Direct Access: Interview with Therese C. Walden, AuD, President of the American Academy of Audiology
Douglas L. Beck, AuD, speaks with Dr. Walden about direct access and its impact on audiologists and patient care.
Academy: Good morning, Therese. Thanks so much for your time and congratulations on your new term as president of the American Academy of Audiology (Academy), which started July 1, 2011.
Walden: Thanks, Doug. It really is an honor and I am very much looking forward to the challenges and opportunities of this position. It’s a total labor of love and I am so happy to dig in and get going. We have a fabulous team of volunteers and staff and it’s going to be an exciting time!
Academy: I agree…it’s going to be great and I’m looking forward to your leadership! Therese, I know your time is limited, and so if you don’t mind, I’d like to focus our discussion today on direct access.
Walden: Absolutely. Let’s do it.
Academy: Okay, square one. What does “direct access” mean?
Walden: Direct access means we’d like to amend the Social Security Act to allow Medicare recipients the option of going directly to their audiologist when they experience a hearing or balance problem. Under current regulations, the Medicare beneficiary must go to a physician for their hearing loss or vestibular complaint, and then many times the family doctor or internal medicine doc or the general practitioner will refer to an otolaryngologist (ear, nose and throat, or ENT physician) and then the ENT physician refers to an audiologist for a comprehensive audiometric evaluation. (Learn more about direct access.)
Academy: That seems like a lengthy, slow, and expensive process!
Walden: Absolutely. You know, Doug, it depends on whose numbers you use, but most of the authoritative reports indicate some 90 percent (or more) of Medicare-eligible patients with hearing loss do not have a medical or surgical hearing problem that requires (or would benefit from) medical or surgical intervention.
Academy: Of course, and we’ve know that for a number for decades. Let’s face it, the two most common reasons people develop hearing loss are presbycusis (hearing loss associated with aging) and noise exposure.
Walden: Exactly. And there are no medications or surgical procedures to address hearing loss that comes from aging or noise exposure. The primary proven and most effective way of treating people with hearing loss due to aging and hearing loss due to noise exposure is through the appropriate fitting of amplification—which for most people will mean hearing aids – and audiologists are uniquely qualified to provide these products and services.
Academy: And as you implied, there are other amplification alternatives, such as FM systems, assistive listening devices, bone conduction hearing aids, cochlear implants, brain stem implants, bone-anchored hearing solutions and more…but the vast majority of all people with hearing loss, again, perhaps 90 percent or more of all Medicare-eligible recipients with hearing loss would benefit from well fitted hearing aids.
Walden: Sure. And today’s highly sophisticated hearing aids offer a range of solutions. Some have been around a long time such as the use of a telephone coil (t-coil) that allows the patient to hear more effectively when using a landline phone or an audio-loop system and there are new options such as wireless connections that can turn the hearing aid into a hands-free device—and of utmost importance—there’s a lot of peer-reviewed and objective evidence proving that well fitted hearing aids improve the quality of life for appropriate candidates.
Academy: Okay, so given all that, why would anyone oppose allowing Medicare beneficiaries direct access to the audiologist.
Walden: Well, that’s the issue. At first blush, it makes no sense to oppose this common sense legislation. Audiologists earned master’s and doctoral-level degrees at regionally accredited universities and colleges—which are very much the same accrediting bodies as those that accredit medical schools. Additionally, audiologists are licensed and trained to diagnose and treat hearing loss and vestibular disorders. Additionally, audiologists are the ones that teach medical students, ENT residents and other physicians about hearing and hearing loss, as well as audiometric diagnostics and treatment with amplification.
Academy: So then, where does the opposition come from?
Walden: Primarily, the opposition is coming from the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS). The leadership of the AAO-HNS contends that by allowing patients the option of going directly to an audiologist for hearing and balance problems, that somehow the safety and efficacy of the patient’s care would be compromised by not seeing a physician first. In fact, there is significant data and research that supports audiologists as an entry point into the healthcare arena for these problems. The AAO-HNS leadership sent a letter to Members of the House of Representatives stating their opposition to the direct access legislation.
Academy: Hold on. Therese…Now, as you know, I’m just a simple country audiologist, but I thought all Members of Congress already had direct access to audiologists?
Walden: Yes, of course they do. Members of the House of Representatives and the U.S. Senate and the Executive Branch (such as the president and the vice president) have direct access to audiologists as do many other federal employees who participate in the Federal Employee Health Benefits (FEHB) plan, and they have had this appropriate level of care for many years now—due to the successful efforts of many audiologists before us.
Academy: Well, that’s pretty impressive! Okay, well given all that previous and current direct access, access, how many cases have been documented in which Members of Congress or other federal employees have been injured or mis-diagnosed or mis-handled by audiologists—or have suffered via “failure to refer.”
