October 1999/November 1999
Dr. Thomas Garthwaite
Acting Under Secretary for Veterans Health Administration
U.S. Department of Veterans Affairs
Dr. Thomas Garthwaite, the acting under secretary for Veterans Health
Administration, at the U.S. Department of Veterans Affairs (VA) recently
shared his thoughts on a wide range of veterans' health issues in his Washington,
D.C., office with Bob Maras, a VVA Board member who also chairs VVA's national
Veterans Affairs Committee, and with Rick Weidman, VVA's director of Government
VVA: There are many figures being discussed for the fiscal
year 2000 VHA budget. If it is a $17.3 billion budget, what will
be the effects on veterans' health care?
Dr. Garthwaite: Maybe the best way to approach this is
to start with the low number and just describe what, incrementally, we
might see as the positive effects or opportunities that might exist if
more money is appropriated. At the balanced budget agreement level,
President's budget level, of $17.3 billion, we have significant challenges
to make the kind of efficiencies that would be necessary to continue the
same kinds of care to every veteran that we've been seeing over the past
It's doable, but the pain and the political push-back I think would
be very significant. And I think that has really been part of the discussion
that's occurred at such places as the House Veterans Affairs Committee.
[<I>Editor's note: The Congress appropriated $1.7 billion more than
the President's original request. As of press time, the FY 2000 budget
for VHA stood at $19 billion.]
The additional billion dollars in the Administration's amended budget
takes a significant amount of the pressure off to make very rapid and difficult
changes, although it doesn't fully replace every dollar that might be necessary
to take on new tasks and to fund the inflationary increases that naturally
occur every year.
So it will still require us to make efficiencies, which we would plan
to do in any case, no matter what the budget. But it does get us
to a point where we think it would be much easier to continue the care
that we are giving to the same number of veterans.
I think it makes the decision to enroll priority-7 veterans a much easier
decision. And I think it allows us to continue to re-engineer the
health care system at a reasonable rate.
The additional dollars beyond that I think allow us some real opportunities
to address needs that aren't being currently met and brings into play things
such as emergency health care. Veterans today are very strictly regulated
in how they can seek care in an emergency room near their homes. If legislation
to expand that benefit is enacted, we could enhance that service.
Additional dollars could help us do more extended care and long-term
care to meet the needs of veterans who need those services.
And I think we could put additional emphasis on service and access issues,
such as additional community-based outpatient clinics and continuing to
chisel away at waiting times and other service enhancements.
VVA: If the budget went to $19.4 million, what would that mean?
There would be more services, plus you had said that the CBOC's would be
able to put more of those out there for the people and cut down on the
waiting time, which is a prevalent issue from what I'm seeing as I go around
the United States to various VA facilities.
Garthwaite: We continue to look at causes of waits that are not
related in any way to budget. We have some very creative and aggressive
things to do over the next several months, including a broad initiative
in all VA hospitals with the Institute for Health Care Improvement where
we're going to undergo a rapid-cycle reinvention of waiting times and clinic
We believe that this initiative will have an impact on waits, regardless
of the budget situation. So we don't believe everything is just money,
but money and prudent management go hand in hand.
VVA: Did VHA analyze the Independent Budget of The Veterans
Service Organizations reach any conclusions or judgments about the effects
of same or the underlying assumptions?
Dr. Garthwaite: I would have to go back and review the
specifics as I haven't read it in several months. As we go through our
budget discussions internally, the IBVSO is one of the important sources
for data and issues. We take it very seriously.
As you're well aware, this is a town where policy gets debated openly
and where many people have input. So as we look at the IBVSO, we find it
is a source for new initiatives and a clear statement of veteran priorities.
Ultimately the IBVSO budget request is one of several numbers that are
put forward during the discussion.
I also find the IBVSO is a good source of analysis. We appreciate the
effort of the independent budget of the veterans service organizations.
I personally use a number of the graphs and arguments that you present
to help advocate for the VA budget.
