Donovan Slack

USA TODAY

WASHINGTON — A Senate investigation of poor health care at a Veterans Affairs Medical Center in Tomah, Wis., found systemic failures in a VA inspector general’s review of the facility that raise questions about the internal watchdog’s ability to ensure adequate health care for veterans nationwide.

The probe by the Senate Homeland Security and Governmental Affairs Committee found the inspector general’s office, which is charged with independently investigating VA complaints, discounted key evidence and witness testimony, needlessly narrowed its inquiry and has no standard for determining wrongdoing.

One of the biggest failures identified by Senate investigators was the inspector general’s decision not to release its investigation report, which concluded two providers at the facility had been prescribing alarming levels of narcotics. The facility's chief of staff at the time was David Houlihan, a physician veterans had nick-named “candy man” because he doled out so many pills.

Releasing the report would have forced VA officials to publicly address the issue and ensured follow up by the inspector general to make sure the VA took action. Instead, the inspector general’s office briefed local VA officials and closed the case.

A 35-year-old Marine Corps veteran, Jason Simcakoski, died five months later from “mixed drug toxicity” at Tomah days after Houlihan signed off on adding another opiate to the 14 drugs he was already prescribed.

The 350-page Senate committee report obtained by USA TODAY also chronicles instances where other agencies could have done more to fix problems at the Tomah VA Medical Center, including the local police, the FBI, DEA, and the VA itself, but it singles out the inspector general.

“Perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC was the VA Office of Inspector General’s two-year health care inspection of the facility,” the report concludes, adding that despite the dangerous drug prescriptions, the IG did not identify any wrongdoing.

After news reports chronicled Simcakoski’s death last year, VA officials conducted another investigation with very different results and ousted Houlihan, a nurse practitioner, and the medical center’s director.

“In just three months, the VA investigated and substantiated a majority of the allegations that the VA OIG could not substantiate after several years,” the committee report notes.

Sen. Ron Johnson, R-Wis., chairman of the committee, which is holding a hearing on the findings in Tomah on Tuesday, told USA TODAY the failures were "systemic" and indicative of a troubling pattern.

"The reasons the problems were allowed to fester for so many years is because in the inspector general's office, for whatever reason, for years, the inspector general lacked the independence and had lost the sense of what its true mission was, which is being the transparent watchdog of VA system," he said.

The conclusions echo other recent findings about the office tasked under federal law to be an independent watchdog exposing problems at the VA and making recommendations for improvement. The Office of Special Counsel, a federal agency that reviews whistleblower reports of wrongdoing, issued blistering critiques in recent months of the office’s investigations in Illinois, Louisiana, and Texas, which it said were incomplete and overly narrow.

USA TODAY also has reported that the VA inspector general failed to release the findings of 140 health care investigations and sat on the results of more than 70 wait-time probes for months.

While a new inspector general, Michael Missal, took over the office last month and promised comprehensive investigations and greater transparency, the lead investigators on health care remain in place, including John Daigh, the physician who made the decision to keep the Tomah report secret.

A spokesman for the Office of Inspector General, Mike Nacincik, said Friday that IG officials had not finished reviewing the Senate report and so could not comment on the findings. But he said that at the time, Daigh felt it was appropriate not to release the Tomah report when it was finished in 2014 because the investigation did not substantiate wrongdoing.

“The OIG has learned important lessons from the Tomah VA Medical Center health care inspections,” Nacincik said.

Daigh’s office opened its Tomah investigation in 2011 after receiving complaints that Houlihan and a nurse practitioner, Deborah Frasher, were prescribing “massive doses of opiates to veterans with post traumatic stress disorder” and employees feared retaliation if they raised concerns. The complaints also said some patients kept getting early refills, suggesting they were abusing or selling their medications.

Little progress was made on the case until February 2012, when Alan Mallinger, a physician in the inspector general’s Washington, D.C., office, was put in charge. It was his first case as lead investigator, the Senate committee found.

Over the next two years, he and his team conducted dozens of interviews, pored through more than 225,000 emails and analyzed opioid prescription rates at hospitals and clinics across the Great Lakes region.

But they didn’t look into whether Houlihan and Frasher were prescribing opiates in dangerous combinations with other drugs – something the VA later concluded was rampant. One of the inspector general’s employees who reviewed charts from patients of Houlihan and Frasher actually noted during the investigation “A LOT of polypharmacy – patients on both uppers and downers, would really love to have a pharmacist look at some of these combos.”

But that didn’t happen because it was outside the scope of the investigation.

“The allegation that we had was that he was using opioids to treat PTSD, and that was the allegation we looked at,” Mallinger told Senate investigators.

They did have independent experts listen to audio of interviews with former Tomah pharmacists who recounted dangerous amounts of narcotics prescribed at the facility and said Houlihan would get hostile if they didn’t fill them. The experts told Mallinger’s team they were alarmed by what they heard. One said the facility could be in danger of losing its DEA license.

But Mallinger said his team did not have those experts review prescription data and could not independently corroborate the concerns with evidence and so discounted them.

“It was not valuable in terms of supporting allegations,” he told Senate investigators.

In the end, the IG didn’t have a standard for deciding when to substantiate allegations and instead decided ad hoc by committee. Their report, released after intense media scrutiny last year, concluded Houlihan and Frasher were among the highest prescribers of opiates in a multistate region, raising "potentially serious concerns." But those conclusions “do not constitute proof of wrongdoing,” the report concluded.

The IG investigation team had intended all along to publish a public report on the findings, but Daigh decided instead to brief local VA officials and close it privately.

“I do not publish reports that repeat salacious allegations that I can’t support,” he told Senate investigators. “So to write a report with all sorts of accusations that I can’t support and throw that into a small community destroys the community and destroys the VA.”

After the report was released last year, a separate VA clinical review found Houlihan had failed to meet standards of care in 92% of cases and Frasher failed in 80%, according to a VA report provided to the Senate committee.

Houlihan and Frasher could not be reached for comment. Houlihan's lawyer did not respond to a message seeking comment. Houlihan defended his record in an interview with WKOW in March.

"I am a good doctor, I do care very much for my patients," he said. "There is a need for good care, great care for our veterans and I think my record really has shown that I've done that."

Nacincik, the spokesman for the new inspector general, Missal, said he is reviewing the office’s operations “with an eye towards making enhancements.”

“We believe that our actions will enhance OIG investigations and increase the confidence that veterans, veterans service organizations, Congress and the American public have in the work of the OIG,” Nacincik said.

VA watchdog sits on wait-time investigation reports for months

VA bosses in 7 states falsified vets' wait times for care

VA doesn't release 140 vet health care probe findings

Newly released VA reports include cases of veteran harm, death

New VA watchdog pledges more transparency