Walden: None that I know of. In fact, there was the 2010 article in the Journal of the American Academy of Audiology (Volume 21, Number 6) in which Dave Zapala and colleagues examined more than 1,500 charts from Medicare-eligible recipients (in the year 2007)at the Mayo Clinic. They evaluated the differences between assessment and treatment plans from ENT docs and audiology docs, as judged by a panel of two ENTs and two audiologists. The bottom line is there were no discrepancies in treatment plans for over 95 percent of the patients. In fact, the article states (page 365) “The jury of four judges found no audiology discrepant treatment plans in over 95 percent of cases.” And, “in no case where a judge identified a discrepancy in treatment plans did the audiologist’s plan risk missing conditions associated with significant mortality or morbidity that were subsequently identified by the otolaryngologist.”
Academy: And if I recall, didn’t the otolaryngologst (neurotologist) report that the only services needed for 78 percent of those 1,500 people were audiologic service?
Walden: Yes, that’s correct.
Academy: Well, my fear with regard to direct access is that it may be rejected out of hand because of expense issues—and we all know there’s not a lot of extra money floating around in Washington! How much more does it cost for the typical Medicare-eligible beneficiary to directly access their audiologist?
Walden: Glad you asked. Here’s what we know…in the September/October 2005 issue of Audiology Today (AT), Barry Freeman and Brandon Lichtman reported a common practice for Medicare-eligible patients was (and remains) a three-step process. That is, the patient went to their primary care physician (PCP), then to the ENT and then finally, to the audiologist.
Academy: So I guess most of them had serious and complicated ear disease or a medical condition which required medical or surgical treatment?
Walden: Actually, Freeman and Lichtman reported that 80 percent of them did not have a medically or surgically treatable condition in this multiple-visit model.
Academy: What did it cost to see the PCP and the ENT, based on the report from 2000 and using “year 2000” dollars?
Walden: It seems to me from reading AT (page 14) the PCPs were paid $84 million from their Medicare benefits, and the ENTs were paid an additional $84 million from Medicare.
Academy: Okay, so then the bottom line was some $168 million assigned to physicians to refer the patients to audiologists! By the way, how much Medicare money was spent on basic hearing tests in that same year?
Walden: Good question. About $41 million was spent on basic hearing tests.
Academy: So, had the patients gone directly to their audiologists, we (the audiologists) would have referred the 10 to 20 percent who needed medical care and the same $41 million would’ve been paid for basic hearing tests. However, instead of each and every Medicare recipient with a hearing problem seeing one or two physicians, only those needing medical care would have been referred and Medicare would have saved some 80 percent of the $168 million spent on physician office visits? I guess we can roughly figure that as a savings of some 130 million per year, and if we had saved that money and gained that efficiency, over each of the last 11 years (since the year 2000), Medicare would have had well over a billion dollars in savings?
Walden: Sure, and Doug, keep in mind the reports we’re talking about are based on data from the year 2000, so the costs have likely increased dramatically, and the savings would likely also show a dramatic increase, again, based on the excessive-use model of multiple physician visits.
Academy: Good point. Well, maybe those in opposition are concerned about setting a precedent by allowing Medicare beneficiaries to go to directly to other qualified state-licensed doctors and health-care providers.
Walden: Well, that may be. Then again, Medicare already allows Medicare-eligible patients direct access to dentists, oral surgeons, podiatrists, optometrists, chiropractors, clinical nurse specialists, clinical psychologists, clinical social workers, nurse-midwives, nurse-practitioners, physician assistants, etc. So indeed, Direct Access already seems to be working pretty well for many other professionals and patients.
Academy: So the bottom line is, hearing loss negatively impacts approximately one-third of all people between the ages of 65 and 74 years of age, and hearing loss negatively impacts almost half of those over age 75 years. Direct access has already been shown to work efficiently and safely in audiology and many other professions and the savings realized (had direct access been in place for the last decade) appears to be well over a billion dollars.
Walden: And of course as the baby boomers age, there’s going to be many more people needing direct access to audiologists to create the least expensive and most efficient, high-quality health-care avenue, with the least amount of wasted dollars.
Academy: I agree. I cannot imagine anyone in good conscience opposing Direct Access.
Walden: I agree. And I think the members of Congress will very quickly see it the same way.
Academy: Thanks, Therese. Congratulations again on your new presidency, and if there’s anything I can do to help, just let me know!
Walden: Thanks, Doug. There is one thing (right now)—I just want to take this opportunity in this discussion to ask the readers to take a few minutes and link to the Academy’s Legislative Action Center and contact their elected representative (who already has direct access!) to ask him/her to support this legislation. Everything they need is right there—the process is simple but the impact is huge. The legislators need to hear from their constituents…all of us and our family, friends and patients! This is our time, direct access if the right move for Audiology and the patients we serve.
Academy: Thanks, Therese. I appreciate your time and knowledge. All the best!
Therese C. Walden, AuD, is the president of the American Academy of Audiology and a research audiologist at the Walter Reed National Military Medical Center, in Bethesda, MD.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology.