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The Case of the Low-Income Disparity

A patient feels like she gets treated differently because she is on state insurance. When faced with a patient in need, how should this eyecare business handle it?




WHILE SITTING AT the front desk, Melanie got a rush of adrenaline when the front door flew open and hit the wall behind it, making a loud bang and shaking the wall. The woman who had so forcefully opened the door came rushing in, clearly in a hurry, and approached her.


Real Deal scenarios are inspired by true stories but are changed to sharpen the dilemmas involved and should not be confused with real people or places. Responses are peer-sourced opinions and are not a substitute for professional legal advice. Please contact your attorney if you have any questions about an employee or customer situation in your own business.


Carissa Dunphy has been working in private practice optometry since 2008 and is the founder of Optician Now ( Follow Carissa on Instagram and Facebook at @opticiannow.

“I am here for my appointment. It was supposed to start 10 minutes ago; I am so sorry I’m late but I don’t have a car and the bus was running behind.” She frantically continued, “I am so sorry, can you please still see me? It’s so hard to make appointments around the bus schedule. The last place I went wouldn’t see me when I was late but I think it was because I have state insurance and they just didn’t want to see me.”

Melanie reassured her, “Ms. Miller, we can definitely still see you if we get you back right away. Leave your insurance and identification cards with me and I will bring them to you in the exam room when I get all of the information I need. Trish will take you back now.”

As Melanie handed the patient off to Trish, the technician, she noticed that the patient was still quite amped up.


The moment Ms. Miller sat down she blurted out, “Please only do the tests my insurance pays for. I can’t afford anything extra.”

Trish was somewhat surprised by the loud and robust remark, but responded, “I completely understand. We do a thorough and comprehensive eye exam, all paid for by insurance. If the doctor feels he needs additional testing he will go over that with you — you won’t have any surprise charges.”

“Okay,” Ms. Miller continued. “The last place I went made me feel guilty about saying no to anything that cost extra. As soon as I said no to the test I felt like the level of care towards me went into the crapper and it was very uncomfortable.”

A bit later Dr. Goodell approached the optician, Bernie, to fill him in on the exam findings and hand off the patient. “Ms. Miller’s eyes are perfectly healthy but she’s a -4.25 with just over 2 diopters of cyl.” The doctor continued,

“She definitely needs new glasses; she said her last pair was broken beyond repair a while back.”

Bernie went out to optical to meet Ms. Miller. “Hello, I’m Bernie, your optician, I’ll be helping you with all of your glasses needs today.”

They sat down and Ms. Miller got straight to the point. “My last pair of glasses were almost 20 years old and they had been broken and rebroken over the years and finally bit the dust a few months ago. I know I need new glasses but my insurance only pays for my eye exam.”

Bernie felt bad for Ms. Miller because she needed glasses badly, but at the same time he was part of running a successful business. He definitely felt backed into a corner on this one…

The Big Questions

  • In your experience, do low- or fixed-income patients, or those on state or federal insurance plans, seem to be treated differently when seeking eyecare?
  • Could you … would you … talk to the owners about a payment plan for this patient? Or is business business and it’s the patient’s responsibility to figure out how to get glasses?
  • Does your business have a system, program, or protocol in place — be it a go-to lab and frame company or local organization that donates eyeglasses to those in need — you rely on in these circumstances?
Tina R.
West Lebanon, NH

I have witnessed individuals who are lower income be treated differently. Our policy is that a deposit be made before glasses are ordered. The patient may make payments but is not allowed to take the glasses until they are paid in full. We work with agencies such as Lions Club and health foundations that provide glasses for low-income individuals.

Jennifer S.
Great Falls, MT

Yes, low income, and even state insurance patients, are treated differently. It’s impossible not to notice; we should meet every patient with equal respect and care. Our clinic would ask for a payment plan to be set up for this patient. Not being able to get the glasses you need over money is the silliest thing ever. Everyone deserves good vision. We have multiple ways of assisting patients in these situations; frames and lenses at lower cost, give-away frames, discount frame packages, and affordable vision provisions. We all have to change the way low-income vision needs are met, and it has to start with equality and respect.

Justin T.
Pittsfield, MA

I do feel that some staff in many locations look down on state and federal sponsored insurance plans and subscribers. I personally do not. We have adopted the philosophy that all patients are created equal and we strive to treat everyone with the same level of respect and care. We dispense eyewear in a tray, accompanied with a complimentary cleaning cloth, hard case, and a bottle of spray cleaner — regardless of the insurance used. We have on occasion provided patients with glasses at no cost. Whether it was a veteran that wasn’t able to be easily transported to the VA Clinic, or a cancer patient down on their luck. Our company absorbed the cost. We’re lucky we have great leadership and ownership that allows us to do that from time to time.

Haley M.
Glasgow, MT

State insurance patients are not treated differently in my office. No payment plans; I’ve been burned too many times. I deliver top quality care and products; if our products are outside a patient’s budget, that’s OK. I’m not in a race to the bottom. I will be beat in price; but not in quality of care or patient experience. Most of my patients who purchase elsewhere will come back for care — and I’m OK with that. We have a non-warranted line we offer that is significantly less.

John L.
Nashville, IN

As an optician I have two responsibilities, first to my employer and then to the patient. I would explain to the patient the costs and payment policies of our value lens/frame combination. If this is not affordable, I would make sure her Rx included her PD and let her shop for her best option. My job is to help, not judge. I would not however try to change company policies to accommodate an individual.

Jennifer H.
Sandpoint, ID

We have a huge base of low- or fixed-income patients. Many of our doctors and staff grew up below the poverty line, so we know that low-income customers just want to be treated equally. Accordingly, all customers are allowed to order a pair of glasses with half-down, and make payments on the other half until they’re paid in full before the glasses leave the clinic. We’ve also partnered with one of our labs to offer a Value Package for back-up glasses or for the less affordable seasons in life. No income requirements to qualify but no warranties and only very basic lens options. If she walked in our front door today, Ms. Miller would be able to get a functional pair of single vision glasses from us for $54.95 — but so would anyone. And that right there is the key.

Chris D.
Coral Springs, FL

I’ve heard remarks from associates when someone has a “state” plan. Humility is the key. And compassion. For the cases I’ve been part of, how it was handled depended on the employer. Some had a charitable arm. Others had selections of reasonable or extremely inexpensive frames and we partnered with a lab or lens rep or we’d find a reasonable payment accommodation. Again the key is remaining humble. How would you want your mother or spouse or child treated? How would you want to be treated?

Michael Y.
Redding, CA

We accept low-income patients and participate in a local program that helps the working poor get eyecare and glasses. The exam and glasses are free and the program is available through a local charity organization. We offer a budget line of frames and lenses for the low-income population.

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