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Baldwin Provisions to Increase Transparency, Improve Patient Safety at Tomah VAMC Clears Major Senate Hurdle

Language included in appropriations bill passes through committee

WASHINGTON, D.C. – U.S. Senator Tammy Baldwin, a member of the Senate Appropriations and Budget Committees, today applauded the inclusion of several of her provisions aimed at addressing issues at the Tomah VAMC in the bipartisan FY16 Military Construction and Veterans Affairs (MilCon-VA), and Related Agencies Appropriations Bill, which passed the committee by a vote of 21-9. The spending bill now heads to the Senate floor.  

“I was proud to include several priorities in this legislation that respond to the problems and tragedies that have occurred at the Tomah VAMC and help prevent them from ever happening again,” said Senator Baldwin. “I worked to include provisions that can improve transparency of VA Office of Inspector General reports, strengthen protections for whistleblowers, and provide stronger oversight of the VA’s prescribing practices. These are significant reforms that take a serious step in the right direction to ensure we address the underlying challenges at the Tomah VAMC and across the nation. However, I have serious concerns that this appropriations bill does nothing to roll back the devastating cuts we’ve seen due to sequestration. Unless Congress can come together on a bipartisan deal to raise these thoughtless budget caps, I have severe reservations about supporting this legislation moving forward.”

Senator Baldwin Provisions Included in the FY16 MilCon-VA Appropriations Bill:

Whistleblower Enhancement for VA Medical Professionals: Would close an existing legal loophole that harms VA medical professionals who have experienced whistleblower retaliation in the form of a negative personnel evaluation. Currently, the Office of Special Counsel (OSC) cannot investigate these types of retaliation because VA medical professional personnel evaluations are governed by Title 38; while OSC’s relevant investigatory power is limited to personnel evaluations governed by Title 5. Senator Baldwin’s provision would address this inconsistency in the law by including personnel reviews governed by Title 38 within the scope of potential retaliatory personnel actions that OSC can investigate.

Revision of Joint VA and DoD Clinical Practice Guidelines: To help address the prescription drug abuse and overdose epidemic, Senator Baldwin included a provision requiring the VA, working with DoD, to update the joint VA-DoD Clinical Practice Guideline (CPG) for the Management of Opioid Therapy (OT) for Chronic Pain, which has not been updated since 2010. In addition, to ensure prescribers have the most up-to-date science, VA will be required to adopt the safe opioid prescribing guidelines for chronic, non-cancer pain in outpatient settings currently being developed by the Centers for Disease Control and Prevention (CDC).

Expansion of Opioid Receptor Antagonists: Opioid receptor antagonists, such as naloxone, are drugs that reverse the effects of opioids, including respiratory depression, and, in certain cases, can prevent death.  Indeed, the VA’s year-old Overdose Education and Naloxone Distribution (OEND) program, which dispenses take-home naloxone kit prescriptions to at-risk veterans, has been credited with saving 33 lives by reversing opioid overdoses. Senator Baldwin included a provision  to expand this program, ensuring every VA medical facility is equipped with opioid receptor antagonists, as well as improve provider and pharmacist education on overdose prevention strategies.

Joint Executive Council Working Group on Opioids and Pain Management: Senator Baldwin authored a provision to create a new joint VA-DoD working group to focus on patient pain management and opioid therapy.  This working group would be established within the DoD-VA Joint Executive Council—an existing forum for senior leadership at both Departments to develop policies and programs to address overlapping priorities—and would cover, at minimum, opioid prescribing practices, acute and chronic pain management, complementary and integrated health, and the concurrent use of opioids and prescription drugs for mental health issues, including benzodiazepines.  The working group would help combat the VA’s continued overreliance on opioids for pain management; limit instances of VA providers prescribing opioids for mental health treatment, which is non-compliant with joint VA-DoD Clinical Practice Guidelines; and improve patient care during the DoD-VA transition.

