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Thread: Ethics of MD dispensing.

  1. #1
    Master OptiBoarder Texas Ranger's Avatar
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    Does anyone besides the AMA think that doctors filling their own Rx's is an ethics question? Would you as a patient feel comfortable if your general physician owned his/her pharmacy/medical equipment facility next door? Comments?

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    sub specie aeternitatis Pete Hanlin's Avatar
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    The question:
    "Would you as a patient feel comfortable if your general physician owned his/her pharmacy/medical equipment facility next door? Comments?
    I surely would. However, the nature of the optical business is rather unique within the realm of medical services. After all, it is perhaps the most retail-oriented of all medical services. The emphasis of eyewear sales lies in the frame, lens material/options, etc.- the Rx, while important, is almost secondary in some cases.

    Yes, I realize the Rx is the component that actually assists the patient in their attempt to see with the best acuity possible. However, if there was only one frame style, one lens style (and so on), there would be no real eyewear business per se. My point being that the focus of eyewear sales is not necessarily on filling the Rx of the doctor- but is often on fulfilling the fashion desires of the patient (i.e., client). Therefore, while some conflict of interest surely occurs when an OD/MD owns a dispensary, overall it is a retail business that is, for the most part, seperate from the doctor's medical practice.

    Pete "just my opinion" Hanlin

    Pete

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    Master OptiBoarder OptiBoard Gold Supporter Judy Canty's Avatar
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    Redhot Jumper

    But Pete, pharmacies are a retail business. If the AMA opposes in-office dispensaries, it should oppose all in-office dispensing, aspirin or eyeglasses.

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    sub specie aeternitatis Pete Hanlin's Avatar
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    Okay, but...
    You also don't spend more on the aspirin bottle than you do on the aspirin. Eyeglass frames are functionally the stylish "bottles" that hold eyeglass Rxs, no? Patients have a lot more choices to make in an optical dispensary than at the pharmacy (where it boils down to generic or name brand).

    True, if a doctor owns the pharmacy, s/he may prescribe more (and more expensive) drugs... but with an eyeglass Rx you are providing a product that will be judged by the patient's subjective feelings. In other words, a patient isn't going to get a refund on Mevacor (a cholestorol reducing drug) if they feel the medicine is ineffective or they feel they spent too much. However, it is almost standard in our industry to refund patients for eyewear if they are not satisfied.

    Pete

  5. #5
    Master OptiBoarder Texas Ranger's Avatar
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    Pete, the conflict is two-fold, first their paradigm is not with the needs of the "whole" person. their objectivity is so out of focus that they either feel that people are paying too much, so they can't justify recommending new glasses at all, or their ego is to the point that they can't admit when they've made a refraction/prescibing error, and surely won't if the cost is coming off their bottom line. They generally don't hire the best optical staff, basically because they, like Walmart see opticians as sales clerks. now in licensed states like fla., at least there is a competency that they can look for, in Tx. where there isn't, that isn't generally the case! It is virtually impossible to prescribe and run a "retail" business filling that presciption without consideration of the economic outcome of your recommendations. Check out the term "capture rate" in eye doc. 101. They care and they care a lot.

  6. #6
    sub specie aeternitatis Pete Hanlin's Avatar
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    I'm sure that we're going to see this issue somewhat differently, because we approach it from different angles. As you know, I manage a multi-OD practice with two dispensaries. To be honest, I don't see how an office that just practices Optometry (without a dispensary) could be very profitable. There is very little money in the practice of Optometry (thank you, managed care).

    I believe a dispensary can be owned by an OD without a conflict of interest, because ours operates on the up-and-up (e.g., patients aren't "pushed" into new Rxs, we don't prescribe +0.25 spheres for every kid that comes in, etc.). We also have liberal return and satisfaction policies.

    Could there be a conflict of interest with an OD owning the dispensary? I suppose. However, the FTC's guidelines concerning prescription release laws provide a standard which should preclude most problems. The problem is that the laws aren't enforced (sort of like gun control... we have it, we just aren't enforcing it).

    I still maintain that eyeglass sales are largely a retail enterprise- not strictly medical. Therefore, rules that apply to medicine may sometimes be neither relevant nor applicable to the optical business.

    Pete "like I say, however, that's just one person's opinion" Hanlin

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    Optical Curmudgeon EyeManFla's Avatar
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    My problem isn't with the MD who has the optical shop. It's with the MD that let's his tech do all the refractions!
    I have had dealings with MDs who have opticals. It no different to me that the OD with his own shop.
    Hey, if Luxottica wants to control all the means of production in the eyeglass business, why should anyone be suprised that MDs want the retail piece of the pie,too.
    Face it, that MD's shop is only as good as the optician that runs it and the tech that does the refraction.

