care for the poor with the message that only dire moves will save the system. The chief threats to the restructuring plan are lawsuits filed by the ACLU and other public-interest groups seeking to stop Garthwaites next round of layoffs and hospital closings. They claim that patients have died at L.A. CountyUSC Medical Center because they were forced to wait up to four days in the emergency room, and that Rancho Los Amigos National Rehabilitation Center must remain open because no other county-run hospital can treat severe brain and spinal injuries. A judge this week barred the county from moving ahead with plans to close Rancho Los Amigos until she has time to make a ruling on the hospitals future, which could be as early as next week.
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Even if Garthwaites plan survives the legal challenge, the question in coming months will be: Can Garthwaite, a medical doctor known for remaking health-care bureaucracies or anyone, for that matter save the massive public health system in L.A. County, where one-third of the residents, or 3.3 million people, rely on diminishing tax dollars to foot the doctors bill? Will he be remembered as the man who resuscitated health care for the poor or left it gasping for air on the operating table?
For two days, I tagged along with Garthwaite at formal and informal gatherings of doctors, administrators and politicians as he made his way around the county to sell his rescue plan. I watched him take on his critics with some of the practiced weapons of an accomplished debater. I saw him try to confront some of the disbelievers in his inner circle of top 35 health professionals. I heard him compare his current mission with his last assignment as a Clinton-administration appointee charged with overhauling veterans hospitals. Its far too early to tell whether he has the prescription for L.A. County. What is clear is that the lines in emergency rooms will not be getting shorter anytime soon, and that medical care for L.A. Countys most destitute will remain on life support for the foreseeable future.
In a federal courtroom earlier this week, Garthwaite got a dose of how hard it might be to persuade U.S. District Court Judge Florence-Marie Cooper to sign off on Ranchos closure. He sat on one side of the courtroom, and said nothing during the 75-minute hearing. On the opposite side, one of Ranchos patients, Susan Rodde, who has cerebral palsy, sat in her wheelchair. Attorneys for the patients and the county debated whether the county would be breaking federal Medicaid rules by shutting down the hospital.
Years ago the county made the decision to serve the disabled at Rancho, Melinda Bird, an attorney with Protection & Advocacy, Inc., told the judge. It cannot turn around and change this because the cost of treating disabled patients is costly. If Rancho closes, the state has an obligation before June 30 to ensure that there is something else.
Cooper said she would rule soon because so much is at stake. Outpatients are profoundly affected by this closure.
Despite how things looked in the courtroom, if you listen to Garthwaite, the prognosis is bright. He wields more than a hatchet. He has ideas for a cure that, if they solve what ails L.A. County, could change the face of public medicine. He wants every L.A. County patient to have a doctor, a Marcus Welby, as he put it. Someone they can trust, he said. Someone they can go to before they have the heart attack or the flu, someone who tracks their care from day to week to year. People love it. He believes enough money is set aside for health care; waste devours too much. He envisions a system that saves money by pushing preventive care over expensive surgeries, that electronically links hospitals and doctors to make sure all the players are serving the best interests of patients and the bottom line. It sounds like managed care for the poor. His critics dismiss his diagnosis as more the work of a medical technocrat than evidence of a compassionate doctor trying to save his patient. Especially as a doctor himself, he should know the unmet need here is great, said Annelle Grajeda, general manager of the Service Employees International Union Local 660, which represents 19,000 of the countys health department workers, many of whom face pink slips in June.
The overflowing ER scene is only the most visible sign of the systems distress. Last fall, hundreds of doctors, nurses and residents showed up at public hearings and begged the Board of Supervisors to keep open its 39 health clinics. Also on the chopping block were High Desert Hospital in the Antelope Valley and Rancho Los Amigos, as well as Olive ViewUCLA Medical Center and Harbor-UCLA, both trauma centers that provide much-needed emergency care.
Sitting in wheelchairs, dragging ventilators, speaking through voice boxes, protesters expressed their unified plea: Keep these hospitals and clinics open, or millions of uninsured residents will suffer and some will die.
In the end, at Garthwaites urging, the board closed High Desert and Rancho Los Amigos along with 16 clinics whose combined annual outpatient visit load is estimated at half a million. The savings: $750 million.
You try to do the least harm, Garthwaite said as he pulled into the USC parking lot earlier that morning. Were not making decisions that are idealistic. They are really hard choices. If you see yourself as a safety net, you just try to be the best safety net and catch as many people as you can.
The system will implode even more in June, when the health department plans to begin laying off 18 percent of its work force. Over the next several years, about 4,000 employees will get the boot, and many others will be shifted around to fill gaps in service. In July, 50 beds will be cut at County-USC, which is already operating at half capacity, and another 50 will be eliminated later. Intern and residency programs will be curtailed. And there will be additional, as yet undetermined, consolidations and cuts.
