Investigator visit to Tomah VA site feels like déjà vu

TOMAH — U.S. Secretary of Veterans Affairs Robert McDonald dispatched a team of investigators to the Tomah VA Medical Center this week to review patients' charts and grill hospital staff after reports of runaway painkiller prescriptions, preventable overdoses and abuse of authority by the hospital's chief of staff.

For many, it was déjà vu, because the same allegations had been scrutinized for two years by the VA's Office of Inspector General — in a report that has never been released officially. That left some questioning whether the agency charged with caring for America's military veterans is capable of policing itself.

"We need the FBI to come in here," said Linda Ellinghuysen, a registered nurse and president of the local chapter of the American Federation of Government Employees, which represents about 900 medical and support staff at the facility. "We need their objectivity and their expertise."

Politicians and hospital employees alike remain suspicious about why they never saw the earlier report. Some say inspectors were not thorough before, and ask why they should assume this review will be any different.

"My impression was that they were more concerned about if there was an asbestos problem or if you had a Coke can out on your workstation where it might spill on a keyboard than the amount of narcotics passing through," David Hughes, a pharmacist who handled purchasing for the Tomah VA, said of the inspector general's investigation. Hughes quit in 2012, citing an atmosphere of hopelessness at the facility.

Hughes said no one from the inspector general's office interviewed him. If they had, he said, he would have told investigators that some patients were receiving 800 oxycodone pills per month, "enough to wipe out a typical retail pharmacy in one go."

The problems at the Tomah VA came to light in a story published by The Center for Investigative Reporting on Jan. 8, and subsequently updated and republished by Gannett Wisconsin Media. It reported that the number of oxycodone pills prescribed at the facility had increased from about 50,000 in 2004 to 712,000 in 2012 under the leadership of the hospital's chief of staff, psychiatrist David Houlihan, and that some veterans had taken to calling the hospital "Candy Land."

A closed case, then a death

Many of the facts in CIR's story — including the startling numbers of painkillers prescribed by Houlihan and two other health care professionals in Tomah, the dismissal or resignation of pharmacy staff who complained of unethical behavior, early refills of controlled substances and criminal behavior by VA patients under Houlihan's care — were first documented in the inspector general's report, completed in March 2014.

Although auditors found Houlihan and a close associate prescribed opiates at a level that "raised potentially serious concerns" that should be brought to the attention of the federal agency's leadership, it also cleared him of wrongdoing. The inspector general then administratively closed the case. It did not publish the report on its website or share it with the House or Senate committees that oversee the VA.

Five months after the inspector general finished its report, a 35-year-old Marine Corps veteran from Stevens Point died of an overdose in the hospital's psychiatric ward.

Two days before Jason Simcakoski's death, the head of the unit, Dr. Ronda Davis, discussed his care with Houlihan. Simcakoski had checked himself in, citing an addiction to painkillers and severe anxiety that was destroying his relationship with his wife and 11-year-old daughter. The Marine Corps veteran's medical record shows Houlihan advised Davis to add Suboxone to his existing cocktail of 14 drugs, which included antipsychotics, tranquilizers, muscle relaxants and the opioid painkiller tramadol.

An autopsy report prepared by the University of Wisconsin Hospital and Clinics declared the cause of death to be "mixed drug toxicity."

In an email, Catherine Gromek, a spokeswoman for the inspector general, said the watchdog agency decided not to publish its report on the Tomah VA because "we could make no conclusive finding of inappropriate prescription practices."

Houlihan emphasized that point in a December interview with CIR. "I've been investigated again and again," he said, "and they've never found anything wrong."

After CIR's story ran, he was removed from his position of chief of staff pending the conclusion of the new investigation. VA officials say he has been assigned to a desk job and is not allowed to see patients or write prescriptions.

Acts of Congress

The watchdog's behavior has drawn ire from both of Wisconsin's U.S. senators. On Jan. 13, Sen. Tammy Baldwin, a Democrat, wrote to VA Secretary McDonald complaining that the unpublished investigation "was limited in focus and therefore not a thorough investigation into the Tomah VA operations." This week she turned up the heat, asking the VA's interim undersecretary for health, Carolyn Clancy, to consider a criminal investigation.

On Jan. 14, Sen. Ron Johnson, the Republican chairman of the Senate Committee on Homeland Security and Governmental Affairs, joined with Rep. Sean Duffy, R-Wausau, in writing a letter to Richard J. Griffin, the acting director of the VA's Office of Inspector General, asking for a fresh investigation of the Tomah VA.

A week later, Johnson wrote to President Barack Obama demanding the appointment of a new inspector general. "The problems surrounding the Tomah VAMC have led veterans and VA employees to question not only the leadership at the facility but at the VA Office of Inspector General," he wrote.

Veterans advocates consider the suppression of the inspector general's report on the Tomah VA part of a larger pattern at the agency, which has a reputation of keeping damning information secret rather than sharing its problems with Congress and the public so they can be solved.

Anthony Hardie, a Gulf War veteran and director of Veterans for Common Sense, said the existence of "secret IG reports is massive, absolutely massive. At the end of it all, who knows what kind of secret IG's reports are out there. Who knows what we don't know."

Rep. Jeff Miller, the Florida Republican who chairs the House Committee on Veterans' Affairs, saw a repeat of the scandal on hidden hospital waiting lists and undisclosed patient deaths that prompted the resignation of the previous VA secretary in May.

"We're very concerned about what else VA OIG may be hiding," Miller said.

In October, after allegations that political interference led the inspector general to downplay the role that secret waiting lists played in the deaths of veterans served by the Phoenix VA, Miller wrote to the agency's acting inspector general, Griffin, asking for "all draft and final versions" of reports "at the time they are originally provided to the Department of Veterans Affairs."

On Dec. 30, Griffin responded, denying the request, saying he only would send copies of reports to Congress as they are made available on the VA's website.

"Providing these reports to Congress absent a compelling legislative purpose would have a chilling effect" on the watchdog's relationship with the agency, Griffin wrote.

At the VA hospital in Tomah, employees expressed hope that this latest investigation will be different. In interviews, many said they had been afraid to speak to investigators before problems at the hospital became public. Ellinghuysen, the union president, said the investigators dispatched by McDonald have asked the union for a list of workers who would like to talk.

Hughes, the former pharmacist, said he hopes investigators "take a step back" and ask a basic question: "Is this normal? Is prescribing these drugs in these quantities to these kinds of patients normal? And if they can say with confidence that it is normal and appropriate, I would be shocked."

This story was edited by Amy Pyle and copy edited by Sheela Kamath at The Center for Investigative Reporting, and by Mark Treinen at Gannett Wisconsin Media. The story was produced by Reveal, from The Center for Investigative Reporting, an independent, nonprofit newsroom based in the San Francisco Bay Area. For more, visit RevealNews.org. Glantz can be reached at aglantz@cironline.org. Follow him on Twitter: @Aaron_Glantz.