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    Master OptiBoarder Jeff Trail's Avatar
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    Originally posted by EyeManFla:
    My problem isn't with the MD who has the optical shop. It's with the MD that let's his tech do all the refractions!
    I have had dealings with MDs who have opticals. It no different to me that the OD with his own shop.
    Face it, that MD's shop is only as good as the optician that runs it and the tech that does the refraction.
    Good posting... and I know two MD's that started to dispense this year near me.. I told them I thought it was a mistake for a couple of reasons... I know that BOTH MD's have this bad habit to over refract on RX's and when they did fluff the refracting off to the techs they, to put it bluntly, STUNK :) .. I do a lot of the local accounts and see the "Dr. Redo" rate that was coming out of these offices on the scripts I was getting just from my accounts.. who knows how many other's went to opticals where I don't do the lab work and they were redone..
    Neddless to say..as of last month the re-do rate was running around 40% !!.. that is down right pathetic.. really makes no difference to me since I get to double bill (less the discount) for all these boo-boo's but sheesh.. that's crazy numbers 4 out of 6 are wrong AND they charge $110 for an exam :).. go figure...

    Jeff"good for my bottom line but still a pain in my butt" Trail


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    I think that there is a huge difference between an O.D. dispensing and an M.D. dispensing. At the risk of offending optometry, but also in their defence, Optometrists are not really and truly "physicians" or "professionals" in the sense that M.D.s are.
    The whole concept of Optometry was to have a guy who could refract, but neither "diagnose nor treat" eye disease. Of course, with changes in the laws of different states and with some better training in optometry, this limitation has been modified somewhat, but I personally do not think of an Optometrist as a professional or a physician, any more than I think of an Optician as being a professional or a physician. They are an alternate form of eyecare. One EXPECTS an Optometrist to sell eyeglasses and contact lenses, because he is basically just a businessman with a degree, but NOT a degree in medicine.
    The whole argument that we used to use in the Guild was that you should go to an Ophthalmologist, not only because he was well trained in general medicine, as well as the eyes, but also because he had no vested interst in your buying a pair of glasses if you didn't need a pair.
    Now, Ophthalmology has blurred the lines between themselves and Optometry, and they SHOULD be better than that. And Optometry had done a darned good job of training themselves better and presenting themselves more as professionals than businessmen. But they are still not physicians, even though the laws of a few states allow them to call themselves that. As far as I know, a "physician" still mean a degree in medicine or osteopathy. Chiropractors like to call themselves physicians as do naturopaths, but would you go to one of them for emergency surgery? Or a complete physical? I wouldn't, but some peole would, if they were allowed to perform such. Some people swear by witch doctors, but that does not make them "real" doctors (except maybe in Louisiana). The biggest mistake Opticians can make is to fall into the "professional trap." We're merchants. Pharmacists are merchants. Optometrists are merchants. We all have different levels of expertise, but for any of us to feign being a full-fledged "physician" is arrogance.
    And those M.D.s who allow the "techs" to do the refracting, and most of them do, are an even poorer excuse for a "doctor" than those Louisiana Witch Doctors. And NONE of them should be selling what they prescribe.
    But you know, a "prescription" for eyeglasses is not really a prescription inthe sense of a prescription for drugs. Nobody ever died from the wrong eyeglasses, but plenty have died from the wrong medicine. A eyeglass prescription is really something less than even a formula. It's just an "order" for something that makes somebody see better. Does a binoculor manufacturer need a licence to "prescribe" 7X35s for the golf course and 10X50s for yachting? No. So why should ANYBODY need a special permit to make something that helps a guy see the newspaper better....or drive down the road? Does it take an M.D. an O.D. or even a Refractometrist to figure THAT out? Not many M.D.s seem to think so anymore.
    I predict the day when you'll be able to go into a booth in the mall, much like a photo booth, stick you head in a mask, open your eyes, and then wait a few minutes for a disposable pair of glasses or contacts to drop down into a little drawer underneath. 100 years from now, with computerization, maybe well before that, people will say, "you mean people used to go to doctors?....for THIS????

