The U.S. Department of Veterans Affairs’ Office of Inspector General has publicly released its scathing report documenting runaway painkiller prescriptions and abuse of administrative authority at the VA hospital in Tomah, Wisconsin.
But the move, which came nearly a year after the independent watchdog closed its case, is unlikely to satisfy veterans’ advocates and members of Congress, who have expressed outrage that the findings weren’t shared with them and the public earlier.
“These are life-and-death issues,” said David Kurtz, adjutant of the American Legion Department of Wisconsin.
Veterans, he said, “are disappointed, dismayed and feel like they are being let down. They feel like the checks and balances aren’t working.”
In an email, Catherine Gromek, a spokeswoman for the inspector general, said the watchdog decided to publish the report “because of continuing public interest” following its disclosure in a story published by The Center for Investigative Reporting on Jan. 8.
Previously, Gromek had defended the inspector general’s decision to keep the report secret, saying, “We could make no conclusive finding of inappropriate prescription practices.”
Many of the facts in CIR’s story – including the startling numbers of opiates prescribed by the hospital’s chief of staff, Dr. David Houlihan, and two other health care professionals in Tomah; the dismissal or resignation of pharmacy staff who complained of unethical behavior; and early refills of controlled substances – were first documented in the VA inspector general’s report, which was completed in March 2014.
Although auditors found that Houlihan and an associate prescribed opiates at a level that “raised potentially serous concerns” that should be brought to the attention of the federal agency’s leadership, they also cleared him of wrongdoing. The inspector general then administratively closed the case. It did not publish the report on its website or share it with the House or Senate committees that oversee the VA.
Five months later, a 35-year-old Marine Corps veteran died of an overdose in the hospital’s psychiatric ward.
The report’s release comes as public officials and agency leaders launch fresh investigations into prescription practices at the Tomah VA.
Late last month, a team of clinical investigators, led by the VA’s interim undersecretary for health, Carolyn Clancy, visited the hospital. That investigation, which is expected to be completed next month, was ordered by VA Secretary Robert McDonald days after CIR’s story.
This week, the inspector general also launched a new investigation into operations at the Tomah VA, focused, Gromek said, on “issues brought to our attention including the quality of medical care provided by the Tomah facility.”
In an interview today, facility Director Mario DeSanctis said investigators “are doing a selected clinical and operations review.”
“We look forward to what results they may have so that we can be improved,” he said.
Melinda Schnell, a spokeswoman for Sen. Ron Johnson of Wisconsin, the Republican chairman of the Senate Committee on Homeland Security and Governmental Affairs, said her boss had launched his own independent fact-finding efforts on the problems at the Tomah VA.
Last month, Johnson wrote to President Barack Obama demanding the appointment of a new VA inspector general.
“The problems surrounding the Tomah VAMC have led veterans and VA employees to question not only the leadership at the facility but at the VA Office of Inspector General,” he wrote.
The White House has not responded to the letter, Schnell said.
This story was edited by Amy Pyle and copy edited by Nikki Frick.