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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TOMAH VAMC: EXAMINING QUALITY, ACCESS, AND A CULTURE 

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94–902 PDF 2016

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 

( 
(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

RON JOHNSON, Wisconsin, Chairman 

JOHN MCCAIN, Arizona 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

JAMES LANKFORD, Oklahoma 

MICHAEL B. ENZI, Wyoming 

KELLY AYOTTE, New Hampshire 

JONI ERNST, Iowa 

BEN SASSE, Nebraska 

THOMAS R. CARPER, Delaware 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

TAMMY BALDWIN, Wisconsin 

HEIDI HEITKAMP, North Dakota 

CORY A. BOOKER, New Jersey 

GARY C. PETERS, Michigan 

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 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA RADEWAGEN, American Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

JERRY MCNERNEY, California 

TIMOTHY J. WALZ, Minnesota 

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 
(III) 

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 
Page

IV 

Simcakoski, Heather—Continued 

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 
(1) 

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. 
2 

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 21⁄2 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 
3 

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. 
4 

1The prepared statement of Senator Johnson appears in the Appendix on page 63. 

2The prepared statement of Senator Carper appears in the Appendix on page 66. 

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 record1 and our ranking 

member, Senator Tom Carper, has also offered an opening statement that I also ask be entered in the record.2

Without objection, so ordered. 

Chairman JOHNSON. Senator Baldwin. 
5 

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 highestquality 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. 
6 

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 
7 

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. 
8 

1The prepared statement of Dr. Johnson appears in the Appendix on page 73. 

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. 

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 
9 

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 inter-
10 

viewed 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 Profes-
11 

sional 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. 
12 

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 longstanding 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 
13 

1The prepared statement of Mr. Honl appears in the Appendix on page 147. 

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. 

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. 
14 

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 
15 

1The prepared statement of Mr. Simcakoski appears in the Appendix on page 249. 

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. 

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. 
16 

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 
17 

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 21⁄2 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 
18 

1The prepared statement of Ms. Simcakoski appears in the Appendix on page 253. 

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. 

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 
19 

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 ad-
20 

1The prepared statement of Ms. Delis appears in the Appendix on page 256. 

diction 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. 

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. 
21 

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, 
22 

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 
23 

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.] 
24 

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 21⁄2

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 21⁄2 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 21⁄2 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. 
25 

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. 
26 

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 serv-
27 

ice 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. 
28 

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, 
29 

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 
30 

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 
31 

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? 
32 

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 
33 

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 
34 

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 
35 

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. 
36 

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. 
37 

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 
38 

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. 
39 

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 
40 

1The prepared statement of Dr. Daigh appears in the Appendix on page 278. 

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. 

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. 
41 

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. 
42 

1The prepared statement of Dr. Clancy appears in the Appendix on page 286. 

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. 

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 
43 

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. 
44 

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. 
45 

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? 
46 

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? 
47 

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? 
48 

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 
49 

1The prepared statement of Lin Ellinghuysen appears in the Appendix on page 295. 

2The prepared statement of Linda Simcakoski appears in the Appendix on page 307. 

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 Employees1 here, and also Jason’s mom, Linda 

Simcakoski, prepared written testimony2 for our committee. 

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 
50 

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. 
51 

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? 
52 

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 redhot 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 
53 

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. Thirtyseven 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 
54 

1The report referenced by Congressman Kind is available at 

www.va.gov/org/pubs/admin-reports/VAOIG–11–04212–127.pdf. 

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. 

Chairman JOHNSON. So ordered. 
55 

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. 
56 

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. 
57 

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 slowmoving 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? 
58 

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. 
59 

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 re-
60 

port 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? 
61 

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. 

(63) 

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Æ