by Art Levine
Heather told the congressional panel in Tomah in March 2015 that Jason tried to fight his addictions in his own way. In 2013, he alerted the local police department as well as the VA’s own police to the burgeoning illegal drug trade—vets selling (or “diverting”) prescription pills—that took place near the hospital itself, which posed a temptation Jason wanted to avoid. “I would like to understand how and why Jason’s police reports ‘disappeared,’” Heather said, quietly furious. “There were reports that were made to Dr. Houlihan, the Tomah VA, the Tomah City Police Department as well as the FBI, regarding patients selling their prescriptions back in 2013, who were making so much money that they had saved enough to put a down payment on a home,” she said.
After her 2015 testimony, the VA declared that its Inspector General’s office—the same one that buried its earlier results—was conducting a criminal investigation. Yet in 2015, it seemed to be a pyrrhic victory. A few Tomah medical officials vilified in the press faced sanctions, such as Houlihan, who was finally fired in November 2015. After briefly having his license suspended, it was restored in April 2016. He was still practicing medicine until he agreed in January 2017 to permanently surrender his license as part of an agreement with state regulators to drop their investigation of him. He had started a new private psychiatry practice in La Crosse early in 2016. “Enjoy life again,” his office’s website promised. Yet, just like Houlihan initially rebounded from the Tomah scandal, there was, it turns out, little sign that the Department of Veteran Affairs could fundamentally change the way it provides mental health care if it continues to uphold a culture that has allowed irresponsible practices to flourish across the country for more than a decade.
Jason’s array of prescriptions didn’t get close media scrutiny—except from the Center for Investigative Reporting—but they pointed to a larger problem. Many VA and civilian doctors were willfully indifferent to the effect of the psychiatric medications marketed so heavily to them as wonder drugs for mental problems. “It is so much simpler to give a pill than to offer complex therapy as treatment,” notes Brigadier General (Ret.) Dr. Stephen Xenakis, a pioneering former Army psychiatrist who is researching more balanced mind-body approaches to PTSD, which avoid high-risk polypharmacy. “There’s not much difference between military and civilian psychiatric practices,” he adds.
For close to two years, when his VA doctor weaned him off the benzodiazepines and eliminated some of his other medications, Jason made progress. He lost weight and worked more often. But in 2014, his life and addictions unraveled again after he saw his family’s dog, Chico, run over by a car, which sent him back to the VA hospital for a three-month stay. His behavior became so bizarre that he even ran around one day at the hospital pulling fire alarms until he was shipped off to the major VA hospital in Madison. He sent desperate text messages to his father: “I can’t take it. I’m going crazy.” The stimulants Adderall or Ritalin worsened his mood, behavior and insomnia. Jason’s doctors had prescribed them to him for a questionable diagnosis of ADHD; it was just one of a dozen or so diagnoses they slapped on him over the years along with bipolar disorder and PTSD.
A day after he went to the Madison hospital, he was released with instructions to wean himself off of Geodon and the benzodiazepine Valium. Two weeks later, after lying around his home while trying to withdraw from some of his drugs, he went back to Tomah for a final time for his addiction and severe anxiety.
Back inside the hospital, Dr. Ronda Davis put him back on Geodon while continuing the regimen of more than a dozen other drugs. Both Jason and his father objected, and Marvin appealed to Davis’s supervisors for a fresh look at his medication and treatment. That infuriated Davis. In a meeting with her, his son and the hospital’s patient advocate a few days before Jason died, she berated Marvin, who worked as a building contractor. “You may know how to build houses and pound nails, but you don’t know anything about taking care of your son,” she said. It was another disturbing sign of what critics of the medical profession see as an arrogance poisoning too many doctors who act as potentates, looking down on their fiefdoms of clinical underlings and patients. Marvin Simcakoski later told the congressional committee, “This really hit me hard to have his doctor tell me I don’t know my son and I caused her a lot of trouble for trying to help my son who needed my help. The reason I called over her head is that my son wasn’t receiving the care from her he needed.” Her only “concession” to his concerns about Geodon and the array of hazardous medications was to substitute the even more dangerous antipsychotic Seroquel for Geodon.
