    [Joint House and Senate Hearing, 114 Congress]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 114-427

                         TOMAH VAMC: EXAMINING QUALITY,
         ACCESS, AND A CULTURE OF OVERRELIANCE ON HIGH	RISK MEDICATIONS

    =======================================================================

                                 JOINT HEARING

                                   before the

                         COMMITTEE ON VETERANS' AFFAIRS
                         U.S. HOUSE OF REPRESENTATIVES

                                    and the

                                  COMMITTEE ON
                   HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   ----------

                                 MARCH 30, 2015

                                   ----------

            Available via the World Wide Web: http://www.fdsys.gov/

                           Printed for the use of the
            Committee on Homeland Security and Governmental Affairs

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                                                            S. Hrg. 114-427

                         TOMAH VAMC: EXAMINING QUALITY,
         ACCESS, AND A CULTURE OF OVERRELIANCE ON HIGH	RISK MEDICATIONS

    =======================================================================

                                 JOINT HEARING

                                   before the

                         COMMITTEE ON VETERANS' AFFAIRS
                         U.S. HOUSE OF REPRESENTATIVES

                                    and the

                                  COMMITTEE ON
                   HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 MARCH 30, 2015

                                   __________

            Available via the World Wide Web: http://www.fdsys.gov/

                           Printed for the use of the
            Committee on Homeland Security and Governmental Affairs

         [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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            COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                        RON JOHNSON, Wisconsin, Chairman
    JOHN McCAIN, Arizona                 THOMAS R. CARPER, Delaware
    ROB PORTMAN, Ohio                    CLAIRE McCASKILL, Missouri
    RAND PAUL, Kentucky                  JON TESTER, Montana
    JAMES LANKFORD, Oklahoma             TAMMY BALDWIN, Wisconsin
    MICHAEL B. ENZI, Wyoming             HEIDI HEITKAMP, North Dakota
    KELLY AYOTTE, New Hampshire          CORY A. BOOKER, New Jersey
    JONI ERNST, Iowa                     GARY C. PETERS, Michigan
    BEN SASSE, Nebraska

                        Keith B. Ashdown, Staff Director
                  David N. Brewer, Chief Investigative Counsel
                      Brian M. Downey, Senior Investigator
                            Kyle P. Brosnan, Counsel
                  Gabrielle A. Batkin. Minority Staff Director
               John P. Kilvington, Minority Deputy Staff Director
                 Brian F. Papp, Jr., Minority Legislative Aide
       Jeremy Steslicki, Legislative Assistant, Office of Senator Baldwin
                         Laura W. Kilbride, Chief Clerk
                       Lauren M. Corcoran, Hearing Clerk
                                     ------

                         COMMITTEE ON VETERANS' AFFAIRS

                         JEFF MILLER, Florida, Chairman
    DOUG LANBORN, Colorado               CORRINE BROWN, Florida
    GUS M. BILIRAKIS, Florida, Vice-     MARK TAKANO, California
        Chairman                         JULIA BROWNLEY, California
    DAVID P. ROE, Tennessee              DINA TITUS, Nevada
    DAN BENISHEK, Michigan               RAUL RUIZ, California
    TIM HUELSKAMP, Kansas                ANN M. KUSTER, New Hampshire
    MIKE COFFMAN, Colorado               BETO O'ROURKE, Texas
    BRAD R. WENSTRUP, Ohio               KATHLEEN RICE, New York
    JACKIE WALORSKI, Indiana             JERRY MCNERNEY, California
    RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
    LEE ZELDIN, New York
    RYAN COSTELLO, Pennsylvania
    AMATA RADEWAGEN, American Samoa
    MIKE BOST, Illinois

                     Jon Towers, Republican Staff Director
             Christine Hill, Staff Director, Subcommittee on Health
      Samantha Gonzalez, Professional Staff Member, Subcommittee on Health
                     Don Phillips, Minority Staff Director

                                C O N T E N T S

                                     ------
    Opening statements:
                                                                       Page
        Senator Johnson..............................................     1
        Congressman Miller...........................................     3
        Senator Baldwin..............................................     5
        Congressman Walz.............................................     6
        Congressman Abraham..........................................    32
        Congressman Kind.............................................    33
        Congressman Duffy............................................    36
        Congressman Pocan............................................    38
    Prepared statements:
        Senator Johnson..............................................    63
        Senator Carper...............................................    66
        Senator Baldwin..............................................    68
        Congressman Miller...........................................    70

                             Monday, March 30, 2015
                               PANEL I WITNESSES

    Noelle Johnson, Pharm.D., BCACP, CGP, Urbandale, IA..............     8
    Ryan Honl, Tomah, WI.............................................    13
    Marvin Simcakoski, Stevens Point, WI.............................    15
    Heather Simcakoski, Stevens Point, WI............................    18
    Candace Delis, Auburndale, WI....................................    20

                               PANEL II WITNESSES

    John D. Daigh, Jr., M.D., Assistant Inspector General for
      Healthcare Inspections, Office of Inspector General, U.S.
      Department of Veterans Affairs; accompanied by Alan Mallinger,
      M.D., Senior Physician, Office of Healthcare Inspections.......    40
    Carolyn Clancy, M.D., Interim Under Secretary for Health, U.S.
      Department of Veterans Affairs; accompanied by Renee Oshinski,
      Acting Network Director, VISN 12, Veterans Health Administrator
      and Mario V. DeSanctis, FACHE, Medical Center Director, Tomah
      VAMC Medical Center............................................    42

                         Alphabetical List of Witnesses

    Clancy, Carolyn M.D.:
        Testimony....................................................    42
        Prepared statement...........................................   286
    Daigh, John D., Jr., M.D.:
        Testimony....................................................    40
        Prepared statement...........................................   278
        Prepared statement revised...................................   282
    Delis, Candace:
        Testimony....................................................    20
        Prepared statement with attachments..........................   256
    Honl, Ryan:
        Testimony....................................................    13
        Prepared statement with attachments..........................   147
    Johnson, Noelle:
        Testimony....................................................     8
        Prepared statement with attachments..........................    73
    Simcakoski, Heather:
        Testimony....................................................    18
        Prepared statement...........................................   253
    Simcakoski, Marvin:
        Testimony....................................................    15
        Prepared statement...........................................   249

                                    APPENDIX

    Statements submitted for the Record
        American Federation of Government Employees, Local 0007......   295
        Disabled American Veterans...................................   300
        Disability Rights WI.........................................   305
        Linda Simcakoski.............................................   307
        Gail Mackie..................................................   311
        Constance A. Walker..........................................   312
    Response to post-hearing questions submitted for the Record
        Dr. Johnson..................................................   314
        Mr. Honl.....................................................   326
        Dr. Daigh....................................................   327
        Dr. Clancy...................................................   329

                     TOMAH VAMC: EXAMINING QUALITY, ACCESS,
             AND A CULTURE OF OVERRELIANCE ON HIGH-RISK MEDICATIONS

                                  ----------

                             MONDAY, MARCH 30, 2015

                                         U.S. Senate,
                               Committee on Homeland Security
                                      and Governmental Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice at 1 p.m., in
    Cranberry Country Lodge, 319 Wittig Road, Tomah, Wisconsin,
    54660, Hon. Ron Johnson, Chairman of the Committee, presiding.
        Present: Senator Johnson, Senator Baldwin, Hon. Jeff
    Miller, Hon. Ralph Abraham, Hon. Tim Walz, Hon. Ron Kind, Hon.
    Sean Duffy, and Hon. Mark Pocan.

                  OPENING STATEMENT OF SENATOR JOHNSON

        Chairman Johnson. This Joint Field Hearing of the Senate
    Committee on Homeland Security and Governmental Affairs and the
    House Committee on Veterans' Affairs is called to order.
        Good afternoon. I would like to begin by thanking Chairman
    Miller of the House Veterans' Affairs Committee for his
    collaboration and leadership in holding today's hearing. I
    would also like to thank all of our colleagues for their
    participation.
        Today's hearing has been called to examine the disturbing
    allegations surrounding the Veterans Affairs Medical Center
    (VAMC) here in Tomah.
        The primary goal of this hearing--and of all of our future
    actions--is to help prevent tragedies like the ones we will
    hear about today from happening to other veterans and their
    families.
        I first became aware of the problems at the Tomah
    Department of Veterans Affairs (VA) following news reports in
    January of this year. I immediately assigned committee staff to
    launch an investigation into what had occurred--and was
    occurring--at Tomah, and the VA's reaction to it. Here is what
    we have found so far.
        In April 2003, Dr. David Houlihan was disciplined by the
    Iowa Board of Medicine for having an inappropriate relationship
    with a psychiatric patient. According to the Executive Director
    of the Board of Medicine, the sanction should have been serious
    concern for any future employers.
        In 2004, Dr. Houlihan was hired as a psychiatrist at the
    Tomah VA Medical Center.
        In August 2005, Dr. Houlihan became Chief of Staff at the
    Tomah Medical Center.
        In November 2007, Kraig Ferrington, a veteran who sought
    treatment at the Tomah facility for medication management died
    from a lethal mixture of drugs. Autopsy reports showed Mr.
    Ferrington had seven drugs in his system.
        In April 2009, it was known and documented by employees of
    the Tomah VA that many of Dr. Houlihan's patients called him
    ``the Candy Man.'' And they were concerned that veterans were
    ``prescribed large quantities of narcotics.'' Again, that was
    April 2009. Almost 6 years ago.
        In June 2009, Dr. Noelle Johnson was fired from Tomah for
    refusing to fill prescriptions that she believed to be unsafe.
    Dr. Johnson had raised concerns to her superiors and sought
    guidance from the Iowa Medical Licensing Board and later spoke
    with the Drug Enforcement Administration (DEA) about Dr.
    Houlihan.
        In July 2009, Dr. Chris Kirkpatrick was fired from Tomah.
    Dr. Kirkpatrick had raised concerns to his union about over-
    medication at Tomah. Tragically, later in the day of his
    termination, Dr. Kirkpatrick committed suicide.
        In August 2011, the VA Office of Inspector General (OIG)
    received an anonymous complaint about overprescription and
    retaliation by Dr. Houlihan at Tomah.
        In March 2012, a second anonymous complaint was filed with
    the Inspector General (IG) against Dr. Houlihan. The Office of
    Inspector General examined 32 separate allegations during its
    2\1/2\ year long inspection.
        In March 2014, the Office of Inspector General finished its
    inspection of Tomah and administratively closed the case
    without making it public.
        On August 30, 2014, Jason Simcakoski died in the Tomah
    mental health wing as a result of ``mixed drug toxicity.''
    Simcakoski was a patient of Dr. Houlihan's. His autopsy
    revealed he had over a dozen different medications in his
    system.
        In September 2014, Ryan Honl began lodging whistleblower
    complaints about patient safety and quality of care at Tomah.
        On January 8, 2015, this year, the Center for Investigative
    Reporting published an article detailing over prescription and
    retaliation at Tomah. The article revealed that veterans and
    employees referred to the Tomah VA Medical Center as ``Candy
    Land.''
        On January 12, 2015, Candice Delis brought her father,
    Thomas Baer, to the Tomah VA Urgent Care Center with stroke-
    like symptoms. Mr. Baer waited for over 2 hours for attention.
    That day, the facility's only computerized tomography (CT)
    scanner was down for routine preventive maintenance. Mr. Baer
    passed away 2 days later.
        On February 6, 2015, the Office of Inspector General
    finally posted its Tomah health care inspection report on its
    website.
        We continued to gather the facts about what occurred at
    Tomah. Our investigation is far from over. Revelations of the
    problems at Tomah have prompted additional whistleblowers to
    contact our committee with information that indicates systemic
    problems within the VA health care system.
        It is important to acknowledge and thank the members of the
    media that have uncovered, reported and highlighted the
    problems within the VA health care system. Without a free
    press, few if any of these problems would have ever seen the
    light of day.
        Legislatively, this hearing is just the first step. In
    order to solve a problem, we must fully understand it and be
    willing to admit we have one. To that end, today we will hear
    from surviving family members, former employees, and
    representatives from the VA and the VA Office of Inspector
    General.
        Tragically, we will hear the stories of two families, the
    Simcakoski and the Baer families, who lost loved ones during
    their treatment at the Tomah facility. They have many questions
    and they have a right to have those questions answered.
        I want to the convey this Joint Committee's sincere
    condolences to the family members and friends of Jason
    Simcakoski, Thomas Baer, Kraig Ferrington, and Dr. Kirkpatrick.
    We thank them for being here today so that Wisconsin and the
    American people can hear their stories firsthand.
        The lack of public knowledge and scrutiny of the problems--
    not only at Tomah, but at other VA healthcare facilities--
    indicates that transparency and accountability both within the
    VA and the VA Office of Inspector General must be improved.
        As the last 2 months have shown, the crucial first step in
    improving service and the quality of care in the VA health care
    system is a process for transparent disclosure.
        In spite of the revelations regarding the Tomah facility, I
    still believe that the vast majority of men and women working
    in Wisconsin's VA facilities are dedicated to providing quality
    care to the finest among us.
        Nevertheless, the VA and the VA Office of Inspector General
    must take necessary steps to ensure that substandard clinical
    practices and the retaliatory tactics used at Tomah never occur
    or go unreported again.
        We owe our veterans the best possible treatment and care.
    Hopefully, with proper oversight, increased transparency and
    swift accountability within the VA, that goal will be achieved.
    Chairman Miller.

                OPENING STATEMENT OF CONGRESSMAN MILLER

        Chairman Miller. Thank you very much, Mr. Chairman. I am
    Jeff Miller, Chairman of the House Committee on Veterans'
    Affairs. I am from the First District of Florida.
        And, while I am here under circumstances that are
    disturbing, to say the least, I am grateful to be in Tomah with
    each and every one of you this afternoon.
        Ladies and gentlemen, those of us up here on the dais right
    now are from different political parties, different houses of
    Congress, different parts of this State and different parts of
    the country. But let me say this, we are all united here in
    Tomah today, because partisanship, stovepipes, and gridlock
    have no place where our Nation's veterans are concerned.
        Let me begin my statement by expressing my condolences to
    the Simcakoski family and the Baer family and to all of you
    here today who have lost loved ones or have been left to carry
    the scars of poor treatment by the Tomah Department of Veterans
    Medical Center.
        However, let me assure you that your pain serves a purpose
    and your calls for help and change have been heard.
        Concerned employees and worried veterans have tried to blow
    the whistle here for years, only to be met with seemingly
    silence by the Inspector General and the Department of Veterans
    Affairs.
        When the problems finally got the attention that they
    deserved, the IG and the VA learned what so many here had known
    and been saying for a long time. Some providers were recklessly
    providing opioids and other high--risk medications that, in
    some cases, were actually harming veteran patients and that
    facility and the Veterans Integrated Service Network (VISN)
    leaders allowed a culture of fear, reprisal and retribution to
    fester until it infected staff morale and impacted patient
    care.
        Unfortunately, many of the issues surrounding medication
    management and a lack of accountability that we are going to
    discuss today are not outliers, but they are symptoms of
    system-wide issues that our veterans and their families face in
    communities like this one every single day.
        I recognize that pain--particularly the chronic pain and
    accompanying comorbid conditions that many of our veterans
    experience--is complex and difficult to treat.
        I also recognize that VA is joined by the medical community
    at large in grappling with how best to treat chronic pain and
    ensure safe, effective use of opioids and other high-risk
    medications.
        However, I have heard VA officials use these two facts as
    de facto excuses for irresponsible medication management
    practices and systemic lack of accountability for far too long,
    while our veterans and their families continue to suffer the
    devastating consequences of VA's inaction.
        It is time for a new message.
        We cannot rewind the clock and bring to light before yet
    another year of inaction passed--the results of the IG's
    initial 3-year investigation that found serious concerns.
        We can never bring back Jason Simcakoski or Thomas Baer.
        But we can use the lessons we learned here in Tomah to
    improve the care our veterans receive and ensure that no other
    veterans, their families or VA employees suffer like some have
    here.
        I appreciate each and every one of you being here today. I
    look forward to your testimony.
        And I yield back to the Chairman.
        Chairman Johnson. Thank you, Chairman Miller. Before I turn
    it over to Senator Baldwin, I do ask unanimous consent to enter
    all of our opening statements into the record\1\ and our
    ranking member, Senator Tom Carper, has also offered an opening
    statement that I also ask be entered in the record.\2\
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Senator Johnson appears in the
    Appendix on page 63.
        \2\ The prepared statement of Senator Carper appears in the
    Appendix on page 66.
    ---------------------------------------------------------------------------
        Without objection, so ordered.
        Chairman Johnson. Senator Baldwin.

                  OPENING STATEMENT OF SENATOR BALDWIN

        Senator Baldwin. Thank you, Chairman Johnson, Chairman
    Miller, for holding this hearing here today. And to my
    Congressional colleagues in the Wisconsin delegation, thank you
    for joining us. And a special welcome to Congressman Walz and
    Congressman Abraham for visiting Wisconsin today.
        I want to echo the opening statement of Chairman Miller, by
    noting that, the fact that there are members here from both
    parties--from both the Senate and the House sends an important
    message to this community that we share a bipartisan commitment
    to get to the bottom of the problems at the Tomah VA, and to
    work together across party lines to make sure that they never
    happen again.
        I hope and I trust that I speak for all of us when I say
    there is no reason for, and no room for politics when it comes
    to ensuring that our Nation's veterans receive the timely,
    safe, and highest-quality care that they have earned.
        I would also like to take an opportunity to say thank you
    to our panelists for joining us here today. In particular, I
    have tremendous respect for the courage of Candace, Heather,
    Marv, Ryan and Noelle.
        Stories that you are going to share today are extremely
    powerful. They are stories of a sacred trust that we must have
    with our veterans and their families and stories of how that
    trust has been broken. Tragic stories of loss.
        Today we are here to fix what has been broken. And to work
    together to restore that trust. And I want you to know that the
    stories you give voice to today will help us do that for our
    veterans.
        The problems at the Tomah VA are both sobering and have had
    tragic consequences. Going back to 2006, veterans who were
    patients at the Tomah VA have tragically lost their lives.
        Veterans who served our country, Angela Colby, Michael
    Bobak, Jacob Ward, Derik McGovern, Kraig Ferrington, and Jason
    Simcakoski, were all under the care of the former Tomah Chief
    of Staff and treated with prescription drugs and all of them
    subsequently died of a drug overdose.
        In fact, according to his sister Kari, who is with us here
    today, Mr. Ferrington, an Army veteran from De Pere, Wisconsin,
    died from a lethal mixture of prescription drugs in 2007, while
    under the care of the former Chief of Staff. The same cause of
    death that would tragically take the life of Jason Simcakoski
    some 7 years later.
        These are six examples of a larger problem that is in
    desperate need of solutions today. As we all know, after two
    decade-long wars, a large number of our service members are
    coming home with the damage of combat.
        Our veterans and their families are facing the difficult
    challenge of facing physical injuries and post traumatic stress
    disorder (PTSD) and other mental illnesses. We must confront
    these problems more aggressively and more effectively and help
    them meet that challenge.
        I believe the VA's overreliance on opioids has resulted in
    getting our veterans hooked instead of getting them help.
        Over prescription of opioids at the VA is clearly a root
    problem, but we must not lose sight of the fact that it is
    growing into a weed. A weed of addiction whose impact is being
    felt beyond the VA walls. The devastation of addiction on
    families and our communities that is being grown at the VA is
    stunning.
        Reports indicate that 6 years ago, a Marine Corps veteran
    was stoned on painkillers and tranquilizers from the Tomah VA
    while driving and killed a 6-week-old child, Ada Mae Miller.
        As the Center for Investigative Reporting wrote about the
    Tomah VA Medical Center, Ada Mae's death is one of dozens of
    tragedies that begin to hint at how the flood of narcotics from
    the VA scarred this region.
        The fact is, the problem of overprescribing at the VA and
    the collateral damage of addiction is not unique to Wisconsin.
    We are not alone.
        The ripples are indeed being felt across America in
    communities we work for every day in Washington D.C.
        The families we have a responsibility to represent are
    struggling with the loss of a husband or wife, son or daughter,
    father or mother, sister or brother, to addiction whose root is
    planted within the VA system. It is our job to make sure that
    they do not feel alone and I believe we have a shared
    responsibility to do everything we can to pull this root out.
        I thank you for providing me with the opportunity to join
    you today. And I look forward to continuing my work with this
    community and my colleagues in Congress to address these
    problems and put the solutions in place to prevent these
    problems and tragedies from ever happening again.
        Chairman Johnson. Thanks, Senator Baldwin. Congressman
    Walz.

