Commentary: Contact Lenses: Focus On Open Markets

Preferring to do what they do best, most doctors gave up dispensing medicines decades ago. They treat patients and write prescriptions--and let pharmacists distribute pills. But there is one stubborn corner of health care where professionals have evaded the law of comparative advantage: eye care. Until recently, optometrists and ophthalmologists have had a lock on the market in most states for fitting and distributing contact lenses. Consumers had no choice but to use their one-stop shops.

No longer. Since the debut of disposable contact lenses a decade ago, mail-order houses, discount retailers, and pharmacies have chipped away at exclusive distribution deals between makers and eye-care professionals, driving down prices and giving users more choice. Pharmacists at many Walgreen Co. stores sell soft lenses like drugs. Mail-order houses such as Lens Express Inc. ship replacement lenses to order. And surfing the Internet gives consumers a potent new option: comparing older mail-order companies' prices with upstarts such as Lens 4 Me.

NEW LOOK. And yet, like a persistent sty, the old system lingers. Despite laws banning the practice in about half the states, some optometrists and ophthalmologists still refuse to release prescriptions to be filled elsewhere. Tied to the professionals because of the need for scripts, some companies won't sell lenses through alternative outlets. "The business has done terrifically," says Bernard W. Walsh, a Johnson & Johnson group chairman who oversees the company's Vistakon eye-care unit. "For us there's just no reason to change."

Nonetheless, the system is being reexamined. This year, Florida is expected to go to trial in a 2 1/2-year-old lawsuit against J&J, Bausch & Lomb, some optometry groups, and practitioners. The suit alleges a conspiracy to shut new companies out of the replacement-lens business. A class action is pending. A suit brought on Dec. 19 in New York by 22 states is aimed at recovering as much as $600 million for lens wearers. Bravo to lawyers, for once. The pressure is having a positive effect on a system that needs changing.

The defendants deny violating any laws, but some manufacturers are slowly changing their sales practices anyway. CIBA Vision, the Novartis unit that ranks second in lens sales in the U.S., last year began selling through some mail-order distributors. Some professionals, too, no longer resist releasing prescriptions. Says Ventura (Calif.) optometrist Dr. Robert L. Pazen: "I got tired of fighting with patients and having them go out of my practice because I wouldn't do this." Pazen adds that competition has largely squeezed the profit out of lenses anyway.

Still other professionals are breaking ranks, using Web sites to set up mail-order businesses. "Rather than fight them, we decided to join those people who are offering alternative channels of distribution," says Huntington (N.Y.) ophthalmologist Dr. Paul L. Krawitz. His year-old Lens 4 Me Web site ( gets 2,500 hits a day, though annual sales are only $175,000. He charges $28.95 for a box of six lenses, plus $8.95 for overnight shipping. Lens Express, an older mail-order rival, charges $19.95 plus shipping but requires a minimum four-box order and a $25, three-year membership fee.

Opponents say it is risky to buy lenses outside a professional's office. An exam can uncover lens-related problems such as corneal ulcers. And making a patient return to a doctor for replacements is an ideal incentive for an exam. "What I find with people who get mail-order is they don't come me or to anyone," says Ridgewood (N.J.) ophthalmologist Dr. Anne Sumers. "It would be no problem for them to get mail-order if they would also come and get a routine follow-up."

MORE RISK. Urging consumers to do the smart thing, though, differs from forcing them to do so. Even annual prescriptions seem coercive, especially since some doctors say healthy folks age 18 to 30 need to visit just every two years. Just as dentists use mail and phone contacts to urge timely visits, so can eye-care professionals--and many patients will take them up on the advice.

For consumers, freer choice brings responsibility and risk. Prices can vary widely, and lens technology changes constantly. Professionals should continue to play a major role in helping consumers deal with such problems. But opening the system will ensure that more information is disseminated and that new, cheaper alternatives for buying lenses develop. Optometrists, ophthalmologists, and manufacturers should start looking at this issue in a new light.