Government and Regulations

Was Anything Learned at Tomah?

Senate committee issues reports on the role of oversight and overprescription of opioids at Tomah VAMC.


On Tuesday The Senate Committee on Homeland Security and Government Affairs issued 2 reports on its investigations into the oversight of the Tomah VAMC, which found that the VA and VA Office of Inspector General (OIG) both failed to adequately address the facility’s problems despite ample warnings of dangerous conditions. It was not until after the death of Marine Jason Simcakoski from an opioid overdose in March 2014 and a 2015 report from the Center for Investigative Reporting that Tomah leadership and opioid prescribing practices came under close scrutiny.

Although numerous complaints surfaced in the past, according to the Senate committee reports, little if anything was done to fix the problems. According to a staff report from committee Chairman Ron Johnson (R-Wisc.), “Despite receiving various complaints over the course of several years, federal law enforcement agencies and other executive branch entities failed to identify or address the root causes.”

In his opening statement, Senator Johnson laid much of the blame on OIG. “The failure of the Office of the Inspector General to live up to its mission is really the root cause of why these problems continue to go on,” said Johnson.

The majority staff report also asserted that a “culture of fear and whistleblower retaliation at the Tomah VAMC allowed overprescription and other abuses to continue unaddressed. The belief among Tomah VAMC staff that they could not report wrongdoing compromised patient care.”

The staff of minority staff member Thomas Carper (D-Del.) also noted in a report that the efforts to address the problems at the Tomah VAMC “were not effective.” Still, according to the minority report recommendations were made, but “Tomah VAMC senior leadership declined to implement both VISN 12 recommendations (such as conducting an administrative investigative board review for Dr. Houlihan) and VA OIG suggestions aimed at addressing problems at the facility.”

According to Senator Carper, chronic understaffing, a shortage of qualified mental health care professionals, and a lack of adequate oversight may have contributed to Tomah’s problems. Nevertheless, Carper pointed out ,“our staff found that the VA OIG’s decision to administratively close an investigation it conducted at Tomah without publicly releasing a report made it more difficult for the VA and the public to identify and correct what was going wrong.”

In addressing the hearing, VA Deputy Secretary Sloan Gibson pledged to change the culture of the facility. “In order to create a more transparent culture and improve communication with Tomah VAMC employees,” Sloan told the committee, “leadership has taken a number of actions, including town hall meetings, supervisory forums, and expanded all-employee communications.”

Deputy Secretary Gibson also touted the VA’s efforts to address overprescription of opioids. According to Gibson, since 2012:

  • 151,982 fewer patients are receiving opioids (22% reduction);
  • 51,916 fewer patients are receiving opioids and benzodiazepines together (42% reduction);
  • 94,045 more patients on opioids have had a urine drug screen to help guide treatment decisions (37% increase); and
  • 122,065 fewer patients are on long-term opioid therapy (28% reduction).

Newly confirmed Inspector General of the VA Michael Missal also tried to focus on the future. “My office has learned important lessons from the Tomah health care inspections that should help us better meet our mission going forward,” he told the committee. “The changes that we have made should increase the confidence that veterans, veterans service organizations, Congress, and the American public have in the OIG.”

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