Hearing examines Tomah VA’s past, future

Senate committee investigation finds "systemic failures" in inspector general's review

A hearing Tuesday examined a 16-month Senate committee investigation into Tomah Veterans Affair Medical Center, highlighting leadership’s role in over prescription practices and intimidation against those who spoke out.

Senator Ron Johnson, chairman of the Senate Homeland Security and Governmental Affairs Committee, issued the 359-page report, “The Systemic Failures and Preventable Tragedies at the Tomah VA Medical Center.” He said the VA Office of Inspector General (OIG) discounted various over-prescription reports over the years. At the hearing, lawmakers questioned VA leaders over the findings.

“These tragedies here at Tomah, I believe could have been prevented had the Office of Inspector General done its job,” Johnson said. “It was the failure of the Office of Inspector General and the failure of other agencies and offices to actually highlight the problems we were made aware of that allowed these tragedies to occur.”

“There’s lots of finger-pointing and everything else,” Sloan Gibson, U.S. Department of VA secretary deputy said. “At the end of the day, we own this. VA leadership owns this. We had ample opportunity over a period of years to fix this. That’s leadership’s responsibility. And we failed to get it done.”

The report finds that from at least 2007 to 2015, there were serious problems of over-prescription and retaliation against whistleblowers, possibly resulting in at least two veterans’ deaths and the suicide of a staff psychologist.

Lawmakers and witnesses went over the hospital’s history at the hearing, along with its chief of staff Dr. David Houlihan. The report said employees at the Tomah VA had been referring to Houlihan as the “Candy Man” since at least 2004 for allegedly prescribing too many painkillers.

The report says during investigations, the VA OIG was informed of concerns that two of the witnesses, including Houlihan, were impaired by drugs themselves, but didn’t fully examine the allegations. At the hearing, Gibson said his first time hearing that allegation was while reading the report.

“We’re right back to leadership. This is what it’s about,” he said. “It’s about delivering safe care to veterans, and the failure of leadership that happened here was the failure on the part of the medical center director to take appropriate action.”

The report also states retaliation against whistleblowers created a culture of intimidation in the workplace.

“One instance led to a suicide, other instances led to people leaving their positions because of the culture that was created, and I just think it’s essential that we fix that,” WI (D) Rep. Ron Kind said.

According to Gibson, new practices at Tomah VA including education and alternative approaches to pain management have led to 9 percent of veterans being prescribed opioids, less than the 13 percent national average.

“Tomah once the symbol the overuse of opioids is actually on its way to becoming a model of change and best practices,” he said.

Houlihan was removed from his position, and a number of leadership changes have been made since the beginning of the scandal.