A publication of Vietnam Veterans of America, Inc. ®
An organization chartered by the U.S. Congress

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 Relations.

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 year.

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 management.

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 treated.

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 decisions.

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 of reasons.

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 priced.

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 worked well.

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 often.

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 do.

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 guiding it.

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 VHA?

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 table.

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 their country?

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 care.

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.

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