                 OPENING STATEMENT OF CONGRESSMAN WALZ

        Mr. Walz. Thank you, Chairman Johnson and Senator Baldwin,
    to my colleagues and a special thank you. It has been an honor
    of mine to serve with Chairman Miller for the past 8 years on
    the Veterans' Affairs Committee, and I can tell you no one
    brings more passion and integrity to the issues to care for our
    warriors than the Chairman does.
        I am Tim Walz. I am a 24-year veteran in the military and I
    serve in the First Congressional District of Minnesota, and my
    District goes up to the Mississippi and many of my veterans in
    southeast Minnesota use the Tomah Facility.
        This hearing, and for our witnesses who are here, fulfills
    our Constitutional responsibility to provide oversight, and to
    provide oversight of the VA, and very few committees have the
    immense responsibility of that oversight, means the care of
    those who are willing to put their lives on the line and their
    families to serve this Nation, so getting it right, as I
    mentioned to some before this hearing, this is a zero-sum
    proposition. We understand many get quality care. We understand
    many are getting what they need. But if one family does not
    receive it, then we have failed. And that is an understanding
    that, that, amongst this family, runs deep.
        I know each of you, if there was anything we could do, and
    I say this to you as a father, a husband, a son and a veteran,
    if we can turn back and make this right, everyone here would,
    would wish that more than anything.
        But what we can do is--two things. We can make sure
    accountability and justice is provided to you, and we can make
    sure that no other family goes through this, so I echo what my
    colleagues said to each of you.
        I cannot even imagine your pain and I will not give you lip
    service. I spoke with one of Mr. Baer's family members, who is
    a 23 year E8. She is pretty much not interested in lip service
    and she's pretty much not interested in a show. She's pretty
    much interested in results. And I think everyone up here
    clearly understands that.
        And so today, the purpose of it is to start to provide you
    justice, to try to understand exactly what happened, and then
    to start coming up with solutions.
        And, the issue here runs deep and it is something, it is
    not new. It's not confined to the VA. It is in the private
    sector also--pain management with injuries, especially injuries
    associated with catastrophic war injuries or service-related
    injuries. And this is something we've tried to do, we've put in
    place, reaching back decades.
        And I have worked with Chairman Miller on things we put in
    to try and address this issue. In 2008 we had a bill dealing
    with chronic pain management and overreliance on opioids. It
    has been there, but for each of your families, what's it is
    telling me, it is not working.
        My colleague, Mr. Kind, and our colleague from up north,
    Mr. Ribble, introduced recently a piece of legislation to build
    on that, to make it even stronger. And so what needs to come
    out of this today, and what I thank each of you is, we need to
    understand what happened. We need to understand what went
    wrong. We need to make sure that there is accountability, and
    if it includes punishment to those and justice for you, that
    needs to happen, and then we need to find those solutions. We
    need to implement things that are working and I hope to hear
    from the VA today the things they've initiated. And there are
    bright spots of things that are happening. And that is going to
    be amongst you, frustrating at times to hear, but please
    understand, for us, what you are going to tell us and help us
    understand is going to ensure that not another family sits
    there.
        And I would close with our two folks here sitting at the
    end, along with the media--as Senator Johnson pointed out--for
    bringing this to the attention. It is a pretty high calling and
    a pretty difficult thing to do to stand up in the face of
    retribution to bring things to light that are harming our
    veterans, and I think, and I have witnessed it in the House
    Veterans' Affairs Committee that tolerance for retribution on
    whistleblowers is less than zero, because it is a cancer that
    prevents us from providing the care that our veterans need if
    anyone in that organization is stymied from being able to speak
    about what is right and what is wrong.
        And so our commitment to you, as it has always been, is to
    make sure that justice is served to you, those who were
    bringing it up. You were not doing it for yourself. You were
    doing it for their loved ones, and, perhaps, had we listened
    earlier, they would not be sitting at the table, because I know
    they would rather be somewhere else.
        So I want to thank you for that.
        I hope we find answers here today. Our Republic requires us
    to have these difficult conversations. Our warriors and their
    families are absolutely counting on us. And what we cannot do
    is undermine the faith of the care we are going to give our
    warriors amongst those who are serving, so I want to thank
    everyone for being here and thank the Chairmans for initiating
    this hearing.
        I yield back.
        Chairman Johnson. Thank you, Congressman Walz.
        Like you as someone who has served your country in the
    military, we have a lot of vets and their families here, so I
    think I speak for everybody here on this Joint Committee when
    we thank you sincerely for your service as a Nation.
        It is the tradition of our Senate Committee to swear in all
    the witnesses, so if all witnesses, would you please stand and
    raise your right hand?
        Do you swear the testimony you will give before this
    Committee is the truth, the whole truth and nothing but the
    truth, so help you, God?
        Ms. Delis. I do.
        Ms. Simcakoski. I do.
        Mr. Simcakoski. I do.
        Mr. Honl. I do.
        Ms. Johnson. I do.
        Chairman Johnson. Thank you. Please be seated.
        Our first witness is Ms. Noelle Johnson. I believe it is
    Dr. Johnson, is it not?
        Dr. Johnson. Yes.
        Chairman Johnson. I will say Dr. Johnson, is a former
    pharmacist at the Tomah VA Medical Center from 2008 to 2009.
    She is currently an employee of the VA facility in Iowa.
        Dr. Johnson, go ahead.

         TESTIMONY OF NOELLE JOHNSON,\1\ PHARM.D., BCACP, CGP,
                            URBANDALE, IOWA

        Dr. Johnson. I would like to take the opportunity to thank
    the Committee for having this hearing today and allowing me to
    have a voice and speak out for our veterans.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Johnson appears in the Appendix
    on page 73.
    ---------------------------------------------------------------------------
        I worked at the Tomah VA as a Clinical Pharmacy Specialist
    from July of 2008 to June 2009. I was fired after refusing to
    fill several narcotic prescriptions prescribed by Dr. Houlihan
    that I believed to be unsafe. I filed a whistleblower complaint
    with the Office of Special Counsel (OSC), which was denied, and
    later the Merit System Protection Board (MSPB). The VA
    requested Federal mediation. And I settled out of court in
    2010. I was then fully reinstated.
        I do believe that I was terminated for blowing the whistle
    and I was contacted by the DEA and agreed to interview with
    them. I met with the DEA in June 2009. And I was fired a few
    weeks later. In my Office of Special Counsel complaint, Dr.
    Houlihan and several others referenced that I had turned him in
    to the Inspector General. I believe this played into my
    termination. I truly believe that Dr. Houlihan is a dangerous
    man and what makes him so dangerous is a lack of respect for
    the medication in which he prescribes. Whatever his motives for
    prescribing the current doses of the medication is almost
    irrelevant. To this day I still question his motives, whether
    it be power, monetary gain, negligence, or ignorance. Maybe all
    of the above. The truth of the matter, the quantities of
    narcotic medications coming out of the Tomah VA facility is
    irrefutably unsafe. This has been demonstrated by several cases
    of overdose and death. Over 2,000 911 calls were made from the
    Tomah VA Medical Center with 24 unexpected deaths over 5 years.
    This is unacceptable. Three of those deaths occurred in a 4-
    month span timeframe in the year that I worked at the Tomah VA.
        The three questions that need to be asked are simple.
    First, what makes the Tomah VA patient population so complex,
    as the Tomah Director put it in his television debut, that they
    require the number of narcotics that are being dispensed? I am
    currently working as a double board certified Clinical Pharmacy
    Specialist in a pain management clinic at the Des Moines VA. I
    am currently the facility lead for the National Opioid Safety
    Initiative. And I can assure you the patients at the Tomah VA
    are no more complex than any other patient that I see on a
    daily basis. At that point we are not even prescribing one
    fourth of the current narcotic medications that the Tomah VA
    is. Specifically as the Veterans Health Administration (VHA)
    Directive is to limit the morphine equivalents to less than 200
    milligrams per day and limit the combination of opioids and
    benzodiazepines due to the increased risk of mortality. I do
    not believe that Tomah would be in compliance with this
    National Directive. The thing I am struggling most with is to
    understand the variance between what the Undersecretary's team
    found and the report that was administratively closed by the
    Inspector General. Unfortunately, for all the veterans
    receiving care at the Tomah VA, the considerable variance that
    was not enough to warrant a serious consideration by the
    Inspector General, as the investigation was administratively
    closed, led to continued harm of our Nation's veterans.
        The second thing. What exact type of pain is the Tomah VA
    trying to treat that they are prescribing the dangerous
    quantity and dosages of this medication? Studies show that no
    proven long-term benefit of opioid medications, let alone the
    significant doses that were being prescribed. As a pain
    specialist, I can assure you that if someone was actually
    taking those medications in the amounts that were prescribed,
    they would have serious side effects or consequences, which
    leads me to believe, in part, that the veterans are not taking
    all of the prescribed medications and are at high risk for
    diversion. This was a substantiated finding by the Inspector
    General. They substantiated the allegation that negative urine
    drug screens (UDS) were not acted on and that controlled
    substances were prescribed in the face of a negative urine drug
    screen.
        The third issue is why is a psychiatrist prescribing opioid
    pain medications at the Tomah VA facility, period? This is
    beyond their scope of practice.
        I am tremendously disappointed in our Federal system and
    our current authoritative figures that are to be governing our
    agencies set in place to protect our veterans and employees. I
    have interviewed with the DEA three times and had a thorough
    interview with the IG. Of the 32 allegations that were
    investigated, many were unsubstantiated. What the disturbing
    thing is, is that I lived the torture and saw the unsafe
    practice daily. I can attest to several of those 32 allegations
    and believe the majority should have been substantiated. The
    Inspector General's investigation did substantiate several
    allegations. However, they still did not find any conclusive
    evidence affirming criminal activity, gross clinical
    incompetence or negligence, or administrative practices that
    were illegal or violated personnel policies. This is
    unfathomable for the following reasons.
        I advise that I alerted Dr. Houlihan on a few different
    narcotic medications and scripts. All were very concerning for
    safety reasons. However, the one that stands out the most to me
    is an OxyContin prescription that a local medical doctor was
    prescribing. He was also tapering this medication because the
    patient tested inappropriately positive for methadone, a drug
    that neither provider was prescribing. At that point in time
    the patient was double-dipping. He was getting OxyContin from
    the VA and from a local medical doctor with refill dates only a
    week or two apart.
        In addition to the inappropriate urine drug screen, which
    the VA did not obtain, the abuse of opioids, the patient left
    his cell phone in the pharmacy. The person on the other end was
    trying to buy medication from this veteran. All of this was
    documented and Dr. Houlihan rewrote the prescription for
    OxyContin three times a day. This was an increase in the
    frequency prescribed. This supports the substantiated findings
    that Dr. Clancy's team expressed. As expressed above, the
    veterans were still prescribed narcotics in the face of
    aberrant drug-related behavior. From a clinical standpoint, I
    am unclear why Dr. Houlihan prescribes these medications in the
    manner in which he does. What matters is the standard of care.
    There is a standard of care that is set in place for providing
    safe and effective care to our veterans. For example, there was
    1,080 immediate release morphine tablets that were dispensed.
    When I confronted Dr. Houlihan, he refused to change the
    patient to a long-acting medication, which would have been the
    standard of care or adding a nonnarcotic medication to treat
    his neuropathic pain. He continued to prescribe 36 tablets a
    day to known substance abuser who was overusing his morphine
    while in the hospital.
        Another example is a prescription of 1,447 milligrams of
    morphine equivalent per day. Dr. Houlihan and Dr. Hyde worked
    on this prescription together. The patient had dangerously
    increased his own medication and they gave the patient a 30-day
    supply when he was supposed to be admitted for inpatient
    facility monitoring for pain management. He was not admitted.
    That is how you have accidental or nonaccidental overdoses in
    your parking lot. I retrospectively reviewed the patient's
    profile the following week. And, as I said, he was not admitted
    according to the plan of care. I was later kicked off the new
    pain committee and opioid work group that I had been assigned
    to or appointed by the Quality and Safety Director by Dr.
    Houlihan, who promptly replaced me with Dr. Hyde, which I do
    not believe to be a coincidence. Dr. Hyde is now being
    investigated by the Wisconsin Department of Professional
    Services. I had very little interaction with Deb Frasher. The
    only thing I can say is that I heard her say that everyone
    needed a cocktail, which consisted of an opioid, a benzo, a
    stimulant, and a sleeping medication.
        My question about her is, again, if she's treating mental
    health, then why is she prescribing 5.3 million milligrams of
    morphine equivalent in one year's timeframe? What is she
    treating? When it did become acceptable or the standard of care
    to treat psychological pain with opioids? This finding was
    unsubstantiated by the Inspector General. However, I can tell
    you that I saw this indication for opioids in the chart several
    times.
        The veterans in the Tomah VA appeared extremely
    overmedicated. Several veterans appeared to be suffering with
    extrapyramidal side effects due to the unsafe combination of
    medications being prescribed. The list of medications the Tomah
    VA prescribed Jason Simcakoski did not follow evidence-based
    guidelines or the standard of care. For example, he was
    prescribed a weak opioid that was prescribed with Suboxone
    which should never be done. Diazepam was prescribed at above
    the maximum recommended dosage. He was also being prescribed
    duplicate benzodiazepine therapy with diazepam and temazepam,
    it was dangerous and not the standard of care. He was also on
    several other interacting medications that effect serotonin
    which put him at high risk for serotonin syndrome, which can be
    lethal, and, unfortunately, it was. One of my main concerns
    about the care provided at the Tomah VA to Jason was that
    Jason's care and the mixed drug toxicology that eventually led
    to his death did not likely occur overnight. I would have
    suspected that the veteran would have displayed signs and
    symptoms of the central nervous system (CNS) depression, and he
    likely did. If that was the case, was there evidence of gross
    clinical incompetence and negligence? That veteran's death was
    a preventable tragedy. Had the Inspector General done their due
    diligence and reported their findings, despite the
    administrative closing of the investigation, the outcome for
    Jason could have been a very different one.
        The majority of my colleagues, with the exception of Dr.
    Hyde, had agreed with my clinical concerns. I alerted my Chief
    of Pharmacy, Dr. Erin Narus, who ordered me to illegally
    partial a methylphenidate script prescribed by Dr. Houlihan
    because neither of us concurred with the current dosing regimen
    and it was prescribed above the maximum recommended dosage. I
    told my Service Line Chief, Jeff Evanson, and his response to
    me being asked to do something illegal was, why are you trying
    to cause trouble? Why are you trying to throw Erin under the
    bus? If Houlihan wants you to fill that prescription, you have
    no right to say no. I reported my concerns to the President of
    the Union, the VISN pharmacy leaders, the DEA, and later the
    Inspector General, as well as the Wisconsin Board of Pharmacy.
    I alerted my licensing agency, the Iowa Board of Pharmacy, who
    advised me not to fill the prescriptions and bring the matter
    to local authorities. The unfortunate part of all of this is
    that despite all who knew, nothing has been done. The true
    tragedy is that more veterans had to die because the Office of
    Special Counsel determined that my clinical opinion was
    different than Dr. Houlihan's.
        The depth of this tragedy is far reaching. I recently
    received a pain management consult at the VA in Des Moines for
    a veteran that was treated by Dr. Houlihan and Deb Frasher. He
    had a long-standing history of substance abuse. He was
    previously taken off opioids for a previous overdose. He was
    later put back on large doses of benzodiazepines and opioids by
    Dr. Houlihan and he has subsequently overdosed two times in the
    last 2 months. He is now an inpatient in our facility being
    taken off all of his medications. I am unclear how the
    Inspector General could not substantiate the findings that no
    conclusive evidence of gross clinical incompetent or negligence
    was found. Veterans lost their lives because of this prime
    example of gross clinical incompetence and negligence.
        I have personally dealt with the repercussions of the
    administrative practices that were illegal and violated all
    sorts of personnel policies. I was asked to do something
    illegal. I refused. I blew the whistle and was fired for
    standing up for doing what was safe and right for the veterans.
    The Inspector General did find that pharmacy staff uniformly
    indicated that they were reluctant to question any prescription
    ordered by Dr. Houlihan or the aberrant behavior by his
    patients because they feared reprisal. If all of these findings
    were unsubstantiated, why have so many clinicians left the
    Tomah VA? The one pharmacist who was brave enough to stand up
    and question those prescriptions was fired. The precedence of
    what not to do if you value your job was set.
        My second Chief of Pharmacy, Tom Jaeger, reported that he
    was actually coerced into writing his personal statement that
    helped lead to my termination. He agreed to take it back and he
    resigned 2 days after my termination. My clinical colleagues,
    Heather Asthmus and Rebecca Bell, were pulled into Houlihan's
    office where he essentially told them, if they valued their
    job, they would not question him like I did. A former provider
    resigned in lieu of termination after refusing to write for an
    opioid that a veteran did not test positive for in his urine
    drug scene. I was told in the pain committee meeting that we
    were not to be drug testing our patients, as when they did not
    test positive for the substance prescribed, and we continued to
    prescribe the medication, then we were liable. I do believe
    that is the point of the urine drug screen is to substantiate
    use and misuse of high-risk medications for the safety of our
    veterans and the public. Dr. Houlihan proceeded to tell the
    Union Steward that there would never be a pain clinic at the VA
    and if pharmacy took over management, pain management, the
    patients would start dying, after which they would bring their
    guns to pharmacy and start shooting.
        I continue to have grave concerns about the clinical
    abilities of several other providers at the Tomah VA, including
    concerns that were ignored or unsubstantiated by the Inspector
    General. What will it take for those in a position of authority
    to do some significant actions? How many veterans' lives need
    to be lost? We are supposed to be taking care of these veterans
    returning from war, not creating a war that they will not
    survive. It is all of our responsibility to stand up for these
    veterans' safety and not contribute to the tragedy that has
    cost so many lives. The leadership at all levels--Tomah, VISN,
    the Veterans Affairs Central Office (VACO), and the Inspector
    General need to be held accountable or true change will never
    prosper and veterans will continue to suffer the ultimate
    sacrifice.
        Chairman Johnson. Thank you, Dr. Johnson. We will, by the
    way, enter full written statements into the record, if we could
    just ask the witnesses to keep pretty close to the 5 minutes so
    we can keep the hearing moving.
        Our next witness is Ryan Honl. He's a former employee of
    the Tomah VA Medical Center, who worked as a secretary in the
    Hospital's Mental Health Clinic. Mr. Honl.

    TESTIMONY OF RYAN HONL,\1\ FORMER EMPLOYEE OF TOMAH VA MEDICAL
                        CENTER, TOMAH, WISCONSIN

        Mr. Honl. Chairman Johnson, Chairman Miller and
    distinguished Members of the committee, as well as the press.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Honl appears in the Appendix on
    page 147.
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        I am the one who blew the whistle on the alarming
    irregularities concerning unethical practices at the Tomah
    Veterans Affairs Medical Center. I am also a disabled combat
    veteran and received care at the VA for 15 years, up until last
    year. I enlisted as a combat engineer after high school, served
    in Desert Storm, earned an appointment to West Point, and then
    became a commissioned infantry officer before being medically
    discharged with, among other things, PTSD. It is important to
    note that I was only the spark to set off years of employees
    raising concerns about the dangerous prescription and
    distribution of narcotics, as well as the resulting
    retaliation. The results were to the detriment of the health of
    veterans, and, in some cases, the deaths of veterans. The
    system was slow to respond, but quick to silence those who
    raised concerns. I just wish the whistle I blew would resurrect
    those who have died due to mistreatment.
        Initially my complaints to the VA Office of Inspector
    General mainly centered on a hostile work environment that
    tolerated fraud and abuse. I only briefly mention that,
    although I was not a witness, since I was a secretary, to the
    overprescription of narcotics, there was a widespread concern
    among my coworkers. I simply stated in my complaint that it
    should be looked into. There is a culture in the VA where
    cronyism runs rampant leaving incompetence in charge at all
    levels that tolerates unethical practices. Once I came out
    publicly blowing the whistle, I had current and former
    employees contact me with information about other unethical
    activities up to and including patient harm and patient death.
        There is a lack of accountability in VA leadership. There
    were years of complaints concerning a retaliatory environment
    and patient harm, yet both VA leadership and the VA Office of
    Inspector General ignored or handed off complaints back to the
    Tomah facility so it could investigate itself. There is a
    culture in the VA of admitting no wrongdoing. Pain management
    and wait times are simply a symptom of a far larger lack of
    accountability. Tomah is not an island onto itself. Dr.
    Houlihan should have been held to account years ago, by not
    just Facility Directors, but those outside of the Tomah
    Facility and VISN 12 leadership. Yet the system protected him
    and not our Nation's veterans.
        The VA Inspector General's office is broken. If it were not
    for a Freedom on Information Act (FOIA) request done by Senator
    Baldwin's office last summer, no one would have known about the
    issues in Tomah. It took an investigative journalist, Aaron
    Glantz, at the Nonprofit Center For Investigative Reporting to
    do the job that the VA Inspector General was incompetent to do.
    The report verified everything people had been talking to me
    about since I blew the whistle--excessive prescribing of
    narcotics, drug diversion, patients not using their narcotics.
    A physician in 2009, Dr. Chris Kirkpatrick who raised concerns
    about Dr. Houlihan's prescribing practices, was terminated and
    went home and committed suicide.
        Tomah municipal police reports of veterans selling their
    medication. Retaliation against those who spoke up concerned
    about their licenses, such as the five pharmacists who spoke
    with investigators about the dangerous levels and early filling
    of narcotics and resigned or were terminated.
        Most incredible to me was a statement about the perception
    of retaliation, implying that it did not really exist. Yet
    numerous people in the report had been forced out of the
    facility for simply raising concerns on behalf of veterans.
        Inspector General Richard Griffin said that he would not
    have done anything different and no one else would have either.
    Ms. Gromek stated that the report could not be released because
    of personally identifiable information (PII). The report
    received through the FOIA request was already redacted.
        I will give you two personal examples of retaliation, even
    after resigning from the VA. After requesting a patient access
    report of my electronic medical records, I discovered that a
    half dozen Tomah employees had accessed my electronic medical
    records after I left the facility over a supposed mix-up in
    Secretary Robert McDonald's office, according to Mario
    DeSanctis, concerning a complaint about my prescriptions.
    Although I had never received care or received prescriptions
    from the Tomah VA, there were a half dozen Tomah nonpharmacy
    employees over a pharmacy complaint in my records. I had
    originally informed my supervisor, Lisa Noe, that I had a PTSD
    diagnosis since I was in vocational rehabilitation with the VA,
    and my counselor in Indiana needed to know information about my
    employment at the VA. I asked that this remain in confidence.
    However, as soon as I blew the whistle, I started hearing from
    coworkers about my instability. Ultimately, the most troubling
    occurred since everything came out in the media. Dr. Houlihan's
    attorney sent a letter to me threatening a lawsuit, a man that
    I reported. In an interview with the Milwaukee Journal
    Sentinel, his attorney, Frank Doherty, alluded to my mental
    health status, which had nothing to do with my credibility. And
    it just so happens that Frank Doherty's wife, Lisa Doherty, who
    is a narcotics compliance officer, reported directly into Dr.
    Houlihan.
        While investigators were in the Tomah VA, Police Chief
    Huffman directed that a police report be done on me by my
    former supervisor, Lisa Noe, and two coworkers, Leesha Dukes
    and Rachel Fleming, 4 months after I resigned over a supposed
    threatening incident that took place while I was an employee
    before I resigned.
        You can see the police report that someone leaked to me in
    my submitted documents. Among the terms used in that report was
    I was threatening. I was red in the face. I was unstable. And
    then the word that was the most damaging for mental health
    professionals in Tomah--that I was crazy. It is in the police
    report--that word. As long as you speak out, raising concerns,
    whether an employee or a former employee, the VA will do
    everything in it's power to discredit you, and the OIG will
    just call it a perception.
        In conclusion, the greatest problem requiring immediate
    change is for President Obama to nominate a permanent Inspector
    General and for the Senate to confirm without bipartisan horse
    trading. The VA Office of Inspector General has the blood of
    veterans on its hands. Senator Baldwin and Senator Johnson have
    each asked the White House to nominate a new Inspector General.
    Elected officials need to make sure that when they hear of
    serious problems in a VA Facility, they direct those concerns
    far higher than the Facility level. When, as in Tomah,
    unethical practices go all the way up to the Facility Director,
    sending those concerns back to that Facility Director only
    leaves the fox to guard the hen house. As Congressman Kind
    stated, when he came to the Tomah facility last summer, there
    was not a peep from Mario DeSanctis that there were any
    problems. Certainly no narcotics problems. Nothing. The VA
    Inspector General should, at minimum, provide a summary of
    problems in a Facility.
        In the case of Tomah, when someone from Congress comes
    calling, they should already have a top line of any concerning
    investigations. This Inspector General's office did not even
    keep senior VA leadership informed. Again, the main problem
    underlying scandal after scandal is a culture that lacks
    accountability. Rogue doctors and those who supervise them will
    never care what the rules are, or they will never follow a pain
    management system, if they are not held accountable as has been
    the case in Tomah. There is a cancer within VA leadership that
    requires excision, not promotions, not transfers and not
    bonuses.
        Thank you.
        Chairman Johnson. Thank you, Mr. Honl.
        Our next witness is Mr. Marvin Simcakoski. Marv is the
    father of Jason Simcakoski, a 35-year-old marine who passed
    away from a reported drug overdose at the Tomah VA Medical
    Center. Mr. Simcakoski.

    TESTIMONY OF MARVIN SIMCAKOSKI,\1\ FATHER OF JASON SIMCAKOSKI,
                        STEVENS POINT, WISCONSIN

        Mr. Simcakoski. Thank you for having me here today.
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        \1\ The prepared statement of Mr. Simcakoski appears in the
    Appendix on page 249.
    ---------------------------------------------------------------------------
        My name is Marv Simcakoski. I am Jason Simcakoski's dad. I
    want to start off by saying that August 30, 2014, was the
    hardest and most painful day of my life. There is not a day
    that goes by when I do not relive that morning. I regret
    leaving my son in his room alone that morning, only to get a
    call hours later that he stopped breathing. I cannot get that
    thought out of my head. I wish I would have been there for him.
    I loved Jason and still do with all my heart and miss him every
    day. Jason was proud to be a marine and to serve his country.
    He loved his fellow Marines.
        This is a summary of some of the important issues to the
    committee as I understand them. I really got to know and
    understand how Jason struggled with his addiction problem, only
    to have it overfueled time and time again by the Tomah VA
    doctors. I have argued with Jason's doctors for the last 4
    years about them over medicating him. I was always told that I
    was not their patient, even thought I was his dad who truly
    cared about him.
        What I would like to know is, if Jason was their son, would
    they have had him on all these medications? When Jason came
    home from one of his inpatient stays, the doctor had him on so
    many meds, Jason and I were confused by all the different
    medications he had to take. His doctor sent him a 3-month
    supply of lorazepam and he took them all in 4 days and almost
    died. I was mad and confused. Why would a doctor that works
    with patients with addiction problems send a patient 3 months
    worth of benzodiazepines?
        After his doctor stopped the benzodiazepines and eliminated
    some of the other meds, Jason started doing a lot better and I
    started giving him his meds daily, 7 days a week.
        Then one day about a year ago, Jason's dog, which he loved,
    was run over by a car in front of him. Jason started to
    unravel. I took him back to the Tomah VA and he was assigned to
    a new inpatient doctor, Dr. Davis. My wife, Jason, and I met
    with her and discussed his treatment plan. This new doctor told
    us that Jason did not need all these meds and she was going to
    take him off most of them. My son stayed at the Tomah VA for 3
    months.
        Toward the end of his 3-month stay in 2014, he was doing
    real well until his doctor put him on a new drug, Geodon. Then
    everything started to spiral downhill. Jason's anxiety level
    went way up. He could not sleep. He started having bad
    thoughts.
        He told his doctor about all of these issues and that he
    did not want to take the medicine any more. She told him, if
    you do not take it, you will be discharged the next morning.
    Jason kept taking it until he could not stand it any more. He
    pulled the fire alarms and went crazy. His doctor was going to
    put him in lockdown for 2 months because of it.
        My son made a good point to me. He said, why am I getting
    punished for something she made me take? Dr. Davis then gave
    Jason the option of going to the Madison Facility or into the
    lockdown at the Tomah VA. He did not want to go into the
    lockdown, so he transferred to the Madison VA the same day. He
    was told there that he was overmedicated on Valium and Geodon
    and that the Geodon can make people crazy. They released him
    the next day. He was sent home to try to wean himself off these
    medications, which I know was next to impossible.
        After being home for about 2 weeks. Jason still could not
    do much more than get out of bed and eat, so I took him back to
    the Tomah VA the day after my father's funeral. Jason was not
    able to attend his grandfather's funeral because of the effects
    of withdrawal.
        Jason told me on the way down to Tomah that if he could be
    like anybody, he would be like his brother Chad, because Chad
    was normal, and he did not have all these daily struggles. The
    last 2 weeks that Jason was in Tomah he was doing OK until his
    doctor put him back on Geodon. He sent me a text 4 days before
    he died and told me he could not take it any more. He was going
    crazy and he reached out to me to help him. I made various
    calls to various offices above his doctor's head. Jason called
    me within 2 hours. He said somebody was helping him. I met with
    his doctor the next day, Thursday, with my son and a Patient
    Advocate.
        When we sat down in the room, his doctor turned and pointed
    at me and she said that I caused her a lot of trouble. She said
    she spent 2\1/2\ hours at meetings because I went over her head
    and she could have been taking care of my son. She also said I
    may know how to build houses and pound nails, but I do not know
    anything about taking care of my son.
        This really hit me hard. To have Jason's doctor tell me I
    do not know about my son and that I caused her a lot of trouble
    for trying to help him was difficult to hear. Jason called me
    that night before he died and wanted me to bring his truck the
    next morning. He was all excited about coming home that
    following Monday for his daughter's birthday that week. His
    wife, his daughter and I arrived as promised.
        Usually when we would come to see him he is waiting. This
    time there was no Jason. I went to the nurses' station and
    asked where he was. And they said he was in his room with a
    migraine, which was strange, because he never had a migraine
    before.
        I went into his room and he was lying on his side with his
    hand on his head. I asked him what was the matter and he
    started to talk, but I could not understand him, because he was
    on so much medication. I went to the nurse's station and asked
    them what was wrong with Jason and the nurse told me that he
    would be fine in a couple hours. They had given him another med
    for a migraine. This medication did not show up on the autopsy
    report. It was Fioricet. I went back to his room and we stayed
    a little longer. He waved us off to go and he went back to
    sleep. We left not knowing that we would never see him alive
    again.
        About 5 hours later we get a call from the Tomah VA stating
    that Jason had stopped breathing. They were working on him,
    trying to resuscitate him, but it was too late. He never got to
    drive his truck or come home for his daughter's birthday.
        I then find out he was still on all the medication, when
    the doctor told us she was going to take him off most of them.
    I think that was insane. Later I find out they also had Jason
    on pain meds, Tramadol, and sent him a bottle of 56 to his
    house. Why do you put someone with an addiction to pain meds on
    pain meds? I cannot begin to tell you how angry that makes me.
    I would like one of these doctors to tell me how mixing all of
    these drugs they had Jason on, was taking, was going to do him
    any good.
        Why does not the Director of the VA Facility take blame for
    all of this? Is not he in charge? I am an independent
    contractor in the Stevens Point area, and when anybody that
    works under me on a job site does something wrong, I am
    responsible because I am in charge.
        If this Facility will not take responsibility for its
    wrongdoing, then I think the system is totally screwed up. I
    think all who had part in my son's death should be held
    accountable. If they are not, then what kind of message are we
    sending? Is it not OK to have a patient die in the mental
    health ward because of overmedicated by the doctors and no one
    is a fault?
        If after today's hearing nothing major gets changed, then I
    think people will lose faith in our government. Let's make some
    historic changes that we can all be proud to be part of. Give
    these veteran men and women a fighting chance for a bright
    future instead of a cloudy one from being overmedicated so they
    know what it feels like to be normal. I think this is going to
    be a great chance to have all government parties work together
    to show veterans you really do care. After all, these people
    should be the most important priority to all of us because they
    are our real life heroes of this country.
        I am proud my son was a veteran and he will always be my
    hero.
        [Applause.]
        Chairman Johnson. Thank you, Marv, for that powerful
    testimony.
        Our next witness is Heather Simcakoski, the widow of Jason.
    Heather.

     TESTIMONY OF HEATHER SIMCAKOSKI,\1\ WIFE OF JASON SIMCAKOSKI,
                        STEVENS POINT, WISCONSIN

        Ms. Simcakoski. Thank you for having me here today.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Simcakoski appears in the
    Appendix on page 253.
    ---------------------------------------------------------------------------
        My name is Heather Simcakoski. I am the wife of Jason
    Simcakoski and mother of our 12-year-old daughter.
        Jason and I met 13 years ago while both serving in the
    Marine Corps together in Hawaii. After the Marine Corps I moved
    from my home town in Ohio to Wisconsin. Stevens Point is
    Jason's hometown and where he had many dreams of one day taking
    over his family business, along with so many other dreams for
    our future.
        Even when life seemed impossible and we questioned
    ourselves, we always found the strength and love to work
    through it. Neither of us could ever give up on each other or
    our marriage. Our daughter and I have been cheated out of every
    Father's Day, having a father at her soccer games, having her
    dad to walk her down the aisle one day, and, most importantly,
    she was cheated out of his unconditional love, support and
    guidance in life.
        Jason was not only my best friend and husband, he was my
    family. When my mother passed way 3 years ago, the same day I
    was diagnosed with cancer, leaving me with no parents, he was
    the one that was there for me during the most difficult times
    of my life. He was my rock. I could always count on his love.
    He drove 9 hours in the middle of the night to be my side
    during emergency surgery. He's the person I called when I had
    something to talk about, whether it was good or bad. He was
    always the person I talked to. He has been taken from me.
    During treatment I never had to question if Jason would leave.
    He loved Anaya and me unconditionally. He was a good person
    with such a good heart and was taken far too early from us.
    This is not how he deserved to lose his life.
        Because of the treatment Jason received at the VA, the only
    family I had here, aside from my daughter, was him. I still do
    not know how we ever find peace, because in my heart I know he
    should be still here with us today. Anaya and I lost more than
    a husband and a father. We lost part of ourselves. A part that
    I do not know you ever get back.
        With this, it is so heart breaking to know that someone
    with such love and passion for helping others has been taken
    from Anaya and I, and I truly believe in my heart that he would
    be here today with the proper treatment.
        I have so many questions which I hope to find answers for.
        I would like to understand how and why Jason's police
    reports disappeared. There are reports that he made to Dr.
    Houlihan, the Tomah VA, the Tomah Police Department, as well as
    the Federal Bureau of Investigations (FBI), regarding patients
    selling their prescriptions. These reports were made back in
    2013.
        Some of the patients were making so much money that they
    had saved enough money from selling their prescriptions to put
    a down payment on a house. Thankfully I have the voice mails
    and text messages between Jason and the officers, otherwise I
    am not convinced anyone would be listening to this point today.
    I would like to understand who is responsible for these
    reports, where they are and why no one did anything with the
    reports.
        Additionally, when you are managing someone with addiction
    to prescriptions, or anyone, for that matter, once they are
    admitted into inpatient care, why do they still continue to
    receive the same medications by mail at their house? The same
    ones that they are receiving while at the inpatient facility.
        I also have concerns about the way Jason was treated by the
    doctors as a patient. When he complained that his medication
    was making him uncomfortable one evening, he knocked on his
    physician's door. She opened it and slammed it shut in his
    face. He was not a prisoner, nor was he in boot camp any
    longer. He was a veteran who was willing to sacrifice his life
    every single day for each and every single one of us, including
    those treating him. And to know this is how they treat their
    patients is devastating and completely unacceptable.
        Also living with Jason I was able to see the long-term
    impact of all the medication. I would see him falling asleep
    while he was eating. He would drive up on the median. He would
    slur his words when he was speaking. He would not be able to
    work sometimes for weeks, even months at a time. There were
    times he would sleep 18 plus hours a day. There were times he
    would not come out of his room for days and he would sleep all
    day. Jason did not even realize his behavior was so erratic at
    times, but there were instances where I would video record it
    and show him later so he would see what I saw.
        I would like to understand how a doctor can prescribe 14
    different medications and know which ones are working and which
    ones are not. When you have that many medications in your
    system, your mind is altered. At that point I question how a
    patient can even articulate to a doctor what normal feels like
    any more, especially after mixing and matching, in my opinion,
    experimenting with medication on our veterans, my husband.
        I would also like to understand why alternative treatments
    were not tried for Jason. After years and years of prescription
    treatment, he was not rehabilitated. Does the VA only believe
    in treating addiction by replacing one addictive medication
    with several others? I personally do not consider this success.
        They did not just take away a person. They took away a
    hero, a friend, a husband, a father, a brother, and a son.
    Everywhere we go and everything we do, there are constant
    reminders of Jason's life and it is so unfair to him and every
    single veteran out there to think that is the type of treatment
    that is acceptable.
        Veterans whom are willing to sacrifice their life for you,
    every single person in this room and in this country, they
    deserve so much more than second class healthcare. They should
    be proud to walk into a VA Medical Center to receive care. It
    should be world class treatment, not a last resort for those
    with no alternative healthcare insurance. This should be the
    last place costs are ever made.
        I believe our family and every single veteran deserves
    answers and there should be significant strides made to rebuild
    the trust of all veterans. That they can trust that they will
    receive the highest quality of healthcare from the VA,
    regardless of the cost. I also feel we all deserve to know how
    to push for change effectively.
        I say this with no sarcasm intended, but it currently seems
    that the only way to get anyone to do the right thing is to
    involve the media. I ask myself today, if it had not been for
    the reports on this story, if there would ever be any changes
    made at the Tomah VA. I would like to understand how processes
    can be put in place to ensure there is accountability without
    such extreme measures.
        Chairman Johnson. Thank you, Heather. And I think I speak
    for all of us here, Heather, Anaya, and Marv and Linda, we are
    so sorry for your loss.
        Ms. Simcakoski. Thank you.
        Chairman Johnson. The next tragic story will be told by Ms.
    Candace Delis. She's the daughter of Thomas Baer, a 74-year-old
    veteran who passed away after waiting for treatment for over 2
    hours in the Tomah VA Medical Center. Ms. Delis.

