Helping adults manage hearing loss is by far the most fundamental aspect of audiology practice, making this the bread and butter of our profession. Hearing instruments play a crucial role in managing hearing loss in adults (Ftouh et al, 2018; Laplante-Lévesque et al, 2010).

The traditional service-delivery model has a linear pathway and includes bundled service packages. We use the term linear to describe the traditional model of service provided by an audiologist that progresses from one stage to another in a series of steps, delivered by the same clinic. Like a straight line on a graph, the linear pathway of care, as defined here, is undeviating: All stages of the buying process are conducted by the same business entity, as shown in FIGURE 1.

Given that hearing-care services have been delivered in this sequential manner for decades, it is considered the traditional consumer value chain. However, various innovations in technology and service delivery have resulted in the decoupling of the traditional consumer value chain. In this article, we aim to provide some insights into possible future service-delivery models for the management of adult hearing loss.  

FIGURE 1. Linear service-delivery model, also known as the traditional consumer value chain.

The Traditional Linear and Bundled Service-Delivery Model

Audiologists, by virtue of their formal academic training, tend to have a myopic view of their role within the health-care system. Audiologists believe they create value by completing three tasks with each person with hearing loss. (In this article, we define persons with hearing loss as adults, age 18 and older). These three tasks include: (1) a diagnostic hearing assessment; (2) treatment planning focused almost exclusively on hearing aid selection and fitting; and (3) long-term follow-up care and management with hearing aid use as a core component. 

The audiologists’ view of service delivery centers on these three main components, delivered in one bundled package and typically paid out-of-pocket by the person receiving the services (ASHA, 2019; Windmill et al, 2016). This provider-centric view of the service-delivery model is not wrong or misguided, but it does not necessarily represent the view of the individuals who receive these services. For that, we turn to a different way of examining the service-delivery model—one that, thanks largely to advances in technology, is evolving rapidly. 

Individuals with hearing loss tend to view their condition through a completely different lens. Like the audiology professional’s view, historically, value is created in a linear manner in the eye of the consumer. This means that, once a person with hearing loss is ready to seek help, they tend to receive all services from one professional in the order outlined in FIGURE 1. This sequence of five events or tasks completed by a person with hearing loss is commonly referred to as the traditional consumer value chain. 

The five components outlined in FIGURE 1 are not unique to hearing care; the model can be applied to just about any product or service that consumers purchase. Another way to think about these five components in the linear service-delivery model is that each component is really a single task that any customer engages in during the buying process. And, importantly, because most consumers are not experts on the products and services they are buying, each of these five tasks comes with risks or pain points. 

TABLE 1. Common Pain Points at Each Phase


Identify a licensed professional that I trust who will serve as an unbiased expert and provide care that meets my changing needs. 


Find a professional or a device that is best for my condition, now and in the future.


Buy a device or service that fits comfortably into my budget.


Wear devices or use services effectively with minimal stress or hassle. Get the most out of my purchase. 


With minimal inconvenience, return for follow-up care when I have a question or problem. Inconveniences could include long wait times and unexpected fees. 


There are several potential pain points or risks encountered by individuals with hearing loss that may hinder their ability to actively seek care for their condition. Many of these are outlined in TABLE 1. From the perspective of the person with hearing loss, these pain points or risks may hinder their ability to seek appropriate treatment for their hearing loss and likely contribute to the low uptake of hearing aids. 

Specific to hearing care, all five phases of the traditional consumer value chain, shown in FIGURE 1, typically occur with the same provider, with payment of services bundled with the purchase of devices. A key attribute of the traditional linear service-delivery model is that, for most individuals with hearing loss, it is inconvenient to switch providers for any one of the five components. Thus, in the traditional model, even if service is subpar, once a person with hearing loss has completed the Evaluate and Choose phases, they are held captive by that provider, at least until it is time to purchase another hearing aid. Notably, however, technological advances are decoupling this linear model, making it easier for those with hearing loss to complete each of these five tasks with a different entity—online, face-to-face, or through a combination of both approaches. 

Innovations in Hearing Health Care

Several technological advances and policy changes over the past decade enable individuals with hearing loss to break away from the traditional value chain. In other words, these advances enable those with hearing loss to engage in each of the five elements of service delivery separately from one or more professional entity. Some of these innovations include:

  • Easy access to a range of direct-to-consumer hearing devices (DCHDs) that allow individuals with hearing loss and their family members to purchase hearing devices without professional consultation.
  • Internet hearing aid review sites (e.g., and independent consumer reviews that provide details of features and functions of hearing devices. Such websites allow consumers to quickly price-match, read product/service reviews, and choose a hearing device based on their need and price-point.
  • YouTube and social media videos from professional experts who post product reviews for consumers (e.g., the Dr. Cliff YouTube channel).
  • Internet sites that sell personal sound-amplification products (PSAPs) and hearing aids (e.g.,, enabling patients to buy hearing devices while at home. 
  • The 2017 Over-the-Counter (OTC) Hearing Aid Act (U.S. Congress, 2018) is a manifestation of the decoupling of the traditional linear service-delivery model. This legislation is intended to allow individuals with hearing loss to buy devices without first consulting a licensed professional. 
  • In addition to the acknowledgment of OTC as an official category of hearing aids, codified by the U.S. Food and Drug Administration, professionals can expect another sub-category of hearing devices, self-fitting hearing aids (Strom, 2018). These hearing aids, programmed and fine-tuned independently of an audiologist, will be available for purchase in the near future. 

In addition to the decoupling of evaluating and choosing products and services, other businesses unlink the purchase, use, and ongoing service components of the linear service-delivery model. The examples listed below can reduce the pain points associated with purchasing, using, and receiving ongoing services related to the purchase of hearing devices.

  • Third-party insurance contracts, such as TruHearing, that lower costs to the consumer but place constraints on product and clinic choices.
  • Hearing aid leasing companies that allow customers to pay a low monthly fee, similar to a mobile phone subscription.
  • Start-up companies, such as Lively Hearing Aids and Blamey Saunders Hears, that provide remote counseling and ongoing support to hearing aid users, in addition to the direct-to-consumer sale of OTC-type devices. 

Benefits of Decoupled Service-Delivery Models

Today, because of these and other innovations, individuals with hearing loss can walk away from the entire value chain and potentially complete each step of hearing health-care service delivery with a different business entity (FIGURE 2. A person with hearing loss may choose this approach for many reasons, including (1) to have more independence in their hearing care and dabble with hearing devices from the comforts of home, (2) to study or consider dozens of consumer reviews before choosing a device and/or services, (3) to have wider options in terms of features and price points, and (4) to be able to pay only for the specific services they use at that point in time. 

FIGURE 2. Examples of a decoupled hearing-health-care service-delivery model.

While a person with hearing loss may take the first step in seeking help to acquire hearing devices, this may not always be the case. In a recent study, it was noted that many friends and family members of those with hearing loss may purchase a DCHD as a gift for the person with hearing loss (Manchaiah et al, 2019). In such instances, the hearing-care journey of a person with hearing loss may start with owning a device, rather than evaluating and choosing one. Individuals with hearing loss may then decide to seek, or not to seek, professional hearing-care services. 

Consequences of Decoupled Service-Delivery Models 

The decoupling of professional audiological services from the sale of hearing devices is likely to have several consequences for audiologists, including the following: 

  • Along with conventional private pay transactions, the audiologist may have to juggle third-party contract business that requires a different set of key business metrics for successful management.
  • Product price-matching may result in customers choosing to opt for the lowest available price, even if that product is not advised by the consulting audiologist. 
  • Easy access to consumer ratings may result in customers choosing the best-rated product and/or services. This may compel some audiologists to fit devices or provide services that have high consumer ratings but are not appropriate for the individual requesting them. 
  • As with the eyeglass model, an individual with hearing loss may obtain an evaluation from an audiologist and then go elsewhere for the purchase of hearing aids.
  • The strengths and weaknesses of hearing devices and services may be discussed more openly in online public forums or on consumer-centric websites. A possible consequence of open discussions in public forums is that audiologists must be more transparent in their interactions with consumers, as unethical business practices or poor service are more likely to be exposed. 

In addition to these consequences, perhaps the most significant byproduct of a decoupled business model is that an individual with hearing loss will purchase hearing devices online and then seek—when needed—professional services locally. Given that most hearing aid purchases today are completed in a bundled manner, the advent of OTC and self-fitting hearing devices will present audiologists with the challenges of offering more unbundled professional services to individuals who purchase devices elsewhere, but afterward need counseling or device-management support. 

Considering the rapid pace of technological advancements at the core of the decoupled value chain, now is the time to actively consider several dimensions of unbundled service provision, including (1) the identification of individuals with hearing loss in need of comprehensive services; (2) the delivery of specific service packages that offer various types of personal-adjustment counseling, in addition to helping those with hearing loss master the proper use of their devices; (3) using less credentialed staff (e.g., audiology assistants) to deliver some of these services; and (4) the efficient delivery and proper pricing of these services to optimize profits without compromising care.

Effective Ways to Offer Decoupled Audiological Services

Some surveys suggest that many audiologists are already offering unbundled or itemized hearing-care services (ASHA, 2012). This may be an effort to cope with the constantly changing needs of individuals with hearing loss and also to differentiate a practice in an evolving health-care marketplace. Such an approach may bring opportunities for audiologists to increase market share by assisting those with hearing loss who may have purchased hearing devices online without audiological services or support. 

Little has been written, however, about the ways in which audiologists can effectively offer decoupled audiological services (ASHA, 2019; Windmill et al, 2016). We suggest the following three considerations for offering decoupled audiological services:

  • Move from a unit-based to a time-based business with a focus on efficiency and separate key performance indicators (KPIs) to manage time spent with patients. In other words, how time is spent is likely to become more critical in a decoupled audiological service model. 
  • Focus on building trust and promoting patient-centered care (Grenness et al, 2014; Preminger et al, 2015). 
  • Offer service packages that are valued by individuals with hearing loss who opt to buy online. These service packages could include (a) training for self-management skills focused on skill-building (e.g., communication tactics), (b) device-mastery training, and (c) help sheets. These services can be offered face-to-face, in groups, or online using digital technologies. 

Final Note

While audiologists must make considerable modifications to current practice to adjust to future service-delivery pathways, we believe that these innovations in service-delivery models bring many new opportunities. By shifting the focus from the bundled hearing health-care services to stand-alone professional services, audiologists could open underserved segments of the market by promoting patient-centered care. 


American Speech-Language-Hearing Association (ASHA). (2012) 2012 Audiology Survey Summary Report: Number and Type of Responses. Rockville, MD: ASHA.

American Speech-Language-Hearing Association (ASHA). (2019) Unbundling hearing aid sales. (accessed May 6, 2019). 

Ftouh S, Harrop-Griffiths K, Harker M, et al. (2018) Hearing loss in adults, assessment and management: summary of NICE guidance. Brit Med J 361:k2219.

Grenness C, Hickson L, Laplante-Lévesque A, and Davidson B. (2014) Patient-centered audiological rehabilitation: perspectives of older adults who own hearing aids. Int J Audiol 53:S68–S75.

Laplante-Lévesque A, Hickson L, and Worrall L. (2010) Rehabilitation of older adults with hearing impairment: A critical review. J Aging Health 22(2):143–153.

Manchaiah V, Amlani AM, Bricker CM, Whitfield CT, and Ratinaud P. (2019) Benefits and shortcomings of direct-to-consumer hearing devices: Analysis of large secondary data generated from Amazon customer reviews. J Speech Lang Hear R 62(5):1506–1516.

Preminger JE, Oxenbøll M, Barnett MB, Jensen LD, and Laplante-Lévesque A. (2015) Perceptions of adults with hearing impairment regarding the promotion of trust in hearing healthcare service delivery. Int J Audiol 54:20–28.

Strom, KS. (2018) New self-fitting hearing aid class and special controls described by FDA letter. Hear Rev. (accessed July 26, 2019). 

U.S. Congress (2018). Over-the-Counter Hearing Aid Act of 2017: S. 670. 115th Congress. (accessed July 26, 2019).

Windmill IM, Bishop C, Elkins A, Johnson MF, Sturdivant G. (2016) Patient complexity charge matrix for audiology services: A new perspective on unbundling. Sem Hear 37(02):148–160. 

Share this