Yet, even for those attending, there is not much time for real discussion in the House. Policy matters usually come up only if they are the subject of a resolution. Debate, "new business" and "good and welfare" are usually lost in the lack of time and the rush toward adjournment.

In such an atmosphere, there is a tendency to leave things undone and decisions unmade. There is a feeling that things will take care of themselves for another year.

High attendance and crowded programs are a way of life at conventions in many fields. However, for delegates the many features should be attractions, but not distractions.

EYEGLASSES, PROFIT AND THE PUBLIC WELFARE

Editor, THE OPTICAL JOURNAL-REVIEW:

BRONX, N.Y., APRIL 18, 1966.

In the April 15th issue, Dr. Samuel Drucker's article "The Challenge of the Hart Bill" presented an interesting evaluation of optometry's position in our changing society. His suggestion that the profit be taken out of professionally dispensed eyeglasses is an excellent one, since Senator Hart's subcommittee will likely soon come to the same conclusion.

The specter of governmental intrusion into the practice of health care is very distasteful to most optometrists. Nevertheless, we had better resign ourselves to the fact that the federal government is in the business of consumer protection to stay. The automotive industry recently discovered that it is no longer master of its fate when the safety and welfare of the public are concerned. It is highly probable that the health-care professions will soon come to the same realization. It would, therefore, behoove the health professions to put their houses in order before the legislators do it for them.

The chief flaw in the optometric structure is the practice of profiting from the sale of self-prescribed materials. It should be obvious to the Senate subcommittee that this system encourages abuses by unethical practitioners. It will be surprising if steps are not taken to further protect the public.

CODE OF THE MARKET PLACE

The interprofessional squabbles that have plagued the field of eye care will undoubtedly be brought out in the hearings. As a result, the ophthalmic professions will be made to appear as self-interest groups rather than as professional people concerned with the visual welfare of the public. We must realize that the privileges awarded to professional men by society may be retracted if they conduct themselves according to the code of the market place.

If the ophthalmic professions would retain the confidence of the public, they must cease their bickering and eliminate practices inimical to the public welfare.

Optometry must eliminate commercialism and restrict its activities to those professional services for which it is best trained. This does not include the grinding or dispensing of eyeglasses.

Opticianry must abandon all claims to contact lens fitting and concentrate on lens grinding and dispensing of eyeglasses.

A rigid system of quality control on all ophthalmic materials should also be imposed.

Ophthalmology must discontinue its efforts to monopolize the field of eye care and must conduct its practices in a manner befitting eye surgeons.

A "summit conference" of leaders of the three disciplines would now be in order to clean up the back yard before Senator Hart does it for us.

VINCENT P. LUPICA, O.D.

The following is taken from the Principles of Professional Conduct of the Medical Society of the State of New York:

PATENTS, COMMISSIONS, REBATES, AND SECRET REMEDIES

Section 6. An ethical doctor of medicine will not receive remuneration from patents on or the sale of surgical instruments, appliances, and medicine, nor profit from a copyright on methods of procedures. The receipt of remuneration from patents or copyrights tempts the owners thereof to retard or inhibit re

search or to restrict the benefits derivable therefrom to patients, the public, or the medical profession. The acceptance of rebates on prescriptions or appliances or of commissions from attendants who aid in the care of patients is unethical. An ethical doctor of medicine does not engage in barter or trade in the appliances, devices, or remedies prescribed for patients but limits the sources of his professional income to professional services rendered the patient. He should receive his remuneration for professional services rendered only in the amount of his fee specifically announced to his patient at the time the service is rendered or in the form of a subsequent statement, and he should not accept additional compensation, secretly or openly, directly or indirectly, from any other source, except as provided in Article VI, Section 3, of Chapter III.

The prescription or dispensing by a doctor of medicine of secret medicines or other secret remedial agents, of which he does not know the composition, or the manufacture or promotion of their use is unethical.

