- Email: [email protected]
Agency-Dispensing Practices
EDITORIALS
660
the long run, an unwillingness to tol erate open discussion of detail as well as principle would bring us neither credit nor advantage. W. H. Crisp. AGENCY-DISPENSING PRACTICES Allegedly with the idea of eliminating or at least reducing subterfuge, and after dis cussion with many persons, and possibly also in order to comply with Government regulations without embarrassment to ref ractionists, and probably to induce refractionists to send their prescriptions to them to be filled, certain companies have adopted a policy which they call agency dispensing. This consists in a written agreement between the licensed refrac tionist and the optical company by the terms of which the refractionist appoints the company as his agent for the dis pensing of eye glasses to the refractionist's patient and authorizes the company to collect from the patient for the re fractionist a sum designated by him in payment for the merchandise. The com pany credits the account of the refrac tionist with the money paid by the patient and sends any balance in this account at the end of each month to the refrac tionist or to any individual or organiza tion designated by the refractionist. The refractionist indicates to the dispenser the method of collection to be employed in the individual case, whether the transaction is to be on a cash or a credit basis. The risk of credit is assumed by the refractionist. All material and service charges are immediately charged to the refractionist's account for whom the agent acts. The agent credits the account of the refractionist with any money col lected from the patient and the resulting credit balance, if any, is sent to the re fractionist at the end of each month. The dispenser assumes the task of the interim
care of the adjusting of the patient's glasses at no further cost to the patient. If, however, the refractionist desires to make a change in the prescription for which he thinks the patient should not pay additionally—for example, if the re fractionist makes a change in the lenses within a few weeks after the original prescription because the patient is not comfortable with the new lenses—the cost of such replacements is charged to the refractionist's account. A notice is displayed in the office of the dispenser that is worded as follows: "Glasses are dispensed only on Rx of and as agent for licensed refractionists." A receipt is given to the patient which states that, ". . . dollars, have been re ceived for the account of Dr. . . ." This agency-dispensing policy has been discussed previously in the Journal, but since it is a matter of extreme importance to ophthalmologists, some reiteration and enlargement of the scope of the discus sion seems warranted. It is obvious that there are many cities in the United States which do not now have dispensing op ticians who perform no refractions them selves. The Guild of Prescriptions Opti cians, whose code precludes the refract ing of patients by its members, has an enrollment of approximately 225 firms. The problem of how ophthalmologists who do not live in communities in which nonrefracting opticians are located shall handle their prescriptions for glasses has always been one extremely difficult of solution. The method of purchasing sup plies from the lens wholesaler and him self assuming the task of fitting the frames, making the constant adjustments, and undertaking the financial responsi bility for the commercial element in the transaction has been one that has been distasteful to numerous ophthalmologists. Many of these have welcomed the agency-dispensing plan as being a simple
EDITORIALS solution to their difficulties in that it pro vides excellent service to the patient at no cost above that of the average dis pensing optician, and it can scarcely be doubted that it has been employed by many ophthalmologists as a means of additional remuneration for the ocular care of the patient. It is the contention of the writer that any practice that gives a hidden fee to the physician, whether it be through the dispensing of glasses, orthopedic appli ances, hearing devices, or drugs, the re ferring of patients to unscrupulous mor ticians or shyster lawyers for a monetary consideration, is unethical. This, how ever, is an entirely negative approach to the subject. The young ophthalmologist must have positive guidance. It, there fore, devolves upon those who formulate policies for organized medicine to advise young men placed under a variety of circumstances and conditions how they should proceed. The question arises whether it is possible for the agencydispensing policy to be so conducted as to be acceptable to those who abide strictly by the provisions of the policy currently in effect in the American Medi cal Association, or not. It would seem that this could be done if the opticians engaging in this practice would take the stand that they would not return to the doctor any balance that might accrue in the doctor's account, but would utilize it to reduce the general cost of glasses to the public. Or, if this policy would meet with too much opposition from nonrefracting opticians and optometrists for it to be tenable, as seems not unlikely because it would inevitably lead to a general reduction in the retail price of glasses, it could still be agreed between refractionists and dispensers and openly proclaimed to patients that any monies accumulating to the credit of the indi vidual doctor would not be given to this
