Update on Academy Initiatives: Interview with President Erin L. Miller, AuD
Douglas L. Beck, AuD, speaks with Dr. Miller about hiring the new executive director, Tanya Tolpegin, reimbursement structures, itemization, bundling, unbundling, outcomes, legislative efforts, ADA, direct access, and more.
Douglas L. DLB (DLB): Hi, Erin. It’s a pleasure to speak with you! Now that we’re about in the middle of your tenure as president of the American Academy of Audiology, I’d like to get an update and see how things are going.
Miller: Thanks, Doug, things are going really well! We’ve had a fantastic first 6 months with many changes, developments, and initiatives and I’m looking forward to the second half!
DLB: As president of the Academy, I know you attend many of the state audiology meetings, and your travel and speaking schedule is pretty well jammed!
Miller: Yes, that’s true. It’s a very busy time for me, but I thoroughly enjoy attending and speaking at the meetings, and of course, it’s a joy meeting and working with so many talented and dedicated colleagues. Doug, as you know, the president also attends other non-Academy association meetings, too, such as AG Bell, ASHA, and more. So, yes, I spend a fair amount of time traveling and collaborating, and I am honored to serve as president of the Academy and to represent our ideas and concerns across the globe to our membership and to our colleagues.
DLB: What’s been the very best thing about your first 6 months as president?
Miller: There have been so many great things…but okay, the very best would have to be hiring our new executive director! Tanya Tolpegin, MBA, CAE, has experience in both “for-profit” and “not-for-profit” worlds and that’s an exciting background because it allows her to manage her responsibilities in accordance with, and based on, successful business models, while attending to the core mission of the Academy. So she brings fresh insight and ability to the Academy and she’s a delight to work with!
DLB: Excellent! I’ll look forward to meeting her! So then, let me change topics a bit. Erin, I was wondering, as president, what are the top three concerns that you’re addressing?
Miller: Good question…Seems to me there are some topics that come up all the time. For example, I think the biggest issue, or at least one that comes up quite often, may be changing reimbursement structures. Most of us have become accustomed to a fee-for-service model, and we know that with the changing landscape in healthcare, alternative payment systems are on the horizon. Reimbursement is a vast and over-arching issue that impacts all of us and we need to pay close attention to it as it impacts Medicare as well as other third-party payers.
DLB: If you don’t mind, would you please share your thoughts on bundling and unbundling?
Miller: Sure. I think we need to move away from the more retail-oriented hearing aid dispensing model that is decades old and is the most common model across the United States, to a more professional, itemized model. That is, as big box stores and the Internet are selling hearing aids as commodities like toothpaste, tires and paper towels and so it seems apparent we need to separate ourselves as professionals, and we need outcomes that reveal our professional services positively impact the short and long-term outcomes for the patient. And so what some people are calling “unbundling,” I prefer to call “itemizing.” I think we need to itemize services because it reveals to the patient and the insurance company they’re purchasing expertise as part of amplification treatment, and without expertise, the product is not as likely to serve the patient as well.
For example, when most new patients try hearing aids for the first time, they have no idea what the world is supposed to sound like. In fact, without professionally obtained measures such as verification, validation and pre-treatment speech-in-noise scores which should be compared to post-treatment scores, how would the patient (or the insurer) know that a successful outcome has occurred? Without real-ear measures obtained while the patient is wearing their hearing aids, how does anyone know how much sound pressure has been placed in the ear canal? And frankly, not knowing can be very dangerous as patients might be over-amplified if they set the loudness themselves, or if the gain and output are set remotely (without real-ear measures). Of course, one fear when hearing aids are acquired via mail order and the Internet is what could happen if the hearing aid gain and output are too loud. It certainly could create additional problems such as noise induced hearing loss, acoustic trauma, acoustic feedback, poor fits and more. Also, I worry about what might be missed relative to medical conditions that might go untreated when a consumer does not see an audiologist prior to the purchase of the hearing instrument. So again, it’s important to have the professional involved, and itemization adds transparency while clearly demonstrating the value of the professional to a safe and effective outcomes-based hearing aid fitting.