VVA: There has been a great deal of publicity about hepatitis
C and the Veterans Health Administration's overall response to this epidemic.
Could you describe the overall VHA response? Do you feel you have
done enough? Where do you feel public efforts have succeeded?
And where do you feel there are challenges yet to be met?
Dr. Garthwaite: Overall I'm very proud of the effort that VA
has undertaken. We've had a major effort to test veterans. We have established
policy to treat veterans. We have established guidelines for testing and
treatment. And we have established two centers to lead the effort in research,
education, and knowledge dissemination, and are supporting some of the
premier efforts in this disease anywhere in the world. That's all
the good news.
The bad news is there are many veterans with this disease, as we found
in our screening. And we have a lot of work to do to get them in,
get them knowledgeable of the disease and its risks, get them tested and
We have a multi pronged approach, including what I've already mentioned,
as well as some efforts in our computer system to track the large number
of veterans who will be or who are affected and will be affected by treatment
Certainly another challenge--a budgetary one--is that the treatments
are expensive. But we're dedicated to getting those treatments to
veterans who need it.
VVA: The home-access health kit, which we think is very
useful, is not on the formulary, but we think it ought to be, for a lot
Eighty percent of veterans do not use the VA at all. That's why you've
made such an effort to get people enrolled and pull the folks who currently
don't use the VA, because they have other options. A lot of the folks who
are carrying the hepatitis C virus don't use the VA. Somehow we have
to reach out to those folks.
In terms of public awareness to reach people who do not currently use
the VA system, what is your plan for reaching those folks? Wouldn't listing
that on the formulary of the home- access kit and using it to do the testing
for people to find out whether or not they ought to come in makes sense
in terms of not flooding an already overburdened VA?
Dr. Garthwaite: I am not up to speed on the home-access kit.
Following my testimony before [Rep. Chris] Shea's committee, I had a series
of things that I asked our staff to do. And I can find that memo for you
and let you know. I think the response is due soon. There are a series
of things, including computer matches to increase our ability to identify,
test, and treat as many veterans as possible.
VVA: Vietnam Veterans of America has called for greater accountability
on the part of VHA as to what happens at the service delivery point as
opposed to policy. Can you comment on our stance, much of which has
been heard--our voice--on Capitol Hill on what you are doing and/or planning
to achieve a greater degree of quality assurance/accountability for performance?
Dr. Garthwaite: I've been here in Washington almost five
years. What we've really worked hard on has been to have objective measures
of actions and outcomes that matter to veterans. We have, arguably,
the best performance-management system in health care. We measure
as many or more parameters about health care that is delivered as any health
care system that I'm aware of. Certainly we've made extraordinary
progress in the last four years.
We know about immunization rates and recidivism in mental health, and
we know about beta blockers and aspirin after heart attacks, and whether
people are counseled on alcoholism and other conditions. We have,
I think, made performance measures the way that we're guiding the system.
In addition to all that, we have several other really interesting and
good and I think effective things going on in quality management. We have
the National Surgical Quality Improvement Program, which monitors all the
surgery that goes on in the VA.
And if the surgical outcomes are ever just slightly askew, experts go
in and find out what's going wrong and fix it. And with that system,
we've improved surgical mortality by 10 percent and surgical morbidity
by 28 percent in the last five years.
At the same time, we've done more operations and treated patients on
average who are a little older and sicker. So it's a good story.
And in medical care, we track the top nine diagnoses. And we found
that despite all the changes in VA health care, the death rate, or mortality
rate, in the top nine medical diagnoses is the same or improved in every
one of those diagnoses. In three, it's significantly improved.
In the others, it was good to begin with, so further improvement may
be not expected. In chronic obstructive pulmonary disease, chronic renal
failure, and congestive heart failure, where management of patients is
important, we've noted improvements. That's very positive news.
Mental health is an area where it is harder to measure outcomes, but
we're very interested in learning how to do that. The Northeast Evaluation
Center is working to understand outcomes in mental health. And we
do believe that we will be successful in finding measures that can help
us be sure that we are improving our service.