        TESTIMONY OF CANDACE DELIS,\1\ DAUGHTER OF THOMAS BAER,
                         AUBURNDALE, WISCONSIN

        Ms. Delis. Thank you for the opportunity to be here today.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Delis appears in the Appendix on
    page 256.
    ---------------------------------------------------------------------------
        I realize that my father's death was not was related to
    medications, but I believe it speaks to a broader issue of care
    at the VA.
        Fifty years is a long time to keep a secret. My father,
    Thomas Baer, was drafted and proudly served in the U.S. Army
    until he was medically discharged with a service-connected
    mental health issue. Between the time he left the Army in 1965,
    until his death in January, 2015, he was treated off and on and
    hospitalized at several VA hospitals. One was Fitzsimons Army
    Hospital at Aurora, Colorado, which is now closed. Another was
    the St. Cloud, Minnesota, VA Hospital. The most recent and the
    last was the Tomah VA.
        He was hospitalized and treated twice in the inpatient
    mental health unit at the Tomah VA. Once in 1970, shortly after
    he met my mother and again in 1982.
        He and my mother remained silent about his illness, even
    keeping it from me until I was in my late teens in an attempt
    to protect me from the realities that they both faced daily.
    Until today, aside from me, my mother, and a few close friends,
    no one other than his doctors knew of his struggle, because
    there was, and still is, maybe to a lesser degree, a stigma
    that goes along with mental health issues. A stigma that causes
    feelings of shame, fear, and hopelessness. A stigma that leads
    to blame, discrimination, and misrepresentation in the media.
    That is why I have not spoken about this in detail until now.
        My father was treated at the Marshfield Clinic Medical
    Center on Friday, January 9, 2015, for a bronchial infection.
    He was prescribed steroids as well as an antibiotic. Over the
    course of the weekend, his behavior had changed. He was
    restless, confused and dizzy. Symptoms that were related to his
    mental health issues and symptoms that could be triggered by
    the steroids. So on January 12, 2015, we tried to make an
    appointment for him to see his regular provider at the
    Marshfield Clinic. We were unable to do so because of
    scheduling. My mother and I discussed it with my father and he
    felt as though he needed to be hospitalized, so we called the
    Tomah VA. We explained the symptoms that we thought were mental
    health related as well as the symptoms of the bronchial
    infection, which included trouble breathing and the fact that
    he had chronic obstructive pulmonary disease (COPD). We were
    told that we could bring him down and he would be evaluated.
        There is an important point that I would like to make. We
    have been questioned by cowardly, anonymous VA employees in
    Tomah on news websites and on forums--one of which hid behind
    the screen name TomahRN. These employees disingenuously ask,
    why did not you take him to a local hospital? Here are our
    reasons why. First, trust. Second, fear. And third, duty.
        First, we trusted the VA nurse who told us to bring him
    after we told her his symptoms. We trusted her medical
    knowledge and training and believed she would tell us to go
    elsewhere if it sounded like his symptoms were life-threatening
    and the VA could not treat him there. We trusted that she was
    confident that the VA could treat my dad in a compassionate and
    competent manner after we drove 60 miles to get there.
        Second, we feared the VA would stick my parents with the
    medical bill. When the nurse told us to come in, we were
    required to come in under implicit threat that my parents would
    bear the burden of enormous medical fees. You see, in the
    1990s, my dad had a similar emergency. My parents made the
    mistake of seeing a community doctor with no prior approval for
    the emergency with the VA and my parents were stuck with the
    bill for thousands of dollars.
        Third, and most importantly, Veterans Affairs has a duty to
    competently treat our nation's veterans in exchange for our
    veterans fulfilling their to duty to protect our country. My
    dad was entitled to competent care and the VA had a duty to
    provide that. I would not be here today if the VA had fulfilled
    its duty to my dad.
        I have thought long and hard about those anonymous public
    jabs at our grieving family from Tomah VA employees. Shame on
    you, whoever you are, because our trust in Veterans Affairs and
    in you to fulfill your duty is what killed my dad.
        We arrived at the Tomah VA Urgent Care at approximately 11
    a.m. We checked in. I explained my father's symptoms and the
    urgency that he needed to be seen. It was not until nearly 2
    hours later when he slumped over in the wheelchair he had been
    sitting in that we were seen. He was unresponsive for several
    minutes. While they were trying to speak to him, I kept telling
    them, I thought he had had a stroke, since his left side was
    limp and he was leaning in that direction and unable to speak.
    They told me he was fine because his vitals were normal. I
    asked them again to please do whatever tests they could do to
    see if he had suffered a stroke. I was told they were too busy,
    and since, at the time he was able to speak and respond,
    although barely, and not understandably, that they were going
    to put him in a room until someone was able to evaluate him.
        They did an electrocardiogram (EKG). I had to help the
    technician fix the machine, because the paper had jammed and
    she did not know how to fix it, and a chest x-ray, but no tests
    relating to a stroke, even though I had asked repeatedly.
    Approximately 45 minutes had passed and my father stated he
    needed to use the restroom. The nurse got him up on the side of
    the bed. My mom and I went outside for a few minutes to give
    them privacy. When we came back in, no more than 5 minutes
    later, we walked into the urgent care to hear the nurse
    screaming for someone to help her. We could hear her at the end
    of the hall just past the nurses' station where there were
    other staff, but no one moved to help. As my mother and I ran
    down the hall, we came into the room to see my father half in
    the chair, half on the floor, completely unresponsive. His left
    side hanging limp, but worse than the first time. The nurse was
    trying to get under him to get him back into the chair. My
    mother was screaming and I went to get someone to help. Finally
    two other nurses came in and got him back into the bed.
        According to their website, out of the 94 doctors and
    nurses, the Tomah VA has one doctor that is board certified in
    emergency medicine. This doctor is Dr. James Patterson, the
    doctor who was working in the Urgent Care that day and the
    doctor who treated my father. Dr. Patterson said my dad had
    suffered a massive stroke and told the nurse that a CT was
    needed. The nurse replied with, we cannot. The CT is down. Dr.
    Patterson said he would need to be transferred to another
    hospital because they were not able to properly treat him
    there. I asked about the clot busting drug for strokes, but he
    told me they could not administer the drug without first doing
    a CT scan.
        They told us they were going to fly him to Gundersen
    Lutheran in La Crosse. A few minutes later they came back
    saying there were no helicopters flying that day, but they
    would not tell us why. It seemed completely strange, since it
    was a clear day with no wind. Then we were told he would be
    taken to La Crosse via ambulance. An ambulance that they were
    intercepting, that was originally on its way for another
    patient who was having a possible heart attack.
        When we arrived at the emergency room in La Crosse, the
    doctors indicated that he should have been given the clot
    busting drug in Tomah and that they could not understand why he
    was not, nor why he was not flown to the hospital. A CT scan
    was done immediately and surgery performed to remove the clot
    from his artery, but my father never regained consciousness.
        Tuesday morning, January 13, my mother was told by a social
    worker at the hospital that the VA would be paying for all of
    my father's medical care at Gundersen Lutheran, as well as any
    rehab that would be needed, but my father never left the
    hospital alive. They did another CT scan on Tuesday evening.
    They indicated he had likely suffered another stroke, and had a
    brain bleed and that his brain was swelling. After long
    discussions with the doctors at Gundersen Lutheran about his
    prognosis, my mother and I decided to remove any life-
    sustaining equipment, and at 4:20 p.m. on Wednesday, January
    14, my father died at the age of 74.
        In 1982, when I was seven, I traveled to the Tomah VA
    Hospital with my mom to visit my dad at the inpatient mental
    health unit. We did this on several occasions, I am told, but I
    only have one memory. I remember being on an elevator inside
    the hospital with my mom and the doors opening between floors
    to a brick wall. Who knew that 32 years later I would be facing
    another brick wall of sorts, again at the Tomah VA.
        We are left with so many unanswered questions, and the VA
    has been anything but transparent.
        The fact that my father, a man who proudly served his
    country, sat for almost 3 hours in the waiting room of Tomah
    VA's Urgent Care department is completely unacceptable.
        Had they done something as simple as a CT scan at Tomah,
    the outcome may have been different. My mother lost her husband
    of 43 years, her partner, and her best friend. My 10 year-old
    stepson lost his grandfather and I lost my father. The man who
    taught me love, compassion and honesty. The man who, no matter
    what, always had time for me, and the man whose words made me
    feel as though I could accomplish anything.
        I am ashamed to live in a country where men and women are
    sent to fight wars where they suffer horrible injuries and
    mental trauma, and, when they return, instead of being rewarded
    for their service and treated with respect, they are ignored,
    neglected and left to die.
        Like the other families here today, I am tired and I am
    grieving, but I will continue to fight for justice for my
    father and for other veterans. I want to do whatever I can to
    ensure that no other family has to go through what we have gone
    through. I want to be proud to be an American again. But
    without drastic and immediate change at the Tomah VA, I do not
    know if that is possible.
        My family and friends have asked what we will do now. We
    will fight back--both in the courtroom and in the court of
    public opinion. This morning we filed an SF-95 claim with the
    VA and intend to sue, while getting the word out across the
    Nation. We are represented by a leading independent journalist
    and attorney fighting for veterans across the country. His name
    is Benjamin Krause. My dad's death will not go unnoticed and
    the VA's treatment of him will not be forgotten.
        [Applause.]
        Chairman Johnson. Thank you, Candace. Candace, again, we
    are so sorry for your loss. These stories are heartbreaking. I
    think everybody in this room feels that.
        I just want to thank all the witnesses for your courage,
    for stepping forward, for coming here and telling your stories
    in such a public forum. It is not easy. I understand this. It
    is not easy to tell the story. It is not easy to listen to
    them. But I hope that America does hear this. I hope Wisconsin
    hears this. I hope the VA hears them.
        Again, thank you for sharing all that. We will proceed to a
    round of questioning here. It will be 5 minutes. I do ask my
    colleagues to please respect the 5-minutes. I certainly will,
    so we can keep the hearing moving.
        Candace, I would like to start with you. At what point in
    time did you see a doctor when you first came into the Urgent
    Care Center? How long did it take before a doctor was even
    present?
        Ms. Delis. A doctor was present after we had waited nearly
    2\1/2\ hours, and then, even after dad had had the first stroke
    it was several minutes before a doctor came into the triage
    room. We were just in there with the nurse. So it was over 2\1/
    2\ hours.
        Chairman Johnson. It is a very small facility, is it not?
        Ms. Delis. Yes.
        Chairman Johnson. Did you ever see a doctor treating
    anybody else? Were there other emergencies going on?
        Ms. Delis. There were people that had come and gone since
    we had been sitting there waiting.
        Chairman Johnson. Who is evaluating your father for stroke
    symptoms? Was it a nurse?
        Ms. Delis. It was a nurse. It was the same nurse that had
    taken his vitals an hour earlier and put us back in the waiting
    room.
        Chairman Johnson. When you finally did see Dr. Peterson,
    did he express any shock that this had been going on for so
    long, or?
        Ms. Delis. It is Dr. Patterson.
        Chairman Johnson. Oh, I'm sorry.
        Ms. Delis. That is fine. No. He had a nonchalance about
    him. He acted inconvenienced that he was taken away from
    whatever he had been doing previously.
        Chairman Johnson. You were told he was going to be
    helicoptered after this 2\1/2\ hour, maybe 3-hour wait,
    helicoptered to Gundersen Lutheran, and then that did not
    happen?
        Ms. Delis. Correct.
        Chairman Johnson. Can you just explain what happened there?
        Ms. Delis. Well, he had asked the nurse to get a CT and the
    nurse told him the CT was down. My mom had overheard someone in
    the hallway. He said, well, what about Tomah Memorial? And a
    nurse told him, we cannot send him there. And then they came
    back in and told us that they were going to Med Flight him to
    La Crosse. So we waited longer and then they came back in and
    said we cannot fly him. We are getting an ambulance. We are
    intercepting an ambulance from another patient and we will get
    you there via ambulance.
        Chairman Johnson. Do you know why they cannot take him at
    the other Tomah facility?
        Ms. Delis. No. No one will answer our questions.
        Chairman Johnson. We will try to get an answer to that.
        Marv again.
        You said Jason had a 3-month stay. Was that for his drug
    addiction?
        Mr. Simcakoski. Right, he was in there 3 months. Basically
    the doctor was going to try to change up his medications and,
    and she thought it would be best if he stayed right there while
    she was changing all the meds, just because of, what kind of
    reactions he would have and, and she wanted to see him,
    supposedly daily, as he was getting switched from different
    kinds of medications to others, which we thought were going to
    be less, obviously. Then after he died--we, we had no idea that
    he was on--I gave him his meds daily, but not when he went back
    into that 3-month period, and then when he came home for a
    couple weeks, I did not even realize that until after he died
    that he was on that high amount of meds.
        Chairman Johnson. But he was being treated for drug
    addiction?
        Mr. Simcakoski. Right.
        Chairman Johnson. How many times did you talk to different
    doctors about your son's care?
        Mr. Simcakoski. Well, my son had the first doctor who was
    there quite a while. And, I would meet with her and with my
    son, and, I mean, there was times that my son was set to go
    home where I would pick him up and he was all slurry yet. And,
    I would say, I do not think he's ready to be going back home. I
    think something is wrong here. And she said, well, he's fine.
    He's fine to go. And, one time I told her, I said, I see him
    and I see a lot of these other patients that are walking around
    like zombis here. Everybody looks half dead.
        And I said, if he's so fine, why do not you let him drive
    your car in the parking lot. And she said, well, he's not
    driving my vehicle. But she said he was able to drive a
    vehicle. Well, he ended up getting a speeding ticket
    afterwards. And I think he went in the ditch one time where he
    fell asleep. And, I mean, he was not in no condition to drive,
    as Heather stated.
        So, it seemed like the nurses and that, it seemed like they
    tried to help, but the doctors would not take advice from the
    nurses or the counselors. I mean, he would go into the group
    meetings, and the 28-day program, and, he did not get anything
    out of it because he was so medded up. He did not even know
    what was going on half the time. All he was worried about was
    getting his medications from the VA.
        Chairman Johnson. So you are just saying the doctors were
    dismissive?
        Heather, did you have discussions with doctors? Did you
    ever get any explanation?
        Ms. Simcakoski. I did not have discussions with the
    doctors, but I would ask Jason, all the time why his behavior
    was so erratic and we would talk to Marv. He would include Marv
    on everything and Marv would talk to doctors, but we never got
    anywhere.
        He was safer, in my opinion, in our home than he was in
    their care, because they consistently did the opposite of what
    we
    would--and what Marv would ask them to do.
        Chairman Johnson. Thank you.
        Chairman Miller. Dr. Johnson, in your testimony, you
    mentioned that your refusal to fill several narcotic
    prescriptions written by Dr. Houlihan were the basis for your
    firing, is that correct?
        Dr. Johnson. Yes.
        Chairman Miller. In your career as a pharmacist, how many
    times have you refused to fill a prescription?
        Dr. Johnson. Those that were from the Tomah VA and one
    other prescription at my current facility. It was for a
    methadone prescription that was trying to be illegally
    prescribed for opiate withdrawal, which is illegal if you do
    not have a special license.
        Chairman Miller. And how many times were you retaliated
    against for not filling these prescriptions?
        Dr. Johnson. Every time at the Tomah VA and essentially
    even the time at the current facility I'm at.
        Chairman Miller. You were retaliated at your current
    facility as well?
        Dr. Johnson. Yes.
        Chairman Miller. Your testimony, you mentioned you were
    only at Tomah for a year?
        Dr. Johnson. Yes.
        Chairman Miller. From July 2008 to June of 2009. Talk about
    your career before and after.
        Dr. Johnson. I came to the Tomah VA Facility--I was
    actually a new pharmacist. I did my residency in Columbus,
    Ohio, at the VA there. I worked under a board certified pain
    specialist at that time. And I also worked in some chronic
    disease state management clinics and then I came to the Tomah
    VA as my first job outside of residency. After the Tomah VA, I
    did a short stint with a retail pharmacy of Walgreens for a few
    months. And then I sought to get back into the VA system in the
    Des Moines VA and I have worked there since 2010, working in
    their pain management clinic as well as doing Patient Aligned
    Care Team (PACT) med management as far as chronic disease state
    management.
        Chairman Miller. Mr. Honl, in your testimony you stated the
    system was slow to respond but quick to silence those who
    raised concerns. Can you elaborate further for us?
        Mr. Honl. Just from the very moment that I blew the whistle
    and I came out publicly--I filed one morning and a few hours
    later I heard from somebody at the OIG, and they basically put
    an option before me. Put me on the spot and said, you can do
    this anonymously and then it will go directly down to the
    Facility and they will have to investigate it, but we will be
    able to more thoroughly investigate if you give us your name so
    you can give it to the chain of command.
        And, of course, it is one of those crossing the Rubicon-
    type things. Once you make the decision to release your name
    publicly, then, especially in the VA culture, get ready for a
    wild ride. I mean, the circus is just beginning.
        And it happened all the way from within my service line,
    and it just built from there. I mean, my initial complaints
    were just fraud and abuse and, trying to get somebody to look
    at it within my service line. And before I know it, everybody
    is telling me, do not go to Dr. Houlihan, who is the one I
    would have to jump over my service line manager to talk to,
    because he retaliates and nothing gets done and he's been
    investigated over and over again.
        And then Mario DeSanctis, well known that he was a rubber
    stamp. Do not go to him, because David Houlihan is the one who
    wears the pants in the Facility. So I was left with, OK, go to
    the OIG, but once I go to the OIG it goes down to VISN 12 in
    Chicago and then comes back down into the Facility for,
    basically for Dr. Houlihan to investigate himself. And just
    imagine where that goes. No where.
        But that's what's been going for years in the Facility. It
    is not just me. I mean, Noelle talked about it and it has been
    going on for years and years where complaints are sent down
    instead of up to the people who can independently and
    objectively investigate.
        Chairman Miller. Heather, in your written statement, you
    questioned why alternative treatments were not provided to
    Jason. Did Jason ask for any alternative treatment?
        Ms. Simcakoski. Jason did not ask for any alternative
    treatments, but I do not know anyone with an addiction to pain
    mediation that is going to ask for a different treatment.
        Most of them cannot say no. They are going to take whatever
    they get and numb the pain, whether it is with that same
    prescription or something different.
        Chairman Miller. Did the doctors ever offer something
    alternative to prescriptions?
        Ms. Simcakoski. Absolutely not in my knowledge. They have
    never offered anything except substitution of medication.
        Chairman Miller. Candace, real quickly, because I only have
    just a few seconds left. But, if your family had not had to
    worry about being charged for going to a hospital other than
    Tomah, do you think you would have gone to another hospital or
    would you have gone to Tomah anyway?
        Ms. Delis. Absolutely. We live in Marshfield and we have
    the Marshfield Clinic there, and it is one of the better
    facilities in the State.
        Chairman Miller. Thank you.
        Chairman Johnson. Senator Baldwin.
        Senator Baldwin. Thank you.
        Heather, you and I have talked about the tragic loss that
    both you and your daughter Anaya must deal with because of
    Jason's death and you deal with that every day. But this
    treatment at the VA, started to effect your family a long time
    before Jason's death. And in your testimony you talk about the
    long-term impact of all the medications that Jason had
    prescribed to him. Can you talk to us about how Jason's
    personality and behavior changed from when you first met him
    and when he began the treatment at the Tomah VA.
        Ms. Simcakoski. Absolutely. When first met Jason, his
    personality was magnetic. I do not know a girl in the world
    that would not have wanted to date Jason. We went down that
    road in the beginning. I mean, Jason was driven, motivated.
    When I met Jason, I truly believed our future was going to be
    limitless. I believed we would have the American dream.
    Everything would be amazing and wonderful and perfect.
        And once he started receiving the treatment, the
    prescription pain medications, it slowly starting with him
    missing a day or two of work. Then he became irritable. It
    became to the point where he would not remember what he was
    saying, what he was promising. He started missing holiday
    events, special occasions because he could not get out of bed.
    He would--to the point where he would lay in bed sometimes for
    days, weeks at a time.
        He did not want to do that, but he, he could not. He could
    not get up. He could not do anything. And there were events for
    our daughter Anaya that he would miss. Very special events.
    There were times he found it hard to get of bed sometimes to do
    very basic tasks for her.
        He became somebody that, like, I did not even know. It was,
    like, Jason's body and face was there, but his personality
    changed so much, to a point where it created so much difficulty
    to where I would have to move out at times and move back in
    once medication would appear to make him normal, and then he
    would go back to the doctor. They would change his medication
    again. He would come back. It was constantly a roller coaster
    ride.
        We always had hoped that he would be the same, but it just
    never was. He would nod off, fall asleep. He would fall asleep
    driving. He would fall asleep eating.
        There were times he would get up in the middle of the
    night, turn on the oven and if I would not wake up, I would be
    afraid he was going to burn the house down. There was all kinds
    of erratic behavior. His appearance. Everything.
        The side effects were just jarring. And I cannot imagine a
    doctor sitting across from Jason, looking at him when he first
    came and got treatment on that first day to the end, would not
    see those side effects, because they were clear to everyone
    around, not even just me, friends, and people in the community
    noticed it as well.
        Senator Baldwin. Marv, you raised Jason from a young boy to
    a proud Marine, and can you also speak with us about the
    changes that you saw occurring with Jason after he first began
    receiving treatment at the Tomah VA?
        Mr. Simcakoski. Well, first of all, he went from about 180
    pounds to 250 before the day he died. He had lost all his self-
    esteem. He did not want to be seen in public anywhere. He did
    not want to go in any place to eat. He would go to a drive-up
    window, because he did not want to go inside anywhere.
        He worked with us in the family construction business. And,
    I mean, I would have to go check on him a lot of days because
    he would not come to work and I would have to get him out of
    bed and get him going and make sure he took his medication.
        And when he first got back from the Marine Corps he was an
    energetic, motivated person. I mean, he wanted to go far. He
    wanted to make our business boom, bigger. He had a lot of great
    ideas. He was really smart. and he had a real nice personality.
    I mean, he could think of anything. I should say, not think of
    anything. He could actually do anything he wanted. He was real
    talented, but he lost all that. He lost his drive for anything.
        And, like I said, his, his weight, I mean, he could not
    bend down good to tie his shoes or anything at the end. I had a
    hard time just getting him to function every day, but he was
    good for awhile. And, like I said, then all of a sudden with
    all these different medication changes, he just went downhill
    real fast.
        Senator Baldwin. Heather, I wanted to ask you about the
    statement you made in your testimony regarding missing police
    reports. Can you recall any instances where Jason reached out
    to the Tomah VA Police Department regarding other Tomah VA
    patients attempting to sell opioid prescription drugs like
    OxyContin?
        Ms. Simcakoski. Yes. I have text messages on one of Jason's
    old phones from 2013. He had gotten a different phone later on,
    but we still have that phone at my house. And when I go through
    it, there is several, I think there is over 160 text messages
    between the Tomah VA police chief and Jason where Jason did not
    want to be on drugs.
        He actually said the temptation of the veteran trying to
    sell him the drugs was enough to make him want to turn that
    veteran in, because he could not resist the temptation. So he,
    actually was working with them. He was willing to actually do a
    controlled buy or wear a wire, or anything he could to get this
    veteran off the streets, per se. And at the end of the day,
    nothing ever became of it. Jason sent screen shots of the
    veteran to the Tomah VA Police Department, screen shots of the
    veteran offering to sell them drugs and nothing ever became of
    it.
        Senator Baldwin. Page three of the----
        Chairman Johnson. Please stick to time limits here.
        Senator Baldwin. OK, we will follow up on the next round.
        Chairman Johnson. OK. Thanks.
        Mr. Walz, if you would also please also just reintroduce
    yourself. I am going to ask Congressman Abraham to do the same
    thing, actually.
        Mr. Walz. I am Tim Walz. I have served on the VA committee
    for the past four Congresses and I represent Minnesota's First
    Congressional District, which is the southern tier of
    Minnesota.
        Once again, thank you all for your testimony. And, Mr.
    Simcakoski, it was painful to hear you to speak, and I hope it
    was painful for everybody in this room to hear it. Because, if
    that is what it takes to shake us out of this, because I am
    going to tell you something here that is this is all senseless
    and avoidable, we are hearing this, but I am going to tell you
    something that is probably really going to make you angry.
        What you are telling, other people have been down this
    road, and folks have tried to implement that and that is what
    gets so frustrating.
        Heather, could I ask, why was Jason being prescribed this?
    What did they say was wrong with him? Why were they prescribing
    him these drugs?
        Ms. Simcakoski. His diagnosis would consistently change.
    One doctor would say one thing, another doctor would say
    another. It was consistently changing. One doctor would say he
    had one mental illness and the next doctor would say he does
    not have that. And they would say he had something different.
    It was always a changing story.
        Mr. Walz. And before he went in there, and as you noticed
    this, and I think most of us in this, there is a lot of folks
    sitting behind you and folks that understand this, that PTSD
    and other things were starting to get to him. Why did he go in
    the first time? What did he hope to get from it? I mean, what
    did he want them to fix, if you will?
        Ms. Simcakoski. His addiction to the pain medication.
        Mr. Walz. All right. And it is the pain medication. This is
    what I want to get back to again. And I want to read this for
    you, Marv. This is going to not make you happy.
        My colleague and I, Jim Ramsey, had introduced and
    subsequently passed through Congress in 2008, VA Pain Directive