The following is taken from the Code of Ethics of the Podiatry Society of the State of New York:

SEC. VI-SPLIT FEES, COMMISSIONS, COMMERCIAL ESTABLISHMENTS

A. Split Fees & Commissions:

1. It is unethical for podiatrists to pay or accept commissions in any form or manner on fees or professional services, references, consultations, pathological reports, radiograms, prescriptions, or on other services or articles supplied to patients. The Society deplores the selling to patients of ready-made shoes, foot powders, lotions, medications, or other similar materials or articles.

2. Division of professional fees, or acceptance of rebates from fees paid by patients to x-ray, clinical or other laboratories, shoe stores, or other commercial establishments is unethical.

3. It is unethical for a podiatrist, directly or indirectly, to pay or to give consideration or a gratuity for the recommendation of a patient.

The following appears in a report of the United States Department of JusticeAntitrust Department of the United States District Court, Northern District of Illinois, Eastern Division:

V. DOCTOR DISPENSING AND ITS EFFECT ON PRICES

One of the forces at work preventing the reduction in the price of glasses to patients of doctors is the spread of the practice wherein oculists do their own dispensing of glasses to their patients. They thereby use the same procedure utilized by optometrists, except that the doctor, in addition to making the refraction and selling the glasses at a profit to himself, also charges the patient a professional fee for making the refraction.

If a doctor wishes to sell glasses in his own office to his patients and make whatever profit he can on such sales in addition to engaging in his professional practice, he is not barred by the judgments so long as he is not acting collusively with others. A resume of the doctor's rights in this respect was set forth in the letter which accompanied the final judgments which were mailed to the class defendant doctors (Exhibit 4).

During what may be termed the rebate era, there were of course many oculists who opposed the rebate practice as being unethical and contrary to proper professional standards. Likewise, today there are many doctors who contend that according to proper ethical standards the oculists should limit themselves to the performance of purely professional services and should have nothing to do with the actual selling of glasses, except in those areas where no optical dispensing houses are available. This point of view was expressed by a North Carolina doctor in answering the questionnaire:

... I have always thought he [the doctor] should have no pecuniary interest in the glasses he prescribes any more than any physician should own an interest in a drugstore or any other medical or surgical appliance business through which he would benefit financially....

A. Florida dispensing optician, who has seen much of his business vanish because most of the doctors in his area are now doing their own dispensing and refuse to give prescriptions to the patient to be filled outside, comments bitterly:

they are trying to sit on two stools at the same time by practicing medicine and selling merchandise at the same time.

A South Carolina dispensing optician, who states he has been unable to reduce prices because practically all of the doctors in his area are now doing their own dispensing at full prices, in addition to charging refraction fees, levels the following attack on these doctors:

the public now suffers from faulty fitting and adjustment, as well as a lot of time wasted, since the doctors handle their own Rx's, either doing the measuring and fitting themselves when they are not skilled and trained in so doing, or in some cases by hiring inexperienced, unqualified people to do this vital job.

... the doctor should write his Rx, and be denied the privilege of selling the glasses in his own office, as in a majority of cases, the patient is the one who suffers.

It is not, of course, the function of the Department of Justice to express any opinion on the question of whether or not doctors should do their own dispensing when independent and qualified dispensing houses are available. It is, however, the duty of the Department to report to this Court available facts relative to the effect which this trend toward doctor dispensing has been having on the price of the spectacles which the patients of doctors must buy.

Approximately one-third of the doctors answering the questionnaires are now doing their own dispensing of glasses to their patients. Most of them have started this practice since these cases were instituted.

The practice is especially prevalent in the smaller towns, in several of the Southern States, particularly Texas, Florida, and South Carolina, and in a number of both large and small cities in Wisconsin, Michigan, and Ohio. The praetice appears to be "spotty" in so far as areas are concerned.

One doctor in Arkansas stated that because the local dispensing houses had not reduced prices the doctors "started doing their own dispensing at a normal profit." On the other hand, another doctor in the same town stated that most of the local doctors were doing their own dispensing at no decrease in the price of glasses to the patients and, perhaps, an increase, although a local dispensing house had, in fact, reduced prices on prescription sales to patients.