661
doctor, but would be paid to any recog nized charity or educational organization designated by the doctor. This would re move the onus of improper action from the doctor, but would not help in the fundamental problem of decreasing the cost of glasses to the patient and prob ably would not be very satisfying to the patient, who would consider that any excess profit should be removed from the transaction. If it can be shown that those utilizing the agency-dispensing policy charge less than those who do not use it because of the credit that the agency gives them, this would be a good talking point for those advocating the plan; but evidence of this is practically impossible to obtain. It seems to the writer that the ophthal mologist who practices in a city where no optical service is available which merely fills the prescriptions without entering into any financial agreement with the refractionist would be acting as ethically as pos sible if he added a clause to his contract with the agency-dispensing organization in which it is stated that it has been agreed that he would not personally participate in any profit from the sale of glasses, but that any such profit accruing to his credit would be contributed at his designation to some recognized charitable or educational institution. This would keep the eye phy sician's relationship with his patient on the high plane on which it belongs and retain the confidence of the public in the integrity of the doctor. By implication it might be argued that his having any type of contract with an agency-dispensing company im plied a tacit agreement with the underlying policy of that company. However, if he has no alternative but to utilize these com panies, his action would certainly be con sidered the best possible one under the circumstances and therefore above criti cism. If these suggestions should prove as
662
BOOK NOTICE
unpopular as the writer imagines they will, the least that dispensers and ref ractionists should do would be to inform the patient in unequivocal language that the refractionist was receiving a re muneration of unspecified amount in ad dition to the fee paid by the patient di rectly to him. As the matter now stands, it seems that the signs in the optician's office and the receipts given to the pa tients are too ambiguous to convey this information to many of those who are the unsuspecting third parties in these transactions. With tongue in cheek the writer would suggest substituting the word "prescription" for the technical "Rx" and adding a phrase so that the notice in the agency office shall read: "Glasses are dispensed only on prescrip tion of and as agent for licensed refractionists who may participate in any profit that might accrue from this transaction." Lawrence T. Post.
BOOK NOTICE INDUSTRIAL OPHTHALMOLOGY. By Hedwig S. Kuhn, M.D. Clothbound, 294 pages, 114 text illustra tions including two color plates. St. Louis, C. V. Mosby Co., 1944. Price $6.50. This excellent book will be of unusual interest to all who practice industrial ophthalmology and truly an eye opener to those not engaged directly in this type of work. The importance of complete familiarity on the part of the ophthalmolo gist with the problems of industries and his actual occasional presence in the plants, to the employees of which he gives service, is brought home strikingly to the reader. Most ophthalmologists probably never visit industrial plants with a view to help ing solve the eye problems connected with them, but merely perform refrac tions, when the employees are sent from
the factories, and take care of injuries, and occasionally represent the company or the individual in court. The possibility of being of service in the plants and to the workers therein by instituting good lighting, advocating the use of protective goggles especially adapted for the work for which they are to be used, and the prescribing of spectacle lenses arranged for the proper working distances of the individual are subjects carefully considered by the author. The material used in preliminary examination, the need of special test ob jects such as those for stereopsis, color, and others for particular types of work, are outlined. Considerable space is given to the evaluation of visual defects in the production of accidents. The reader will be convinced that his expert advice, pro vided he has educated himself properly to give such advice, will be of great im portance to the plant in increasing pro duction and saving lost hours from in effective work due to poor vision and in the prevention of accidents. An excellent chapter on industrial in juries from solid bodies has been written by Dr. Albert C. Snell. Prophylaxis and treatment are included. Many seemingly trivial but undoubtedly important points are brought out in the chapter on eye protection. Attention is called to such matters as the care of goggles and the importance of having clean paper or antifogging solution readily available. Another point is the value of the con stant attendance in large plants of an op tician with an instrument carriage that can be moved from worker to worker for the adjustment of the spectacles, for the repair of breaks, and in general for servicing spectacles. Considerable discussion is given to welding, also to actinic or flash conjunc tivitis and epidemic keratoconjunctivitis. In the appendix are discussed toxic
