Mail Order: Nightmare or Reality

Carol A. Schwartz, O.D., MBA
April 1999

Mail-order companies have made many practitioners uneasy. See what they have to say about this new presence in the market.

Just when you think mail order couldn't possibly get any tougher, they come up with a new twist. Contact lenses are now being offered as a benefit to Amway distributors through Lens Expresss. Not that Amway is getting into the business of steering their members to other health care products, such as prescription medications or mamography. No, an Amway spokesperson confirmed that contact lenses are the only prescription product on the plan, which includes Jiffy-Lube, Avis and Gateway 2000.

Mail-order shopping is most prevalent in the United States, with more than 30 firms claiming to offer the best service at the lowest price. The United States dominates the list with 31 entries, the United Kingdom and Europe each have two mail order suppliers, and Australia, Canada, Oman, France and Israel log in with one firm each. Although not a complete list, this indicates the extent of the problem in this country and the potential for it spreading. 1-800 Contacts claims to be the largest mail order firm in the country. Their sales have increased from $500,000 in 1995 to an estimated $60 million in 1998 -- nearly a 2,000 percent increase in three years! Each day the Utah-based firm ships 50,000 lenses to patients, many of them sold through the Internet or obtained through the diversion of grey market. There's no point looking backward. Yes, mail order could have been prevented, but the genie is out of the bottle and there's no way we can shove it back in. Acknowledging that it's here to stay does not mean that practitioners shouldn't have some valid concerns and take measures to protect their patients from the worst abuses. The major concern cited by expert practitioners and educators is patient health. They fear that patients could be lost to follow-up and may neglect routine eye-health screenings.

"As an educator, I emphasize the importance of preventative health care," says Edward S. Bennett of the University of Missouri-St. Louis School of Optometry. "With mail order, patients may not be encouraged to return to their practitioner and may be seen less frequently. Therefore, not only are contact lens induced complications not observed until the patient is symptomatic, but glaucoma and retinal disease may not be caught in the earliest stages."

There have been many cited cases of mail-order companies ignoring expiration dates or the limits indicated on prescription refills. Practitioners are also concerned about unauthorized substitutions and related problems and see themselves in the role of quality-control supervisor, making sure that the patient's contact lens is correct, optimum for their eyes and not causing any ocular injury.

Liability Issues Addressed

"My chief concern is that selling contacts via mail order greatly reduces the quality control of the provider," says Daniel C. Harris, O.D. of Piqua, Ohio. "If providers are to be held responsible for the health of patients' eyes, they should also be able to control what goes on their eyes."

Part of the practitioner's problem in this role is that there is no reliable way to know if a substitution was made. When a patient returns with a problem wearing a mail-order lens, it may be difficult for the practitioner to verify that it's the same contact lens as originally prescribed.

Internet-ordering, while convenient for the patient, is a great potential source of error. The patient fills out their prescription from information on their prescription or the box in which their current lenses were provided. It's easy for patients to make mistakes in transcribing their parameters, and because the mail-order company never sees the doctor's original prescription, the mistake won't be caught until the patient has a problem with the lens. They may also mistakenly be given old parameters. Legal liability is therefore also a concern.

Michael G. Harris, O.D., J.D., M.S., assistant dean and professor at the University of California Berkeley, is an expert on optometric liability. Dr. Harris believes that if the prescription is filled inaccurately, after expiration or when all refills were used, the practitioner's liability is probably negligible. "The prescribing doctor shares liability no matter where the prescription is filled," he explains. "If the prescription is filled incorrectly, the doctor may still be sued, but they've got a pretty good defense."

Still, even if the problem is not the practitioner's fault, the patient has been injured by a contact lens, a problem that all practitioners find repugnant. Some practitioners we interviewed are concerned that once a patient begins filling their prescriptions by mail, they'll be less likely to return for needed follow-up care. Disposable lens wearers seem most likely to be lost, says Art Epstein, O.D. of Roslyn, N.Y., who adds, "The more recognizeable the brand, the lower the patient loyalty." If the practitioner has such concerns, has noted them in the file and still writes the prescription Dr. Michael Harris says their liability "is absolutely increased."