In the midst of all that, we also have started a patient safety center,
headed by Dr. Jim Bagian. The goal of that center is to discover
why things occasionally go wrong in health care. Every health care
system has some unintended events. Health care systems have not been
engineered for safety. It is our goal to use modern information technology
and training efforts to increase the safety margin for patients.
If you have surgery or if you have a tube placed or if you have a procedure
or you get a medication or you interact with some piece of technology,
all those things have an inherent risk. We want to make that risk as close
to zero as humanly possible.
We're working very hard at that. We're one of the leaders in the
country at identifying and addressing issues of patient safety. And
we're committed to leading in engineering health care systems to be better
and safer over the next several years.
VVA: What are your specific and general goals in your new
capacity overseeing the world's largest medical system?
Dr. Garthwaite: I think there are really six things.
The first is I've bought into the basic direction--that is, to create exceptional
value in health care, high quality, efficiently delivered. I think
that's the quest we all have, whether we are buying a car or buying health
care. We know we have value when we get really good quality and it's reasonably
The basic direction includes moving from hospital-centered care to patient-centered
care; from thinking of individuals being treated aggressively at the end
of life or at the end of an illness, emphasizing disease prevention and
avoiding whatever illness is possible; to achieve the maximum health potential
of every person who is enrolled in the VA health care system. And I think
we need to keep on that track.
There are a couple of things that I'm interested in pursuing.
First of all, I want to make a sharper distinction between what we are
doing in reinventing the VA and what is managed care. Although we've
borrowed a couple of principles from managed care, we're not trying to
turn the VA into a managed care organization. And I want to make
that very clear to veterans, so that they don't believe that all the negative
things they read in the paper about managed care is where the VA is headed.
Secondly, I want to have a very broad initiative where we put "veteran''
in "veterans health care.'' In this, I give a lot of credit to Vietnam
Veterans of America, because they've stimulated a lot of my thinking in
this regard. It's a multi pronged approach.
Part of what Vietnam veterans taught me is we really do need to the
service history as part of the medical history. That is to say, if your
occupation was in the military, what are the occupational exposures you
had that might affect your health downstream?
We put a lot of effort into understanding what happened if you worked
in an asbestos factory, but being in the military can be a pretty toxic
environment also. And so we need to build computer systems and databases
that include that. Why? So we can correlate the exposures to
the outcomes. If we find new knowledge, we can get the information back
to the veterans who would be affected and their doctors.
The military exposure information will also help our research efforts.
The military history is important not just to veterans who use the VA health-care
system, but to all veterans. We're going to explore whether or not we can
give all veterans the ability to register their military history. A veteran
could sign on, get his military history registered confidentially, and
if we had a news update or if we had information about his exposure, we
then target that information back to him.
That's a benefit that could be to all veterans, and it really begins
to emphasize our responsibility to veterans in not only maintaining their
health when they use us for health care, but also in providing information
about what we find out about the unique health aspects of having served
in the military.
We also plan to develop a veterans health certification for our doctors
and other health-care providers. We will look at specific veterans health
issues, whether Gulf War illness, exposure to Agent Orange, hepatitis C,
or Post-traumatic Stress Disorder, and develop health education modules
for those physicians and other providers. And then, if they pass
all those, give them a certification in veterans health.
I'm quite willing to pay certified providers more money as an incentive
to acquire and maintain veteran-specific health knowledge. Many of our
physicians and providers will want to be able to say that they're certified
in veterans health.
Another way to view this is that if you have heart disease, we get you
to a heart specialist. If you have a veteran-specific issue, we need
to get you to somebody with demonstrated knowledge in that particular area.
One other piece that is part of putting the "veteran'' in "veterans
health care'' is that I want us to be seen as the resource in the world
for medical knowledge about veteran-specific health. That means that if
you go to your local doctor, and that local doctor is interested in how
your service to your country might be affecting your health today. I want
the place they go to look for that information to be a web site that we
manage. So I want us to be seen as the repository and an easy place to
get that information.
