Accessibility and Affordability of Hearing Care for Adult Consumers
Issue Statement from the American Academy of Audiology
January 26, 2017
The American Academy of Audiology supports consumer autonomy with respect to control over their health care decisions, including access to safe and affordable hearing care. In this context, hearing care describes a broad range of services, including the assessment of hearing function, determination of the type and extent of the hearing loss or loss of function, diagnosis of the cause of the hearing loss or loss of function, determination of the options available for treatment or management of the loss, and the provision of those services or technologies to mitigate the hearing loss or minimize the communicative impairment.
The increasing need for hearing services among the aging population, including management of hearing loss with hearing devices, coupled with advancements in technology that may offer consumers more opportunity to self-direct their care, have recently garnered the attention of federal regulatory agencies and advisory boards. It is well documented that hearing aid adoption by individuals with hearing loss is low. Studies have suggested that barriers to adoption include mild hearing loss or no perception of activity limitations or participation restrictions, younger age, perceived stigma, lack of encouragement to seek intervention from primary care provider or significant others, and perception of more obstacles than benefit to amplification (Jenstad and Moon, 2011; Meyer and Hickson, 2012). The Academy recognizes that accessibility, appropriate assessment and management, and affordability of treatment options may be critical components to encouraging appropriate adoption of hearing technologies. As such, the Academy seeks to offer guidance that will optimize the quality of care for patients with hearing loss in light of recent proposals that suggest changes in the established hearing care delivery model.
Recommendation #1: Accessibility
Several factors may make access to appropriate hearing care challenging for consumers. These include several classes of hearing devices, various providers of services, geographic distribution of providers and heterogeneity among industry manufacturers and devices. The American Academy of Audiology recommends improving access to hearing healthcare for consumers through the development of the following:
- A common language and terminology to be used across hearing healthcare venues and providers that the consumer can easily understand. This language should apply to professional practices, providers, and hearing devices, regardless of point of service or sale.
- A clear differentiation of the cost of services from the cost of products when purchasing hearing devices. Continued bundling of the cost of products with the cost of services does not provide the transparency that allows consumers to make informed decisions nor does it encourage consumers to appreciate the role the audiologist plays in assuring optimal outcomes when treatment is indicated. Bundling products and services is therefore not in the best interest of the consumer nor the members of the Academy, nor the audiology community at large.
- Regulatory or statutory requirements that allow direct and cost-effective access to audiologic services, including elimination of the requirement for Medicare beneficiaries to obtain a physician's order for audiologic evaluation and the elimination of the FDA requirement for medical clearance or waiver prior to fitting a hearing device (as opposed to non-enforcement of the current regulation).
- Increasing access to audiology services through the support for telehealth initiatives that allow consumers in underserved markets to receive hearing care services.
Recommendation #2: Identification and Assessment
The Academy endorses the rights of individuals to self-direct their hearing care provided that care is safe and effective. The Academy supports the concept that consumers may be able to "self-identify" the presence of a communication problem or a functional limitation or participation restriction. However, no studies suggest that consumers can differentiate degree, type or etiology of hearing loss, or to discriminate those hearing losses that require audiologic or medical intervention. The concept of self-diagnosis implies the capability to determine the etiology, the type, and the degree of the loss, which is not possible without a comprehensive audiologic evaluation. Therefore, the Academy does not support the concept of "self-diagnosis" with respect to self-directed hearing care, and instead recommends that the term "self-identification" be used to identify the consumer's ability to determine the need for hearing care.
Ideally, individuals who believe they have a communication problem or functional limitation hearing loss are best served by having a comprehensive audiological evaluation prior to their accessing any treatment option. There are a growing number of tools (e.g. smartphone apps, on-line tests, home hearing tests) available for patients to assess their hearing without the need for a professional evaluation. In their present form, however, these tools only provide general classifications of loss or function, but cannot provide comprehensive data on degree, configuration, type or etiology of loss, nor quantify communication ability. As such, the Academy recommends that any devices or applications that claim to evaluate hearing or auditory function, and are made available to the consumer for self-evaluation, clearly describe their use as a screening tool rather than a diagnostic hearing test, and that labeling of devices indicates that these devices are used solely to screen communicative function rather than hearing loss per se.
Furthermore, the Academy endorses the need for increased awareness of hearing loss and its comorbidities as part of annual primary care examinations, and encourages increased referral for a comprehensive evaluation with the understanding that there is no "normal" age-related hearing loss, and any degree of hearing loss should be appropriately evaluated.