At one point during his stay, Jason knocked on the door of Dr. Davis. The drugs were making him uncomfortable. But when she opened the door in response, she slammed it in his face. Heather, told later about the incident, was enraged. Her husband had been willing to sacrifice his life as a soldier for every American, including the physicians then caring for him. Now they could not show him even common decency. “To know that this is how they treat their patients is devastating and completely unacceptable,” she testified. (Davis, whose prescribing conduct was investigated by state officials, still practices medicine. When she reached an agreement in November 2016 with the state licensing board allowing her to avoid sanctions after she took additional medical training, Davis denied any negligence or improper prescribing in Jason’s death.)
On the Friday night before their next planned visit, Jason called his father to tell him he was feeling better and looked forward to coming back home for his daughter’s twelfth birthday on the upcoming Monday. But the potentially toxic side effects of the newly prescribed Suboxone—recommended a few days earlier by Houlihan to his treating physician, Dr. Davis—were mixing in his bloodstream with tranquilizers. On top of that, in the morning he complained of a migraine, which he hadn’t suffered from before, and they soon added a migraine medication, Fioricet, to the mix. Unfortunately, no one seemed to notice that it posed a major risk of respiratory failure, coma or death when interacting with the Suboxone that was endangering him in combination with his tranquilizers, Tramadol and the antipsychotic Seroquel.
Jason’s wife, daughter and father arrived at 9 a.m. Saturday expecting to greet him as usual outside the hospital or on his floor. Told he had a migraine, they rushed into his room. He was lying on his side, his hand on his head, answering their questions with slurred, incomprehensible words. Marvin testified, “I went to the nurse’s station and asked why he was so messed up and the nurse told me he will be fine in a couple of hours. We left not knowing that we would never see him alive again!”
About five hours later, they returned from their hometown more than an hour away. His dad got a phone call: Jason wasn’t breathing. The staff hadn’t checked up on him while they thought he was sleeping off the migraine, Heather later learned.
Hoping to see him recovered, Jason’s family members met a doctor in the lobby. Jason has died, the doctor said. At first, the staff blamed a brain aneurysm for his death. “I was devastated,” Heather says. “It was the most painful thing to go through after all the challenges Jason and I had lived through.”
For his father, the agony remains. “There isn’t a day that goes by when I don’t relive that morning,” he told the congressional panel. “I regret leaving my son in his room alone that morning only to get a call hours later that he had stopped breathing. I can’t get that thought out of my head; I wish I would have been there for him.”
Heather believes that the VA might reform Tomah, but she isn’t confident that much will happen without scrutiny. “I truly believe if people stop following up with them and pushing them, it will just go back to the way it was,” she says.
Despite her skepticism, Heather and Marvin Simcakoski worked with Senator Tammy Baldwin (D-Wis.) for legislation to curb and monitor opiate overprescribing, and appeared at a news conference in June 2015. The name of the bill: The Jason Simcakoski Memorial Opioid Safety Act.
At a Senate hearing, however, the VA’s representatives and some sen
ators openly wondered whether the bill duplicated current safeguards. After all that had happened at Tomah, they still asked if mandating tougher oversight was even needed.
The legislation sought to curb overprescribing in various ways. On paper, it would upgrade and strengthen guidelines and training; promote alternative, non-drug pain treatments; and ensure real-time monitoring of prescriptions and high-risk health conditions by expanding the scope of the agency’s new, slow-moving Opioid Therapy Risk Report. It was ultimately incorporated into a package of opiate abuse legislation signed into law by President Obama in July 2016.
After her return from Washington in 2015, Heather Simcakoski was hopeful but wary about the bill’s real-world impact. Yet it’s not clear that there will be much improvement. The VA’s vaunted electronic records and drug-interaction alerts too often fail to work in practice, and drug warnings are often brushed aside when they do pop up on screen. Noelle Johnson, a VA pharmacist who was fired from Tomah in 2009 after she refused to fill high doses of opiates, told me that then—and now—the VA’s outmoded software didn’t flag potentially fatal opiate-benzodiazepine interactions or excessive dosages of some dangerous drugs. Pointing to software that didn’t issue alerts for 1,080 morphine pills in thirty days prescribed for a patient in Tomah with “psychological pain,” she also observes of the VA administrators, “My bosses tried to strong-arm pharmacists.” That’s a practice that she says continued at her new post as chief pain pharmacist at the Des Moines VA.
