The other Rand Paul:
R. Paul, MD

This Rand Paul — whose goal is also the Oval Office — tells his peers how he’ll fix the U.S. health-care system.

By Ophthalmology Management staff

Rand Paul feels his peers’ discontent.

Not of those on the Hill. This junior senator from Kentucky, now a presidential contender, understands the angst of his fellow surgeons. From 1993 until his senatorial election in 2010, he practiced ophthalmology in Bowling Green. His memories of filing reimbursement claims — for corneal transplants, cataract and glaucoma procedures — still irk him.

“It [took] me longer to fill out the … forms than to do the surgery,” says the senator and presidential contender in an interview with Ophthalmology Management.

In Salama, Guatemala, Dr. Paul discusses a patient’s eye health with the patient. Notice the media mic in front of Dr. Paul’s shin.
COURTESY SENATOR RAND PAUL

To the senator, the filings are just one indication of a larger, more worrisome syndrome in U.S. health care: too much government intrusion. The 52-year-old father of three lists plenty of other indicators: Mandated quality measures. Lack of tort reform. A lengthy, money-draining drug approvals process.

As for Obamacare, he cites it as the cause of rising health insurance premiums, including his own. “I had for many years, a $5,000 a year deductible… now, it’s $20,000 year. They have mandated all these things underneath the deductible. One thing you cannot get anymore is inexpensive health insurance. They have outlawed comprehensive health insurance.”

While acknowledging “small victories” like eliminating the sustained growth rate, he says, the enormous amount of paperwork, and increasing governmental rules are creating “a lack of morale.” To combat these trends, Dr. Paul believes it is critical that organized medicine “not be a pushover” for government programs.

For example, Dr. Paul says, “If you want to pay physicians 3% more if they turn in some paperwork to government, the assumption is that physicians are trying 3% less than they could. Now, I don’t know any physician who would say, ‘Oh, I’m trying 97% of my capacity to help patients, and I’ll try 3% harder if I receive money for filling out this 15-page form on my exams.’ I’m not a big believer that pushing paper or checking boxes is somehow going to make better doctors.”

Of course, health care is a topic that will likely figure prominently in the 2016 presidential contest. In his conversation with OM, Dr. Paul discussed what he sees as the problems in our health-care system and the solutions he would propose.

No middleman

If Dr. Paul had his way, free market would describe how U.S. citizens conduct business, how patients find a doctor. It is wrong, Dr. Paul says, to place a middleman between a patient and his physician. Why is medicine the lone enterprise that the government: a) imposes its definition of what quality is; and b) dictates how physicians will be rewarded for achieving said definition, he asks.

“Do we need the government to have people who make iPads to fill out forms and send them to the government until we get quality iPads? The reason you have a quality iPad that dominates the market is because consumers choose the best quality.”

To a large extent, people recognize the best physicians because they acknowledge them as having the best diagnostic and surgical acumen, Dr. Paul says. Transparency is good — some of that the market does dictate — such as infection rates. “But top down, where the central authority decides how quality is determined, is inconsistent with how our marketplace works. We don’t do it for anything else, and we seem to achieve quality in so many other things. Why would medicine be the one area where government has to dictate it?”

In his discussions with his own constituents, and with citizens across the country, Dr. Paul finds they too tend to dislike any “middleman” — whether it’s government or an insurance company — coming between them and their doctor. “I think one of the things that hurt the president the most … was when it became apparent that his promise [regarding Obamacare] that ‘If you like your doctor, you can keep your doctor’ wasn’t true. I think people don’t like the idea that their selection of doctor will be taken away from them through any kind of mandatory program.”

A real “fix”

So is it possible to achieve health-care reform that would eliminate middlemen, or at least reduce their role, and keep costs down? Dr. Paul believes so. While he wants to replace Obamacare, he knows that the previous system included its share of significant problems. “The system that I practiced medicine under, I heard complaints about every day, including from people who are friends and politically aligned with me — they complained because of cost.”

U.S. Sen. Rand Paul (R-Ky) speaks at an event sponsored by the Missouri Republican Party to honor former Vice-Chairman Susie Eckelkamp with the Spirit of Reagan award in Frontenac, Mo. in May 2013.
GETTY IMAGES

The two big problems he sees are cost and access. “President Obama sort of fixed the access problem but at the expense of the cost. Nothing is free. He gave everyone access, but then those who are paying for their insurance are going to have to pay more, the people paying taxes are going to have to pay more.”

Prices were rising so quickly under the pre-ACA system, Dr. Paul says, because the patient was separated from the cost of the service. “When the doctor doesn’t care about the price and the patient doesn’t care about the price, then the price will go up much faster than other areas of the economy.” Contrast that phenomenon, he says, with medical services in which people pay out of pocket, such as elective plastic surgery and refractive surgery. “The average person who gets LASIK surgery calls four different surgeons before they get it done — and they ask for price.”

