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The Follow-Up Visit
In our survey
we found that 57% of eye doctors require follow-up exams before releasing
a prescription, but 43% do not. The Texas Contact Lens Prescription Act
does not require patients to return for a follow-up visit in order to
take away their prescription. However, Board Rule 279.7 (issued by the
Optometry Board before passage of the Act and still in place) requires
every patient to have at least one follow-up visit.(17)
Almost half of the eye doctors surveyed are in violation of
this rule, since they allow patients with no medical problems to take
away their prescriptions after a single visit. These doctors are in compliance
with the spirit of the statute, however.
The requirement that lens wearers return for a follow-up visit in order
to get their prescription filled elsewhere creates an unnecessary barrier
to competition and is clearly not aimed at the specific medical needs
of individual patients. According to a recent FDA survey of eye care practitioners,
the majority recommend annual visits for contact lens wearers.(18)
Among wearers who actually complained to the Optometry Board about their
problems getting a prescription released, the follow-up visit restriction
was one of the most commonly cited barriers. Consumers Union reviewed
44 contact lens complaints from the Texas Optometry Board. About a third
involved follow-up, where doctors refused to release the prescription
because patients did not come back for one of the doctor's recommended
follow-up visits. Some of these were long time wearers of contact lenses.(19)
Nineteen-year old Ms. B. of Longview visited Childress Vision Clinic for
a contact lens exam on November 24, 1998. She had already worn contacts
for five years. According to the Childress Clinic, Ms. B. attended a follow-up
visit on December 2 to fit the lenses and "allow the lenses to conform
to their ocular environment." She sat in the office for about an
hour with the lenses in her eyes. At that time the clinic sold her a "continuing
service agreement" (costing $100 for a year) and told her that she
would have to return for "contact lens progress evaluations."
She returned again on December 30 to pick up her lenses, and the eye doctor
scheduled her for yet another follow-up exam January 5. She did not show
up for this visit.
In May, Ms. B called the Childress Clinic because she had ripped her lens.
She did not like the price quoted for replacements and asked for her prescription.
According to her mother, the clinic refused and the family could not get
a satisfactory explanation. They asked their insurance carrier to intervene.
"Our insurance company said Dr. Childress said he couldn't give the
prescription because her exam wasn't complete," Ms. B's mother wrote
to the Optometry Board. Her daughter had in fact visited the office three
times in the course of a month, and had apparently experienced no trouble
with the prescription thereafter. The "service agreement" she
purchased required her to return for an exam every six months, in addition
to the series of initial exams.
When her mother complained to the Optometry Board, the eye doctor agreed
to a fee refund but did not agree to provide a copy of the prescription.
The Board wrote to the family that "the complaint is the type of
business dispute which is not within the Board's jurisdiction," and
further noted that the eye doctor had offered her a fee refund. The Optometry
Board closed its file.(20)
This "service contract" was not a singular incident. Some eye
doctors require a patient to sign up for a long-term contract of ongoing
care, and if they are not available for that ongoing care, they cannot
have their prescription.
Amy Greer, a medical student in Lubbock, went to an eye doctor in her
home town of North Richland Hills for a contact lens exam and prescription
in the summer of 1999. At that time, the office charged her $120 in exam
fees, including a $66 fee for "professional fees which include any
contact lens related visits for a year." She did not purchase contact
lenses, but a few weeks later she asked for her prescription. At that
point, the eye doctor told her that since she would not be available for
"ongoing follow-up care" he would refund her fee of $66 and
forward her exam records to a doctor in the Lubbock area, but he did not
agree to give her the prescription.
"I am professionally liable for patients for which I write contact
lens Rx's," he told the Optometry Board. "We do routinely release
contact lens Rx's as long as the patient realizes that we are still the
prescribing doctor and responsible for follow-up care services. It is
hardly fair to ask a doctor to be responsible for a patient for an entire
year and then not allow the doctor access to that patient to insure that
all is physiologically well as per FDA guidelines."
According to this doctor, patients should return for follow-up visits
at least every three months for extended wear contacts, and every six
months for daily wear contacts. According to the final letter from the
Optometry Board to Ms. Greer, the doctor is not required to release a
contact lens prescription if no examination "and/or follow-up"
is provided to the patient. The Board recommended that she seek out an
eye doctor in Lubbock, which she ultimately did, having to pay her exam
fee all over again. (21)
How much care is really needed for regular contact lens consumers who
are comfortable with their contacts?
Most medical doctors do not sell pharmaceuticals or medical devices (the
Food and Drug Administration categorizes contact lenses as a medical device).
Physician investment in labs or testing facilities to which they refer
patients is restricted to prevent a conflict of interest. The law places
physicians at an arm's length from companies that profit on the tests,
medical devices and drugs they prescribe because profit on these items
might affect their medical judgement. In particular it might lead to overprescribing
and unnecessary care. But eye care practitioners may sell the items they
prescribe and make a profit. In this case, the financial interest in bringing
people back to the office, where they will very likely purchase their
lenses, may lead some eye doctors to overstate the medical need for follow-up
visits. Eye doctors who place unnecessary burdens on all of their customers
in the name of "ocular health" violate the intent of the Contact
Lens Prescription Act, and illustrate the conflict of interest that exists
when one business both prescribes and sells a medical product.
The "Fitting"
Eye doctors say follow-up
visits are required to complete the "fitting," for which they
typically charge a fitting fee. But what exactly is the "fitting,"
and does it require multiple visits to the eye doctor?