660
the long run, an unwillingness to tol erate open discussion of detail as well as principle would bring us neither credit nor advantage. W. H. Crisp. AGENCY-DISPENSING PRACTICES Allegedly with the idea of eliminating or at least reducing subterfuge, and after dis cussion with many persons, and possibly also in order to comply with Government regulations without embarrassment to ref ractionists, and probably to induce refractionists to send their prescriptions to them to be filled, certain companies have adopted a policy which they call agency dispensing. This consists in a written agreement between the licensed refrac tionist and the optical company by the terms of which the refractionist appoints the company as his agent for the dis pensing of eye glasses to the refractionist's patient and authorizes the company to collect from the patient for the re fractionist a sum designated by him in payment for the merchandise. The com pany credits the account of the refrac tionist with the money paid by the patient and sends any balance in this account at the end of each month to the refrac tionist or to any individual or organiza tion designated by the refractionist. The refractionist indicates to the dispenser the method of collection to be employed in the individual case, whether the transaction is to be on a cash or a credit basis. The risk of credit is assumed by the refractionist. All material and service charges are immediately charged to the refractionist's account for whom the agent acts. The agent credits the account of the refractionist with any money col lected from the patient and the resulting credit balance, if any, is sent to the re fractionist at the end of each month. The dispenser assumes the task of the interim
care of the adjusting of the patient's glasses at no further cost to the patient. If, however, the refractionist desires to make a change in the prescription for which he thinks the patient should not pay additionally—for example, if the re fractionist makes a change in the lenses within a few weeks after the original prescription because the patient is not comfortable with the new lenses—the cost of such replacements is charged to the refractionist's account. A notice is displayed in the office of the dispenser that is worded as follows: "Glasses are dispensed only on Rx of and as agent for licensed refractionists." A receipt is given to the patient which states that, ". . . dollars, have been re ceived for the account of Dr. . . ." This agency-dispensing policy has been discussed previously in the Journal, but since it is a matter of extreme importance to ophthalmologists, some reiteration and enlargement of the scope of the discus sion seems warranted. It is obvious that there are many cities in the United States which do not now have dispensing op ticians who perform no refractions them selves. The Guild of Prescriptions Opti cians, whose code precludes the refract ing of patients by its members, has an enrollment of approximately 225 firms. The problem of how ophthalmologists who do not live in communities in which nonrefracting opticians are located shall handle their prescriptions for glasses has always been one extremely difficult of solution. The method of purchasing sup plies from the lens wholesaler and him self assuming the task of fitting the frames, making the constant adjustments, and undertaking the financial responsi bility for the commercial element in the transaction has been one that has been distasteful to numerous ophthalmologists. Many of these have welcomed the agency-dispensing plan as being a simple
EDITORIALS solution to their difficulties in that it pro vides excellent service to the patient at no cost above that of the average dis pensing optician, and it can scarcely be doubted that it has been employed by many ophthalmologists as a means of additional remuneration for the ocular care of the patient. It is the contention of the writer that any practice that gives a hidden fee to the physician, whether it be through the dispensing of glasses, orthopedic appli ances, hearing devices, or drugs, the re ferring of patients to unscrupulous mor ticians or shyster lawyers for a monetary consideration, is unethical. This, how ever, is an entirely negative approach to the subject. The young ophthalmologist must have positive guidance. It, there fore, devolves upon those who formulate policies for organized medicine to advise young men placed under a variety of circumstances and conditions how they should proceed. The question arises whether it is possible for the agencydispensing policy to be so conducted as to be acceptable to those who abide strictly by the provisions of the policy currently in effect in the American Medi cal Association, or not. It would seem that this could be done if the opticians engaging in this practice would take the stand that they would not return to the doctor any balance that might accrue in the doctor's account, but would utilize it to reduce the general cost of glasses to the public. Or, if this policy would meet with too much opposition from nonrefracting opticians and optometrists for it to be tenable, as seems not unlikely because it would inevitably lead to a general reduction in the retail price of glasses, it could still be agreed between refractionists and dispensers and openly proclaimed to patients that any monies accumulating to the credit of the indi vidual doctor would not be given to this