Yet in a rare example of the VA paying out for overmedication, the VA agreed to a legal settlement of over $1 million, including added benefits to the widow of former paratrooper Ricky Green, forty-three. He was killed in 2011 after getting much higher opiates and tranquilizer dosages after back surgery than he’d earlier been receiving since an injury he received in Operation Desert Storm in the 1990s. The Fayetteville VA pharmacists admitted under oath that their software didn’t flag either the higher dosages or that he had a sleep apnea condition that fatally interacts with those drugs.
The VA is still coasting on its twenty-year-old reputation as a pioneer in health software. But little-noticed assessments by the Institute of Medicine, internal IT documents and the MITRE Corporation have found that the agency’s electronics records software is obsolete and that sweeping upgrades are needed to “reduce frequency of adverse events and save lives,” as administrators of the VA’s bungled Pharmacy Reengineering Software project observed a few months before Jason died.
Heather Simcakoski remains justly skeptical about the VA’s reform intentions. “The bottom line comes down to money: will the VA be willing to spend the money to make sure these veterans are functional again?” she asks. For example, it’s doubtful that the VA will truly comply with the law named after her husband. For more than a decade, the VA has not even followed its own mental health treatment and prescribing guidelines. Now this new bill relies primarily on the agency itself to monitor, train and sanction prescribers, although the VA’s toothless Inspector General and the related Office of Medical Inspector have rarely been vigilant. Real prescribing reform appears unlikely.
One glaring sign of the VA’s failure to strongly respond to agency abuses became clear in June 2015, when the acting Inspector General, Richard J. Griffin, was forced out of his post in disgrace after forty-three years of federal service. The Inspector General’s office had responded so poorly to all the far-flung scandals since 2014 that it was brutally pummeled in congressional hearings and in media investigations, especially by USA Today. One of Inspector General Griffin’s several low points was his September 2014 report on the Phoenix wait times which concluded that despite forty people dying while waiting for care, his office couldn’t conclude that “the absence of timely care caused the death of these veterans.” The original whistleblowing doctor at the Phoenix VA, Dr. Samuel Foote, blasted the report as a “whitewash.” Worse, as an alliance of whistleblowers, the VA Truth Tellers, later wrote to President Obama shortly before Griffin resigned, the VA Inspector General used his office to target whistleblowers, rather than address the problems they uncovered.
The Inspector General office’s debacles were spotlighted once again by the Senate governmental affairs committee, chaired by Sen. Ron Johnson (R-Wis.), which concluded in May 2016 that there were “systemic failures” in the Inspector General’s response to the crisis at Tomah. The horrifying details of this so-called VA watchdog that ignored the deaths of dozens of Tomah patients were outlined in a devastating 359-page report issued by committee Republicans. In a rare admission, Sloan Gibson, the then-deputy secretary of the VA, testified at this May hearing in Tomah, “This is a leadership failure.” The report also found that a culture of fear and whistleblower retaliation still continues at the facility.
The indifference to patient safety and the pattern of revenge against whistleblowers was indeed woven into the VA’s warped approach to health care, raising doubts that it could be overcome by Senator Baldwin’s well-meaning legislation to limit high-risk opiate prescribing and other grand reforms. As a White House report concluded in June 2014, “A corrosive culture has led to personnel problems across the Department that are seriously impacting morale and by extension, the timeliness of health care”; it blamed poor management, distrust, retaliation against concerned employees and “a lack of accountability across all grade levels.”
For Heather Simcakoski, the White House report’s conclusions rang true. “The officials felt protected because they’re working at a government agency. They wouldn’t have done anything without all the media attention,” she said. “Before that, all we ever got was the staff telling us, ‘We’re sorry for your loss.’” The VA staff couldn’t even keep the most basic promises: the nurses promised they’d send her twelve-year-old daughter, now facing life without a father, a birthday present, but never did. “They couldn’t even do that,” she says with a hard bitterness that hasn’t yet faded. “Nobody really cared.”
