County Health Chief Chosen

Los Angeles County supervisors on Friday selected the top medical officer of the Veterans Health Administration to head the county’s ailing Department of Health Services, concluding a nine-month search to fill what some see as one of the toughest health-care jobs in the nation.

Dr. Thomas L. Garthwaite, undersecretary of health affairs for the VA, is set to begin his new job in February. He will make $275,000 a year and be the first medical doctor to run the county’s $2.9-billion health department.

At the VA, Garthwaite has won praise for helping a notoriously bloated and politicized bureaucracy shift its emphasis from pricey hospital care to cheaper treatments in clinics--a medical challenge similar to the one that faces him in Los Angeles. The VA is the largest integrated health care system in the United States, with 163 hospitals serving 4 million patients each year.

Although the county department is far smaller than the $20-billion VA system, Garthwaite’s new job comes with some fresh challenges. The VA’s budget had held steady during his tenure while demand has increased, but Los Angeles could lose nearly a third of its budget in the next four years. Cuts in federal aid will leave the health department with a nearly $1-billion deficit in 2005.

Also, it may prove more difficult to secure money to treat the uninsured of Los Angeles than to fund care for veterans. And Garthwaite will report directly to five strong-willed politicians, who critics say have hampered essential reforms in the nation’s second-largest public health system.

The former county health director, Mark Finucane, was ousted by supervisors in March after five years of public browbeating by his bosses. Finucane’s predecessor once collapsed while under fire by supervisors.

Garthwaite, whom colleagues describe as mild-mannered yet determined, said he was ready for the challenge.

“I’ve always looked for a job worth doing,” said Garthwaite. “It seems to me that trying to develop a system that can become a model for effectiveness and efficiency at delivering health care for the poor and uninsured is needed.”

At the VA, Garthwaite said, he helped cut costs while increasing medical treatment and patient satisfaction. “It remains to be seen whether that’s doable in L.A.,” he said.

Supervisors said they hoped Garthwaite could do what the county has yet to achieve in the last six years--streamline Los Angeles’ public health system.

“He’s a reform agent,” Supervisor Zev Yaroslavsky said. “He’s not frightened by change, and he’s not afraid to make difficult decisions, to take on sacred cows, as he’s had to do at the VA.”

But local observers cautioned that the task Garthwaite faces may be too much for any individual.

“I wish him well,” said Dr. Brian Johnston, an emergency room physician and past president of the county medical association. “He’s been asked to captain a sinking ship.”

“I admire his courage,” Johnston added, “but I’m skeptical that any human being would be able to deal with the situation without significant increases in funding.”

Supervisors went through an unusually painstaking selection process for their new health director, who will have to run the agency during what is expected to be among the most turbulent periods in its 30-year history. The board considered nine candidates, including the agency’s current interim director, veteran county administrator Fred Leaf, who is popular with many supervisors. Supervisors during the selection process said they wanted to come to a consensus on the new director.

In the end, the board unanimously selected the outsider, Garthwaite, but made an unusual decision to keep Leaf as a prominent No. 2, giving him the title of chief operating officer and saying he will run the health department with Garthwaite in “a team approach.”

The gravelly-voiced Leaf, a longtime internal investigator for the scandal-ridden health department, was elevated to acting director after Finucane left. He is trusted by supervisors and many other longtime county officials. He will earn $217,000 in his new position.

“The idea is to combine his fresh look with my many years of experience to come up with the changes we will need to make in the not-too-distant future,” Leaf said.

Garthwaite said he was happy to have Leaf aboard. He said he was “coming in from the outside to a system that doesn’t have the time to waste on another long and difficult search.” For that reason, Garthwaite said, it is good to have an assistant familiar with and respected by the system.

‘Team Approach’ Is Sought

Annelle Grajeda, general manager of the politically powerful Service Employees International Union Local 660, which represents most health workers, said she was glad Leaf would have a prominent role. “He’s got a real inside working knowledge of the department and he also, I believe, has the trust of its employees,” said Grajeda, adding that she looked forward to working with Garthwaite.

Supervisor Gloria Molina said that Leaf can help Garthwaite deal with the board and navigate the treacherous waters of Los Angeles County health care. “We really wanted to put together a team, and I think it will help Garthwaite navigate this system,” she said.

Molina added that it was critical that Garthwaite gets unanimous backing from the board “because what he does is going to lead to cuts in all of our districts.”

The health department almost dragged the county into bankruptcy in 1995, until it was saved by a Clinton administration bailout. That aid has been extended but begins dropping off next year, when the county faces an $187 million deficit. In three more years the gap grows to $884 million--compounded by additional Bush administration health cuts.

In the face of looming financial disaster, the county has taken only small steps toward restructuring and cutting back. Finucane was sharply criticized by the board for the slow pace of his reforms, but supervisors, loath to cut medical care in their districts, also complicated the process.

Supervisors have pushed for new, politically popular anti-smoking programs, for example, while demanding their health department cut spending. Earlier this month, they also directed the agency to study expanding the emergency room in Olive View-UCLA Medical Center and building another ER in High Desert Hospital--a facility Finucane had once considered closing.

Joe Bader, director of the Los Angeles office of the Union of American Physicians and Dentists, which represents county doctors, said he hopes Garthwaite is up to the political challenge. “They certainly need someone who has some chutzpah,” said Bader, whose union has sued supervisors to block planned cuts in physician benefits.

“The first time he makes a recommendation that makes some sense and changes anything in a hospital in one of their [supervisors’] districts that would make a difference, and the board blocks him and blames it on him--we’ll see how long he lasts,” Bader said.

If there ever were a job that might prepare someone for the political and health care challenges of Los Angeles County, it may be Garthwaite’s job at the Veterans Administration, said several health-care experts.

“He’s been running a health care system that’s at least as politically complicated as the L.A. County Department of Health Services for the last several years,” said Kenneth J. Clark, who oversees Veterans Health Administration health care facilities in Southern California and Nevada.

Garthwaite began his medical career in the VA Medical Center in Milwaukee, becoming chief of staff at that facility before moving to Washington, D.C., in 1995 to become deputy under secretary of health for the Veterans Administration under President Clinton.

A strong advocate of using computer systems in health care, Garthwaite helped spearhead reform of the VA. During his tenure, the VA opened a patient research center to track and prevent medical errors and implemented bar code scanners to match patient drugs and doctor orders. Perhaps most significant, the VA computerized patients’ records--a goal Los Angeles County is far from achieving.

When President Bush appointed a new Secretary of Veterans Affairs this spring, Garthwaite offered his resignation, but agreed to stay on until a replacement was found.

“Dr. Garthwaite is a master at building consensus around the need for change and reform,” said Dr. Frances Murphy, the current Undersecretary of Veterans Affairs for Health, who worked under Garthwaite in Washington.

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Times staff writer Evelyn Larrubia contributed to this report.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Dr. Thomas L. Garthwaite

* Born: July 8, 1957

* Residence: Rockville, Md.

* Education: BA from Cornell University, MD from Temple University, fellow at Medical College of Wisconsin

* Career highlights: Undersecretary for health, former deputy undersecretary for health, Department of Veterans Affairs; former chief of staff, VA Medical Center, Milwaukee

* Family: Separated, with two children, Jill, 26, and Ben, 25, and two grandchildren