What Are Those Online Retailers Up To?

Optometrists have seen the bad behavior online. Some companies are promoting online vision testing and spectacles and contact lens prescription renewals without requiring an examination. These companies appear to be prioritizing profit over patient health.

Most optometrists care deeply about their patients’ well-being and safety—that’s why we do what we do every day. How can optometrists who see the potential dangers of these corporate behaviors compete with these very well-funded disrupters?

There are three tangible ways for optometrists to stay above the fray, protect patients, and stand up for the doctor-patient relationship. We must understand what these competitors are up to, support national efforts to rein in these behaviors, and undertake our own local efforts to fight them by offering world-class customer service to our patients. This article explores each of these in turn.

Know your competition

The first thing ODs can do is know their competition. It is imperative that you stay up to date on these companies’ tactics, such as those listed below.

Passive Verification

If you are a member of any of the online optometry forums, you have heard colleagues complaining about the marketing tactics of online contact lens retailers. Some market directly to consumers, advertising the opportunity to skip “the annoying air puff test” and dilation. Others tell their customers that they don’t need a prescription at all. But one thing many of these online retailers (or middlemen, as we call them, because they do not add value to the system) have in common is that they exploit loopholes in the passive verification system to skirt prescription rules.

Passive verification came about as a provision of the Fairness to Contact Lens Consumers Act of 2003, which states that prescribers must verify the accuracy of a patient’s prescription within 8 hours of a reseller’s request. Cynthia Williams, general counsel for 1 800 Contacts, said in a 2018 interview that 60% of that company’s orders are passively verified.¹

Online contact lens middlemen use several tactics to exploit passive verification. For example, they will call optometrists’ offices shortly after closing so that there is no chance of verifying the prescription within 8 hours. My office receives multiple requests around 5:05 pm. They also make it so that there is no way to interact with the seller. David Cockrell, former president of the American Academy of Optometry (AOA) and a fierce patient advocate, said, “Every doctor gets contacted virtually every day by a seller with a prescription that is expired or incorrect. When we try to recontact the entity that sent it, there is no way to do so. It’s a one-way issue.”¹ Further, these companies leave garbled, unintelligible messages that are nearly impossible to follow. In a lecture I give on this topic, I play an actual recorded message from a contact lens middleman. In the message, it is almost impossible to discern the patient’s lens brand, power, or base curve.

Online Vision Testing

Online contact lens middlemen realized early on that doctors who perform comprehensive examinations and educate patients about good contact lens habits and hygiene are barriers to their sales. Patients feel loyalty and camaraderie to local providers and most often purchase their materials from their doctors. So these retailers enacted strategies to take the doctor out of the equation.

Many online contact lens sellers have partnered with companies offering online vision testing that promises to determine a prescription. Some of these services do explain that their test is not a substitute for a comprehensive eye examination, but this disclaimer is veiled. By providing a prescription, these online tests remove the incentive that drives many consumers to optometrists for comprehensive examinations.

In 2017, the FDA issued a warning letter to Opternative for its online eye examination mobile medical app.² The FDA warned the company to stop marketing this device to consumers because the test did not have FDA clearance. To this day, this company continues to market its test to consumers under another name (Visibly) in defiance of the warning letter.

Direct-to-Consumer Contact Lens Companies

There are three contact lens companies operating in the United States that do not require a prescription to purchase their proprietary contact lenses online. These companies use direct-to-consumer marketing, and they mail trial lenses directly to consumers without requiring corneal curvature measurement, evaluation of the eyes, or inspection of lenses on the patient’s eyes.

These companies appear to simply disregard the need for doctor oversight of a class II medical device, which, if true, would be illegal. Some use passive verification loopholes to substitute their lenses for prescribed lenses, which would also be illegal.

Lack of Enforcement

Why is this activity allowed to continue? The answer is a lack of enforcement dollars. The AOA has reported this activity on numerous occasions to the US Federal Trade Commission (FTC), which has jurisdiction over these matters. It appears that the FTC has either ignored requests for regulatory enforcement or cannot keep up with the number of violations.

This type of activity is not unique to the contact lens industry. The FDA recently issued warning letters to six mobile telehealth companies offering devices that the companies claim are as good as mammograms.³ Regulators seem to be flooded with digital companies that appear to be operating outside the law.

National Efforts

To battle well-meaning doctors on the regulatory front, several companies have banded together to form a lobbying organization that was originally called the Coalition for Contact Lens Consumer Choice. Members included 1 800 Contacts, Costco, and Lens.com. The organization spent millions of dollars in Washington advocating against the ability of optometrists to sell contact lenses, for the marketing of generic contact lenses, and for the relaxation of contact lens prescription requirements. A Buzzfeed article noted that multiple articles written by fake, nonexistent authors were linked to the coalition’s website. Essentially, it appears, the organization was disseminating “fake news.”⁴

The organization subsequently changed its name to Americans for Vision Care Innovation, and Visibly (formerly Opternative)⁵ and Smart Vision Labs (another online vision test company) were added as members. This organization is currently opposing the AOA on multiple issues.

Luckily, an organization on our side of the issue, called the Health Care Alliance for Patient Safety, or APS (patientsafetytoday.com), was formed around the same time. This group was chartered with the aim of protecting the doctor-patient relationship in all aspects of vision care. Its advocacy efforts focus on raising awareness of health and safety issues that either directly or indirectly affect the preservation of vision.

The second thing optometrists’ can do to combat these online retailers is to support the companies involved in this alliance. Also, if you know your local representative for these companies, thank him or her, and let it be known that these issues are important to you.

Individual Efforts

Third, on the local level, every optometrist has the ability to work against this problem. It just takes a little attention to the issue.

Speak Up

It is incumbent upon all of us to report bad behavior through channels that have the ability to create positive change. It is helpful when aggregated multiple complaints can be presented to legislators and regulators. Some of the channels available to us are listed in Report Problems.

Educate

Use each and every visit with patients to teach them why an in-person examination is necessary. This idea was once a given, but no longer. Explain all of the tests you are performing and why they are important. Teach good contact lens habits and hygiene, even to your most seasoned lens wearers.

Provide Conveniences

The online contact lens middlemen prey on patients’ desire for convenience and their lack of understanding about what they are risking. When it comes to providing conveniences for our patients, we can probably make some improvements. For example, it is well documented that modern patients do not want to speak with your office on the phone. Text messaging is the current preferred means of communication for many.⁶

Luckily, there are services that can add a text communication system to your practice. The service I use in my office (Weave) also offers other conveniences, such as allowing patients to pay their bills by text, facilitating Google reviews, sending appointment reminders, and more.

Adapt

If we continue to provide the same services to our patients without adapting to the way they want to receive those services, we will go the way of the print news industry.

One way to adapt is to offer contact lenses that are not off the shelf and available as commodities. My practice recommends specialized contact lenses at the first sign of difficulty. We use hybrid lenses, such as those from Synergeyes, for normal corneas as first-line treatment for most patients with astigmatism and high prescriptions.

Summing Up

By employing the strategies mentioned above and by keeping our patients’ best interests in mind, optometry will not only survive as a profession but thrive as never before. The companies that wish to disrupt this industry know that our connections with our patients are unbreakable, so long as those patients step into our offices. This is why they are expending incredible amounts of effort to prevent patients from going to our offices.

The opinions expressed by the presenter are his own and not the opinions of the AOA, AAO or Alliance for Patient Safety.