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UNFORTUNATELY, IN THE FACE OF MORE THAN A 50 PERCENT INCREASE IN the numbers of veterans since 2006 grappling with PTSD and other mental illnesses, indifference appears to have been the default mode of the VA’s approach to mental health care. That’s the reality facing the roughly 1.5 million veterans receiving mental health treatment, undercutting all the statistics, hiring and training initiatives, and evolving guidelines the VA’s leadership cite to show their dedication to providing world-class care. The respected Institute of Medicine reported recently, for example, that only half of veterans diagnosed with PTSD were getting the bare minimum of psychotherapy sessions, let alone getting evidence-based treatments. Equally worrisome: the agency doesn’t even bother to measure patient outcomes.
Before the Phoenix and Tomah scandals, VA leaders touted their ambitious plans to implement top-quality mental health programs and they continue to make such claims. Dr. Matthew Friedman, the former executive director of the VA’s National Center for PTSD and now its Senior Advisor, told me, “We promote clinical excellence.” The VA has also been hailed in health reform books (such as Phillip Long-man’s Best Care Anywhere: Why VA Health Care Would Work Better for Everyone) and in prestigious medical journals for outperforming the nation’s leading hospitals in monitoring and treating medical illnesses, such as diabetes. None of those accolades has improved the agency’s approach to mental health care. The Department of Veteran Affairs has not made delivering first-rate, evidence-based mental health treatment the same priority that reforming its medical care was for the agency in the late 1990s.
In April 2014, the VA scandals were exposed when The Arizona Republic revealed that more than forty veterans had died and, in some cases, killed themselves while waiting for care at the Phoenix VA. Yet the agency’s defenders claim that once access barriers are overcome, the care veterans receive from the agency across the country is excellent.
But the new VA scandals and emerging revelations found in lawsuits, whistleblower complaints and previously dow
nplayed or buried Inspector General reports undermined those cheery assertions. The unfolding data-rigging and quality of care scandals spurred at first new VA investigations into more than ninety VA hospitals, as well as DOJ federal criminal probes into forty of those sites, although those investigations seemed to be leading nowhere by 2016. On top of that, the Center for Investigative Reporting showed that in the decade after 9/11, the Department of Veterans Affairs paid $200 million to nearly 1,000 families for wrongful deaths. There would doubtless be far more lawsuits, but the agency is protected by its narrowly legalistic counterattacks against grieving families and court rulings that limit the department’s liability.
The VA’s administrative practices have also incentivized endangering patients’ lives. The agency’s approach across many of its facilities has been to reward administrators and staffers with cash bonuses who meet faked performance and safety goals, to protect wrongdoers and to punish employees who object to unsafe conditions, corruption and rigged data. In 2013, nearly $300 million in extra pay and bonuses were given to top executives and other employees who, investigators later found, often fabricated claims that they met the official wait-time and quality goals.
A leading recipient was one of the very few officials fired in the VA debacle, Sharon Helman, director of the Phoenix VA Health Care System where dozens died waiting for treatment. But she was fired for failing to disclose that she received a trip to Disneyland and other gifts from a lobbyist—not for the delays. A court later ruled that the VA had to return the initial $5,000 garnished from her wages, even though she collected over $41,000 in bonuses awarded for her bogus “outstanding performance” through 2013. Her lawsuit contesting her termination as unconstitutional remained pending in federal court throughout 2016 until an appeals court sided with her in May 2017. She had seemed early on likely to win—until she was sentenced in May 2016 to two years probation for taking thousands in gifts from the lobbyist—because a sloppily written new 2014 law didn’t grant her the right of an administrative appeal. (She still pursued the civil lawsuit after being convicted in criminal court, and the appeals court overturned her firing when it agreed that the new law unconstitutionally restricted her right to appeal to the independent Merit Systems Protection Board [MSPB]. That board for civil service employees seemed likely to uphold the basis of her original firing.)