[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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.

                            A P P E N D I X

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