For the recent AAA 2021 Virtual conference, held April 14–16, 2021, we hosted a roundtable that explored ways in which private clinics can maximize revenue. This article reviews those insights solicited from our colleagues’ best ideas and takes examples from our sister professions of dentistry and optics to replicate efficiencies and create an enhanced patient experience with a wider range of services and product offerings.
From Retail to Details: Using Audiology Assistants to Boost Clinic Efficiency
While new retail products can hold promise for increasing clinic revenue, increasing operational efficiencies and boosting providers’ available time might be an easier sell for some practices. Dr. Soriya Estes found that using audiology assistants offers a cost-effective way to do baseline or annual testing, listening checks, cleaning care, and continued counseling, not to mention giving patients an extended “go-to” resource for Bluetooth troubleshooting, insertion re-instruction, wax-trap support, and all the other new user experiences.
In addition to freeing up the provider, audiology assistants can lend great support to a clinic’s front-line patient-care coordinators so they can focus on phone calls, scheduling, and intake protocols. The training protocol for an audiology assistant varies from state to state. Typically, within a 12-week process, along with supervised hours, an assistant will be ready to take on greater clinical responsibilities and manage hearing aid lab responsibilities. Again, this may allow better patient management and care, with the audiologist maintaining revenue-generating appointments and the assistant tending to more maintenance care.
“Since 2013, our team has been successfully using licensed audiology assistants in the practices,” Dr. Estes says. “Our clinical schedule enables us the ability to have our assistants conduct the first half of the hearing aid fitting appointments to review cleaning, care, insertion, chargers, pairing of phones, and app instructions. The assistant then connects the devices and prepares the probe microphone tips and software for the professional component of the fitting process. Afterward, the audiologist enters the fitting room to perform real-ear, programming, answer any questions, and finalize the fitting process.”
Increasing Provider Availability
With this model, providers can see two patients within a one-hour clinic block because their professional time is not needed for the first half of the hearing aid fitting appointment. Instead, providers can see another appointment in that time, finish up a professional report, or take care of other needed clinical tasks.
Working in this manner with assistants also may create a strong relationship between the patient and the assistant, so if new hearing aid users have problems soon after the fitting, they are not filling up a non-revenue appointment with an audiologist to find out why their calls are not streaming into their devices. Instead, the patient has the opportunity to call or walk in to ask their trusted assistant. This delineates further what is valued as a professional appointment versus something that can be handled by clinical support staff.
The Role of Audiology Assistants in an OTC World
As we enter into 2021 with over-the-counter (OTC) devices on the horizon, the role of the audiology assistant can be inspired by what we’ve learned from our colleagues in the field of optometry. Every audiologist has seen a patient for a consultation who is “just not quite ready yet” for the investment of hearing aid technology and professional help. Instead of sending them out the door for another three to five years in their hearing-acceptance journey, the professional may consider offering them the option of OTC. The consultation can then turn to “hearing cheaters,” just as our friends in optics have done.
Patients can see an assistant for their OTC device, pairing, use, and instruction. The patient can then continue to receive exceptional care and service while building a relationship with our office and support staff. Annually, the patient can see the audiologist for testing, review of any changes in their hearing, and discuss communication improvements and challenges. When the patient is motivated or the degree of hearing loss increases, we will recommend prescriptive hearing aid technology that is fit and channeled through the provider versus the assistant.
Working with audiology assistants in this way can lead to patient retention and satisfaction, regardless of where a patient is in their better-hearing-motivation life cycle. This process also enables clinics to incorporate lower-margin devices into the practice business model as an extended value-added service. Prior to hiring an audiology assistant, review your state’s laws and licensing requirements for audiology assistants. Also, for more information, please refer to the Academy’s recently published Audiology Assistants Position Statement, which is discussed later in this issue.
Cognitive Screenings in the Clinic
Dating back to 2011, audiologists have known about the association between cognition and hearing, as confirmed in the landmark study published by Lin et al (2011) and in more recent studies (Livingston et al, 2020; Panza et al, 2019). In fact, hearing loss may be the number one modifiable risk for cognitive decline if identified in midlife (Livingston et al, 2020).
Recent research suggests that rehabilitative strategies including hearing aids may decrease the progression of cognitive decline in individuals with hearing loss (Glick and Sharma, 2020; Karawani et al, 2018; Maharani, 2018; University of Melbourne, 2020). These important findings highlight the importance of audiology and hearing technology in managing older patients who may be facing cognitive decline.
Cognitive screenings are within the scope of the practice of audiology (American Speech-Language-Hearing Association, 2018) and are important, given the large aging population in the United States and the need to generate appropriate medical referrals for these patients. Although many audiologists do not incorporate cognitive screenings in their practices (Black and Souza, 2020), the early detection of cognitive decline is critical to ensure timely intervention support (Shen et al, 2016). Audiologists who use cognitive screenings often use paper and pen cognitive screenings (Shen et al, 2016), which, in some cases, might be time-consuming for the clinician.
Dr. Noël Crosby has been using a 10-minute, self-administered computerized screener, the Cognivue Thrive (2021), since May 2020. Other similar computerized cognitive-screening tools are available or are being investigated (Zygouris and Tsolaki, 2015). Cognivue Thrive is adaptive and evaluates multiple cognitive domains and speed-performance parameters. Results are categorized as red (poor), yellow (moderate), or green (good) cognitive function. She believes this screener provides the missing piece of the puzzle for serving her older patients and provides an excellent and affordable alternative revenue stream. Cognitive screenings are not covered by insurance, so it is important to have a conversation with the patient about the cost and the importance of the screening.