    ------------------


  10. #10
    Master OptiBoarder Texas Ranger's Avatar
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    Bob, what a great statement. that little booth in the mall will probably be doing auto-lasik; just swipe your smart card first! I think the thing with MDs is a generational thing. They change the criteria of med. school entance requirements a couple decades back, shifted to a very much more pronounce emphasis on GPA instead of compassion and common sense; medicine's been going downhill ever since, and that's not just ophthalmology. The last generation of MD's wouldn't be caught dead in such a conflict of interest, they were "physicians", not merchants. you're right we're merchants, with varying degrees of product knowledge and dispensing skills, and product access. and what's wrong with that. my accountant has a client that makes a ton more money than I do, selling corny dogs at the mall, and another that mows lawns and another that sells ice to snow cone stands, they all make more money, by a bunch! than most opticians, and maybe some ODs. But we provide a unique service and love solving people's vision problems. But MDs aren't merchants! and they've delegated most of what they do do, so i guess they could operate their offices without themselves, that's a pretty good job!

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    Pete you are all wet on this one. Until recently the AMA, the American College of Surgeons, and many other organizations would not allow dispensing ophthalmologist accredation in their various organizations. Eventually some idiot told one of them there was money in it and the genie was out of the bottle. The various organizations finally had to say to themselves, "Hey these guys are making a lot of money and have a lot of clout! We need people like them."

    Just last year our state medical licensure board had in it's bylaws: A physician cannot prescribe or recommend any drug or devise or place of service in which he has a financial interest over that which he does not have an interest. Now it has been "interpreted" "that only applies to drugs. i.e. the drug people have a lot of clout and money so we won't take them on yet.

    I read a law suit once that got the doctors out of the dispensing business for a while and established the "common roof law" now deceased. I went though the records of some of the plaintiffs and found record where the financially interested doctors prescribed .12 cylinders for welding goggles. Why, you get a lot more money for Rx welding goggles.

    Saw lots cases like this. Just as you see nit picking Rx's and Rx changes on Medicare exams that you would not see on exams for the general "pay your own bill public." Don't even think for a minute that more education equals more integrity.

    Absolute power corrupts absolutely! Shakespeare

  12. #12
    sub specie aeternitatis Pete Hanlin's Avatar
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    "Pete you are all wet on this one."
    It occurs to me that glasses, unlike contact lenses, are not classified as medical devices (I don't believe the FDA has to approve new spectacle lens materials, lens treatments, etc. because there is not direct contact/interaction with the body).

    Also, as other posts in this thread have intimated, ODs are in a somewhat unique position in the medical field. Basically, Optometry evolved from Opticianry... the prescribing and dispensing of eyewear is fundamental to their area of practice (that Optometry is moving away from this causes me bewilderment).

    Unlike most medications, eyeglass lenses are custom made devices. These devices must be applied correctly for the patient to realize optimal vision. Ideally, ODs would take an active role in making sure either they or their qualified staff are ensuring the proper application of their prescriptions.

    In the end, it is entirely possible that I am completely soggy on this issue. I just haven't seen a good enough argument to convince me that an OD operating/owning an optical is equivalent to an MD operating/owning a pharmacy. Perhaps if prescription release laws didn't exist, I would be more sensitive to the issue.

    I suppose the case against an MD owning/operating an optical dispensary could be better supported (however, the argument against eyeglasses being considered medical devices would still apply).

    Pete "you may be right, I may be crazy... but it might just be a lunatic you're lookin' for" Hanlin

    [This message has been edited by Pete Hanlin (edited 08-04-2000).]

  13. #13
    Master OptiBoarder Joann Raytar's Avatar
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    Question

    Coincidentally we were having this same discussion today at the office. I agree, there do seem to be a few issues with MDs having their own dispensaries. The problem is that eyeglasses are being seen as durable goods not necessarily medication. In other words, if you go to a physician's office or a walk in center you cannot get a prescription filled there for pain medication but you can purchase a pair of crutches. Pete hit the nail on the head in his first post. If all frames were limited in style to the point where they differed only to accomodate sizing and if all Rxs were filled with the same lens material they would be the equivalent of an MD dispensing crutches. However, frame fashions and premium lenses make it eyewear sales more of a business transaction. There is a fine line between selling premiums just to make money, ie. selling safety poly ARs to a welder, and offering your patients the newest in products. People want thin lenses, they want to achieve the best visual acuity; however, it is important that they know these are options and that they have choices.

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    Optical Curmudgeon EyeManFla's Avatar
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    Bottom Line, Guy......Opticians, O.D.s and M.D. are ALL businessmen....ok,and women...

    WE ARE ALL IN IT FOR THE MONEY>>>>>>>!!!!!!!

    Opticians want to refract and O.D.s want to do LASIK...why,.....TO MAKE MORE MONEY !

    Let's face it....our various prosessions must adapt or die, it's that simple.