Mail Order's Perceived Impact on Practices

While ocular health is the primary concern of the practitioners interviewed for this article, they also have concerns about what mail order is doing to their practices. Patient loyalty to the practice may diminish, and professional services may be thought to have little value or to be as much of a commodity as contact lenses have become.

Dr. Daniel Harris, who has had patients ask for their prescriptions in order to take advantage of the Amway promotion, says he believes that the commodity mentality is to blame. "The only reason Amway is involved in contact lenses is because to them, there's not a whole lot of difference between a box of contact lenses and a box of soap," he explains.

So if contact lenses themselves are perceived as a commodity, how do we convince patients that the accompanying service involved (professional skill) is not a commodity as well? What can practitioners do to protect themselves and their patients from mail-order abuses? The first step is patient education.

Advice on Keeping Your Patients

"We tell patients that we don't care where they get their lenses. We just want to participate in their health care," says Craig W. Norman, FCLSA, director of the contact lens section of the South Bend Clinic, Ind.

Contact lens patients must be made aware of the need for follow-up care and regular check-ups. They must be taught that the issue of lens care is independent of the product.

Keep track of competitors -- Maintain a list of the prices of alternative suppliers. Several of the practitioners we interviewed keep records of the costs involved with mail order and have the list available for patient comparison-shopping. Dr. Daniel Harris does this, and although most patients find that they can purchase their contact lenses as cheaply through his office as through mail order, he makes sure that when they find a bargain elsewhere, they leave with their prescription knowing that they'll be welcome back to his practice for care.

Load up on supplies -- Consider keeping large contact lens inventories. Milton Hom, O.D. of Azuza, Calif. does, and he notes that his patients find replacing lenses through his practice to be much faster than with mail order, a convenience they appreciate. "We also supply samples as needed," he says. "We hope this extra measure of service and goodwill will keep patients loyal to the practice, and we also emphasize RGPs."

Hold competitors at bay with specialty lenses -- Stressing specialty lenses, particularly RGPs, was something all of these fitters agreed to be important. "Obviously a basic tenet of our profession is to do what is in the best interest of the patient," says Dr. Michael Harris, who adds that custom-ordered lenses are unattractive to mail-order suppliers and that stressing them in your practice is a way to keep patients loyal. "RGPs play a growing role in our strategy of offering our patients the healthiest and best contact lens choices, choices they can't get just anywhere and that require professional care tangibly different than what they have previously experienced," says Dr. Epstein, whose practice specializes in contact lenses and anterior segment disease.

Dr. Jon Kendall, O.D., Santa Ana, Calif., cites an example of a patient who wanted to order replacement RGP contact lenses by mail. The supplier called him for the prescription, which he gave, and then called back 10 days later with questions about the parameters. In the meantime, Dr. Kendall had already sent a note to the patient saying that he'd provided the prescription as requested, and explaining that the lenses might have to be modified in his office after she received them in order to optimize performance. He asked her to call him and let him know how the new lenses were working out and explained his fees for modification, and that this service was included in the cost of all the contact lenses that he supplied. After several weeks, she called him and placed an order for new lenses, as the mail-order house still hadn't managed to fill her prescription. She got her new contact lenses the next morning. With custom and specialty contact lenses, mail order can't approach the level of service that the original practitioner can provide.

A Final Suggestion

Dr. Bennett suggests a three-pronged approach to protecting your patients from mail-order misadventures. First, he suggests that you compete effectively on materials costs and make these clear to the patient up front. Second, consider expanding your office Web site to include on-line order capability, offering the patient the same convenience from a familiar source. Third, fit more RGP contact lenses. "I have very little empathy for those who complain about mail order but who fit very few RGPs or even soft torics," he says. "We all know that non-traditional outlets cater to volume lenses."

Over one million individuals (a small percentage of all wearers) have used mail order services. We also know that the majority of these contact lens wearers use disposable or spherical soft contact lenses and that pricing policies make it difficult for private practitioners and even small groups to compete with high-volume discounts.

"I think that 18 to 36 months down the line we're going to have to ask ourselves if we want to dispense soft lenses at all," says Mr. Norman. "Mail order is a fact of life and we all may have to modify our practices accordingly." CLS