Hearing Statement: “Tomah VAMC: Examining Quality, Access, and a Culture of Overreliance on High-Risk Medications”

WASHINGTON – Today, the U.S. Senate Committee on Homeland Security and Governmental Affairs and U.S. House of Representatives Committee on Veterans’ Affairs held the joint field hearing, “Tomah VAMC: Examining Quality, Access, and a Culture of Overreliance on High-Risk Medications” in Tomah, Wisconsin. Ranking Member Tom Carper (D-Del) submitted the following statement for the Record:

“First, I want to thank Chairman Ron Johnson, Senator Tammy Baldwin and my colleagues in the House Committee on Veterans’ Affairs for working together to address this serious issue and for holding this important hearing today.

“As a veteran, I understand the sacrifices that the men and women of the Armed Forces and their families have made to defend our country and the freedoms we cherish. We have a responsibility to ensure that our returning heroes have the support and the resources they need when they come home, and to make sure they are taken care of long after. That includes ensuring that veterans have access to top quality health care.

“I was deeply troubled to learn about allegations of maltreatment of veterans and a management ‘culture of fear’ at the U.S. Department of Veterans Affairs Medical Center (VAMC) in Tomah, Wisconsin. A January 2015 report from the Center for Investigative Reporting described a disturbing and heartbreaking situation that put veterans in harm’s way at a place that should be helping them. The report highlighted growth in the number of opiate prescriptions at the Tomah VA, which more than quintupled from 2004 to 2012 even as the number of veterans seeking care at the hospital declined. The report also noted that some veterans started calling the center ‘Candy Land,’ and a high ranking official at the facility the ‘Candy Man’ as a result of the number of controlled substance prescriptions dispensed under his watch. Patients would ‘show up to appointments stoned on painkillers and muscle relaxants, doze off and drool during therapy sessions, and burn themselves with cigarettes,’ according to the report. Tragically, Jason Simcakoski, a 35-year-old Marine Corps veteran, died in August as a result of an overdose in the facility’s psychiatric ward.

“Our veterans deserve better than this. Practices such as those found at Tomah and reports of other misconduct at VAMCs across the country are simply unacceptable. Congress, the Administration, and the VA leadership need to work together to fully investigate this and any instance of misconduct and do whatever it takes to prevent similar incidents from happening again.

“Today in Tomah, we have an important opportunity to learn the facts from the families and individuals affected directly by events at the Tomah VAMC. I thank the witnesses for being with us today and I appreciate their courage to stand up and shine a light on this deeply troubling situation. Their stories should remind us all of the solemn responsibility we share ‘to care for him who shall have borne the battle.’ We will also hear from the VA and its Assistant Inspector General for Healthcare Inspections on what went wrong and what corrective steps they’re taking to address this problem immediately.

“On March 10 of this year, the VA released its summary of phase one of its clinical review of prescribing practices at the Tomah VAMC. The VA found that unsafe clinical practices in areas such as pain management and psychiatric care revealed that patient harm could be at least partially attributable to prescribing practices at the facility. Further, the VA also found that an apparent ‘culture of fear’ at the facility compromised patient care and hurt staff satisfaction and morale. Additional reviews at the facility are ongoing.

“Finally, while the work of the VA Inspector General’s office has been helpful in uncovering a number of issues with the Tomah facility, I am concerned about the lack of access to timely information from that office on conditions at the Tomah VAMC. Earlier this month Chairman Johnson, Senator Baldwin, and I joined with our colleagues on the Homeland Security and Governmental Affairs Committee to approve legislation that makes key reforms to enhance oversight and greater transparency in the work that is conducted by our Inspectors General. Under this legislation, the work of the Inspectors General would have to be sent to the agencies’ leadership and appropriate Congressional committees so that action can be taken when necessary to fix problems that are uncovered. Inspectors General would also be required to post reports online no more than three days after agency leadership receive them.

“As I’ve said before, fixing the problems at the VA isn’t a partisan issue. It’s a shared responsibility among Congress, the Administration, and the VA’s leadership. We must continue to work together to improve veterans’ access to health care and to restore both veterans’ and taxpayers’ trust in the VA.”