Enhancing VHA Opioid Reduction Efforts: VA has had some success reducing the use of opioids to treat pain, including through the Opioid Safety Initiative (OSI) and the use of the Opioid Therapy Risk Report tool.  However, capability gaps exist in these initiatives, and more needs to be done. To help reduce rates of opioid addiction and fatal overdose, it is critical that real-time data is available at the individual prescriber and pharmacist level as well as the pharmacy management level to prevent inappropriate prescribing before it occurs.

Senator Baldwin included a provision that directs the VA to develop and deploy mechanisms for including real-time patient information on existing opioid prescriptions within VHA as well as patient controlled substances prescription information in the state prescription drug monitoring program.  The mechanisms must also alert a provider or pharmacist in real-time that an opioid or benzodiazepine prescription would be inappropriate and protect against “double-prescribing” when an in-patient continues to receive take-home opioid prescriptions despite being treated with opioids at a VA facility.  The provision further directs VA to submit information on controlled substances prescriptions to state prescription drug monitoring programs.

GAO Audit of VA Opioid Therapy: The Center for Investigative Reporting has noted that prescriptions for four opiates – hydrocodone, oxycodone, methadone and morphine – have increased by 270 percent in the past 12 years. This drastic increase has also been seen in local VA facilities, including the Tomah VAMC in Wisconsin. To strengthen oversight of VA opioid prescribing practices, Senator Baldwin included a provision directing the Government Accountability Office, in consultation with the Department of Veterans Affairs, to report to Congress on the effectiveness of the VA Opioid Safety Initiative and overall opioid prescribing practices throughout the VA system. This report shall include recommendations on improvements to the Opioid Safety Initiative, deaths involving veterans prescribed opioids, overall opioid  prescription rates and indications at all VA facilities, including facilities and prescribers that are among the top ten percent in the nation regarding the percent of their patient population receiving opioids and the average dose per patient. In addition, the report shall note the use of benzodiazepines and opioid concomitantly and their prescription rates and indications along with facilities and prescribers that are among the top ten percent in the nation regarding the percent of their patient population receiving opioids and the average dose per patient.

VISN Pain Management Boards and Complementary and Integrative Health: To further help reduce the inappropriate use of opioids for chronic pain and increase the use of complementary and integrative health, Senator Baldwin included a provision that encourages the VA to establish a pain management board within each Veterans Integrated Service Network (VISN) comprised of health care professionals and—to give veterans a greater role in their care—veteran  patients and/or family members of a veteran patient. The pain management boards would serve as a resource for the region’s facilities, patients, and family members; provide best practices recommendations for pain management to the VA facilities within its region, including patient, family member and medical perspectives; provide an annual report to the Secretary of Veterans Affairs about pain management practices within its region, which would then be sent to Congress.

VA Inspector General Transparency Improvements: Senator Baldwin, along with Chairman Mark Kirk (R-IL) authored a provision regarding increasing transparency at the VA Office of Inspector General (OIG).  Based on an amendment Senator Baldwin included in S.579, the Inspector General Empowerment Act, the joint Baldwin-Kirk amendment would amend current law to ensure that when the VA OIG completes a report, it is promptly shared with the VA Secretary, Congress, and the public.  This bill language would help address failures of transparency and agency oversight by requiring recommendations made by the VA OIG during investigations, audits or other reports to be sent directly to the VA Secretary.  In addition, these recommendations would be available to the public and submitted directly to relevant Congressional oversight committees.  Lastly, if the Inspector General initiated an investigation based on information provided by an individual, the recommendations would also be shared with that individual.

GAO Report High Risk List: In 2015 GAO placed VHA on its annual High Risk List, identifying VHA programs as high-risk due to their greater vulnerabilities to fraud, waste, abuse, and mismanagement or the need for transformation to address economy, efficiency, or effectiveness challenges.  Accordingly, Senator Baldwin  included language to require the VA Secretary to issue to Congress quarterly progress reports on Department action to address GAO findings and recommendations.

Armed Forces Retirement Home (AFRH): The bill includes a provision authored by Senator Baldwin requiring the AFRH to report on actions taken to implement recommendations made by the Department of Defense Inspector General (DoD IG) in a July 2014 report.