Vital Signs

Thomas L. Garthwaite may have just taken on the toughest job in California, even if it pays -- at $275,000 per year -- the highest public government salary in Los Angeles County. Garthwaite is the new chief of the county‘s Department of Health Services (DHS), with its six public hospitals and nearly 150 clinics. And he’s its third head in 17 generally difficult years. He proposes to do what his DHS-director predecessors Robert Gates and Mark Finucane were not able to do. Which is to make the $4.3-billion-a-year department (whose budget is far larger than that of the city of Los Angeles) provide fair and complete health services to a swelling and largely indigent patient population of around 2.8 million without threatening to bankrupt the county. He must do this in the face of what the county supervisors anticipate to be a $900 million total federal-funding shortfall over the next two years. More than $300 million of this will fall on the DHS. Garthwaite, in his first public appearance before the Board of Supervisors, recently was asked to make $100 million of such cuts over the coming fiscal year.

DHS is the second largest public-health agency in the nation, but that still makes Garthwaite overqualified for the job. He comes directly from the U.S. Veterans Administration -- the $91 billion agency that provides care for 25 million Americans of all ages -- where he rose, over 25 years, to the lofty position of undersecretary of health and was credited for 20 percent cuts in patient-care costs. Unlike his bureaucrat DHS predecessors, Garthwaite‘s also a medical doctor who’s practiced and taught at hospitals and has published considerable research in the field of endocrinology. Slim and sandy-haired, he looks little more than half his 54 years; he was interviewed in his ninth-floor offices at DHS‘s downtown headquarters.

L.A. WEEKLY: So you have moved from a huge federal bureaucracy with problems to a large local bureaucracy with huge problems. From an agency in which most of your patients vote and have Social Security numbers to an agency that serves many noncitizens. How does that feel?

THOMAS L. GARTHWAITE: I’ve been telling everyone I know that I‘m going from a frying pan into a frying pan. Both institutions are very politically connected. Both have histories of budget challenges. Of course, nearly everyone is for veterans. But no one ever [quite] figured out what [qualified one as] a veteran. So we had vague eligibility rules. And we were asked to give [care] until it hurts. Of course, veterans have a more effective lobby in Congress. They are a shrinking population. But there are still about 25 million out there . . . We’re seeing more Vietnam vets with an increasing need for care . . . a

What lessons can you bring from that system to this one?

We must show that we are willing to make changes, to delve into our institutions.

Your department‘s most recent progress report suggested last month that cuts be made ”to favor those showing the greatest return on investment.“ What do you take that to mean?

I think it means that if you don’t have the money you need to do all things you‘d like to do, you have to go back to what are the clearest legal mandates . . . In the VA we actually had a statute that told us what priority of veterans were the first to get care. Service-connected was first, right down to high-income [people] with non-service-related disabilities as the lowest priority. What I think is being said [is] that in times of a budget crisis, the first dollars spent are for the highest needs.

You’re the first M.D. to be put in charge of DHS in at least 40 years. What difference will this make?

I have actually worked in hospitals, I‘ve worked in emergency rooms and with individual patients. So I have a pretty good idea of exactly what effect that budget cuts can have on our patients. And on our doctors, how they might push back against the changes we have to make. [My experience] will help me craft the message in such a way that they can buy in. I want to articulate new directions to give people reasons [to cooperate]. That’s a more compelling reason than just the budget has to be balanced. I want to articulate new directions to give people reasons to change that are compelling.

You have a vast patient clientele that‘s widely dispersed, including many noncitizens. What must you bring to this population?

I think that if we are going to reach them, we need to reach out to their communities. The challenge is to do that at a time when we are so swamped in our facilities and the budget is so strained.

One long-standing DHS problem has had to do with how much easier it is to get federal funding to hospitalize patients than to treat them in clinics. Failure to move patients into clinical care throughout the system over the past six years has left the county with that $900 million federal-waiver payoff due. How did the VA prioritize such care?

Here is [an] example from the VA. We increased our immunization rate from 30 percent to a high 80 percent rate. [The result was] a dramatic increase of health in our community -- but also a great reduction of inpatient pneumonia. [We determined that] we saved $294 every time we gave a shot. The cost of the shot and the effort made were made up for by the avoidance of hospital stays. In our case, the incentives were aligned so we saw that $294 and could put it over into other programs. But the way [county reimbursement is handled], the only way the county makes money is on [federal reimbursement] for pneumonias, and it costs you [extra] money to prevent them. That’s why the county‘s incentives are so screwed up.

So the effort is to get the incentives aligned, if we can do the things we need to do to prevent disease, if we can get things diagnosed and treated early, the results are better for patients. What we really want to do is to get in there earlier on the disease continuum . . . more effort at prevention [and] more effort at early detection.

For nearly 20 years, the county has been unable, despite spending hundreds of millions of dollars, to create an organized database of all its patients in its clinics and hospitals. Getting that one together sounds like a crucial step in what you propose.

It’s a huge piece. But [more importantly] I think there are good people out there, working hard. My furniture hasn‘t arrived yet, so I spent the last couple of nights in the medical centers, just walking around. Yes, they’re busy. They‘re really working hard. And there are a lot of patients. But when you’re so busy out there, it‘s hard to back up and look and say: Could we have prevented this by better outpatient work?

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