In the end, Garthwaite says, those cuts, combined with $250 million in state and federal funds, the countys share of a statewide lawsuit settlement on Medi-Cal payments and the overwhelmingly voter-approved Measure B tax, will stave off collapse.
As public clinics and other alternatives disappear, people are landing in the emergency room in record numbers. Gary Payinda, a resident physician at County-USCs emergency room, said he often goes home at the end of a shift only to return the next day and see some of the same patients still waiting for care. These patients have nowhere else to go. I feel like Im just bandaging people up until they come in sicker the next time. Its just staving off catastrophe.
The crisis is not new, its only getting worse. During the Clinton administration, the countys health system was rescued twice from the worst budget shortfall in its history by bailouts totaling $2 billion. The money was granted on the condition that the county become more self-sufficient. When the Board of Supervisors hired Garthwaite last winter, it was a move as critical as bringing in a new doctor in the middle of an open-heart surgery that wasnt going well. The patient the countys $2.9 billion health system was nearly out of cash for the second time in less than a decade. Garthwaite stepped in with a degree of confidence and decisiveness that some found off-putting, but which gained him respect and cautious support from key players who had previously refused to budge. They know that much of what Garthwaite wants to accomplish was already the goal before he arrived. But nobody was willing or able to take on the job.
Supervisor Yvonne Brathwaite Burke, who agreed to Garthwaites unprecedented cuts in services at King-Drew Medical Center, was relieved that he signed on. This is a career-breaking job, she said. There is nothing you will do that wont cause an uproar when you dont have the money.
On that morning in early March, Garthwaite, who makes $275,000 a year, had traveled to Harbor-UCLA to meet with a group of doctors and others from Harbor and Long Beach, two of the remaining four county-run hospitals. On the agenda: hospital performance and future cuts. Driving over, Garthwaite laid out what he expected to hear. Usually they try to hit me up with something, he said. Its a combination of claiming magnificence and begging for resources. He laughed. I tease, I tease, he said. But not too much. When you get the chance to have the director down, you hit him up with the things you want him to believe. Try to change my belief system.
In a meeting room, a few doctors had already gathered around a long narrow table when Garthwaite arrived. More than a hint of stress hung in the air. One doctor wore a Dont Panic button. Others shuffled papers nervously or made small talk about bad drivers. A plate of muffins sat untouched. Garthwaite smiled and greeted everyone warmly. Tall and trim with wire-rimmed glasses and a full head of reddish-blond hair, the former athlete has a way of setting a room at ease. He grabbed a muffin and picked up on the bad-driver theme with a Bob Newhart joke. Oh, maam, oh maam. You were in the left lane with your left turn signal on, he said, then paused and shrugged for comic effect. I thought you were going to turn left. Corny, but it did the trick. Everybody laughed and the tension level dropped.
As Garthwaite predicted, the news from the docs had a positive spin. Ophthalmology and urology referrals at Long Beach Hospital are up. Average number of days wait for a clinic appointment there is down. And the hospital has managed to increase services with no additional money: an anticoagulation clinic for diabetics, a podiatry center and expanded walk-in hours. By meetings end, though, talk turned to the need for more funding. We can be creative, one doctor said, but ä theres only so much we can do given what we have to work with. Garthwaite was sympathetic. He took notes and asked questions but made no promises.
After the meeting, several staffers stuck around to talk. Lewis Lewis, the countys director of physician relations, scheduled a meeting to discuss intern positions that could be eliminated. Lets face it, Lewis said, Tom has to start his implementation and its going to get ugly.
Thomas Leonard Garthwaite never planned to be a bureaucrat. His mother was a teacher and his father owned the town grocery in tiny Port Allegheny, Pennsylvania. He has a flat, slightly nasal way of speaking, most apparent when he says measure, or may-sure, as in: If you measure things, they will improve, because you will have a standard from which to work.
Garthwaite occasionally worked in his dads store, but devoted most of his spare time to sports. He played football, basketball, baseball and golf and competed in javelin, discus, high jump and hurdles. He was voted most likely to succeed in his senior year of high school.
He continued to run track as an undergrad at Cornell, holding the school record for several years. He got his medical degree from Temple University, interned in Milwaukee and then took a job as an endocrinologist for the VA. While working on a research project, he complained about the long waits for access to test subjects and was drafted to reform the process. Thus began his shift from practitioner to administrator. Looking back, he said, hes more than satisfied with the change. In the end more people were affected by what I did in management than by what I could do in an exam room, he said. When you reform a system, you cant point to the person youve helped, but you can be sure intellectually that you did.
Health-care systems are generally considered among the hardest bureaucracies to fix, in no small part because doctors are notoriously independent. When Cedars-Sinai Medical Center recently tried to set up a computerized patient-tracking system, the doctors revolted and the effort failed. At County-USC, a glitch in the new data-tracking system shut down the entire network for two days in late April, causing chaos and leading some doctors to declare the project a disaster. But Garthwaite remains optimistic that changes can succeed. One good piece of news is Ive worked in a very large system thats been successful in making changes, Garthwaite said. And secondly also being a physician, I kinda know whats BS and what isnt.
In 1995, when Garthwaite took the VA undersecretary job, a federal probe had just recommended disbanding the entire VA health-care operation. As Garthwaite likes to describe it, those were the days of the VA à la Born on the Fourth of July, when service was shoddy and saying you worked for Veterans Affairs was worse than saying you worked for Ma Bell. Instead of shutting down, the institution underwent a major shift, opening 600 new clinics and reducing the number of hospital beds by half. From 1995 to 2000, the agency cut registered nurses by 10 percent and nursing assistants by 30 percent, relying heavily on contract workers to fill the void.
The staff cuts brought sharp criticism from some veterans and from health-care workers, who said that the quality of care was compromised. In many ways the VAs health care is still reeling from the budget cuts that occurred during that period, said Linda Bennett, a lobbyist for the American Federation of Government Employees, which represents VA health-care workers. The average waiting time now for veterans to see a physician for non-emergency care is six months. Still, Bennett said, it would be a misrepresentation to single out Garthwaite for blame. Instead, she says, the responsibility lies with Congress and with both the Clinton and Bush administrations, which cut the VAs budget dramatically. He clearly did the best he could in an era where we are expected to do more with less, she said. But the budget was unacceptable, and ultimately the VA is doing less with less.
In spite of those constraints, however, Bennett and others say Garthwaite significantly improved the system. The VA became the national leader in patient safety, computerized patient records and prescription services and began measuring performance in ways unheard of anywhere else. In one hospital, the computerized prescription program cut dosage errors by 70 percent. The percentage of patients who could identify their primary-care physicians went from about 25 percent to more than 80 percent.
At the VA, he said, he required every manager to sign a contract directly with him detailing work responsibilities and goals. When this program was put in place, he said, There were certainly a lot of tight sphincters and gulps around the room. But I think this is really what turned the VA around.
Improvements at the Veteran Health Administration are so dramatic that it is now the basis for a case study taught to health-care professionals at Harvards School of Public Policy, and health-care watchdogs use its programs as models for other organizations. I risk overstatement, said Donald Berwick, head of the Boston-based, nonprofit Institute for Healthcare Improvements. But I think the work going on at the VA may be the largest-scale successful effort of its type in the world.
While at the VA, Garthwaite honed his unflappable approach in a highly charged environment. You will never frustrate him and you will never see him lose his temper, said Hershel Gober, who, as acting secretary of the VA, was Garthwaites boss. He is very astute at looking at something and saying, This is stupid. Why are we doing this? He looks at the core values and says, This is our mission. This is what we should be doing. If anyone can help L.A., Tom Garthwaite can.
What his work meant at the VA, and what it now means in Los Angeles, Garthwaite said, is shifting the focus from medical accomplishment to patient satisfaction. In health care, if whats important to you is how many people get their hearts operated on, thats not the goal of the patient, he explained. Can you live your life better because of the care you received? He paused. Hardly ever measured.
But Garthwaite is making some of the same types of cuts that cost his old boss his job at the VA. When Rancho Los Amigos closes this summer, hundreds of patients who rely on the center for treatment for spinal-cord injuries, respiratory illnesses and a wide range of physical therapies and rehabilitation services will be forced to seek care elsewhere. One such patient, Gary Harris, is a plaintiff in the lawsuit filed by Neighborhood Legal Services of Los Angeles County, the Legal Aid Foundation of Los Angeles and the American Civil Liberties Union of Southern California, which seeks to halt the cutbacks. Harris, a 47-year-old uninsured L.A. resident, was shot in the spine and throat in a random drive-by shooting in December. Another plaintiff, Susan Haggerty, is a 46-year-old uninsured diabetic who had a left toe amputated last year and who has suffered diabetic hemorrhaging in both eyes. In February she was treated at Rancho for a bone infection in her right foot. These patients typify the countys clients, Legal Services attorney Yolanda Vera said, in that they have no money and limited mobility and are totally ä dependent on the county for their health care. A hearing on the lawsuit, the second such action to challenge the cuts, is scheduled for May 12.
One thing his VA experience did not prepare Garthwaite for was dealing within the county bureaucracy. At the VA, I had discretion over millions of dollars, he said. Here you need a special session with the Board of Supervisors to spend a buck fifty.
Behind Garthwaites vision for a new health-care system for L.A. County is one seemingly revolutionary idea: The cash is out there. I think theres close to the right amount of money in health care today, he said, while making his way down the freeway to yet another meeting. Its 14 percent of the GDP, and were a pretty rich country. Im not real popular for saying it. Doctors and people dont like to hear you say that. But theres a lot of waste, and the incentives are wrong.
Some potential savings and revenue sources include curbing administrative costs, increasing the number of elderly clients, whose care is paid for by Medicaid, refusing non-emergency care to non-county residents and cutting costly duplicated services. As one example Garthwaite offered, all four remaining county hospitals have their own neonatal centers. Consolidating programs will cut costs, but it will also force residents to travel greater distances for care, no small matter in a county sprawled across 4,000 square miles.
Garthwaites contention that theres plenty of fat to be trimmed has gained support from unlikely quarters. Theres still a lot of waste in the system, said Liz Forer, executive director of the Venice Family Clinic, the largest free clinic in the U.S. and a county partner in providing outpatient care. Now that the financial piece is beginning to stabilize, we get to see him use the skills he was hired for, which is revamping the system. By doing some of the things he has proposed, we will begin to lose some of that waste. The challenge is to do it without losing care.
William Stringer, director of medicine at Harbor-UCLA and the doc who sported the Dont Panic button at the meeting with Garthwaite in early March, brings a long-term perspective to the current crisis. Back in 1995, Stringer quit rather than continue to work in a system which he felt was being senselessly downsized. After three years in the private sector, he came back. For all the problems here, this is not a greedy, grubby financially driven system, he said. We all agree that we need to treat people regardless of what is in their wallet. If there needs to be some pain along the way to making that happen, it is unfortunate, but unfortunately I think it is probably necessary.
Garthwaite has a few salves in his medicine bag to improve the bottom line without further meddling with care. The first addresses whats called the patient mix. The government pays hospitals a set rate for services for the disabled through Medicaid (known locally as Medi-Cal) and for the elderly through Medicare. The federal payouts for seniors can be as much as 50 percent higher than for those on Medicaid, and Garthwaite hopes to raise cash for the county by making the over-65 crowd a bigger part of the patient population. Right now just 4 percent of the countys patients are on Medicare.
However, the morning session at Harbor-UCLA brought an unwelcome revelation. One of Garthwaites strategies is to capture coveted Medicare dollars available to care for senior citizens. But that morning he learned that only 6 percent of the population in the area served by Long Beach Hospital is age 65 and over. That stopped me in my tracks, Garthwaite said later. It was a real ah-ha moment. It was like, Whoa. It almost defied my imagination. If those numbers are reflective of the county as a whole, its going to be real challenging.
Another strategy is to persuade the feds to abandon their formula that pays big bucks for patients who wind up in the hospital but next to nothing for prevention and outpatient care. For example, the county receives nearly $6,000 per admission from the federal Medicare program for elderly patients with heart failure. All medications needed during the hospital stay are covered. But the reimbursement rate for a comprehensive outpatient visit that could treat and prevent heart failure is less than $200, and for the vast majority of the countys Medicare patients, prescription drugs taken outside of a hospital stay are not covered at all.
The problem is that in the short-term, outpatient care is not cheaper because clients who are persuaded to see the doctor in an outpatient setting then become more likely to see the doctor more often, studies have shown. Indeed, when the county first began emphasizing outpatient clinics over hospital care back in 1995, many people erroneously believed that this tactic would save the county so much money it would solve the budget crisis. Though some money was saved, much of those savings went into covering the increase in costs as people got used to seeing their doctors on a regular basis.
In the long run, clinic-based care does cut costs because those whose health is being monitored are less likely to develop costly conditions down the road. In the meantime, though (and it could be a long meantime), the county has to come up with the money to pay for it. Its like climbing a mountain, Garthwaite said. Right now were on our way up the mountain, and it looks impossible. But if we can get up to the top, well be doing okay.
Garthwaites favorite example of the VA improvements is one he says has saved thousands of lives. Studies have shown that after a heart attack, patients should immediately take either aspirin, a beta-blocker or an ACE inhibitor. Even with that information in hand, the best-performing hospitals manage to provide the appropriate medication only about 70 percent of the time, according to an article published in the September 13, 2000, issue of the Journal of the American Medical Association. At VA hospitals, according to the article, the rate is 94 percent. I cant tell you whose lives Ive saved, Garthwaite said. But I know that because of the way the VA did business at the end of the last seven or eight years versus the beginning, at minimum 5,000 people are alive who wouldnt have been.
What will the verdict be at the end of Garthwaites tenure in L.A. County? Will he be able to point to the remaking of the health-care system and say he saved lives? Or will critics continue to charge that reductions in services are killing patients? In response to an e-mail asking whether he anticipates losing his job as his old boss did at the VA, Garthwaite was circumspect. Will try to keep it data-driven rather than personal, but will accumulate baggage for making decisions (or for not making decisions), he wrote. For me, no way to make everyone happy.
Christine Pelisek contributed to this story.
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