I don't know exactly how that's developed, but what I think the goal
is, very simply stated, when you think about veterans health, you should
think about the Veterans Health Administration and its ability to provide
that information easily to doctors caring for veterans, whether they're
VA doctors or private sector.
VVA: Along those lines, is it possible to get your Regional Office
to maybe set up some type of little room there where veterans could go
in and there is a Web site they could go to.
Dr. Garthwaite: This would be done on the World Wide Web.
Anyone could get to this as far as I'm concerned, whether you're a doctor
or not. I mean it would be more meaningful to a doctor because of
the technical language.
So, just to reiterate, there are many facts that are related to veterans'
health. We can try to educate every doctor who steps foot in a VA with
all that knowledge, but that's going to be a frustrating experience.
I think it's a better approach to make sure that we match people with specific
needs with doctors with that specific knowledge. It's very similar
to how we get you to specialists, and we need to be able to do that and
do it quickly, efficiently, and well. Where we've done it, it's really
In Pittsburgh, I had the opportunity to testify in a hearing where they
brought veterans back for a second appearance before Chairman [Arlen] Specter
[R-Pa.]. And he asked each one of them, "How is the VA treating you?''
The answers at the previous hearing were not good, but at this hearing
they all said, "We get great service.'' I congratulated the medical center
director and asked why. They all were seen by the same doctor who knew
a lot about Gulf War illness and who had a great bedside manner. So it
really gets down to the knowledge and the ability to translate that knowledge
and communicate it to the veteran. We're trying to make that happen more
VVA: Vietnam Veterans of America has called for the creation
of a new section of NIH to deal with the effects of a toxic battlefield,
perhaps to be called National Institute of Military Medicine. Would such
a new entity, in your opinion, be helpful to overall efforts to test new
weapon systems for deployment and examine after-effects of such weapons
that have already been utilized?
Dr. Garthwaite: We need to look at the specific proposal in terms
of how it might interrelate with other initiatives. As a fundamental
principle, it is important for scientists interested in health to be coordinating,
talking, and understanding the toxic effects of war so that issues are
identified early so that good strategies are employed to try to find answers.
We have proposed a VA center to study the effects of war on health.
I also know that the Gulf War coordinating board has evolved into a veterans
health coordinating board. They have as their core mission to try to coordinate
such efforts. We are interested in the concept and the findings.
VVA: VVA has said that there has been a significant diminishment
of organizational capacity at the VHA to deal with specialized services.
What steps has the VHA taken to stop this erosion of capacity? What
is the status of your plan to rebuild organizational capacity?
Dr. Garthwaite: I'm committed to the specialized services
that the VA gives to veterans. They are a significant part of the reason
we exist and a critical part of what we aim to deliver exceptionally well.
I think we already do. Services are often not available elsewhere, and
one of the reasons that veteran services organizations ask us frequently
to maintain and have concerns that we aren't maintaining capacity is related
to the fact of their uniqueness and their quality.
One of the hardest issues in here is capacity--understanding what capacity
is. Is capacity the cost, the beds, the providers? Or is it the number
of veterans served to a specified level of quality?
Clearly, the capacity to deliver money to a bank's patrons might be
measured by the number of banks, but it turns out that a much better solution
is the automated teller machine.
So it's not the number of banks, the number of employees at the banks,
or the number of tellers, that actually define the capacity to deliver
a customer's money in a convenient and reasonable fashion.
It is true that we have made changes in how we deliver health care and
are making changes. What we have to do is recognize, I think, that
we can't just take away the banks before we put the ATM machines in.
And so, as we evolve, we have to be exceptionally careful and reasonable
about how we put any new services in and get them running before we begin
to dismantle all the old ways of doing business.
VVA: What steps are you taking to achieve better measurement
of global activity performance? Do you feel that you have sufficient
authority and control over VISNs and their directors, over individual medical
centers and their directors? Are there other additional tools that Congress
could give you to improve such control and accountability mechanisms?