As another example, Dr. Paul cites those in his community from the Mennonite faith who don’t get insurance due to religious reasons. “They call in advance; they want to know price,” he says. “They will negotiate the price. And negotiating and caring about the price brings it down.”

Dr. Paul (right) and Dr. Alan Crandall, co-director of the outreach division of the Moran Eye Center, work in tandem on a patient during the charity mission in Salama, Guatemala.
COURTESY SENATOR RAND PAUL

Health savings accounts with high deductibles and lower premiums thus would be helpful, Dr. Paul believes. “Competition works,” he notes. “What you have to do is connect, or allow the consumer/patient to be connected to the price, and directly to the doctor without interference by government or insurance.”

Torts and trials

Dr. Paul also believes that “tort reform is an important part” of trying to fix the health-care system, but that fix won’t come from the president. “There is resistance from the other side of the aisle.”

Which is unfortunate. More physicians are moving to states — like California and Texas — that have adopted tort reform, because business is better, he says. But in states like his “where the trial lawyers still control the state legislature,” defensive medicine adds to costs, detracts from quality and patients must endure many tests.

Another systemic problem that Dr. Paul feels needs a makeover is the speed, or lack thereof, in which drugs and devices get to market. The system needs streamlining, he says. Our country should share and use data from other countries, especially from those countries where a drug, in trials in this country, has been in use for many years there. “I would think that [usage data] is bigger than any other trial that we would have here.”

Colleagues weigh in

David F. Chang, MD, clinical professor, University of California, San Francisco worked with Dr. Paul last year when the two physicians performed outreach cataract surgery in Guatemala with a team from the John A. Moran Eye Center, University of Utah Health Care.

Dr. Chang says the Guatemalans presenting for surgery had the most challenging cataracts that any American ophthalmologist might face — small pupils, mature white and brunescent nuclei, pseudoexfoliation, poor corneal visibility and a frequent history of trauma.

In addition, physician senators, unlike their House counterparts, cannot maintain a practice while holding public office. So, an eye surgeon on sabbatical who wants to look good before the media who are covering his every move might avoid the developing world. And the reporters: They were in the clinic and in the operating room, where they would take turns observing.

“I was impressed that Sen. Paul was willing to tackle these cases, but that he also knew when to turn over a case that was becoming too complicated,” says Dr. Chang. “At first, I was a little hesitant to offer surgical advice, but in fact he welcomed suggestions and was quick to pick things up.”

Barbara Bowers, MD, in private practice in Paducah, Ky., has also performed pro bono work with Dr. Paul. She too was impressed that Dr. Paul’s surgical skills had not atrophied despite his new “day job.”

“I was amazed at how he just walked into my OR and sat down at my microscope and used my phaco machine and my instruments to do the absolute toughest hand motion/light perception cataracts. It takes a great surgeon to do that.”

He never requests any special instruments or blades, Dr. Bowers adds — he just adapts and uses what he has at his disposal. She called his surgeries “exquisite.”

Dr. Chang says that Dr. Paul’s message resonated with ophthalmologists when he spoke last year at the ASCRS annual meeting. “One of his main messages is that eliminating free market forces in order to have the government micro-manage health-care delivery will only increase waste and inefficiency.”

According to the ASCRS website, Dr. Paul spoke before a “packed audience” at the 2014 ASCRS meeting in Boston. He encouraged his peers to get involved in the legislative process. “Without input from practitioners in the field who understand the impact on patient care, laws and regulations will not meet the goal of encouraging improved quality of care.”¹

He is a co-sponsor of ASCRS-deemed priority legislation, including repeal of the Independent Payment Advisory Board and postponement of ICD-10 implementation.²

In the Oval Office

Dr. Paul believes a physicians’ skill set translates well to elected office. “Doctors don’t care about your religion, we don’t care about your politics, we don’t care about anything as regards to opinion. We try to solve a problem, and I think we need more of that in politics.” He cites instances of having brought this pragmatic, problem-solving attitude to his job as senator. “While I am someone who has strong beliefs, I try not to let party get in the way of those beliefs. I have strong beliefs about privacy, and I’m willing to work with progressive Democrats on those beliefs; I have strong beliefs about criminal justice and I’m willing to work with progressives on that; I have strong beliefs about balancing the budgets and low taxes and shrinking government that I have in common with conservatives.”

Dr. Bowers says Dr. Paul would bring to the Oval Office or to any job, his intelligence, drive to educate himself about issues with which he’s not familiar, decisiveness, leadership and his conviction to stand for what he believes in. Dr. Chang believes the qualities he brings as a physician translate well to political office. “We learn to make difficult decisions by researching and relying on evidence, seeking multiple opinions, valuing teamwork and admitting when we are wrong or don’t know the answer. Sen. Paul certainly embodies these traits that explain why physicians so often make great leaders.”

As for Dr. Paul, he agreed with Dr. Chang, adding what he saw as a major advantage: “There are too many lawyers in Washington.” OM

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