Dr. Crosby explains to patients that this tool “helps her learn more about ear-to-brain information and provides her with missing pieces of the puzzle.” Her nominal fee for the screening ($39) is packaged with speech-in-noise testing. Given the affordability of this package, new patients very rarely decline to include it as part of their assessment.
She also offers this service to existing patients who report they are struggling to hear in everyday listening situations. She also will confirm the patient’s hearing aids are working and set appropriately. To examine any changes in cognitive function, cognitive screenings are repeated after 60 to 90 days of hearing aid use.
Dr. Crosby explains that, “the cognitive screening can also be used as a counseling tool to increase acceptance rate of hearing aids. Explaining the link between cognition and hearing helps patients to understanding the importance of earlier intervention and consistent hearing aid use.”
She describes results for a patient with a mild hearing loss who initially scored in the yellow and red on Thrive. After about 60 days of consistent hearing aid use, a repeat screening showed higher scores in the yellow and green categories and the patient reported better functioning. Initially, this patient was on the fence about hearing aids, but after reviewing her initial scores on the screening, Dr. Crosby encouraged her to purchase hearing aids, which made a world of difference.
In summary, Dr. Crosby believes cognitive screenings are a great addition to private practices. They allow her to assist her patients in a more meaningful and informed way, increase revenue, and form more connections to local physicians and professionals in her area.
Working with TPAs: Is Reduced Reimbursement Worth It?
We have looked at ways to increase retail income and clinic efficiency, but what if your main objective is increasing patient load?
Dr. Gyl Kasewurm explains that, “For many practices, the decision to partner with third-party administrators (TPAs) in the insurance reimbursement process has proved to be a double-edged sword—while it brings increased traffic to the practice, it is often at significantly reduced reimbursement rates.”
“For those who aren’t familiar with them, TPAs serve as middle-men between the provider and the insurer, employer, or membership group and their key function is processing claims. TPAs refer their ‘members’ to registered, in-network providers for evaluation, fitting, and long-term service,” clarifies Dr. Kasewurm.
TPA programs are being offered by traditional commercial payers and their subsidiaries, Medicare and Medicaid contractors, government entities, worker’s compensation programs, and third-party administrators. As these groups work to reduce the cost of hearing-health care and the prices consumers pay for hearing aids, most of these TPAs have grown significantly in subscribers and have positioned themselves to be able to negotiate discounts, coverage, and control discounts that can be offered and benefit offerings.
As TPAs Grow, the New Patient Pipeline Shrinks
As TPAs have flooded the market, they have captured many hearing-benefits contracts and often control the way their members approach hearing-health care. Hence, many audiologists are threatened with losing significant numbers of patients unless they agree to participate with these third-party programs.
Dr. Kasewurm says that, “While the growth in the number of potential patients can be attractive to a provider, the reduced reimbursement has the potential to dramatically affect profitability. As a result, audiologists are having to make the sometimes-difficult decision whether or not to participate with these programs.”
The question of whether to say “yes” to accepting these third-party programs is really about business and whether the business can survive what a reduced reimbursement is, usually as compared to the fee schedule for private-pay patients (Zipnosis, 2021).
This must be a business decision. If the schedule is full of private-pay patients, participation may not be necessary. However, if multiple appointment times are going unfilled and the business is not generating enough revenue to cover expenses, participation may be a viable option.
Crunch the Numbers; Read the Fine Print
For audiologists to make informed decisions and use the many resources available to them when negotiating third-party contracts, professional audiology organizations strongly encourage members to consider the following before signing any agreement with a third-party payer.
The following information was compiled in collaboration with, and authored by, representatives of the Academy of Doctors of Audiology (ADA), the American Academy of Audiology (AAA), and the American Speech-Language-Hearing Association (ASHA) (American Academy of Audiology, 2021; Cavitt, 2011).
Calculate the break-even hourly rate for the practice. This will help determine how much you need to generate each hour to break even. Most businesses cannot afford to accept reimbursement levels that fall below their break-even rate, except on a very limited basis.
Consider if the third-party contract will generate non-covered services and products. If so, factor that into your financial analysis.
Read the entire agreement from the third-party payer and ensure that it includes a description of covered services and products plus a current fee schedule.
Verify all contract terms and that your practice can meet those contract terms. In addition to the fee schedule, consider infection control, licensing, quality assurance, site visits, and any other requirements that are stated in the contract.
Understand the type of contract you are signing. Is it discounted fee-for-service, capitated, ancillary care, or some other type of contract? Each has its pros and cons.
When you sign a contract, you are saying you agree to all the stipulations in the contract and, of course, that means you need to read every bit of the agreement to make certain you are willing to comply. Have an attorney review each contract before signing to make certain your interests are protected.
It’s also good practice to periodically review existing contracts to determine whether they still meet your needs.
The same goes for the vendor. Trust your relationship with key vendors, but also verify that they are performing to your expectations and contractual obligations.
TPA Relationships in Pandemic Times
“While I have never been an avid promoter of getting involved with TPAs, the COVID-19 pandemic changed my opinion. While my office was essentially closed and revenue was very limited, colleagues that were participating with TPAs continued to generate significant revenue because of the delayed reimbursement schedule of these programs,” explains Dr. Kasewurm.
“In addition, several colleagues have indicated that, when they reopened, the TPA patients were the ones filling their schedules. While they had trouble getting private-pay patients to make appointments, patients with TPA coverage were more likely to come in,” says Dr. Kasewurm.
Conclusion: Weighing the Impacts on Your Business
When weighing decisions about any new revenue streams or operational changes, the most important decision a hearing-health-care owner or manager needs to make is what type of impact participating—and not participating—in these programs will have on the business.
As we move forward into 2021, we look forward to collecting more stories of innovative steps practices have taken to generate new income and grow their business during these unusual times.