Dr. Garthwaite: In terms of overall control and authority,
I truthfully am not sure that anyone ever has a whole lot of control and
authority over people. Sure, you can make their lives miserable, and you
can give them bad performance ratings, and you can occasionally fire people.
But what's really better is when everyone says, "I see that vision.
I'm going there, too, and don't get in my way.'' It's a whole lot better
way of leading an organization. That's what I think we've tried to
And so my sense is that I have way more authority than I want to have
to exercise. I don't think it's a matter of authority if people want to
go where you want them to go. They'll knock you down getting there. I think
we've got a lot of people on board the train, and they're pushing it and
We still need to renew our conversations with our academic partners
as I'm not sure we all have the same vision today.
We have an exceptionally noble mission--caring for America's veterans,
finding new cures for disease, and educating the health-care providers
of tomorrow. Those are good reasons to get up in the morning. I think most
people can resonate with the mission. We have to keep that out in front.
VVA: Some in Congress, as well as within our membership,
think that veterans would be better off with Medicare-type card rather
than having to receive care from the VHA facility. How do you see
the role of VHA in the next decade? Is it the most cost-effective,
cost- efficient way to deliver veterans health care and veterans' mental
health care? Is there a justifiable reason to strive to keep a strong
Dr. Garthwaite: A lot of people say why don't you just
give veterans a voucher. I think if you were to voucher out routine surgical
procedures and simple medical care, you could do that easily.
It's not hard in America to get good prices and availability on herniontraphies,
colystectomies, back surgery, and total hip replacements. They pay
well in the private sector and consequently there are many physicians who
would readily provide that service for a fee.
The line is not long, however, for people lining up to treat patients
with AIDS, hepatitis C, chronic mental disease, multiple complex medical
problems, one layered on top of the other, with frequent visits and lots
of medication adjustments, and patients who are slow getting on the examining
I'm actually very interested in a very competent study of what vouchering
would cost. I'm told, although I've never seen it, that the Reagan
administration did one and realized the folly of pursuing it and
stepped back from it. Whether that's true or not, it's part of the
folklore of the VA.
But I'm not afraid of that type of study because I have looked at our
numbers and I look at what Medicare plus choice numbers are, and for the
average veteran getting care in the VA health care system, we're spending
significantly less per patient for the complex care that we're giving.
So I'm not afraid of the comparison; I welcome it.
I think that veterans deserve to have someone very interested in PTSD.
I think veterans deserve to have someone who wants to set the standard
for delivering care for patients with hepatitis C, or HIV, or chronic mental
disease, or the combination of serious mental disease and a medical disease,
multiple medical diseases.
I'm not saying that the private sector doesn't want to, but the forces
for them are not aligned the same way they are for us. And will they
do it with the sense for research, to understand even better ways of restoring
to maximal health and functionality people who have given the most for
Until you can demonstrate that's true, let's back off of that argument
because I think we can demonstrate what we've contributed.
VVA: Could you tell the readers of <I>The VVA Veteran<$>
why you do what you do?
Dr. Garthwaite: I do what I do because of what I just said--that
it's a good mission. If you can take care of people who are either
there because they were injured in the defense of the country or because,
for one reason or another, they're low on resources and also have served
their country, that's a pretty noble thing to do--to improve their health
If you add that you also get a chance to contribute to the knowledge
for all humanity by leading a system that finds a gene for schizophrenia,
improves the treatment for hypertension, describes the mathematics behind
CT and MRI, or develops the radio immunoassay (all VA research discoveries),
you have the opportunity to stimulate and foster the environment where
those ideas and advances can occur.
And at the same time, if you can develop a system that's compassionate
and has values and tomorrow's providers can be trained in that environment,
it's good for the nation. It's pretty hard not to believe that's
a good reason to go to work every day, even if you have to tackle the Capital
Beltway. The private sector may pay more, but you don't get to take the
money with you anyway.
E-mail us at TheVeteran@vva.org