Recommendation #3: Management of Hearing Loss
The symptom of hearing loss is loss of communicative function, and therefore individuals may seek to self-manage their communication deficits, but this should not be construed as treatment for hearing loss or a medical condition. Self-treatment cannot occur in the absence of an accurate diagnosis. The Academy believes individuals who have self-identified with a hearing loss or communicative impairment are best served when diagnosis leads to the development of a comprehensive treatment plan that may include instruction, counseling, rehabilitative services and/or amplification products. It is critical to recognize that any selected device is only one aspect of the successful management of hearing loss and cannot be considered in isolation as the only necessary treatment. Furthermore, the Academy remains concerned that consumers may not understand the ramifications of under-fit or untreated hearing losses, which may include, but are not limited to, negative impact on cognitive function and diminished success with appropriate but late-fit hearing devices. The Academy recommends a hearing care delivery model that optimizes safe and effective management of hearing loss, and is firm in its position that such a model includes the following:
- determination of appropriate management option based on a comprehensive evaluation and individual hearing needs assessment performed by an audiologist;
- consideration of a spectrum of hearing management options that may be appropriate including, but not limited to, hearing aids, assistive listening devices, implantable technologies, communication strategies, and auditory-based therapy;
- recommendation for medical assessment and intervention when appropriate; and
- counseling and recommendations that is cognizant of individual factors that may limit access to appropriate hearing healthcare, including but not limited to geographic constraints and financial limitations.
Recommendation #4: Affordability
The Academy appreciates that consumers are concerned about the cost of hearing care, particularly as many insurance plans, including Medicare, provide inadequate payment for diagnostic services, and limited coverage for non-surgical treatments for hearing loss, including hearing aids. Moreover, unlike dental care or optometric care, there are few supplemental insurance plans available that cover the cost of hearing care. Improved reimbursement for hearing care services would serve to reduce the burden of consumers to access affordable hearing care. Additionally, requirements such as the need for a physician referral for audiology services by Medicare can add further costs to hearing care by compelling prerequisite physician visits to acquire that referral. The Academy recommends removal of statutory and regulatory requirements that place additional financial burdens on individuals who seek hearing care, particularly for those with mild hearing losses or communicative impairments. Removal of regulations such as that requiring physician referral will result in reducing the cost of hearing care to the consumer.
The Academy also supports access of individuals with hearing loss or communicative impairment to low-cost alternatives for treatment, including low-cost amplification technologies. As such, the Academy recommends that audiologic practices include a broad range of amplification treatment options for patients, and that members endeavor to provide both services and products that meet the communicative and financial needs of patients. In this same regard, the Academy supports the development of a purchasing model for devices that benefits both the practice and the consumer.
The Academy recognizes that for some consumers, there may be a discrepancy between their perceived communication limitation and the relative value of hearing devices. As a result it is possible that over-the-counter (OTC) hearing aids may represent an introductory path to hearing healthcare that seems more palatable for those consumers with mild hearing loss or mild communicative impairment. While the Academy appreciates that there may be potential benefits of over-the-counter (OTC) hearing aids, their safety and efficacy have not been established. The number of individuals who gain benefit from OTC devices, the magnitude of that benefit, and the patient perspective about the benefits can only be established once the devices become available to the public. Similarly, the risk associated with OTC devices in the United States has not been determined. The likelihood of risk, the severity of harm, the number of patients who fail to receive necessary medical treatment, the use of devices by populations other than that intended, and the patient tolerance of risk will be determined if and when the devices are available, and the short-term and long-term outcomes become evident. Until such time that the safety and efficacy of OTC devices has been established, the American Academy of Audiology believes the consumer of hearing care products must continue to be protected from accessing products that put them at risk for greater hearing or economic loss, or fails to provide benefit for their communication impairment. However, the Academy also recognizes that hearing devices are currently under-utilized by appropriate candidates and recognizes that identifying the root cause of this situation as well as appropriate countermeasures should be a high priority focus or professional organizations and government agencies.
Recommendation 5: Education
The Academy recognizes that regulatory or statutory changes to the hearing care delivery system or products require a comprehensive and collaborative education process for the consumer, primary care physicians, the audiology community, other hearing care providers, and government and non-government agencies. The Academy recommends a collaborative approach with key stakeholders to develop the message, materials and delivery system to support this educational endeavor.
The Academy recognizes that existing service delivery models for hearing care may need to be reconsidered in order to optimize hearing healthcare for a greater number of consumers impacted by hearing loss. Improving accessibility, encouraging appropriate assessment and management of hearing loss, and recognizing the impact of affordability on amplification usage are all priorities for the Academy. To this end, the Academy presents this position statement on the accessibility and affordability of hearing care for adult consumers.