AMA Journal of Ethics^®

Case

Dr. Brenner, an ophthalmologist who had been practicing in the same city for over a decade, noticed that an increasing number of patients in his community were simply requesting their contact lens prescription in his clinic and ordering them online instead of through his office, resulting in reduced revenue for his practice.

Over the next couple of years, as more ophthalmologists established themselves in his area and some patients elected to have refractive surgery with other specialists, his practice generated less revenue, and Dr. Brenner was forced to make changes in the way he ran his office. He began working longer hours, participating in more community outreach efforts, and reducing the salaries of his office staff.

To retain patients and revenue, Dr. Brenner began to prescribe mostly varieties of contact lenses that are not easily available over the internet and implemented a policy requiring patients to purchase their first month’s supply of lenses from him. There was no change in the quality of contact lenses provided to patients, and the policy was outlined in paperwork that patients reviewed and approved prior to their office visit.

Commentary

The case brings to mind the often-discussed conflict between ethical behavior and business decisions, and it illustrates that many times the conflict is perceived rather than real.

Our eye specialist, Dr. Brenner, believes that he will generate greater revenue by prescribing “private-label” contact lenses. If he is selling lenses only differentiated by their packaging and higher cost, his behavior is at best dishonest, even if he’s not deceiving patients outright.  Hiding costs or increasing them beyond market rate typically backfires; patients catch on and seek care elsewhere.

Practical considerations aside, ethics alone obligates physicians to provide patients with sound, accurate information about the treatment options, including the risk and benefit of each alternative. Dr. Brenner can dispense private-label contact lenses ethically and as a way to enhance revenue if they are in fact unique—as are “customized wavefront” contact lenses, not available over the Internet or from other contact lens outlets. In that case, he would be providing a unique service and, perhaps, a better product and could charge accordingly, if it were the best choice for the patient.

Dr. Brenner’s policy of utilizing offbeat brands not typically available over the Internet and requiring initial purchase from his office may in fact be ethical, even if it might not be especially helpful to his bottom line. It depends on the written material he provides and the clarity with which he spells out his policy. It may even be ethical to require that the first pair of lenses be secured from his office if the purpose for doing so is to confirm good fit and comfort, as determined in a follow-up visit, where adjustments can be made if needed. Generally, a contact lens prescription should not be issued until the fitting process is complete, and this typically includes a follow-up exam soon after trying new lenses. Dr. Brenner should point out to his patients that he cannot be of any help to them if they are dissatisfied with the lenses they purchased online. He has no control over the quality or accuracy of the prescription.

Given the current nature of contact lens marketing, it can be simpler and more ethical to separate the cost for fitting the lens (professional fee) from the cost of the lenses (material and handling fee). This separation of service from goods is fair to both patients and practitioners, and allows the charges to reflect what is actually being provided. This transparency lets patients know what they are paying for, and their satisfaction will help develop loyalty to the practice and maybe even referrals of new patients.

A better plan for increasing revenue and enlarging his patient base would be to expand his services. If Dr. Brenner adds to his skills by handling specialized lens fitting—such as contact lenses for keratoconus and post-LASIK patients or customized lenses—he will enhance the practice’s reputation for individualized service and bring in these new patients.

In short, ethical behavior does not have to be bad for business. This is as true for a medical practice as for any other type of business. Good ethics can be a cornerstone of your service and distinguish you from the competition, including internet outlets.