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    Hi Ya'll;

    I just wanted to ask a question. I have heard that in Florida, Optometrist's are now called Eye Care PHYSICIANS. If this is true, then the seperation between OD's and MD's is getting narrower isn't it. Maybe some of our Florida Optiboarders can confirm this. Jim Seebach

  16. #16
    Optical Curmudgeon EyeManFla's Avatar
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    [QUOTE]Originally posted by Jim Seebach:
    [I]Hi Ya'll;

    I just wanted to ask a question. I have heard that in Florida, Optometrist's are now called Eye Care PHYSICIANS.

    The actual title is "Certified Optometric Physician".........


    And you are right. It a way to blurr that line, on purpose!

  17. #17
    Master OptiBoarder Texas Ranger's Avatar
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    Y'all, it's always so good to stimulate such great conversation. Some of this issue involves the percieved "rightness" of which party has the most "prestige" with the clients. Doctor told me it was like the golden rule, "those with the gold, make the rules". In thirty pus years of watching how getting into dispensing changes doctors,i'm just saying it doesn't seem to be in the pts best interest. i can appreciate Pete's position better, since the optometrists do the refraction and exam "personally", generally use minus cyl phoropters, and we have about 99% less problem rx's with their rx's. Actually, an optometrist that practices eye exams and contact lens fitting can do quite well. Jeff is right, can't be a very profitable deal for some MD's when thay have to actually pay for their own ineptness. many pts feel like if they can't write better rx's, how could they be a good surgeon? good question, from the lay point of view.

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    Before I say what I'm going to say, let me give you a little backround on me. I'm a semi-retired "old Guild guy" who at one time was actively involved in a group that wanted to strip Optometrists of the right to call themselves "Doctor" and eventually outlaw the whole profession.
    But with what has happened in Ophthalmology, when I need a new pair of glasses or contacts, do I go to an M.D. (and I'm close with all of them in my town)? No. Not to get checked out by one of their teenagers. I mainly refract myself. And every couple of years, I go to an OPTOMETRIST for a really good refraction. I still let an M.D. check me for the eye health business once in a while. How's THAT for a change in heart? And the M.D.s are ruining themselves. It's a funny coincidence that at about exactly the time that Medicare cut their fees in half, or more, for cataract surgery, they all of the sudden got into the optical business, and out of actually doing the "routines" themselves. Less "chair time' for them. The patient still pays the same as when an actual MD did the whole thing. Now they are all pushing "refractive surgery", which most of them used to view as "corneal mutilation." Big money, no insurance company to tell them what to charge for 20 minutes of labor. But now it's OK, because it's done with a Laser. If your house gets bombed in a war, does it make any difference if it was done by a 5 ton bomb or by a nuclear device, as far as you are concerned? I don't think Bowmans Membrane knows the difference either.
    Soon, Lasic will become real cheap, as Lasic centers, staffed by MDs with no following, open up all over. Then, ODs will start to do it, probably starting in Florida, then nationwide. Then what will the MDs do? They'll be confined to industrial injuries, and the few who handle retinal problems, and most MDs, frankly, couldn't muster the boards in that specialty.
    They'll wish they had "left it the way it was" as my father used to say about just about everything.
    In Augusta, a group of the best MDs in town, who should have better sense, have taken out a half-page ad in the phone book, complete with photographs, billing temselves as "The Eye Guys." They've even appeared on T.V. in that format.
    Would any of you like to stay in training until you're into your 30s to end up being an "Eye Guy?" And these are my friends, to whom I have referred thousands. They must be pretty desperate.
    My daughter is an M.D. in residency for OB/GYN. If I ever see her picture in the phone book billed as "Gyno-Girl" I'm going to personally nail her office door shut.

    ------------------


  19. #19
    Master OptiBoarder Shwing's Avatar
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    Redhot Jumper

    Actually, Bob, good job in parenting. I just don't foresee a huge fall off in demand for Ob/Gyns.

    We are proud that the baby boomers are now just hitting our prime hunting season ie: presbyopia. That, and 40% or whatever of the population needs a correction.

    How about 1/2 the pop. needing your services...

    As to your daughter's potential nickname, I wouldn't be too concerned if she decides on 'Gyno-girl', as I can quickly think of much less uh, desirable, er, polite, um, politically incorrect titles; none of which I can post....

    Trade ya. I have identical twin girls, blonde, age 8.5, and rather independent... Not even God can help me in the coming years.