    2009-053, calling for implementation of a system wide tiered
    pain management model that stepped up before we got to where
    you got. We went all the way through this and the Institute of
    Medicine, which is the gold standard for looking at this, this
    is what they said about the VA. They said the VA has done an
    excellent job in developing this comprehensive blueprint.
        Did any of you speak to a pain care management person?
        Mr. Simcakoski. Absolutely not.
        Mr. Walz. Do you know how many people do? Seven percent
    were on pain management?
        Mr. Simcakoski. I did not even know there was one.
        Mr. Walz. Yes. You did not know there was one.
        Mr. Simcakoski. No.
        Mr. Walz. And do you know what that person's job was
    supposed to be? To counsel you as the family and you with your
    right to sit there advocating for your son as an advocate to
    explain to the entire family and to the patient exactly what
    these things were.
        And what the Chairman was asking about is, were there other
    alternatives? Like chiropractic care? Because if you can
    relieve the pain--the issue here is to get rid of the pain.
        The issue is not--and be very clear. These drugs are
    powerful and important and helpful tools in the right dosages
    in the right situations. But the problem is, it is an easy way
    to get away from looking at the root cause of the problem, and
    you were never asked. You were never asked to get there.
        I am going to ask you, Dr. Johnson, was that available? The
    pain care management? Was that available at Tomah?
        Dr. Johnson. Absolutely not.
        Mr. Walz. So it was never implemented? Because here's what
    it says, unfortunate stepped-care model for the critical but
    unfulfilled component of their national pain strategy. So no
    one told you about it?
        Dr. Johnson. No.
        Mr. Walz. And, Mr. Honl, you are convinced, even if it was
    there, that these guys would have gone around it anyway.
        Mr. Honl. That is absolutely correct.
        Mr. Walz. Do you think, though, if it would have there been
    there, it would have been part of the culture, that everybody
    who came in, like Jason, and they had to go through this with
    their family and to get all this, because I think each of these
    people hit on something very important. This sense of trust. We
    expect them to do the right thing. And do not get me wrong. The
    vast majority of employees at the VA want to do that, but the
    fact of the matter is, I am not a pharmacologist and I do not
    know pharmacological interactions and everything else. That is
    somebody else's jobs. And their job is also why we put this in,
    to explain it to the most important person, that is the end
    user and the veteran. Nothing like that happened?
        Dr. Johnson. No.
        Mr. Walz. At your new facility, is it being done?
        Dr. Johnson. At our new facility, we do have a pain
    management, I guess, actual program, and we do offer
    alternatives, not just opioids. And we do try to get those
    patients under the 200 milligram morphine equivalent that they
    are on, but our interdisciplinary team offers chiropractic
    care, acupuncture. We have a physical therapist (PT) and
    occupational therapist (OT), psychologist. We have that whole
    team in place.
        Mr. Walz. Basically what the law asked to do?
        Dr. Johnson. Yes.
        Mr. Walz. They have that in Minneapolis, but they have one
    chiropractor for 10,000 people. And they offer a yoga class at
    2 p.m. on Wednesdays. Work that into your schedule.
        Dr. Johnson. Yes.
        Mr. Walz. My issue here is----
        [Applause.]
        The issue is changing the culture on this. I would ask you,
    in your professional opinion, before my time runs up, and maybe
    ask the Simcakoski's on this. We cannot guarantee that would
    have prevented this senseless loss, but do you think it might
    have done something?
        Dr. Johnson. I believe that the tragedies that happened to
    them were absolutely preventable.
        Mr. Simcakoski. I do not know. I guess it may have helped.
    It just all depends on what the doctors did after that point. I
    mean, if they were not willing to work with the pain management
    team, then I guess it would not help.
        Congressman Walz. Just as a side note. It expired on
    October 31, 2014, in the VA. We have not been able to
    reauthorize it.
        Dr. Johnson. Can I reiterate something here? Even if the
    doctors would not have agreed to work with the pain management
    team or done that, it is the pharmacist's job and their
    responsibility. The drug stops there. It comes out of their
    hands. They are the end gate. They should have stood up and
    said no. I would not have processed those medications that were
    prescribed to Jason. Obviously I did not dispense some that I
    did not feel were appropriate. Had somebody said no, even if
    the doctor decided whatever they want to do.
        Doctors are not God. They have a license. They need to
    stand up and say no. And everybody at that Tomah VA should be
    held accountable for that. Not only the people that knew, but
    every single pharmacist that has dispensed one of those
    medications.
        Those medications on the street, every single one came
    through the hands of those pharmacists. There needs to be
    accountability.
        Congressman Walz. Thank you. Thank you, Mr. Chairman.
        [Applause.]
        Chairman Johnson. Congressman Abraham, if you could
    introduce yourself real quick before you start questions?

                OPENING STATEMENT OF CONGRESSMAN ABRAHAM

        Mr. Abraham. I am Ralph Abraham from Louisiana. You can
    probably pick it up from the accent. I am a practicing
    physician also, so I want to first say thank you for your moral
    courage. I see many of our veterans out in the audience. And
    acts of courage that are unbounded, I know you have performed,
    but moral courage, you have time to think what could happen
    when you testify like this, so thank you so much for showing up
    and speaking up and being here.
        And, as a physician, you are right, Doctor, there still
    exists sometimes a God complex that we tend to endow, and shame
    on us for doing that, and kudos to you for saying no when you
    should have. If more of that would go on, then we would be more
    held accountable.
        Like Senator Baldwin said, there is a sacred trust. And
    what more sacred trust between a doctor and a patient? To me it
    is even more sacred than a marriage, because a patient will
    tell me things that they will not even tell their spouse. So we
    are entrusted with so much of that and when we reach that,
    then, again, what a tragedy for, for you guys, because you all
    have lived it and there are no words to describe that.
        My question to you, Dr. Johnson, and I think you mentioned
    in your opening statement, there were no routine urine drug
    screens, used to monitor drug use or abuse, is that correct
    statement?
        Dr. Johnson. That is correct. And we were actually advised
    against urine drug screen testing because, in the face of a
    negative drug screen, doctors were being coerced or forced into
    still prescribing the medication, and then we were told we
    would be held liable for those medications that were being
    dispensed when something unfortunate happened, which is the
    case.
        Mr. Abraham. Yes. How crazy is that? I mean, we know if it
    is not in the urine, it is not being used.
        Dr. Johnson. Correct.
        Mr. Abraham. It is being diverted somewhere. On the Opioid
    Safety Initiative, were any of the National Opioid Safety
    Initiatives that I am familiar with, were they implemented at
    the Tomah facility?
        Dr. Johnson. When I was there, no. A lot of those Opioid
    Safety Initiatives did not come out until 2013.
        Mr. Abraham. Right.
        Dr. Johnson. But even just one of the initiatives right now
    is to keep it under 200 milligram morphine equivalents per
    patient, which is still actually a fair amount of opioid.
        Mr. Abraham. That is a lot.
        Dr. Johnson. The unfortunate part with Dr. Houlihan, that I
    believe even with some of the other providers, was that they
    were unwilling to implement the standard of care or try to
    bring those patients down. He absolutely refused to change some
    of those prescriptions, which does not make sense to me.
        As, if you are going to give immediate release acting
    medication, why would you do that? Why would you not change him
    to something that could have been long acting that would have
    given better pain control or just try something different that
    would have given overall a better outcome for the patient. And
    that is why I think the motives of him need to be questioned,
    because it does not make any sense, as a clinician, why he, he
    prescribed the way he prescribed.
        Mr. Abraham. And I think, Heather, it was you that said, we
    cannot measure--once we put more than one drug in a person's
    system, much less 14 or 15, no, we do not really know the
    interactions. Everybody metabolizes drugs differently.
    Everybody handles drugs differently. And there is no way to
    know that.
        One thing the VA, as a system, Mr. Honl wants is continuity
    of care. That is what they tout is they want that veteran to
    come back over and over. But in Jason's case, especially, and a
    little bit in your case to, Ms. Delis, that when they saw the
    physical changes in Jason, the weight gain, the unability to
    perform work, the purpose of continuity of care is to--somebody
    say, hey, what is different here? And, unfortunately, and
    tragically, it did not work in this case, but that is the
    purpose.
        So, again, like you say, Mr. Honl, it goes back to the
    culture of the system. And, the panels, everybody up here, we
    have talked and we understand that it has to be changed and it
    has to be changed quickly. We are behind the curve by light
    years and we need to catch up, so, again, thanks for your
    testimony.
        I am most honored to be here.
        I yield back to the Chair.
        Chairman Johnson. Thank you, Congressman. Congressman Kind.

                 OPENING STATEMENT OF CONGRESSMAN KIND

        Mr. Kind. Thank you, Mr. Chairman.
        I am Congressman Ron Kind. I have the responsibility, the
    honor, really, of representing this district, as well as the
    Tomah VA Medical Center.
        And Chairman Miller, Chairman Johnson, thank you for
    agreeing to hold this field hearing. This is not easy. These
    stories are not easy to be told or to be heard. And hopefully
    by having it here in the Tomah community it made it a little
    bit easier for all of you to share that.
        I want to thank Senator Baldwin and my colleagues for
    joining us at this field hearing.
        And, I was born and raised on the belief that we owe our
    veterans a debt of gratitude, as well as the benefits that have
    been promised to them that can never fully be repaid, but we
    have to try. And we can study all the reports, and look at all
    data, and all the trend lines, look at all statistics that we
    want, but there is nothing more powerful to us policymakers
    than these personal stories and how difficult it is for you to
    share them with us.
        We share in your grief. We offer our condolences. But as I
    have had the chance to speak to all of you about what you have
    just gone through, I think there is an agreement at this
    witness table, and you have all done a great job testifying,
    that you want to do your best to help us ensure that no other
    veteran and no other family has to go through the type of pain
    and live through the type of tragedy that you just shared with
    us today. And that is the higher calling, I think, that we here
    as Members of Congress are responsible to ensure that our
    veterans are getting the care and the treatment that they
    earned and that they deserve. And I think that is our promise
    to you that we are going to not rest until we can achieve that
    goal.
        So thank you for testifying and for being here today.
        Dr. Johnson, let me ask you, because I have limited time. I
    do have a few questions for you. Are we getting better? Is the
    VA system getting better at recognizing protocols of care or
    best practices or best evidence of medicine when it comes to
    the proper pain treatment that our veterans need right now?
        Dr. Johnson. Overall I would like to say yes. After the
    2013 VHA Directive came into play limiting those morphine
    equivalents, that has become a big thing. The pendulum on pain
    management is swinging from constant opioid medications to
    finding alternatives for patients. We are trying to implement
    those cognitive behavioral therapy programs for several of
    those veterans.
        It is a slow change. And we have built a culture so far
    that we have been giving these patients this medication for so
    long, they are addicted--it is hard to bring those patients off
    of that medication. So it is going to take time for the whole
    entire culture and the facility VA wide to change, but I do
    believe, for the most part, and most of those VAs, this is
    occurring.
        Mr. Kind. But you feel more confident that there are
    complimentary forms of treatment, alternative forms of
    treatment, that can supplant the cocktail type of default
    button that seems to be pushed all too often with our veterans?
        Dr. Johnson. Yes. And I would actually like to note that
    the American Academy of Neurology actually just posted that
    article recently and said that there is no long-term evidence
    to support chronic opioids in back pain, fibromyalgia, or
    headache pain. That is probably three fourths of the patient
    population that I see.
        I am not doubting the patient's pain. What I am trying to
    say is that as the brain chemistry changes because of the drugs
    we are giving, we need to find ways to find other medications
    or other nonpharmacological ways to deal with that, because the
    brain can do that.
        Mr. Kind. Here's what I have been having problems with the
    knowledge. I do not have a medical degree. I did not go to med
    school or anything, but my suspicion is every individual's pain
    threshold is going to be different. Therefore it's going to
    require a more individualistic type of treatment regimen for
    that veteran. How good are we getting at being able to provide
    that individual recognition to the veterans?
        Dr. Johnson. I do think we are starting to get a little bit
    better. There are some sites that, would potentially even offer
    some genetic testing or those things to try to make sure that
    there are those who would absorb or break down the medication
    differently. Each patient's pain is definitely different. It's
    my job as the pharmacist on the team to make sure that we are
    prescribing the medications that are directly related or best
    to treat their pain. More often than not, it's not an opioid,
    unfortunately, for chronic pain patients. I mean, acute pain is
    a different situation, but I do believe that we are trying to
    individualize.
        I will be honest, what I see a lot in my pain management
    team right now, unfortunately, is trying to deal with the mess
    that we have made, and that we are dealing with a lot of
    addictions. We are not necessarily dealing with pain
    management.
        Mr. Kind. Mr. Honl, let me switch to you. And thank you for
    your courageous effort in all of this, with the pushback that
    you encounter now, even threatening letters for defamation that
    you have had to endure, but you talk about the problem of not
    having the entities investigate themselves, but clearly we
    cannot send every complaint at a VA Medical Center outside for
    independent investigation. Are there lines that we can draw
    here that can help us where that's needed in certain
    circumstances and what needs to be dealt with internally?
        Mr. Honl. Yes. I would just say, out of my experience,
    better staff work. I mean, if you are going to have a veteran
    staffer, they should probably be a veteran. They should
    probably be somebody, when they look at a report that they can
    identify that quickly.
        In this case, really, the bigger problem is with the OIG,
    because that's their job, right? I mean, they are the ones who
    field complaints, along with you guys. And in a perfect world
    it would be the OIG that would be trusted, so they would not
    have to go to you all.
        And so the problem is things just kind of snowball. You
    guys get hammered with more complaints, because nobody trusts
    the OIG, so you are overworked and you get these reports coming
    back and forth. I mean, balls are going to be dropped, right?
    It's just human nature.
        So, again, I bring it back to two things.
        No. 1, the big thing is accountability--whether it's the
    OIG or VA leadership. The VA is a big bureaucratic
    organization. And you have a lot of sacred cows and you have a
    lot of moving parts there. And when you have that type of a
    system, you have to have a system of accountability that's
    tightly controlled.
        Out of my experience, when I was in the Army and I had to
    rate non-commissioned officers (NCOs), there was the best NCO,
    there was the worst one. And that's how you rated them. There's
    a bottom one. There's a top one.
        When I was a sales manager in the corporate world, there
    was the best sales representative, the worst sales
    representative.
        You know what it is in the VA? It has not gotten much
    press. 470 senior executives in the VA. Nobody below the line.
    Nobody. I mean, that's something to me that just defies logic.
        And on top of that, they all get paid bonuses.
        So until, there's accountability, until there's a ranking
    structure where you can go, here's the people that are below
    the line. Here are the people that need work or they need to go
    somewhere else.
        The VA is hijacking itself and I do not think the proper
    response from the VA is to say, well, it's Federal workers.
    It's harder to get rid of somebody, blah-blah-blah. They are
    hijacking themselves. They cannot even rate who a poor
    performer is, so of course they are going to have a hard time
    getting rid of the poor performers, because they are all great.
        Mr. Kind. Again, I thank all of you for your testimony
    today. We appreciate it. Thank you.
        [Applause.]
        Chairman Johnson. Congressman Duffy.

                 OPENING STATEMENT OF CONGRESSMAN DUFFY

        Mr. Duffy. First I want to thank Chairman Miller and
    Chairman Johnson for holding this hearing in Tomah. So often
    these hearings take place in Washington D.C., but the impact
    that the Tomah VA has had on this community and on our
    community, I think it's important that this hearing be held
    here in Tomah. And I am grateful for both of you for agreeing
    to have it here where so many people can attend and be part of
    the process.
        I do see a lot of veterans here as well. I want to thank
    you all for your service and I know you are coming out not just
    to make sure we are holding the Tomah VA accountable, but you
    are here supporting your fellow families, who are very
    courageously telling their stories to this committee, and
    sometimes to the public for the first time, so thank you all
    for coming and participating.
        I do want to make one note. We are hearing some of the
    horrific stores of some of the bad actors in the Tomah VA. I
    know a lot of veterans who do get good care here in Tomah and
    we have a lot of people who care for our veterans here in Tomah
    and they work their heart out every day to make sure they offer
    good care. And we cannot forget about that either.
        But the stories that we have heard today are absolutely
    unacceptable. We should not have any of the stories of spouses,
    of daughters, of fathers of people who have passed away because
    of inadequate care.
        But I do want to make that one note that it's not all bad.
    And I think it's important to note that.
        This is, I will say, not the last step. This has to be our
    first step. I think our community, our delegation, the
    Veterans' Affairs Committee cannot let up. We cannot go home
    after today and say, this is the end. This is the first step in
    a long process to make sure we reform the VA so it works for
    our veterans, the men and women who have raised their hand to
    serve their country and are lucky enough to come home, to think
    that their lives would be risked in the healthcare system that
    was set up to benefit them, I mean, is absolutely unacceptable
    and untenable. And I think it's all of our jobs to make sure
    that this is the beginning of the end of poor care in the VA
    system.
        Candace, I want to be clear. When your, when your dad was
    showing the first signs of a stroke, from the first signs--I
    know there was--you could argue, well, he had some other issues
    medically that could have been misdiagnosed on the phone, but
    when you made it here to Tomah and he became limp on the one
    side, how long was it from that point until you actually left
    to go to La Crosse?
        Ms. Delis. There was an hour, about an hour in between the
    first stroke and the second stroke and then there was about 30
    to 40 minutes after the second stroke that we actually left to
    go to La Crosse, and then it was another over an hour to get to
    La Crosse.
        Mr. Duffy. So it's fair to say there was an hour and a half
    where he was showing the signs of having a stroke and care was
    not provided to him?
        Ms. Delis. That's correct.
        Mr. Duffy. He sat in the waiting room and then back in the
    emergency room?
        Ms. Delis. I would like to add that, in the waiting room,
    when he had the first stroke and he was slumped over, visibly
    slumped over in the wheelchair, my mom was screaming. The woman
    at the desk sat there and did nothing.
        Mr. Duffy. Did nothing?
        Ms. Delis. I got up. I ran to the desk. I said, you need to
    get a doctor. And then she finally got up, took her time, went
    down the hall.
        Mr. Duffy. Slow walk.
        Ms. Delis. And got someone. All the while we are trying to
    talk to my dad and get him to respond.
        Mr. Duffy. An hour and a half and then another hour to La
    Crosse?
        Ms. Delis. Yes.
        Mr. Duffy. Ms. Johnson, you had indicated there were--and
    we have not talked about this a lot. If you could try to answer
    this somewhat quickly. I have limited time. You said there were
    three people who really have not been talked about who died
    in--is it the parking lot here in the Tomah VA that are not
    part of the official reports, is that correct?
        Dr. Johnson. Yes. There were three unexpected or
    unexplained deaths in the parking lot that spanned a 4-month
    time frame. I believe it spanned over the 2008 and 2009 period,
    so it would have been the winter months. Those are actually
    documented, you can see, in the concerns of the President of
    the American Federation of Government Employees (AFGE) that she
    had submitted to the IG and Capitol Hill, I believe, in 2009.
        Mr. Duffy. Do you know what those deaths were attributed
    to?
        Dr. Johnson. No. At the time, I said this to VA
    Accountability Review Committee, that I was not there. I never
    saw the person in the parking lot. I am just saying that the
    Tomah VA is a small facility. I was told that they were Dr.
    Houlihan's patients. I do not know whatever happened to those
    patients. I do not know whether they were ever accounted for or
    whether there was an autopsy done.
        Mr. Duffy. Did you tell the IG about these deaths?
        Dr. Johnson. Yes.
        Mr. Duffy. And just quickly, did you see the cocktail of
    drugs that Jason took before he passed away?
        Dr. Johnson. On the MSNBC list, yes, I got to see it.
        Mr. Duffy. Was that a dangerous cocktail, in your opinion?
        Dr. Johnson. Absolutely. I would have never ever dispensed
    them. The diazepam alone was 60 milligrams. The maximum is 40.
    Plus he was on temazepam. That's two benzodiazepines. Plus
    Suboxone and tramadol. You would never do that. Never.
        Mr. Duffy. My time is about to end, but I have five
    daughters myself, Heather, and I cannot imagine your daughter
    at 12 years old not having a father to walk her down the aisle.
    I think that was the most touching point. Little girls should
    have a dad and little girls should have a dad walk their
    daughters down the aisle when they get married and I am sorry
    for your loss and I promise this panel will do everything we
    can to make sure that we remedy what has taken place here.
        Thank you for your testimony.
        Chairman Johnson. Congressman Pocan.