DLB: What are your thoughts on “tiered service models,” such that the patient purchases the hearing aid from the provider, or retail (big box or the Internet) and then selects a level of service, or a tier, which provides multiple services and service levels?
I can envision very soon after someone purchases a hearing aid via retail, they’re likely to realize they have no idea how to use it! So perhaps they would go to an audiologist and acquire a service plan such as Tier One, which might be a 30 days of adjustments and programming. Maybe Tier Two offers six months of the same, and perhaps Tier Three would be a one year period of adjustment and programming and maybe includes cleaning and tube changes…and maybe Tier Ten is three years of service, cleaning, warranty repairs and more…Would that sort of model make sense?
Miller: Yes. This is the sort of model many colleagues are discussing. Of course the details, the quantity of tiers, the depth of services at each tier and many other factors would have to be worked out by the individual practices. However, yes - that model makes sense and could work. I don’t know that there’s a specific “right model” for the whole profession, but there are multiple models being explored and considered and they are being developed and evolving. So to me, these are all very positive initiatives and hopefully an itemized or unbundled model will take hold sooner rather than later. The key is flexibility, so the audiologists in the trenches can use a protocol which works best for them in their setting.
DLB: Okay, and besides reimbursement issues, what other issues do you find yourself thinking about and addressing daily?
Miller: Another huge area is “outcomes.” I know you speak about this across the country, too, and it is critically important to the health of the profession. As we move forward, it’s our responsibility to use scientifically-based protocols, and we need to know and report the outcomes with respect to those same protocols. Simply stated, we need evidence-based-outcomes which clearly demonstrate the value of our evaluation, management and treatments. Frankly, it seems the importance of outcomes will clearly increase as time goes on and insurers and regulators request evidence to prove that our services have positively impacted the lives of the patients.
DLB: And how do we go about gathering this vast quantity of data?
Miller: Well, we’re thinking that through and exploring options. It seems at this time, we’re going to need a registry of some sort, into which audiologists can enter data and update results. It has to be easy, efficient and perhaps “universally accessible” to our colleagues working at universities, clinics, medical centers and more…so it’s not going to be easy, or quick, or cheap! But we need to work towards the development of such a tool and we’ll need to recruit subject matter experts and more to fully develop this concept.
DLB: I can see the need and the logic. I agree, it’s not going to be easy! Okay, is there another major issue or concern that demands a lot of your time?
Miller: Well, yes. The legislative efforts that the Academy is involved with are of enormous importance and they are, of course, forward looking and can be somewhat complicated. That is, legislative efforts involve our colleagues who work with us, local, state, and federal politicians, people, and associations who may oppose our initiatives, and of course, financial and legal concerns. So legislative efforts require a delicate balance of knowledge, desires, compromises, collaboration, and more. We have an excellent team at the Academy who steer these initiatives.
One recent development was that ADA asked the Academy to endorse HR 5304, which is the “Audiology Patient Choice Act.” As you know, the Academy previously stated our long-range goal was to achieve physician status for audiologists within the Medicare Act. And so while we were pursuing direct access, which is part of our long range goal, we thought it was appropriate to endorse the Audiology Patient Choice Act. These reciprocal endorsements to/from ADA and Academy for both initiatives, only makes us stronger in the eyes of our membership and in Congress and it helps unify the profession and makes it clear that we seek autonomous practice for doctors of audiology to best serve the patients who we are honored to serve. We will continue to work with our colleagues in all audiology associations as we develop next steps for the Academy’s legislative and regulatory advocacy in the 114th Congressional session.
DLB: Erin, it’s been a pleasure chatting with you and I wish you continued success in the second half of your presidency!
Miller: Thanks, Doug. I appreciate your support and interest!
Erin L. Miller, AuD, Board Certified in Audiology, is president of the American Academy of Audiology and the coordinator of the Northeast Ohio AuD Consortium.
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.