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    Shwing;-}

  20. #20
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    Bob,

    As an OD who does read this list, I have to reply to your comments regarding the profession of optometry.
    Your statement that optometry is not a profession seems to be based on not having a medical degree. Engineers are professionals, and few of those have medical degrees either. A profession is designated in many ways, but generally it is a self-regulating group with a specific set of special skills and sufficient responsibility that leaving it non-regulated would pose considerable risk to the general public. Optometry would fit that model.

    Your statement about optometric refracting and fitting glasses is probably a reflection (no pun intended) of the initial development of the profession. Things have changed. The treatment and diagnosis of eye disease is equally important, and provides services (at least in Canada) that are unavailable/cost prohibitive to have ophthalmologists deliver. (Every state now allows optometrists to diagnose and treat eye diseases, at varying levels.) And primary care physicians (my brother among them) don't have the equipment or the specialized knowledge to allow them to treat more than basic eye conditions, certainly not binocular vision/neurolgical and or anterior/posterior segment disease.

    I am not a physician (whatever magic that word conveys), nor do I wish to perform surgery. However, improving people's vision and diagnosing/treating their eye disease is both necessary and fulfilling. (and yes, untreated eye disease CAN lead to blindness, and does matter more than getting the Rx wrong on an Rx)

    I think it is important that all of the "O"'s understand each other's roles, responsibilities and capabilities, in order to work together a bit better for the common good (and yes, all receive fair payment for their services). Drop into an optometrist's office some time and see what they do these days!

    Yours in clarification.

    Rick

  21. #21
    Master OptiBoarder Texas Ranger's Avatar
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    Dr. Rick, that was an excellant statement; I'm sure that most of these "dispensing' issues are a matter our not quite understanding the O's roles. As an optician, with excellant training and experience, I feel like what many eye doctors imply to their pts. is that we are just merchants, trying to get into their pocketbook, and since it's just a matter of order taking, you might as well let us do the same thing, since you're already here in the office. I'd like to think all we go through to be opticians(some not very much), makes us a bit more than a salesman, though that may have some truth to it. I think that eyewear consumers are exploited by deceptive retail games aimed at the naive, while being encouraged by MDs to self refract themselves at the ready made reader counter. There's a whole lot of room in the middle! Our clients, as a rule, are telling us that they are far happier with the eye exam from an independent optometrist than that of an MD practice; wonder why that is? Now when someone asks where should they go for an exam, where should we refer tehm to?

  22. #22
    Optical Curmudgeon EyeManFla's Avatar
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    When I can into the business back in the mid-70s, the rolls of the three 'O' were pretty well defined. MDs cut,ODs refract and fit contact lenses and Opticians filled Rx and also could fit contact lenses.
    When I was a member of the Washington Guild, Opticianry was a well repescted PROFESSION, by the other 'O's as well as the public. Some of my more veteran (read that older) brethern (sorry, Ladies) were even called "Doctor" by their patients (excuse me,customers).
    When did all this change and who's to blame. MDs wanting to refract is not the problem. ODs wanting to treat patients is not the problem. Opticians wanting to refract, well, that's a problem but not the main problem. Corporatization ! All of out professions have been deminished by the corporate slugs that have taken over and destroyed the value of the proper eye exam and the well made, well fit eyeglasses.
    Sorry, given the state of eyecare today, I can't blame MDs for wanting to have their own opticals. Of course, as I stated before, those eyeglasses are only as good as the tech who refracted you and the 'optician' who made them. There is no doubt in my mind that for a good basic eye exam, I would much rather go to an OD then go to an MD if there was a problem.

  23. #23
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    About ODs in Florida... (I'm in Tampa)

    Not only are they deemed "Certified Optometric Physicians", but they are also fighting for hospital privilages.

    A friend of mine and I were talking about different fields, etc, (he's in his last year of residency of med school...a 6 year residency!) Anyway, when I told him the politics of our field, he just kind of laughed and said that opticians probably will refract, OD's will probably do laser surgery, and this shift of paradigms (sp?) will force the MD's to create...to push the ceiling higher, which is how society grows.

    I thought that was an interesting perspective...

    -Laurie

  24. #24
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    Any MD who dispenses or has an economic interest in the filling of his precriptions has no ethics. Case closed.

  25. #25
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    i will only feel comfortable if the MD have a qualified licensed optician to fill the Rx.

    as for the ethics part of it, i think that it is hypocritical of the MD's to single out the opticians because they can out muscle us in the political arena but not the large drug companies because they are far too powerful of a challenge for them.

    as far as i am concerned, a prescription is a prescription. one can find differences in anything till it suits their needs.


    don A.

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