02.11.15

U.S. Senator Tammy Baldwin Raises Concerns about VA Mismanagement and the Veterans Health Administration’s Lack of Oversight of Individual VA Facilities

At Homeland Security and Governmental Affairs Committee hearing, Baldwin highlights problems at Tomah VA as clear example of how systemic failure of VA management and oversight harms patient care

U.S. Comptroller General cites “lack of compliance with existing policies” and “inadequate oversight and accountability”  

Washington, D.C. – Today, U.S. Senator Tammy Baldwin (D-WI) attended a hearing of the Homeland Security and Governmental Affairs Committee and highlighted problems at the Tomah VA Medical Center (VAMC) as a clear example of systemic failures of management and oversight by VA leadership and the Veterans Health Administration (VHA) as well as inconsistent and noncompliant processes at individual facilities.

“It appears that the Veterans Health Administration lacks not only clear and appropriate system-wide policies and protocols, but also lacks the ability to ensure that they are followed at the facility and the regional VISN level,” Baldwin said during the hearing. “For example, at the Tomah VA facility in Wisconsin, current and former employees and veteran patients have brought to my attention allegations of inappropriate opioid prescription practices and abuse of administrative authority, including retaliation against whistleblowers. This facility is currently under investigation by Secretary McDonald, and we all hope that it yields positive results.  But make no mistake: extremely troubling issues have come to light regarding the VA and this specific facility, and I believe that Congress is going to have to act in a variety of ways to make improvements so that our veterans in Wisconsin receive the care that they deserve.” 

The hearing, entitled “Risky Business: Examining GAO's 2015 List of High Risk Government Programs” featured Eugene L. Dodaro, U.S. Comptroller General of Government Accountability Office (GAO). Since 1990, at the beginning of every new Congress, the GAO releases and reports to Congress on its High Risk List, which highlights the highest risk and most vulnerable aspects of the federal government. Since 2000, the GAO has reported on VA facilities’ failure to provide timely care to veterans, which at times, has caused serious harm or death to these individuals. While the VA has taken action to address some GAO recommendations, more than 100 recommendations have not been fully addressed. Of note, this year, the GAO added VA Healthcare to its list of high risk government programs.

In response to Baldwin’s concerns, U.S. Comptroller General Dodaro cited a “lack of compliance with existing policies” by the VHA. Debra Draper, a Director with GAO’s Health Care Team, acknowledged that the VHA is “a system that is in need of major transformation.”

Baldwin also questioned U.S. Comptroller General Dodaro about findings in a separate GAO report from November 2014 that underscore the types of mental health treatment and prescribing problems at the Tomah VAMC, points to a systemic lack of oversight throughout the VA, as well as raises concerns about the delivery of appropriate care at individual facilities.

“VA policy states that antidepressant treatment must be consistent with the VA’s current clinical practice guidelines; however, the GAO’s review of medical records identified deviations from those guidelines for most veterans reviewed,” Baldwin said. “And I will quote the report now, ‘As a result, VA does not know the extent to which veterans with Major Depressive Disorder who have been prescribed antidepressants are receiving care as recommended in the clinical practice guidelines and whether appropriate actions are taken by VAMCs to mitigate potentially significant risks to veterans.’ In other words, the VA doesn’t know if veterans with severe mental illnesses are getting the correct care.  This is completely unacceptable.”