Frederica Freyberg:

Whistle blowers and families joined Congressional leaders at a Tomah hearing. At issue, a systematic over prescription of medication that led to veterans dying at the Veteran Affairs Medical Center.

Noelle Johnson:

The quantities of narcotics is irrefutably unsafe. This has been demonstrated by several cases of overdose and death. Over 2,000 calls were made from the Medical Center, with 24 unexpected deaths over five years. This is unacceptable. Three of those deaths occurred in a four-month time frame in the year that I worked at the Tomah VA.

Frederica Freyberg:

U.S. Senator Ron Johnson led the hearing.

Ron Johnson:

Revelations of the problems at Tomah have prompted additional whistle blowers to contact our Committee with indications that indicate systemic problems within the VA. Legislatively this hearing is just the first step.

Frederica Freyberg:

U.S. Senator Tammy Baldwin and Congressman Sean Duffy, Mark Pocan and Ron Kind also took part in the hearing. Congressman Ron Kind, who represents the part of the state where the Tomah VA is located, joined us earlier this week to discuss what happened at the hearing, as well as what comes next. Congressman Ron Kind, thanks very much for being here.

Ron Kind:

My pleasure.

Frederica Freyberg:

What was the value of the holding the joint Committee hearing in Tomah?

Ron Kind:

I thought it was a great opportunity for the Congressional Committees to come to Tomah and hear firsthand what took place there and allow the witnesses, especially the family members, to offer their testimony, which was very compelling, very heartfelt and very tragic at the same time. Congress has a responsibility to identify a problem if it exists, in Tomah or anywhere else in the VA system, and figure out a way to fix it so all our veterans are getting the care and treatment they earned and deserved.

Frederica Freyberg:

What did you learn that you hadn’t known before?

Ron Kind:

Well, there is more need for a collaborative approach when it comes to pain management practice, complementary and alternative forms of medicine that can be applied rather than establishing cocktails and going with pain medication drugs. There are protocols of care and best evidence medicine that does work and we need to start instituting that in a system-wide basis. Tomah’s in the heart of my district. They typically rank in the top 10% in quality measures and metrics, but clearly there’s been a doctor there, whether it’s been a rogue doctor or whatever. There should never be a situation where anyone is fearful of coming forward with ideas or complaints that they might have for fear of any retaliation or even losing their job.

Frederica Freyberg:

What is the number of veterans or patients that died at Tomah VA as a result of drug toxicity?

Ron Kind:

Well, that’s still being established, but we had three families that were there yesterday that had stories to share of how they lost their loved ones, veterans who were getting cared and treatment at Tomah. Senator Baldwin highlighted about a half a dozen more that she wanted Dr.Clancy to also look into. As we get into this, I think more information is coming forward and more people are feeling safe enough to come forward to share what they know, what took place.

Frederica Freyberg:

Do you believe that what happened at the Tomah VA is kind of the tip of the iceberg for the VA across the country? Or do you believe it was an isolated practitioner?

Ron Kind:

Well, there’s certain aspects of what happened in Tomah that could be isolated based on the personalities there, but I think the overall message when it comes to proper pain medication practice with veterans, I don’t think it’s unique to Tomah. I think it’s a system-wide problem and not just unique to the VA system, but throughout the entire health care systems, difficulties that overall health care providers are having with pain management techniques. And so that’s one reason why Representative Ribble, here in Wisconsin, and I teamed up to offer the pain management improvement act, calling for pain management boards to set up a more collaborative process of reviewing case files, collecting the data, using best evidence medicine practices, but also getting the veterans and family members themselves participating on the Boards so they have a say in all of this. And sometimes that gets overlooked when it comes to health care decisions, is what the veterans and also the family members, who are on the front line, and they know when things aren’t working or that are working, to make sure that they’ve got an avenue for their voices to be heard.

Frederica Freyberg:

Knowing what you know now about what happened at Tomah specifically, what is the level of outrage out there?

Ron Kind:

Well, there’s a lot of concern about how pervasive this is, but also the staff is worried that they’re being painted with too wide a brush, since there is a lot of dedicated professionals who are doing a nice job of delivering the quality of care that our veterans need. But to Secretary McDonald’s credit and Undersecretary Clancy, when Senator Baldwin and I immediately contacted them when the stories came out, they knew they had to get back in there and do a dual track medication, not only on how pain management is being practiced, but this alleged culture of intimidation or coercion that may have existed at Tomah.

Frederica Freyberg:

Do you think that that culture may exist, again, VA-wide?

Ron Kind:

I think this also is an opportunity for Congress to step up the protections with our whistleblowers throughout the nation. We need people who are at the front lines, and if they see something that is not working or does not make sense, to have the safety and the confidence to come forward with that information without fear of retaliation. So we need to look at the whistleblower statute as it exists right now, find out why it did not work that well in the case of Tomah and make sure it’s not repeated.

Frederica Freyberg:

What consequences might you be looking for for VA staff involved in both bad patient care and this retaliation?

Ron Kind:

Well, again, to Secretary McDonald’s credit, he has removed the Chief medical staff doctor, where all fingers seem to be pointed right now.

Frederica Freyberg:

He’s still employed by VA.

Ron Kind:

He’s still employed pending outcome of the investigation. There are due process elements involved. They also removed the director of Tomah and reassigned him, as well. Hopefully that’s creating a safer environment for staff and for our health care providers to be able to come forward with information that they need to be sharing with the investigative teams.

Frederica Freyberg:

What’s your understanding of what’s happening right now at Tomah? Has the culture changed dramatically there?

Ron Kind:

Well, you know, couple years ago I received an anonymous complaint laying out some of these allegations and I immediately forwarded it on to the Office of Inspector General and that in part precipitated the two-year investigation that the Inspector General did. At the conclusion of that report, they had findings, but also recommendations that they wanted to see implemented at Tomah. To Tomah’s credit, they immediately started putting that in place last year already. Last year we had a system-wide survey from the Inspector General’s office on pain medication, with five specific recommendations, and that, too, is being moved forward in the VA system and to be implemented. That’s why I’m hoping that we’re going to be able to conclude these investigations as quickly as possible, get to the bottom so if there are problems that need further fixing, that we can move forward on it right away.

Frederica Freyberg:

Congressman Ron Kind, thanks very much.

Ron Kind:

Thank you.