                 OPENING STATEMENT OF CONGRESSMAN POCAN

        Mr. Pocan. Thank you Mr. Chairman.
        My name is Mark Pocan. I represent south central Wisconsin,
    parts of six counties in the lower part of the State.
        First of all to the family members, I do not know if I have
    the words adequately enough to express the condolences. I just
    want you to know that what you are doing today and what you are
    continuing to do, to talk out will definitely leave a legacy
    for your family members, because it's so powerful. We will get
    something done. And it's because of your courage and your
    speaking out that that's going to happen.
        If I can just ask a quick question of Heather, it's all
    right.
        Your husband, was he receiving the opiates because of a
    physical injury while he was serving? I am not sure if I quite
    understood that.
        Ms. Simcakoski. No. Jason did not have any kind of chronic
    pain, so his receiving all of those medications was completely
    bizarre from day one.
        Mr. Pocan. Did you think he was receiving the opiates
    because of post-traumatic stress?
        Ms. Simcakoski. Yes. And other, maybe anxiety, things like
    that, but I am not a physician.
        Mr. Pocan. Sure.
        Ms. Simcakoski. But just applying common sense, when you
    are treating with an addict, even if there are other addictive
    medications that can be prescribed, even if they are not his
    pain killer of choice, there's popular street alternatives that
    were given to him that anybody with common sense would not give
    somebody with an addiction problem.
        Mr. Pocan. Sure.
        Ms. Simcakoski. Those medications for treatment.
        Mr. Pocan. Thank you. And then a couple questions for Dr.
    Johnson and Mr. Honl.
        So I cannot wait for the OIG and the VA, quite honestly, I
    have lots and lots of questions for them and, looking at that
    report, one of the problems that we have talked about is how do
    you get rid of the problem performers? But if you look at that
    report that we only got because a member of Congress had to
    make a formal request that they did not get otherwise, which I
    find outrageous, that if it had not been for that formal
    request we would not even have this to move forward, but the
    fact that--it's not just the employees that we need to get rid
    of, that, may have been around for a little while, but in both
    of your cases, you were around short enough that you had no
    protections. And I believe, if I remember right, Dr. Johnson,
    you were a couple weeks before your year was up where you might
    start getting those is when this happened to you. And, Mr.
    Honl, I think, same thing. Before you left you had a couple--
    within a week of you making an accusation, that's when you
    started getting the formal complaints.
        Can you both just, one, just say if that is correct? Two,
    what recommendations do you have for people like yourselves
    that are watching this and able to blow the whistle, but, if
    you do, you risk your jobs? What could be improved to make sure
    you are getting the protections?
        Mr. Honl. I have said this over and over. I think
    ultimately there are not any real whistleblower protections.
    Just by definition, when you blow the whistle, you are doing it
    on wrongdoing, and when there's wrongdoing, there's wrongdoers,
    and they are not going to like that you blow the whistle, so,
    real protections, yes. I mean, you mentioned a probationary
    period. I mean, that's been used here in this case. I was only
    there for 8 weeks, but, you are faced with what all
    whistleblowers are faced with. Do you hang in the system until
    the bitter end, until the OIG gives Dr. Houlihan, the
    investigation, and all of a sudden you do not have
    whistleblower protection and, I was a secretary, so maybe I did
    not cross all the t's or dot all the i's, and see you later,
    right, and have a termination on your record, or, do you do
    what I did and I resigned. I mean, I just got out of there.
        And initially I was going to be like any other person that
    had been run out of there. I just wanted to forget about it.
        Mr. Pocan. Sure.
        Mr. Honl. And, since I was public, then I just had
    everybody out of woodwork coming to me with stuff as serious as
    patient deaths. So, yes, I mean, I do not really have an answer
    for it, other than, yes, the system needs to be examined,
    because one thing that--I think that there's a misperception in
    the public about Federal employees. And that's that they cannot
    be fired. Let me say, definitively, that is not true. OK? The
    470 senior executives cannot be fired, because they are
    incompetent and do not know how to do proper ratings, but the
    people on the front lines like Dr. Johnson, on the front line,
    they get run out all the time. And a lot of the times it is in
    that probationary period, so.
        Mr. Pocan. If we could just give couple seconds to Dr.
    Johnson to respond. Thank you, Mr. Honl.
        Dr. Johnson. I was just going to say, I was taught, right
    is always right and wrong is never right, so, as a
    whistleblower, I guess no matter what kind of repercussions are
    going to happen, I was not going to be responsible for more
    deaths in the parking lot.
        That being said, I believe that any legislation that was
    trying to be enacted and to protect those whistleblowers, and I
    believe her name is Ms. Flanz, I think, or something I read in
    the article that she said that the current system is fine and
    it works just fine. It does not work just fine. We are both
    examples of that and it only protects the management. So if
    anything can come of that and that portion of it, I would
    really like there to be legislation that actually passes and
    goes through that holds those people accountable. Even at the
    current facility I am at now, I have experienced it over again,
    and nothing happens to those people. They are allowed to
    continue to do that because they are in a position of
    leadership.
        Mr. Pocan. Thank you.
        [Applause.]
        Chairman Johnson. I know I have lots of questions. I know
    my colleagues do too, but I want to be very respectful of
    everybody's time, so we always hold the record open for 15
    days. I would ask all the witnesses here to be willing to take
    questions from Members of this panel. It would be very helpful
    to us.
        I certainly want to thank you for your thoughtful
    testimony, your thoughtful answers to our questions, your
    courage to tell these stories.
        I think I speak for everybody on this panel. We are
    committed to doing everything we can to make sure these
    tragedies do not happen to others. And I just ask you to,
    please, continue to share your story. It's probably the best
    possible solution for the steps we can take to solve these
    problems.
        So, again, thank you very much and with that I will call
    the next panel.
        Thank you.
        We have seated another panel. Again, it is the tradition of
    this Committee to swear witnesses in. I guess we have two main
    witnesses and other people who may assist, so everybody who may
    testify or assist in testimony, please stand and raise your
    right hand.
        Do you swear that the testimony you are about to give
    before this Committee will be the truth, the whole truth, and
    nothing but the truth, so help you, God?
        Dr. Daigh. I do.
        Mr. Mallinger. I do.
        Ms. Clancy. I do.
        Ms. Oshinksi. I do.
        Mr. DeSanctis. I do.
        Chairman Johnson. Please be seated.
        Our first witness is Dr. John Daigh. He's Assistant
    Inspector General for the Healthcare Inspections of the
    Department of Veterans Affairs Office of the Inspector General.
        Dr. Daigh is assisted by Dr. Alan Mallinger, Senior
    Physician within the Office of Healthcare Inspections of the
    Department of Veterans Affairs Office of the Inspector General.
    Dr. Daigh.

     TESTIMONY OF JOHN D. DAIGH, JR., M.D.,\1\ ASSISTANT INSPECTOR
      GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF THE INSPECTOR
     GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY
     ALAN MALLINGER, M.D., SENIOR PHYSICIAN, OFFICE OF HEALTHCARE
                              INSPECTIONS

        Dr. Daigh. Good afternoon, Chairman Johnson, Chairman
    Miller and other Members of Congress.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Daigh appears in the Appendix on
    page 278.
    ---------------------------------------------------------------------------
        Thank you for the opportunity to appear before you today in
    Tomah to discuss quality of care issues at the Tomah VA.
        I am accompanied today by Dr. Mallinger. Dr. Mallinger has
    published over a hundred articles in peer review journals, held
    prestigious positions in psychiatry and pharmacology at several
    prominent medical schools and led research programs in
    psychiatry at the National Institutes of Health (NIH). He has
    worked in the office of Healthcare Inspections for the last 4
    years.
        Additionally he is currently on the Ethics Committee of the
    American College of Psychiatrists.
        In 2010, the VA and the Department of Defense (DOD)
    published the Clinical Practice Guideline: Management of Opioid
    Therapy For Chronic Pain. Our national review, VA Patterns of
    Dispensing Take-Home Opioids and Monitoring Patients on Opioid
    Therapy, which was requested by the Senate Veterans' Affairs
    Committee and published in May of 2014, includes the following
    statement: ``Opioids are powerful medications that can help
    manage pain when prescribed for the right condition and when
    used properly. However, if prescribed inappropriately or used
    improperly, they can cause serious harm, including overdose and
    death.''
        This national review, which mirrored the timeframe of our
    work in Tomah, demonstrates that in 2012, VA providers were in
    general noncompliance with this guideline. Whether it be in the
    use of urine drug screens and followup visits, where we found
    they had 37 percent compliance with the guideline, or whether
    it be in the practice of refilling prescriptions early, 23
    percent of the refills were filled early, the concomitant use
    of benzodiazepines and narcotic medications, which was used 92
    percent of the time in the chronic opioid population, or
    ensuring that veterans with substance use disorder and chronic
    pain receive concurrent treatment for their substance use
    disorder and random urinary drug screening, with which there
    was 10 percent compliance.
        The data in this report makes clear that VA as a system of
    care was managing this patient population very poorly.
        The report states, the concurrent use of benzodiazepines
    and opioids can be dangerous because opioids and
    benzodiazepines can depress the central nervous system and
    thereby affect cardiac rhythm, slow respiration, and even lead
    to death.
        The report also highlights the risk of liver toxicity as
    several combination medications include a narcotic and
    acetaminophen. And that a dose, among the chronic opioid user
    population, 45 percent of the veterans were prescribed at least
    one daily dose of four grams or more of acetaminophen, placing
    them at significant of risk for liver failure.
        Who are these patients?
        One in 16 served in Operation Enduring Freedom or Operation
    Iraqi Freedom; one in three was diagnosed with a mood disorder;
    one in five with PTSD; one in seven with substance abuse.
        My written statement reviews the timeline of events related
    to the Tomah administrative closure.
        In summary, it was alleged that narcotic medication was
    being used as the primary treatment for PTSD, that specific
    patients were receiving poor quality of medical care, and that
    numerous patients were dying of narcotic overdose, that Tomah
    providers were contemplating the amputation of a veteran's leg
    as treatment for his pain syndrome and that there was
    inappropriate interference with the administration of the
    Pharmacy Service by Tomah management.
        The administrative closure's first four pages deal with the
    steps OIG staff took to determine if these allegations had
    factual support. We reviewed numerous medical charts and peer
    reviews. We interviewed many current and former employees. We
    contacted the local Tomah police, the Milwaukee police, the
    DEA.
        We pulled the e-mail of 17 employees. The OIG Office of
    Investigations examined aspects of these allegations. We found
    that the allegations that led us to Tomah could not be
    substantiated.
        We did find examples of the failure to comply with DOD/VA
    Chronic Pain Guideline consistent with the national data
    discussed today.
        Given that the data we collected did not support the
    allegations that led us to Tomah, and knowing that our national
    report would highlight the many deficiencies in VA provider's
    compliance with these guidelines, I chose to administratively
    close this report.
        To ensure that the deficiencies we identified were
    corrected by VHA, Office of Healthcare Inspections staff met
    with the Director of Tomah, met with the VISN Director, and I
    was in frequent contact during this period of time with
    managers at Central Office, discussing the issues related to
    Tomah.
        Both the Director of the facility and the VISN Director
    were familiar with both the individuals and the issues that we
    brought forward to them at Tomah. These leaders discussed the
    changes that had been instituted and future planned actions to
    address the deficiencies we identified.
        The Office of Healthcare Inspections reviews aspects of
    hospital performance on a 3-year cycle and reports the results
    of each review in a Combined Assessment Review report. A review
    of medical center compliance with current VA stroke guidance is
    part of our current ongoing review.
        Upon the completion of data collection and analysis, a
    summary report with recommendations will be presented to the
    Undersecretary for Health and then published.
        I will be pleased to answer your questions.
        Chairman Johnson. Thank you, Dr. Daigh.
        Our next witness is Dr. Carolyn Clancy. She's the Interim
    Under Secretary For Health in the Department of Veterans
    Affairs. Dr. Clancy is assisted by Ms. Renee Oshinski, the
    Acting Network Director of Veterans Integrated Service Network
    12, and Mr. Mario DeSanctis, the Medical Director, Center
    Director of Tomah VA Medical Center. Dr. Clancy.

     TESTIMONY OF CAROLYN CLANCY, M.D.,\1\ INTERIM UNDER SECRETARY
    FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
    VETERANS AFFAIRS; ACCOMPANIED BY RENEE OSHINSKI, ACTING NETWORK
    DIRECTOR, VISN 12, VETERANS HEALTH ADMINISTRATION, AND MARIO V.
     DESANCTIS, FACHE, MEDICAL CENTER DIRECTOR, TOMAH VAMC MEDICAL
                                 CENTER

