7 Things You Need To Know About The Embattled Tomah VA

The Veteran’s Affairs hospital in Tomah, Wisconsin is under the spotlight for a potentially large scandal that could garner further media attention. Here are seven things you need to know about it.

1. The Tomah VA was known as “Candy Land” for over-prescribing painkillers. Ryan Honl, the whistleblower who first brought attention to the Tomah VA in 2014, writes in The Capital Times that he began working in the Tomah VA in a secretarial position. He eventually noticed “missing medical files for patients, falsely reported information pertaining to doctors’ continuing education requirements, and I was even ordered to report absent staff as present.”

Honl filed a complaint to the Office of the Inspector General, and was sent a copy of a March 2014 IG report that found the facility’s chief of staff, David Houlihan, who is known as the “Candy Man,” had “prescribed the equivalent of 25,000 milligrams of morphine to each of the 128 patients he saw in 2012,” which “raised potentially serious concerns.” Honl also discovered that according to VA data, the number of oxycodone pills prescribed skyrocketed from 50,000 a year in 2004 to 711,000 a year in 2012, even though fewer patients were admitted into the facility.

At a congressional hearing in March 2015, Noelle Johnson, a former pharmacist at the Tomah VA, testified that she witnessed “unsafe levels of opioids and other drugs being prescribed to patients,” including those who had struggled with drug addiction.

“I truly believe that Dr. Houlihan is a dangerous man,” Johnson declared. “I lived the torture and saw the unsafe practices daily.”

Houlihan was fired in November 2015.

2. Many veterans died as a result. According to Johnson, a total of 24 veterans died unexpectedly at the hospital, three of which were in the parking lot, in the 2008-2009, and six veterans linked to Houlihan died from drug overdoses over the past ten years. One veteran that died under Houlihan’s care was Marine Corps veteran Jason Simcaskosi, who had a history of addiction to painkillers and was being treated for anxiety, and at one point said “he felt suicidal,” according to The Center for Investigative Reporting. Houlihan prescribed Simcaskosi even though he was already on 14 other drugs.

The drugs took a serious toll on Simcaskosi, his wife, Heather Simcaskosi, testifying that “he would sleep for 18 hours a day, missing work and activities with their 12-year-old daughter.”

Simcaskosi’s father, Marvin Simcaskosi, testified that he would constantly ask the doctors treating his son why they “put someone with an addiction to pain meds on pain meds.” In response, they would tell him that “I may know how to build houses and pound nails, but that I don’t know how to take care of my son.”

Simcaskosi eventually passed away in August 2014 from a “mixed drug toxicity” in the hospital’s psychiatric ward. According to the IG report, the VA was responsible “for failing to obtain the required written consent before administering dangerous drugs” as well as not providing Simcaskoski with all the risks associated with the drugs.

Another veteran, Thomas Baer, went to the Tomah VA to get treated for complications stemming from a bronchial infection, where he spent almost three hours in the waiting room and suffered two strokes. The VA said they couldn’t treat him because he didn’t undergo a CT scan and their scanner was under maintenance that day. Baer died later that day when he was being transferred to a different hospital.

3. Anybody who spoke out against the VA’s practices would face blowback. Honl testified that “the VA will do everything in its power to discredit you” if anyone stood up to them.

In his column in The Capital Times, Honl writes that after he informed his superiors of what he saw occurring in the hospital, they relocated him “to an isolated office and relieved [me] of all of my job responsibilities.”

“I wasn’t even allowed to use the restroom without permission,” writes Honl. “The facility’s officials went so far as to add false information into my personnel file.”

Johnson testified that she “was fired for standing up for what was right for veterans,” which included refusals to write out prescription forms.

According to a Senate report, the “culture of fear and whistleblower retaliation continues at the facility.” The Tomah VA union president wrote in a memo to Wisconsin lawmakers that pharmacists who refused to carry out Houlihan’s orders of prescribing an absurd amount of painkillers would “be yelled at and perhaps fired.”

4. A Tomah VA counselor was also arrested for sexual assault. In addition to the lax handouts of painkillers, an unidentified male counselor at the VA was arrested for suspicion of sexually assaulting patients in the psychiatric unit of the facility.

5. The Senate report also found that the VA Office of Inspector General failed to fully expose the problems at the Tomah VA. According to the report, the office made the following errors in their probe:

• Not releasing their findings to the public.
• Not adopting a clear measure for improper behavior.
• Ignoring certain evidence.
• Having too narrow of a focus.

The report also alleges that the inspectors thought that Houlihan and nurse practitioner Deborah Frasher may have been under the influence of drugs when they were interviewed in 2012, although Houlihan’s lawyer denies this charge.

6. A number of Wisconsin lawmakers knew about the scandal and did nothing about it. Honl alleges that Rep. Ron Kind (D-WI) and former Sens. Russ Feingold (D-WI) and Herb Kohl (D-WI) received numerous memos in 2008 and 2009 about the wrongdoing occurring at the Tomah VA and didn’t take any action. Honl also claims that Sen. Tammy Baldwin (D-WI) received a copy of the March 2014 IG report and she basically didn’t pay any attention to it.

Kind also reportedly received a phone call from Simcaskosi, and refused to answer Wisconsin Watchdog‘s questions about it.

7. It is now in the national spotlight because it’s a campaign issue. As National Review‘s Jim Geraghty points out, incumbent Sen. Ron Johnson (R-WI) is chairman of the Senate Committee on Homeland Security and Governmental Affairs, and his challenger, Feingold, is facing allegations that he knew what the Tomah VA was doing and did nothing to stop it. The coverage on the Tomah VA is only just beginning.

Geraghy also links to a full timeline of the scandal that can be found here.