Institute of Medicine, Evidence-Based Practice, and Unbundling: Interview with Stephanie Sjoblad, AuD
Douglas L. Beck, AuD, spoke with Dr. Sjoblad about itemized billing, the Audiology Patient Care Act, limited license physician status, and more.
Academy: Hi, Stephanie! Thanks for taking the time to speak with me this morning. I know you're at the University of North Carolina (UNC), Chapel Hill, and you've been there about 16 years or so?
Sjoblad: Yes. That's right. I am a clinical associate professor and clinic director for the UNC Hearing & Communication Center (UNC-HCC).
Academy: And, you're teaching quite a few courses, too?
Sjoblad: I teach a business and practice management in audiology class, and a class called Seminars in Audiologic Rehabilitation (AR) for our AuD students. I also teach Principles of AR for Speech Language Pathology students, and, finally, I co-teach one of the hearing aid fitting and dispensing class.
Academy: Thanks for that overview, Stephanie. In addition to your teaching and management responsibilities, you recently gave a presentation (June 2015) to the Institute of Medicine (IOM, an advisory group to the Centers for Disease Control, CDC), addressing "Evidence Based Practice with Itemized Billing."
Sjoblad: Yes, that's right. It was an interesting meeting in many respects, and you know how hard it is to give a meaningful presentation in 15 minutes—but that was the allotted time!
Academy: Wow. That's pretty brief! What points were you able to make?
Sjoblad: They wanted me to focus on our unbundled, itemized, and evidence-based model of hearing aid dispensing at UNC-HCC, which we've been using since 2005. Let me say from the beginning that in my opinion, the best way for itemization to work is to tie the unbundled/itemized costs to evidence-based practice.
As we move to the future, and see all the possible ways that hearing aids may be procured, we must take the focus off the device solving the hearing loss and focus on the treatment process. We should promote audiologists as the most qualified professional to provide hearing health care—and like other health-care providers, we bill for services rendered.
Academy: And of course that means real-ear measures. I'll play the "bad cop" here. We've known the value of real ear for decades, yet I believe fewer than one-fifth of all hearing health-care professionals use real-ear in every fitting, which does mean, the rest are guessing, and guessing doesn't cut it in 2015. Seriously, I believe you either have to use best practices and do the work required, or you kinda/sorta have to admit you're kinda/sorta guessing, and if you're guessing, how that's different from a first-fit based on thresholds, which can be done totally automatically? Seriously…why do we need professionals if we're automating and following a first-fit process? And now I'll climb off my highly worn soapbox…
Sjoblad: I could not agree more. If all audiologists would use evidence-based models when fitting hearing aids and obtained measurable outcomes I believe we would see more patients seeking help. In addition, we would have more concrete data to give insurers about the efficacy of our treatment plan which might encourage better reimbursement. My hope is some day in the near future, not only will there be better coverage for procedures, like conformity (real ear, validation), but that audiologists will be recognized as providers for audiological rehabilitation services as well. We are so much more than just the widgets we fit.
Academy: And in fact you use the Academy Guidelines, right?
Sjoblad: Yes, we use the American Academy of Audiology Task Force Guidelines from 2006, and other Academy documents, we'll link to some of them here:
- A Systematic Review of Health-Related Quality of Life and Hearing Aids: Final Report of the American Academy of Audiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults
- American Academy of Audiology Clinical Practice Guideline:
Adult Patients with Severe-to-Profound Unilateral Sensorineural Hearing Loss
- Guideline for Audiologic Management of the Adult Patient
Academy: Thanks Stephanie. I'm glad you mentioned the Academy best Practice guidelines, I believe they are an unequalled with regard to quality and outcomes, and they are very straightforward, and I'm sorry to say, they are grossly under used.
Sjoblad: Sadly, that's true.
Academy: Okay then, so tell me how you go about dispensing hearing aids at the UNC-HCC?
Sjoblad: Sure. Step one is, of course, a thorough hearing evaluation. We use the standard medical model there, as the goal is to document hearing loss and rule out medical disease and/or surgical candidates. Of course if any of the red flags are present, we refer to our physicians, but as you know, more than 95 percent of the folks we see have sensorineural hearing loss or noise-induced hearing loss, and so there are no medical or surgical options for them. Given that situation, if the patient is motivated to improve their communication, we schedule a Functional Communication Assessment.
Academy: And that includes subjective and objective measures, such as, lifestyle questionnaires, assessing their ability to understand speech in noise, acceptable noise levels, loudness discomfort measure and more?
Sjoblad: Yes, this appointment allows us to gather more information beyond pure tone thresholds to determine specific patient needs and goals and then we develop a treatment plan to help them meet these goals. Hearing aid amplification and other assistive devices are a part of the solution, but we refrain from suggesting that technology alone is going to cure the hearing loss. So then, assuming we're proceeding with hearing aid amplification, every hearing aid undergoes a thorough electro-acoustic analysis (EAA).
Our in-house study revealed that 12 percent of new hearing aids arrived from the manufacturer not working property (and 18 percent of repairs were not completely fixed). A listening check alone is not enough. Our quality control includes testing the maximum gain, reference test gain, equivalent input noise, and directional mics, tcoil, etc. We know the hearing aid is functioning correctly before it's ever placed on an ear.
Academy: Did you say there is a CPT code for EAA?
Sjoblad: Yes, 92594/92595,depending if it's a monaural or binaural procedure. When we have a billing code, it doesn't make sense to guess that the hearing aids are working. The same for fitting. When we guess at these measures, chances are we will be wrong more often than right. As we know, hearing aids don't cure hearing loss. One has to go through the whole process to get the best and most appropriate solutions for their hearing needs. Doug, as you say in your lectures across the country, "pure tones tell you almost nothing about perceived sounds and they tell you even less about the ability to listen…"
Academy: Right. Thanks for that. The goal is not to cure hearing, it's to increase the ability to maximally listen to the sounds one chooses to listen to. But back to your dispensing protocol.
Sjoblad: After the functional communication assessment, we get to the hearing aid fitting, and then the hearing aid follow-up, and, of course, individualized and/or group AR.
Academy: And, you had some fairly robust recommendations for the IOM, too?
Sjoblad: Yes. I endorsed a few things. Audiologists should be recognized as limited-license physicians under Medicare, I endorsed the Audiology Patient Care Act (HR2519). I recommended insurance plans should be structured such that the patient can choose the level of technology and service to best fit their needs after their functional communication assessment and the patient should have the ability to upgrade at their own expense. And finally, I recommended that AR should be billable by audiologists and all services should be covered at a rate that allows us to stay in business! I noted that simply acquiring the hearing aid was not the goal and is not the solution—it's all about professional services that positively impact outcomes.
Academy: Stephanie, it's been a joy speaking with you. Thank you for your sample HAE billing forms and sample hearing aid fitting forms. I think those will be very useful!
Sjoblad: Sure thing, Doug. Thanks for your interest and thanks for pushing these issues forward.
Stephanie Sjoblad, AuD, is the clinic director and associate professor at University of North Carolina at Chapel Hill.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology and the director of public relations with Oticon, Inc.