        Dr. Clancy. Good afternoon, Chairman Johnson, Chairman
    Miller, and Members of the Committees.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Clancy appears in the Appendix on
    page 286.
    ---------------------------------------------------------------------------
        Thank you for the opportunity to participate in this
    hearing and to discuss the quality of care at the Department of
    VA, Tomah Medical Center. To be efficient, I will not repeat
    your introductions of Senator Johnson of my colleagues.
        I want begin by expressing my profound sympathy to the
    families of the veterans we have lost here. The stories you
    have told today have been noted by others are profound and an
    invaluable gift to us about and we will use that to improve.
    And it's an invaluable gift to current and future veterans, so
    both those who are served by this facility and across our
    system and, I have a personal stake in this. My brother, my
    husband's brother has devoted his career to military service
    and is now served by VA and I am sure that's true for all of us
    in the room. If it's not us personally, we have family members.
        So our commitment to you is that we will use this
    information to improve, now and in the future.
        In addition, I also want to thank the whistleblowers who
    stepped forward. We heard their courage. It's at some personal
    risk. We heard that earlier. They refused to be silent when
    they observed problems.
        Secretary McDonald, Deputy Secretary Sloan Gibson, and I
    have met with whistleblowers and have consistently emphasized
    that retaliation will not be tolerated.
        Last I want to express our appreciation to multiple members
    of the Wisconsin congressional delegation for their input and
    inquiries.
        VA is committed to providing timely, high quality care. We
    can and have to do better. We have significant challenges to
    overcome here in Tomah and we own them.
        Unfortunately, unsafe practices in pain management and
    psychiatric care and reports of fear and intimidation have cast
    a dim light on care provided at this facility. And the bottom
    line is that there have been a number of failures. Failures to
    veterans, and, frankly, failures to the frontline staff at
    Tomah who work very hard every day. I want to assure you that
    as investigations are concluded, we will act quickly,
    decisively, and productively, with veteran outcomes in the
    forefront of all of our decisions.
        I also want to assure you that we are not waiting for the
    completion of all investigations to make required improvements
    here and across the system right now. We are also supporting
    research, as I speak, to evaluate alternatives to opioids in
    the management of chronic pain. That's nonnarcotic medications,
    acupuncture, biofeedback, other kinds of treatments, and,
    frankly, we are optimistic that this work will also help all
    Americans suffering with chronic pain.
        We are working internally to address these issues, and, as
    you know, are receiving assistance from outside of Tomah. VA
    Central Office sent in its clinical team review and that
    preliminary findings were released. That initial review
    identified gaps in care and failures to adhere to recommended
    practices, and we acted by disseminating a tool system wide
    that makes it far easier for clinicians to do well by veterans
    and to identify veterans who may be seeking narcotics from
    other facilities within the system.
        The OIG, the Joint Commission, and the Drug Enforcement
    Agency have reviewed the Tomah facility and Wisconsin's
    Department of Safety and Professional Services are also
    investigating, and we welcome that.
        We realize that we need to regain trust. It will take
    transparency as well as candid, honest, clear, consistent
    communications across the organization.
        First is the veterans' trust. And the only way to regain
    that is to put the veterans first in every decision. The
    individual veteran's outcomes from their perspective is our
    true north.
        We also need to regain the public's trust, as well as the
    trust and confidence of veterans' representatives, both in
    Congress as well as Veterans Service Organizations and other
    entities.
        That will take time. And, frankly, it will take
    demonstration of results.
        Last, central to any success is to regain the trust of the
    Tomah frontline employees and staff, the vast majority of whom
    are doing their best to serve their veteran patients every day.
        During my visit to the Tomah facility 2 months ago, I met
    with many dedicated staff members who are bearing the brunt of
    these issues. I heard directly from employees here about their
    concerns and fears. And while investigations continue, it's
    imperative that we also focus on care provided to veterans we
    have the privilege of serving here at Tomah.
        And, those employees have a lot to be proud of. In
    benchmarking with the private sector, the Tomah facility
    actually does very well in a number of areas.
        So, in conclusion, you can expect that the Secretary,
    Deputy Secretary, and I will always put veteran outcomes first.
    And we will act swiftly. And when we have actionable
    information, we will act on it promptly.
        These investigations are an opportunity to get to the
    bottom of any issues so that moving forward we can make sure
    that these preventable deaths are not repeated here or
    elsewhere.
        But, mostly importantly, the reason I can be optimistic, is
    that the devotion, resilience and passion of the frontline
    staff here at this facility will help us overcome these
    challenges.
        Thank you and I look forward to your questions.
        Chairman Johnson. Thank you, Dr. Clancy.
        Let me start with the last point being about regaining
    trust of the employees and also the point you made that we
    really need greater transparency and accountability. In terms
    of
    retaliation--first of all, how long have been at the VA?
        Dr. Clancy. A year and a half.
        Chairman Johnson. A year and a half. What did you do prior
    to that?
        Dr. Clancy. I worked at the Department of Health and Human
    Service (HHS). I directed a research agency that focused on
    safety and quality of care.
        Chairman Johnson. I will say in our communication and work
    with you, I have been very pleased with your cooperation, so I
    truly appreciate that.
        Dr. Clancy. Thank you.
        Chairman Johnson. In your year and a half in your position,
    how widespread do you find this type of retaliation that you
    are witnessing and hearing about here in Tomah?
        Throughout the VA? Is this really a very unusual situation
    or do you think that type of retaliatory behavior against other
    whistleblowers, because it sounds like it might be more
    widespread?
        Dr. Clancy. I do not think that we have celebrated negative
    feedback, uncomfortable feedback as a gift that it is.
        It is a gift. If someone tells us very specifically,
    whether that's an employee, a patient, a family member, you
    could have done better or my family member would have done
    better if you had done this, that's the only way we get better.
    And I do not think that we have celebrated that enough.
        Some of our facilities do. Some actually have awards for
    employees that identify near miss mistakes and so forth, but we
    are not good enough about that.
        Chairman Johnson. Are you, actively working on cases
    similar to this in terms of the severity of retaliation that's
    being reported.
        Dr. Clancy. Yes, we are.
        Chairman Johnson. How many?
        Dozens? A couple?
        Dr. Clancy. I do not know the numbers. More than a couple,
    for sure. And I am not sure that we have identified all of the
    cases that need to be investigated. I am sure, as a result of
    this, having spoken with Dr. Johnson earlier today, that we
    will identify more that we did not know about, so I want to be
    very cautious in terms of using numbers.
        I think you know that the Secretary instituted a single new
    team, the Office of Accountability and Review, specifically
    focused on investigating retaliation by senior leaders to
    employees.
        Chairman Johnson. I appreciate that's. It's a very positive
    development here and we truly appreciate that.
        Dr. Daigh was in charge, I think, of the report that was
    signed on March 12, 2014. The final report says, signed by Dr.
    Daigh, that I concur with the recommendation for administrative
    closure of this inspection. Was that closure, administrative
    closure, was that recommended by somebody? Was it a panel? I
    mean, how exactly did that work? Or did you decide that on your
    own?
        Dr. Daigh. My office routinely has a number of hot lines
    that we review. And if at the end of that hotline review we
    determine that the allegations are essentially not
    substantiated, then we may make the decision not to publish.
        Chairman Johnson. So that's basically a team decision then?
    So you are concurring with the team of inspectors on doing the
    administrative closure?
        Dr. Daigh. Yes.
        Chairman Johnson. OK. So, again, you base the
    recommendation on a team within the Inspector General's office?
        Dr. Daigh. So the folks that work with me, we sat down and
    decided that was the right answer.
        Chairman Johnson. I want to ask some standard for
    substantiation of some of these charges. I am going to read
    from your report. ``While we did not substantiate the
    allegation of abuse of authority, intimidation, retaliation
    when staff questioned controlled substance prescription
    practices''--OK, so you did substantiate that--``we did find
    that these are widely held beliefs and concerns among most
    pharmacy staff and among some other staff.''
        What does it take to substantiate claims of retaliation and
    intimidation? What would be the standard for substantiation, if
    that's not it? If everybody in the pharmacy is basically saying
    there's retaliation and there's a climate of fear?
        Dr. Daigh. So what we were looking for was clear evidence
    of somebody threatening a person or somebody saying in an e-
    mail or somebody making the statement, if you do not do this,
    then I will do that, so we were looking at evidence beyond a
    story. Something we could use to support the story.
        Chairman Johnson. When you were before the Senate Veterans'
    Affairs Committee on Thursday, I asked you, when did you first
    find out about problems in Tomah. And you stated about 2011,
    although some of those anonymous letters that were brought to
    the fore, did you go back in time? I do not know if you were
    here when I was going through the timeline of when Dr. Houlihan
    has hired, how we have people, employees of the facility
    documented they were, back then, in 2009, already referring to
    him as the Candy Man? And this is Candy Land? And that they
    were already concerned about large quantities of painkillers
    being prescribed? I mean, were you aware of that? Was that part
    of your inspection?
        Dr. Daigh. So the short answer is no. I did not look prior
    to 2011. We got an allegation in 2011 that indicated along the
    same lines that we eventually turned into an administrative
    closure, but that review, I sent it to the VISN Director and
    said, these are serious allegations. Please look at these.
        We get in the order of 40,000 complaints a year to the IG.
    My office gets in the order of magnitude 2,400 hotline
    complaints regarding quality of healthcare. So we have to have
    a way to address those complaints. So we have a group of us and
    we sit down.
        And 10 years ago we had three to five complaints a week.
    Now we get more than 10 a working day.
        I have a capacity to produce 50, 60 reports a year. So we,
    if we think the complaint is one we can take or should take, we
    do that. If we think it's serious, we send it to a level of
    leadership above the level of the complaint and ask them to
    respond back to us. We then read those responses back, and if
    they seem reasonable, then we end up closing that case.
        Chairman Johnson. Thank you.
        Dr. Daigh. This is a similar process.
        Chairman Johnson. By the way, that's a very helpful and
    interesting metric you just measured there or that you just
    mentioned. The number of complaints per day and the fact that
    is has risen dramatically, I guess that tells us something that
    Dr. Clancy has got a real challenge on her hands. Chairman
    Miller.
        Chairman Miller. Dr. Daigh, in your written testimony you
    state that given the totality of the facts at the time, the
    administrative closure was appropriate. So given the totality
    of the facts that are known today, would you make the same
    decision?
        Dr. Daigh. I think the issue is whether or not my
    discussions with VA leadership would have resulted in change.
    And I think, looking back, those discussions with leadership at
    all levels, Facility Director, VISN Director, VA Central
    Office, did not result in change. Change obviously needed to
    occur.
        So if I were able to understand that change would not have
    occurred, I would have made a different decision. At that time
    I had faith that, that they would make the change.
        Chairman Miller. How has the experience changed the way the
    IG is going to handle similar investigations moving forward?
        Dr. Daigh. I think that certainly I have decided, and Mr.
    Griffin has decided that we will not administratively close
    hotline complaints. Further, they will all be published to the
    web.
        I think the broader issue of the volume of work is an issue
    that we need to discuss with the committees in terms of how we
    communicate the issues that are in front of us, the locations
    of those issues, so that you understand what we are doing and
    similarly the VA understands what the issues are.
        Chairman Miller. I was troubled by Mr. Honl's allegations
    that an official from the Medical Center instructed him to not
    give files to anyone, especially the OIG. Were you aware of an
    effort by the leadership at Tomah to keep information from your
    investigators?
        Dr. Daigh. No.
        Chairman Miller. So how can you be sure that during your
    initial investigation your investigators had access to all of
    the information that was needed to conduct a thorough
    investigation?
        Dr. Daigh. When complaints are anonymous we sometimes have
    a hard time figuring out exactly who the complaint pertains to,
    so what we often have to do then is take a look at patients,
    for example, those who are in a group of patients receiving
    high doses of narcotic or a panel of patients that were under a
    certain set of circumstances that are described and we have to
    go through and check a sample of those patients. So we relied
    on reading e-mails that they did not have the ability to
    withhold from us. We relied on sampling charts that they did
    not have the ability to control. So I think we did everything
    we could to try to get the right answer and the right data.
        Chairman Miller. Dr. Clancy, we heard about the gentleman
    who had the stroke, that clot busting drugs were not
    administered because they could not get a CT scan. I mean, is
    that typical protocol that you do not administer that prior to
    them going through a scan?
        Dr. Clancy. Yes. The reason for that is that there is
    essentially two ways you can have a stroke. One is a clot, in
    which case the clot buster would be a really good idea. And the
    other is that you are actually having a hemorrhage, in which
    case that would be the end. So you actually need to know from a
    CT scan what's happening.
        The CT scan was down at Tomah that day for preventive
    maintenance, and it's my understanding that the patient should
    have been sent to Tomah Memorial.
        Chairman Miller. And why was the patient not sent to Tomah
    Memorial?
        Dr. Clancy. I do not know, and we need to find that out.
        Chairman Miller. And what are you doing to find that out?
        Dr. Clancy. I know that there is an IG investigation
    ongoing now and I am also trying to work across the system to
    figure out--we have the bottom line is it's hard to get clot-
    busting treatment in Tomah, Wisconsin, regardless of where you
    get care. If we had gotten the CT scan, we could have gotten
    that, but we have the capacity to actually make this available
    virtually across our system and that we can make happen.
        Chairman Miller. Is it they cannot get the clot-busting
    treatment at the VA in Tomah, or they cannot get it in Tomah?
        Dr. Clancy. It's my understanding that there is not a
    stroke team at the local community hospital. I have not
    verified that, but that's what I have been told.
        Chairman Miller. What is the normal maximum--normal. What
    is the maximum dosage of opioids for pain that is effective for
    chronic pain? I had a doctor tell me that there is a level at
    which more does nothing to help stop the pain?
        Dr. Clancy. I would actually need to consult Dr. Johnson
    here for a more technically correct answer. I know that right
    now we are working to keep it below the 200 morphine
    equivalence dose per day.
        Chairman Miller. And what I understand, that is if it is
    being used for mental health purposes?
        Dr. Clancy. No, that is not used to treat mental health
    disorders. That is used to treat pain.
        Chairman Miller. OK, well I----
        Dr. Clancy. And it gets confusing, because many of our
    veterans have both chronic pain for a variety of reasons, as
    well as other mental health disorders, but morphine is not
    being used to treat mental health problems.
        Chairman Miller. But that is what Jason was being treated
    for. He had no chronic pain.
        Dr. Clancy. Well, what I heard his wife and dad say, and I
    have not looked at his records, although I know there has been
    a thorough investigation, was that the diagnosis kept changing.
        In general, narcotics are not used to treat mental health
    disorders.
        Chairman Miller. I believe, and I will go back and check
    the record, but I believe she said he did not have chronic pain
    issues.
        And, and my question is, I was told that basically anything
    above 50 milligrams, there is a question as to whether or not
    it is effective. And my question is, if you are using it for
    psychotic purposes, for some type of mental health, you are
    talking about 200 milligrams, so you are giving somebody
    something that is highly addictive.
        Dr. Clancy. Well, I think Dr. Johnson said it well when she
    said that in some ways we are actually treating the problem
    that has been created by overuse of these medications, so we
    have people whose tolerance levels are very high and we need
    to----
        Chairman Miller. Well, how about we do not take Dr.
    Johnson, because she is not on the panel.
        Dr. Clancy. Yes.
        Chairman Miller. How about Dr. Clancy?
        Dr. Clancy. Sure.
        Chairman Miller. On the record.
        Dr. Clancy. Yes.
        Chairman Miller. And talk about it.
        Dr. Clancy. I was just being respectful of another
    discipline. Forgive me.
        So I do not know the specific number at which you can say,
    beyond that, it does not work. I know that many of our veterans
    are on doses that are too high. I am pleased to say they are
    coming down, but they need to come down faster. And, very
    importantly, what I am almost more worried about is the fact
    that they are on narcotics in combination with other
    medications, like Valium, the benzodiazepine group, which can
    put them at very high risk of adverse effects.
        Chairman Miller. And real quick. We heard today where
    people have lost sons.
        Dr. Clancy. Yes.
        Chairman Miller. They have lost husbands. They have lost
    fathers. We even heard a lady say she's lost her country. She
    is ashamed of her country because they have let her down. I
    hope that sinks in at the VA.
        Dr. Clancy. It certainly sunk in for me and I will make
    sure that we honor their experience by committing to do a lot
    better.
        Chairman Johnson. Thank you, Mr. Chairman. That point that
    was well worth the few extra seconds.
        Chairman Miller. Thank you.
        Chairman Johnson. Senator Baldwin.
        Senator Baldwin. Thank you.
        I wanted to start--I meant to do this at the end of the
    last panel, but to offer to both committees, testimony that was
    prepared by Lin Ellinghuysen, the President of the American
    Federation of Government Employees\1\ here, and also Jason's
    mom, Linda Simcakoski, prepared written testimony\2\ for our
    committee.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Lin Ellinghuysen appears in the
    Appendix on page 295.
        \2\ The prepared statement of Linda Simcakoski appears in the
    Appendix on page 307.
    ---------------------------------------------------------------------------
        Chairman Johnson. Without objection, so ordered.
        Senator Baldwin. So the VA's current investigation into the
    Tomah VA began this January, and it is looking at a number of
    issues--prescribing, retaliatory environment, the deaths
    associated with the Facility.
        A recent media report revealed that employees at the Tomah
    VA had called local law enforcement more than 2,000 times
    seeking help with cases of battery, burglary, an attempted
    kidnapping, and 24 unexpected deaths. And you heard that in the
    testimony also in the first panel.
        Dr. Johnson stated that there were three unexplained deaths
    in the Tomah parking lot and that all three were patients of
    Dr. Houlihan's.
        So, prior to the current investigation, did the VA ever
    investigate these allegations, including reports of 24
    unexpected deaths and the deaths that Dr. Noelle Johnson says
    took place in the Tomah VA parking lot?
        Dr. Clancy. I am going to ask Ms. Oshinski if she has more
    information on that.
        Ms. Oshinski. I believe there have been a variety of
    investigations over the years, although, Senator Baldwin, I
    would have to say they were probably case specific. I would
    also say that I was stunned by the numbers and was not aware
    that there had been as many as you had mentioned.
        Senator Baldwin. Well, I ask that you include all of those
    in your investigation moving forward.
        Accountability is an essential piece of the VA's
    investigation into Tomah. This investigation will rightfully be
    judged in part by whether those who are found responsible for
    wrongdoing are held accountable. The veterans who have lost
    their lives and their families deserve no less.
        And so far, Dr. Clancy, your review has resulted in some
    remedial administrative action against responsible VA
    employees, including Dr. Houlihan, but let me be clear. It is
    my expectation that these are merely first steps. And so I
    would ask you to please provide the committees with an update
    on all administrative actions taken to date and can we expect
    additional discipline and when?
        Dr. Clancy. I do not want to prejudge the process, so I
    want to be very careful about what I am going to say. What I
    released before was the first phase of a clinical review. The
    administrative reviews, which is looking specifically at
    retaliation is ongoing.
        There is also a second phase of the clinical review, and I
    think that there will be additional actions, but that's all I
    am going to say about it right in this moment.
        But I commit to you and other committee members and members
    here that we will let you know about that promptly when that
    takes place. We are not intending to make this many months or
    even many weeks. But we want to make sure that the entire
    process is fair and rigorous and will withstand appeal.
        Senator Baldwin. My office, and it sounds like other
    members of this panel, recently learned that Dr. Houlihan was
    the subject of a wrongful death claim resulting from the tragic
    death of Kraig Ferrington, a U.S. Army veteran, back in
    November 2007. And most disturbingly, the claim reports that
    the veteran who is under Dr. Houlihan's care died from drug
    toxicity. This is the same cause of death of Jason Simcakoski.
        In other words, more than 7 years ago Dr. Houlihan and his
    inappropriate treatment practices were implicated in the death
    of a Wisconsin veteran, and last August Jason passed away from
    the same cause. How did the VA investigate this death and Dr.
    Houlihan's treatment at the time or since? And I am referring
    to Kraig Ferrington.
        Dr. Clancy. Hold on.
        Ms. Oshinski. Yes.
        Dr. Clancy. At that time there was a malpractice claim made
    against the VA, and it was initially denied. And then appealed
    and a settlement was made. When that happens, all practitioners
    involved in the care of that veteran are reviewed by a
    centralized office of medical and legal affairs to determine
    whether they have met the standard of care.
        And, as it happens, about 40 percent of the time the
    practitioners are deemed not to have met the standard of care.
    In this case, Dr. Houlihan and a physician's assistant were
    both considered to have not met the standard of care. And at
    that point, the next step is to report the two to the National
    Practitioners Data Bank.
        Dr. Houlihan appealed that decision and it was upheld. So
    he was not reported. So there was an investigation. I know that
    some of you have actually had the opportunity to review the
    specific details on camera. That is what I know right now.
        Chairman Johnson. Congressman Walz.
        Mr. Walz. Thank you, Chairman and thank you all for being
    here and your service to our veterans. Certainly no one
    questions our commitment to our veterans.
        And, Dr. Daigh, you and I go back quite a ways too and you
    know that my issues with your staffing issue goes back to 2007.
    The need to have an impartial, fair, and accurate IG is
    absolutely imperative to the system. So I understand that. And
    I also understand you have to triage cases, but I am grateful
    for the change of policy on the administrative closures, just
    to let us know. It's another eye. And, again, it has been said
    by the Senator, having the press, they are another eye. They
    are partners in this. And I know you view it that way.
        Dr. Clancy, also I thank you for your service. And you have
    heard me say very often, I am the VA's staunchest supporter and
    harshest critic when they need to be.
        Just a couple things for me. Do you need us to reauthorize
    the Pain Management Directive? The one I was speaking of--
    2009-053, that expired in October, or can you do that?
        Dr. Clancy. We can do that and we are also working with new
    directors from the DEA in terms of how often prescriptions can
    be written and, how long they can be written for, and using
    that to tighten up even further our diversion policies and the
    ability to take back drugs that people are not using, because
    that is an important source for the community. I do not think
    that we need legislation, but I certainly would welcome your
    demanding regular reports, because I will be.
        Mr. Walz. Is the step care model, has it been implemented?
        Dr. Clancy. It has been implemented, but probably not as
    consistently as it could have been. I have just mandated last
    week that across the system we implement a system called
    Academic Detailing, which actually works with each frontline
    clinician and their specific panel of patients to help them
    customize care and solve problems.
        As I think you have heard from Jason Simcakoski's family, a
    lot of times veterans do not necessarily want to go down this
    road, and may even get angry, so it takes some skill to help
    them get to a better place. And we have people who are quite
    skilled at teaching people how to do that. We need to make sure
    that happens everywhere.
        Mr. Walz. I think that is an important point you bring up,
    and it is certainly in the private sector also. There is about
    25 percent of Americans going through this. And the Opioid
    Safety Initiative (OSI) that is being implemented, and this is
    very controversy, pain contracts.
        And I think members up here will tell you this. We receive
    a large number of calls to our office of veterans who were
    pulled away from these and either for pain management or for
    the pain of addiction withdrawal that comes afterwards----
        Dr. Clancy. Yes.
        Mr. Walz. Is equally dangerous. And so, to get this right,
    this is a national dialogue and things that have to be put into
    place. The question I would ask is, how are you handling the
    folks who are initiating this?
        And I ask you this because many of my veterans, because
    your pilot program is in Minneapolis on the OSI, and I am
    getting those calls from veterans. How are you handling the
    soft landing for these folks that are coming down from the
    addictions?
        Dr. Clancy. Well, first of all, we actually actively
    discourage, it is inappropriate for people to simply say to a
    veteran you are done, if they have been taking these
    medications for awhile. That would be instant withdrawal for
    some. The one thing that we are checking on and using our new
    tool as a way to do this is to make sure that people are not
    making the reports look better by actually forcing new patients
    to make that very hard landing. But it is a tough journey.
        Now, on the other side of it, there are people who could
    not be more appreciative that they do not need these drugs any
    more, and so forth. And I think that we need to give a louder