In general, the eye exam measures the power of the prescription, while
the fitting measures the shape of the front surface of the eye. The eye
doctor typically uses an instrument called a keratometer to determine
the proper curve and size for the contact lens. The eye doctor may also
measure the dryness of the surface of the eye, making sure that once placed
on the eye the lens fits and moves properly.
For most consumers there is no bright line between the end of the "exam"
and the beginning of the "fitting" except that they believe
both are generally done when they leave the office, especially if there
are no changes in brand or type of lenses. A long-time contact lens wearer,
and particularly a typical wearer of two week disposable soft contacts
who likes his or her current lenses, can probably be examined and "fitted"
at a single visit for replacement lenses, according to the Contact Lens
Clinic at the University of Washington.(22)
But many eye doctors link the practice of "fitting" the lens
with the follow-up visit requirement. "Fitting" must be "complete"
before the office will release a prescription. When Laura A. of Austin,
a contact lens wearer of several years, went with her father for an exam,
he disputed the "fitting" charge prior to the start of the exam.
Before even looking at Laura's eyes or her prescription the staff informed
him that follow-up was mandatory.
"He was not pleased that we charge the fitting fee since she had
been wearing contacts for several years," wrote the optometrist.
"We explained that even though she had been wearing lenses, we did
not have any record of that and she would need to be treated as a new
patient and return for a follow-up visit."(23)
For this office, there was no distinction between "fitting"
and the follow-up requirement. And when Laura did not return for the follow-up
visit, the office later told her father that he could not have her prescription.
In some cases, eye doctors link the "fitting" directly with
the purchase of a supply of lenses. If the consumer does not purchase
a supply of lenses from the eye doctor, he or she won't "finish"
the "fitting" and therefore does not have to provide the contact
lens prescription to the patient. When the eye doctor is willing to sell
boxes of lenses directly without a follow-up exam, but not willing to
give the consumer a prescription to buy those same boxes somewhere else
without a follow-up exam, he or she is circumventing the law.
Vicki A. of Houston wrote to the Board in 1999 after she was denied her
son's contact lens prescription. Her son Mat was already a disposable
soft contact lens wearer. During the initial visit the eye doctor examined
the boy's eyes, measured them for contacts ("refitting"), and
placed contacts in his eyes. While the eye doctor was placing the lenses,
a staff person explained the charges: $60 exam fee, $50 for "fitting"
and unlimited follow-up visits, and $90 for 4 boxes of lenses (a six month
supply).
Ms. A. did not want to purchase the lenses from the eye doctor, and asked
if she could have the prescription at the end of the fitting. "I
asked if I could pay for the trial pair and the fitting charges, and just
get the prescription," she wrote. At this, the staff person instructed
her son to remove the trial lenses from his eyes and said that if she
didn't order the contacts her son could not wear the trial pair home.
According to Ms. A., she would have to purchase six months of lenses "in
order to continue with the fitting" and come back in six months for
a follow-up visit. At that time, she could finally have the prescription
if she wanted it.
When queried by the Optometry Board, the eye doctor declared that her
son had "poor hygiene techniques" and needed six months of observation.
The Optometry Board told Ms. A. that this was "a matter between the
doctor and patient" and not within its jurisdiction.(24)
Ms. A. was not the only consumer to complain to the Board that
eye doctors require patients to purchase six months worth of lenses before
finalizing the prescription and releasing it.(25)
Doctors cite two main reasons for requiring follow-ups and/or requiring
the patient to buy the first set or supply of lenses from them: finalizing
the prescription ("fitting") and liability.
But many patients who have worn contact lenses before do not need to return
for a follow-up visit to finalize their prescription, and eye doctors
have a clear financial interest in bringing consumers back into their
store. This conflict leads consumers to believe that there may be no medical
basis for the return visit for "fitting" completion.
People are used to seeing a medical doctor for a problem and having their
prescriptions filled somewhere else. If the prescription is not satisfactory,
they return to the doctor to discuss it. Similarly, contact lens wearers
who have discomfort in their eyes will undoubtedly call or return to the
eye doctor. If they do not return and purchase contact lenses on their
own, the Texas Contact Lens Prescription Act says that eye doctors are
not liable for a patient's subsequent use of a contact lens prescription.
According to the Act, "a physician, optometrist, or therapeutic optometrist
is not liable for any subsequent use of a contact lens prescription by
a patient if the physician, optometrist, or therapeutic optometrist does
not examine the patient."(26)
Notes:
17 Texas Administrative Code, Board interpretation number
seven, Rule 279.7
18 An FDA Survey of U.S. Contact Lens Wearers, Contact Lens Spectrum,
July 1997. Available on the FDA web site at www.fda.gov.
19 Texas Optometry Board complaints, TOB #s: 99098, 00008, 99058, 98137,
99051, 99116, 00100, 99080, 00113, 99059, Vicki Amos 1999, Michael Morrow
1999, Deborah Young 1998, Maggie Saucedo 1999, Patricia Novoa 1999.
20 Texas Optometry Board complaint, TOB#99098, June 25, 1999.
21 Texas Optometry Board complaint, TOB#99116, August 24, 1999 and telephone
interview with Amy Greer, December 13, 2000.
22 Contact Lens Clinic at the University of Washington, www.depts.washington.edu/ophthweb/contacts.html.
Downloaded December 13, 2000.
23 Texas Optometry Board complaint, TOB#99080, April 23, 1999.
24 Texas Optometry Board complaint, [no complaint number], May 24, 1999.
25 Texas Optometry Board complaint, TOB#99003, September 18, 1998. Texas
Optometry Board complaint, TOB#99106, July 15, 1999.
26 Occupations Code, Chapter 353, Contact Lens Prescription Act, Article
353.201.
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