Most of the doctors who have turned to doing their own dispensing report they are charging "prevailing retail" prices in addition to refraction fees. A Washington doctor frankly stated that he was doing his own dispensing because he considered it a legitimate business “and a profitable one as well" and that he charged the "prevailing retail price." There appears, however, to be some variation in the prices the doctors charge. In some cases the doctors report they charge the wholesale price, plus a handling charge, and others a wholesale price, plus a flat mark-up, but, in the main, the answers show that the price charged is substanially the same as the ones the patients paid when the rebate system was prevalent. This is probably to be expected, because it is doubtful whether the doctor would go to the trouble of doing his own dispensing in his own office for his own patients unless he could make a profit on the sale of the glasses in addition to charging a refraction fee.

The questionnaires and other data received indicate that in many areas of the country doctors who have switched, or are contemplating switching to doing their own dispensing have shown signs of hostility to local dispensing houses which either reduced prices on prescription sales to patients or proposed reducing them. In many cases, the volume of prescription filling business available to such dispensing houses has been so materially reduced, because the doctors refused to release prescriptions to their patients, that the dispensing houses have encounted difficulty in maintaining the lower prices on a reduced volume, and in some cases have been forced out of business entirely, or are reduced to doing repair work almost exclusively.

The impact of doctor dispensing on dispensing houses which reduced prices on prescription sales to patients is illustrated by the experience of a Texas dispensing house which reports that in 1949 it advised the local doctors that it would thereafter make no rebate payments but would make prescription sales to their patients at wholesale cost, plus fitting fee. (This is what the dispensing houses retained out of the consumer price when rebates were paid.) The doctors then stopped referring patients to this dispensing house and began doing their

own dispensing instead. The dispensing house makes the following observations on its experience:

Glasses now cost the patient more than previously in most cases. Our business has definitely been hurt and we have lost patients who have traded with us for years because the majority of doctors refused to give the patients their prescriptions. . . . If the doctors charge a professional fee for refracting and turn the prescriptions loose we could still lower our prices 15 to 20% and operate on a volume,...

You might be interested to know that most of the dispensers for the doctors are paid a salary and a per cent. The dispenser makes the prices and, naturally, the more he charges the patient the more he makes. We feel this is unfair to the public.

The same dispensing house further stated in another communication:

... the oculists are now controlling their prescriptions far more than they ever did before, as most of them absolutely refuse to give their patients their prescription . . . They are determined to still make a profit on the glasses they prescribe.

A dispensing house in another Texas city reported that in 1948, when it was doing a $6,000 a month business on prescription sales to patients of doctors on a rebate basis, it announced to the doctors it would thereafter discontinue the payment of rebates and would sell on prescription to patients at prices substantially under the consumer prices then charged. Its volume of business then dropped to $150 a week, as the doctors switched to doing their own dispensing. A similar experience is reported by another dispensing house in the same city which announced to the doctors that if the rebate system was outlawed by the local medical society the dispensing house would reduce prices on prescription sales to patients to the wholesale price, plus dispensing fee, and thereby give the average patient a saving of $10 a pair on glasses. He reported shortly after the final judgments went into effect as follows:

I have repeatedly offered to heavily reduce prices of glasses to the public if they [the doctors] would turn prescriptions loose; and was told that if I reduced prices, that every prescription I filled would be pronounced as inaccurate and that I would be forced out.

In the same State another dispensing house reports a similar experience and states that 53 out of 65 local oculists are now doing their own dispensing.

In still another Texas city, two dispensing houses each report that their business in prescription sales to patients of doctors has been almost wiped out because of doctors doing their own dispensing and that with this reduced volume of business and the refusal of doctors to release prescriptions to their patients, they are unable to reduce prices, even though the doctors charge the patients the pre-rebate price or more.

In Michigan, one dispensing house with a number of branches stopped rebate payments in 1950, before the judgments were entered, and put into effect a substantial price reduction on all prescription sales to patients. One Michigan doctor referred as follows to the institution of this policy:

This attempt to eliminate the practice is a grand step toward honesty and fair business.