    voice to them, but I try to watch both sides of that.
        Mr. Walz. I look forward this. I think you bring up a good
    point. It is the outcomes that we care about. I am very
    interested in working with you on maybe some reportings that
    come out of this, because from us to micromanage, and I think
    you saw what happened is, is that we got together. We passed a
    pretty good bill working with folks, but if it does not have
    the outcome--if I have a father here, it did not work. And so I
    have to figure out how it works.
        I am also going to say, in preparation for this hearing, I
    went to, like, the wholesalers, McKesson, and some of those,
    and worked through them on how this those whole thing works in
    the private sector, how the wholesalers get it to the
    pharmacies, how they retail it out and the State prescription
    drug monitoring system. If I get a prescription written here
    and I get it filled, what happens when I drive back to Mankato?
    Can I fill it again or will that red-hot when I try and do it?
        Dr. Clancy. We are working with the State prescription drug
    monitoring programs in 20 of the 49 States that have them. And
    we will be getting to the 50th. We had an internal issue about
    differences of opinion about whether it meant, whether we could
    share the information in a way that did not violate our
    security policies. We are working through that right now.
        Mr. Walz. Good. And that is the one I wanted to work with
    you on. I think this just makes good sense. It is the right way
    to do it. It is an extra check and it makes sure that these
    families said that we are not filling multiple prescriptions
    and they end up on the street.
        And, Dr. Clancy, you and I have always had a very candid
    and good working relationship. This is just for me, a
    suggestion on this and I am thinking of this as a father.
    Review Jason's file. Just let his dad know you looked at it. I
    do not speak for him, but I would want to know as a father.
        I yield back.
        Dr. Clancy. Thank you.
        Chairman Johnson. Congressman Abraham.
        Mr. Abraham. Yes. I went to the Tomah facility this morning
    and did a tour, and you are right, Dr. Clancy. Everybody, or,
    most everybody that I came in contact with was motivated,
    generally seemed to care, but we certainly have a problem
    embedded within not only Tomah, but the VA system. And my
    question to you, in the VA system in toto, is there a protocol
    or a requirement for urine drug testing, prescription
    monitoring, training, having the patient come back every month
    to receive a narcotics prescription? Is there anything like
    that out there?
        Dr. Clancy. There is a guideline that we jointly developed
    at the department.
        Mr. Abraham. It's not required?
        Dr. Clancy. Well.
        Mr. Abraham. I am saying----
        Dr. Clancy. I am just struggling with the word.
        Mr. Abraham. As a physician, if I know that my
    prescriptions, narcotic prescription that I am writing will be
    monitored, if I know that I am required to get a UDS on that
    patient, if I know that that patient is supposed to see me
    every 30 days in order to get 60 or 90 narcos, then I need to
    check those boxes, and that's my question.
        In the VA system, is there a required protocol in place for
    those physicians?
        Dr. Clancy. We have a required protocol in place. We also
    recognize that an unexpected result on a urine drug screen can
    mean a couple of things. It could mean our worst fear, that
    they are not taking the medications and selling them on the
    street. It could mean that they are only taking them
    intermittently.
        So the first step is to actually have a conversation with
    that veteran and then up the frequency of those drugs.
        Mr. Abraham. Exactly, and you and I can get into the we
    as----
        Dr. Clancy. Yes.
        Mr. Abraham. As to what one UDS over another one means,
    but, overall, I think it's a good monitoring system----
        Dr. Clancy. Yes.
        Mr. Abraham. For narcotic abuse or use or diversion. So I
    guess the answer is right now there is not a required protocol
    out there, is that a fair statement?
        Dr. Clancy. There is a clearly specified protocol. I think
    it is fair to say it has been encouraged. It is now being
    mandated.
        Mr. Abraham. Thank you very much.
        Dr. Daigh on your report, you gave some objective data.
    Thirty-seven percent of the physicians did not adhere to the
    guidelines. Twenty-three percent got early refills.
        If objective data is not being used in your determination
    that some of these claims are unsubstantiated, what did you use
    to have a conclusion on your report? I mean, I am looking at
    objective data here that is pretty damaging.
        Dr. Daigh. That's correct. So what I am saying is that the
    people, the providers at Tomah were no better than the general
    population in terms of following the guidelines. They did not
    follow the guidelines. That was the point we made to the
    Director and the VISN Director in our report.
        The specific allegations that led us to Tomah, we could not
    support. I realize there may appear to be a distinction or a
    contradiction there, but we were forced to write allegations
    fairly narrowly, so that we can actually try to understand what
    is going on. And so we did not find, for example, that they
    were trying to cutoff a gentleman's leg because he had a pain
    syndrome.
        And when you get to some of these allegations that are
    made, for example, the allegation that a certain provider
    threatened that there will be retaliation if a drug sale was
    not stopped or there was not some action taken to break up a
    drug sale, when we actually get right down and we push it, we
    find someone who previously would say that they supported that
    allegation, we find that they melt away and they would not
    provide that allegation. So I pushed very hard to get facts to
    support the allegations that I listed in my oral statement, and
    I just could not get what I needed.
        Mr. Abraham. Dr. Mallinger, you and Dr. Johnson are the
    experts, certainly, in this field in this room. Do you, having
    written many articles and studied this,
        I am sure, most of your life, do you have a recommended
    protocol for opioid or benzodiazepine use for chronic pain?
        Dr. Mallinger. Well, again, I am a psychiatrist and I would
    not portray myself as an expert on the use of opioids for pain
    management, but as a physician I certainly have some training
    along those lines.
        Psychiatrists who are treating pain in their patients,
    along with psychiatric disorders, have a pretty difficult job.
    And the truth is that every patient is a little bit different.
    And it becomes very difficult to write any sort of universal
    guidelines.
        I think the question was asked before, is there a maximum
    effective dose for opioids?
        The truth is that as people use opioids over a period of
    time, I am sure you are aware of this, they develop a pattern
    of tolerance and the drugs become less effective. And in order
    to get the drug to work, physicians find themselves increasing
    the dose. And that may work for awhile. It may also be lead to
    what we call hyperesthesia, where they can actually make the
    pain worse or produce other kinds of pain, so it need to be
    worked out on the level of the individual patient.
        Pain can be an exacerbating factor for psychiatric illness.
    Someone who has bipolar disorder, for example, if you introduce
    enough pain into the equation, it may trigger mood episodes. It
    is very hard to come up with a universal recommendation is what
    I am saying.
        Mr. Abraham. I yield back.
        Chairman Johnson. Congressman Kind.
        Mr. Kind. Thank you, Mr. Chairman.
        Thank you all for your testimony here today.
        Dr. Daigh, you were the lead person on the OIG 2-year
    investigation with the Tomah VA Medical Center, is that right?
        Dr. Daigh. That's correct.
        Mr. Kind. That was 2012, 2013, roughly?
        Dr. Daigh. That's correct.
        Mr. Kind. That led to a report that was concluded and
    closed out in March 2014, is that right?
        Dr. Daigh. That's correct.
        Mr. Kind. Mr. Chairman, I would like to submit for the
    record a copy of that report,\1\ if it has not been already.
    ---------------------------------------------------------------------------
        \1\ The  report  referenced  by  Congressman  Kind  is  available
    at
    www.va.gov/org/pubs/admin-reports/VAOIG-11-04212-127.pdf.
    ---------------------------------------------------------------------------
        Chairman Johnson. So ordered.
        Mr. Kind. After you had concluded and closed out that
    report, did you send a team to Tomah VA to brief them on your
    findings, as well as recommendations to be implemented?
        Dr. Daigh. We met on the telephone with the Facility
    Director and went over the report and recommendations.
        Mr. Kind. Are you reasonably confident that they had moved
    forward on implementing the recommendations that were contained
    in your report?
        Dr. Daigh. Yes, by what they told us and what sounded
    reasonable. We met on a separate occasion in Washington when
    the schedules worked to meet with the VISN Director and that
    gentleman told us similar things about what they had done to
    make changes at Tomah.
        Mr. Kind. Director DeSanctis, you were the Acting Director
    at Tomah VA at the time, is that right?
        Mr. DeSanctis. Yes, I was.
        Mr. Kind. And based on a previous meeting that I had with
    you and your management team, you assured me that you took the
    recommendations in this report and started implementing them
    immediately during the summer of 2014, is that right?
        Mr. DeSanctis. Yes. In fact, we had already worked on
    corrective action plans in instituting the recommendations,
    even before we got the report. We actually got the report at
    the end of June, 2014.
        Mr. Kind. Was there anything in any of the recommendations
    that you disagreed with? That you decided not to move forward
    on?
        Dr. DeSanctis. No. It's just that it made it very difficult
    for me, though, as a Director, because there was nothing in the
    report that indicated that there were any patients at risk,
    based on what was going on, or whether or not the standard of
    care had been met.
        Mr. Kind. Well, when I showed up in your office in the
    summer of 2014, this is shortly after the Phoenix story broke
    and I came and was asking for information, just to assure
    ourselves that Wisconsin was not in the same type of situation,
    and also asking of any potential problems, and at the time you
    did not talk about this report to me at all. You did not reveal
    that it had been done, that you had been briefed or you were
    going forward with the implementations, but you also indicated
    that you were instructed not to, is that right?
        Dr. DeSanctis. Yes. I was instructed by the lead
    investigator that was in contact with me to not distribute
    copies of this internal document to others.
        Mr. Kind. Did they give you a reason or explanation why?
        Dr. DeSanctis. No, they did not.
        Mr. Kind. Dr. Daigh, you cannot imagine how frustrating
    this would be from our perspective. I mean, in part, your 2-
    year investigation was precipitated based on an anonymous
    letter that my office received. And when I read through the
    allegations, I felt they were serious enough from Mr. Honl's
    point, to not just to report it to the Tomah management team so
    they investigate themselves, but it went directly to the OIG,
    which led to the 2-years. You guys did it. You concluded the
    report. You closed it out and you did not publish it.
        And I am glad to hear today that you have taken action now
    to publish on your website all future reports of this nature,
    but does that also include notification of the appropriate
    congressional offices too when you finish reports?
        Dr. Daigh. Yes, sir, it does. So if we are aware, and we
    try to keep accurate track of when you, for example, send us a
    letter, we would call that a congressional hotline, and we
    traditionally come back and go to a Member of Congress, whether
    it is an admin closure or not, and report the results of the
    report, so that is our past practice and that would be our
    future practice.
        Mr. Kind. Because we have a communication problem that
    needs to be worked out.
        Dr. Daigh. I agree.
        Mr. Kind. It is a serious one, whether you are going to be
    facing more panels like this in the future with unpleasant
    questions.
        Now move onto a different topic. OIG also finished a report
    dated May 14, 2014, on healthcare inspection, VA Patterns of
    Dispensing Take-Home Opiates and Monitoring Patients on Opioid
    Therapy. Are you familiar with that?
        Dr. Daigh. Yes, sir.
        Mr. Kind. Dr. Clancy, you are shaking your head too. You
    are familiar with it?
        Dr. Clancy. Yes.
        Mr. Kind. You have been moving forward on recommendations
    systemwide?
        Dr. Clancy. Yes.
        Mr. Kind. Based on this? Earlier this week, I, along with
    Representative Reid Ribble of Wisconsin had introduced
    legislation, the Veterans Pain Management Improvement Act, in
    part based on recommendations for the establishment of a Pain
    Management Board at the VISN centers. Have you had a chance to
    look at that legislation? Do you have any opinion?
        Dr. Clancy. I have and I actually think it is terrific. I
    would have one request, which I think would be very much in the
    spirit of this bill. I would hope that at least two members of
    that Board would be veterans or family members.
        Mr. Kind. Yes.
        Dr. Clancy. Because I think that voice would be incredibly
    important.
        Mr. Kind. It is part of the recommendations in the
    legislation that veterans and also family members, so that we
    get their direct input on pain management practices. I think
    that is terribly important as we do move forward.
        Dr. Clancy, I do want to commend you and Secretary McDonald
    for the responsiveness of the situation. And when this all came
    to light we immediately went to Secretary McDonald asking for
    the formal investigation to take place. He did not hesitate. He
    put you in charge. We had Deputy Secretary Sloan Gibson here a
    couple weeks ago. We had a chance to brief with him as well.
    And I commend you for taking these allegations coming out of
    Tomah seriously and for the attention and the focus that they
    deserve.
        We look forward to working with you and the VA system to
    fix any problems that might exist.
        Thank you, Mr. Chairman.
        Dr. Clancy. Thank you.
        Chairman Johnson. Congressman Duffy.
        Mr. Duffy. Good afternoon.
        Mr. DeSanctis, you were the Director here at Tomah, right?
        Dr. DeSanctis. I am currently at the----
        Mr. Duffy. No. You were?
        Dr. DeSanctis. Yes.
        Mr. Duffy. And for how long in that capacity?
        Dr. DeSanctis. Since February 2012.
        Mr. Duffy. And so the buck stops with you, right?
        Dr. DeSanctis. Yes.
        Mr. Duffy. You got these reports, did you not? You knew
    what was being said about the Tomah VA. You knew what the
    employees inside were saying. They told you, right?
        Dr. DeSanctis. The retaliatory accusations did not come to
    me.
        Mr. Duffy. So you were clueless? You were the Director and
    you had no idea what was going on inside the Tomah VA by, by
    the hundreds of employees?
        Dr. DeSanctis. No, that is not correct. Actions that were
    brought to my attention, I took action to ensure that they were
    resolved.
        Mr. Duffy. Does it sound like you took action? Because I
    think Jason's parents would say you did not take action. Or Mr.
    Baer's family would say you did not take action.
        Ms. Clancy, you and I want to touch on this briefly. You
    and I spoke last week, and, I agree, you cannot diagnose Mr.
    Baer over the phone. You made a good point. But the fact that
    he sat in the Tomah VA for an hour and a half showing signs of
    a stroke where doctors are on staff and nothing happened? They
    sent him on an hour drive to La Crosse? I mean, this is
    outrageous stuff.
        I mean, the original point you made is fine, but what are
    we going to do to change the culture inside the VA system,
    where if we have a veteran who is 74 years old who is showing
    signs of a stroke, we have to act. It is like out of a movie
    that you have slow-moving bureaucrats lumping around when a guy
    is dying. I mean, the Baer family should be absolutely
    outraged, and they obviously are.
        What are we going to do to change culture inside the Tomah
    VA?
        Dr. Clancy. I think that this was less a culture change
    issue. First of all, the care was completely and totally
    unacceptable. I think that needs to be said. And the only
    thing, we cannot bring him back. I wish we could. But I am
    moved and inspired by his daughter's being here today and
    speaking out against this and I hope she does not stop.
        Mr. Duffy. Dr. Clancy, I think what----
        Dr. Clancy. No. What I was----
        Mr. Duffy. If her father did not die in vain.
        Dr. Clancy. No.
        Mr. Duffy. And she knows that changes are going to be made
    inside.
        Dr. Clancy. Exactly.
        Mr. Duffy. There's not another slow-moving bureaucrat when
    someone else is in serious critical medical scenarios would
    actually move and help them?
        Dr. Clancy. We have staffing shortages in that Urgent Care
    unit, and we are working to rectify those, and we have also
    worked with nursing staff to identify some very clear
    deficiencies that were revealed as a result of that care.
        Mr. Duffy. I appreciate that. Did you read the IG report?
        Dr. Clancy. This one?
        Mr. Duffy. Yes.
        Dr. Clancy. Yes.
        Mr. Duffy. Would have you substantiated the claims? I am
    flipping the role here. Usually the IG is looking at what the
    VA is doing, but in your role, Dr. Clancy, in the VA, if you
    had seen that report, would have you substantiated the claims?
    Would have you made that report public?
        Dr. Clancy. I do not think the results found in that report
    were definitive. I think this is a problem with our process.
        Dr. Houlihan's practices have been reviewed by many
    external parties. And that is what actually prompted me to
    remove him from seeing patients and make sure that he could not
    prescribe further. His privileges were revoked, along with the
    nurse practitioner in January, was a Review Commission by the
    network.
        Mr. Duffy. OK. And just by the way, is Dr. Houlihan still
    employed at the VA?
        Dr. Clancy. He is, yes.
        Mr. Duffy. Is Mr. DeSanctis still employed?
        Dr. Clancy. Yes.
        Mr. Duffy. Ms. Davis, who prescribed the lethal cocktail
    that killed Jason, is she still employed?
        Dr. Clancy. She is on administrative detail and is under
    investigation.
        Mr. Duffy. Is she getting a pay check from the American
    taxpayer?
        Dr. Clancy. Yes.
        Mr. Duffy. She is?
        Dr. Clancy. Yes.
        Mr. Duffy. I think that's what makes people angry here.
    People are not held accountable and not fired.
        Dr. Clancy. No.
        [Applause.]
        If I could just say one thing, Congressman. The only thing
    that would be worse is if we had doubts about a practitioner,
    rushed through it, and a good attorney made sure that they had
    to keep a job, and, you know what I'm saying, is that the
    taxpayers had to pay them for long periods of time.
        Mr. Duffy. I will move on to Mr. Daigh. I thank you for
    that.
        I do not know if we need more evidence, we need e-mails,
    voice mails, text messages for our burden of proof? As a
    prosecutor, you could bring in--I was a former prosecutor. You
    can bring in witnesses that give compelling testimony, and
    juries can listen to that and they can convict. And it sounds
    like you had pretty compelling evidence that was presented.
        Even Dr. Clancy found that--was it 2.5 percent higher rates
    of prescription drugs of 400 milligrams? Did I say that a
    little bit wrong?
        Dr. Daigh. Right.
        Mr. Duffy. And that you have people who are notoriously
    frightened throughout the Tomah VA and we kind of throw our
    hands up in the air and go, well, I guess there is nothing
    going on here.
        What I found, when my staff came back and said, listen, you
    did not want to put, make that report public because you were
    more concerned about the employees of the Tomah VA than caring
    for the veterans in the VA system. That is what concerned them
    and you actually told them that.
        In regard to what you are doing now, making all the
    complaints public, I applaud you for that, but I have to tell
    you, the perception that we have of the IG is it is arrogant.
    You are annoyed that you are here. You are annoyed that you
    have these veterans looking to you to protect them from the VA
    system and that you are being held to account publically. That
    is frustrating them. They are frustrated with you.
        [Applause.]
        I hope you take this back and you listen to the families
    that testified here and know that you may be the last line of
    defense for them as they tell their story to you privately,
    that you go and you work your hearts out for the men and women
    that raised their hand and served their country and fought for
    the freedom and the liberty that we enjoy.
        You owe that to them and I hope that you leave this hearing
    and have a new refreshed attitude and devotion and conviction
    to protect them from inadequate care in the VA system. I yield
    back.
        [Applause.]
        Chairman Johnson. Congressman Pocan.
        Congressman Pocan. Thank you, Mr. Chairman.
        I am going to pick up right from there.
        Sorry to the IG's office, but you said you have 50 to 60
    reports a year. How many of those are administratively closed a
    year?
        Dr. Daigh. I publish about 50 reports a year. I admin
    closed over the last 3 years about 20 to 25 reports a year.
        Mr. Pocan. Over the last 3 years? So the last 3 years----
        Dr. Daigh. So the average output would be something like 50
    reports published to the web, and something like 20 to 25
    reports admin closed.
        Mr. Pocan. Every year?
        Dr. Daigh. For the last 3 years.
        Mr. Pocan. So 50 a year? So 150 versus 25 get
    administratively closed. How many Freedom of Information
    Requests do you get from Members of Congress in order to get a
    report, in that same 3-year period? How many of those did you
    get?
        Dr. Daigh. I think this is the first time I can recall
    that.
        Mr. Pocan. Do you realize how extraordinary that is? The
    fact that this report was administratively closed, many of us
    have a lot of disagreements with the report, and that a Member
    of Congress had to do a Freedom of Information Request to get
    the report so we could get even this far? That's part of our
    frustration that we have.
        I served on the Oversight and Government Reform Committee.
    I dealt with Inspector General's Offices on a lot of different
    issues and, even now you are going to publish all of them. I
    would say go one step farther. A little electric file. You
    could send every report to every Member of Congress and we can
    decide whether or not it is a report that relates to our
    district, our committees, or our constituents.
        [Applause.]
        So a Member of Congress should never ever again have to go
    to that extraordinary length to get a report from your office.
    I want to say that.
        Let me ask specifically, because I do not want to use up my
    time.
        Jason's case, specifically his family said it, his opiates
    were not because of an injury. Specifically your report says
    you did not find any documentation that opiates were used to
    treat PTSD.
        Can you tell me, was Jason's case one of them that you
    looked at when you did this report?
        Dr. Daigh. No.
        Mr. Pocan. It was not, OK. Dr. Clancy, I am going to
    reiterate what Dr. Walz said and Chairman Miller, please take a
    closer look at this on behalf of Jason's family, because,
    clearly, to get 14 or 15 different drugs, it was not even
    looked at in the report that was not released to us until we
    had to make a special request to get it. And at least we owe it
    to the family to figure out, so that for many other veterans,
    that if they are going to be prescribed something that's not
    something sufficient, or for the wrong cause, which this seems
    to be, we need to at least do that.
        Dr. Clancy. I absolutely will and I agree with you.
        Mr. Pocan. And let me follow-up too. When I talked to Mr.
    Honl and Dr. Johnson, before the last panel, specifically when
    they talked about, for those employees are fairly new that have
    no protections who want to be whistleblowers, but we do not
    really protect them, what are you doing specifically, not just
    here at Tomah, but across the system to figure that out? So
    that those kind of employees do not feel afraid or have to risk
    their jobs 2 weeks out from her year, or someone else have to
    resign because they are not being heard?
        Dr. Clancy. I will be looking into that. I had not
    recognized that previously as a serious weakness in our system.
    I will say I am utterly delighted, and I told Noelle Johnson
    that this morning, that she had found her way back to work in
    the VHA, so I consider that a real success. I am hoping that we
    have more of that, that more whistleblowers have a path back,
    because they are incredibly vital to what we do.
        Mr. Pocan. And let me just ask this as, perhaps, a final
    question. So with what we are seeing here at Tomah and it took
    to this point the extraordinary lengths to have family members
    sharing their stories, and how we are finding out potentially
    about additional deaths that were not at all looked at through
    an Inspector General report, what are we doing system-wide to
    make sure that what happened here, not just here, that--we have
    to fix what is happening in Tomah--this does not happen in
    other places, because clearly, I wish every pharmacist was like
    the pharmacist that got fired, because she had the guts to
    stand up and do the right thing based on that, but what are we
    doing to make sure that we do not to worry about someone who is
    willing to take that risk, to put their job on the line, to do
    the right thing?
        Dr. Clancy. So we are doing several things. First is that
    we had made it very clear and we will continue to make this
    clear again and again, because you have to make it clear again
    and again, that retaliation will not be tolerated, No. 1.
        No. 2, whistleblowers and people who step forward and say
    there is something wrong here, who stop the line, right to
    solve a problem, should be celebrated. We should be giving them
    awards. The Secretary and I have even discussed a Paul Revere
    award. I do not know if that is the right name for it. But the
    bottom line is, we need to celebrate that kind of feedback,
    because that is how we get better. That is a terrific thing.
        In terms of the opiates specifically, we have disseminated
    a new tool system wide, which makes it much easier for
    frontline clinicians to have right in front of them how all
    their patients are doing on all aspects of care, including
    whether there's been an informed content, the urine drug
    testing, what other medications they are on, and are they
    getting those medications from other parts of our system. So
    that is a good thing.
        And we are mandating that a much more focused effort take
    place system wide and we will be following that quarterly.
        Mr. Pocan. Thank you.
        Chairman Johnson. Thank you, Congressman Pocan.
        I want to thank all of my colleagues here for
    participating.
        I want to thank all the members of the community for coming
    out and showing your concern and showing your support, being
    interested.
        I certainly want to thank our witnesses for your thoughtful
    testimony, both in the VA and the Office of Inspector General.
    I appreciate your comments, Dr. Clancy, now that you have heard
    the stories and they have affected you. I think they affected
    all of us.
        I want to thank the whistleblowers for your courage for
    coming forward.
        I want to thank future whistleblowers. We need this kind of
    information if we are going to solve these problems.
        I really want to express my sincere gratitude and again
    condolences to the surviving families.
        I remember, I believe when I was talking to you Marv and
    Heather, and I asked you if you would be willing to come
    public?
        Would you make a public case? Will you tell the story? And
    I said, if you do that, certainly my commitment would be to
    hopefully use those stories. If there is any good to come out
    of this tragedy, it is that your story will be used as a
    catalyst to enact real reform so again, these tragedies never
    have to effect another veteran's family.
        So, again, I just want to thank everybody for your
    involvement. Keep telling your stories. Let's keep showing the
    American people what we need to do.
        And you have a commitment from people on this committee to
    do everything we can to solve these problems.
        The hearing record will remain open for 15 days, until
    April 14 at 5 p.m. for the submission of statements and
    questions for the record.
        This hearing is adjourned.

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