661
doctor, but would be paid to any recog nized charity or educational organization designated by the doctor. This would re move the onus of improper action from the doctor, but would not help in the fundamental problem of decreasing the cost of glasses to the patient and prob ably would not be very satisfying to the patient, who would consider that any excess profit should be removed from the transaction. If it can be shown that those utilizing the agency-dispensing policy charge less than those who do not use it because of the credit that the agency gives them, this would be a good talking point for those advocating the plan; but evidence of this is practically impossible to obtain. It seems to the writer that the ophthal mologist who practices in a city where no optical service is available which merely fills the prescriptions without entering into any financial agreement with the refractionist would be acting as ethically as pos sible if he added a clause to his contract with the agency-dispensing organization in which it is stated that it has been agreed that he would not personally participate in any profit from the sale of glasses, but that any such profit accruing to his credit would be contributed at his designation to some recognized charitable or educational institution. This would keep the eye phy sician's relationship with his patient on the high plane on which it belongs and retain the confidence of the public in the integrity of the doctor. By implication it might be argued that his having any type of contract with an agency-dispensing company im plied a tacit agreement with the underlying policy of that company. However, if he has no alternative but to utilize these com panies, his action would certainly be con sidered the best possible one under the circumstances and therefore above criti cism. If these suggestions should prove as
662
BOOK NOTICE
unpopular as the writer imagines they will, the least that dispensers and ref ractionists should do would be to inform the patient in unequivocal language that the refractionist was receiving a re muneration of unspecified amount in ad dition to the fee paid by the patient di rectly to him. As the matter now stands, it seems that the signs in the optician's office and the receipts given to the pa tients are too ambiguous to convey this information to many of those who are the unsuspecting third parties in these transactions. With tongue in cheek the writer would suggest substituting the word "prescription" for the technical "Rx" and adding a phrase so that the notice in the agency office shall read: "Glasses are dispensed only on prescrip tion of and as agent for licensed refractionists who may participate in any profit that might accrue from this transaction." Lawrence T. Post.
BOOK NOTICE INDUSTRIAL OPHTHALMOLOGY. By Hedwig S. Kuhn, M.D. Clothbound, 294 pages, 114 text illustra tions including two color plates. St. Louis, C. V. Mosby Co., 1944. Price $6.50. This excellent book will be of unusual interest to all who practice industrial ophthalmology and truly an eye opener to those not engaged directly in this type of work. The importance of complete familiarity on the part of the ophthalmolo gist with the problems of industries and his actual occasional presence in the plants, to the employees of which he gives service, is brought home strikingly to the reader. Most ophthalmologists probably never visit industrial plants with a view to help ing solve the eye problems connected with them, but merely perform refrac tions, when the employees are sent from
the factories, and take care of injuries, and occasionally represent the company or the individual in court. The possibility of being of service in the plants and to the workers therein by instituting good lighting, advocating the use of protective goggles especially adapted for the work for which they are to be used, and the prescribing of spectacle lenses arranged for the proper working distances of the individual are subjects carefully considered by the author. The material used in preliminary examination, the need of special test ob jects such as those for stereopsis, color, and others for particular types of work, are outlined. Considerable space is given to the evaluation of visual defects in the production of accidents. The reader will be convinced that his expert advice, pro vided he has educated himself properly to give such advice, will be of great im portance to the plant in increasing pro duction and saving lost hours from in effective work due to poor vision and in the prevention of accidents. An excellent chapter on industrial in juries from solid bodies has been written by Dr. Albert C. Snell. Prophylaxis and treatment are included. Many seemingly trivial but undoubtedly important points are brought out in the chapter on eye protection. Attention is called to such matters as the care of goggles and the importance of having clean paper or antifogging solution readily available. Another point is the value of the con stant attendance in large plants of an op tician with an instrument carriage that can be moved from worker to worker for the adjustment of the spectacles, for the repair of breaks, and in general for servicing spectacles. Considerable discussion is given to welding, also to actinic or flash conjunc tivitis and epidemic keratoconjunctivitis. In the appendix are discussed toxic