Unfortunately, the price reduction policy instituted by this dispensing house was not popular with numerous other doctors who then switched to doing their own dispensing and refused to release prescriptions to their patients. This so cut down the volume of prescription business available to the dispensing house that it was forced to close some of its branches which were located in the cities where the bulk of the doctors had switched to doing their own dispensing.

Another Michigan dispensing house reported that although it reduced its prices one-third on prescription sales to patients, its volume of business in this field was reduced 80 per cent because practically all of the oculists in the area had switched to doing their own dispensing.

In a large Wisconsin city, the doctors stated that a considerable number of dispensing houses had reduced prices substantially on prescription sales to patients. The reports from these companies confirmed this, but they complain bitterly of the fact that such a large number of oculists had switched to doing their own dispensing that on the reduced volume of business the optical houses are finding it difficult to keep the lower prices in effect.

Numerous complaints have been received from Florida regarding doctors having switched to doing their own dispensing and of maintaining high prices for glasses. One optical house makes the following observation, which is typical: it was generally agreed in most sections of Florida [when the judgments went into effect] . . . that the prices of glasses would be reduced by the optician, and the Doctor would increase his refraction fee, thus enabling him to be compensated for the lack of rebate.

These two practices were put into effect. However, the low price of glasses was short-lived. Today the user of glasses is generally paying more over-all for a pair of glasses than prior to the discontinuance of rebate. Secondly, with the Doctors rapidly setting up the practice of selling and dispensing glasses in his own office, a monopoly is created as far as the patient is concerned.

In areas where a large percentage of the doctors have turned to the system of doing their own dispensing, their patients appear to have considerably less hope of obtaining the price reduction on glasses made possible through the elimination of the rebate system than is the case of patients in areas where doctors do not generally do their own dispensing. Most doctors who have turned to doing their own dispensing probably have no great incentive to reduce prices, because of the pecuniary interest which they have in the sale of glasses. Furthermore, the dispensing houses in such areas may have difficulty in either reducing prices or in keeping price reductions in effect if the flow of prescription patients to these houses is blocked at the source-the doctor's office.

It must not be assumed, however, that price competition is entirely lacking among the oculists in those areas where they do their own dispensing. These oculists purchase their completed spectacles from wholesalers who make up the glasses to prescription and sell them to the doctor at the Rx or wholesale price. The doctor is then faced with the problem of determining what the markup on these glasses is to be in reselling them to the patients. In a majority of instances, the doctors report that they charge the prevailing retail price, but some report that they use mark-ups which result in a price which is less than that which prevailed under the rebate system. Furthermore, the doctor who does his own dispensing tends to place himself in more direct competition with the optometrist who invariably dispenses to his patient but does not usually make a separate charge for the refraction service.

In some cases, doctors have turned to doing their own dispensing because they resented the fact that local dispensing houses did not reduce consumer prices when the rebates were eliminated. This is of course a danger which dispensing houses necessarily run if they do not reduce consumer prices to reflect the saving which is theirs through not having to pay debates on their prescription sales.

What can be accomplished when doctors restrict themselves to professional practice and dispensing houses pass to consumers the benefits derived from the elimination of the rebate is illustrated by the reports received from such places as a large city in Minnesota and a large one in Missouri. In these cities, the reports show that most, if not all, of the dispensing houses put substantial price reductions into effect almost simultaneously with the entry of the judgments. They have been able to continue making prescription sales to patients at the lower price level because almost none of the local doctors have turned to doing their own dispensing. With the volume of prescription business going to the dispensing houses remaining unimpaired, the elimination of the rebate has enabled them to continue to sell at lower prices notwithstanding the increases which have occurred in material prices, labor, and other costs of operation during the past few years.

In Chicago, reports have been received concerning a considerable number of responsible dispensing houses which put substantial price reductions into effect on their prescription sales to patients when the judgments went into effect. Relatively few doctors here have switched to doing their own dispensing during this period, complaints of violation of the judgments have been negligible, and there is little or no evidence of use of either the "charge and send" plan or of the group doctor ownership of dispensing houses. Patients of oculists in the Chicago