Harvey Abrams PhD
“Peeling the Onion” is a monthly column by Harvey Abrams, PhD.
As you have likely heard, the President’s Council of Advisors on Science and Technology (PCAST) has issued a report that, if its recommendations are put into effect, will likely have a significant impact on the consumer electronics and hearing health care industries in general, and audiologists in particular.
PCAST in Review
Chrstine Cassel MD
The recommendations are largely the result of an industry review performed by the PCAST Aging and Technology Study Full Working Group chaired by Christine Cassel, M.D. The slide deck briefing of Dr. Cassel’s presentation to the PCAST can be found here, but it will be worth your while to view the entire webcast of her presentation.
Aside from several unfortunate factual errors and misrepresentations, what struck me in viewing the webcast was the complete absence of any discussion describing the professional services associated with selecting and fitting hearing aids.
Bundling Bites Back
After viewing the webcast, many of you will likely react with dismay and outrage. Once I got over my own initial disbelief, I took a step back and asked myself this question:
“How does Dr. Cassel, a distinguished physician and health care policy expert, a senior advisor to the President of the United States no less, arrive at a world view of hearing health care as simply the purchase of a product completely devoid of any professional component?”
After a few moments, I answered my own question as I considered that what I had just observed was a completely logical and inevitable consequence of the decision to bundle the hearing aid with the professional services we provide.
One could argue that if Dr. Cassel had simply performed her due diligence, she would have discovered the range and value of professional services that are critical for successful hearing aid fitting outcomes. In fact, one of Dr. Cassel’s working group staff members communicated with several members of our profession who impressed upon her the importance of the professional services that hearing health care providers perform.
In the end, however, this critical talking point was never included in the presentation to the PCAST nor considered as part of the subsequent recommendations of the working group. I will not presume to understand the reasons why. I would suggest, however, that the seeds of what we are observing here were sown at an important turning point in our professional history.
There Was a Time…
As most of you know, there was a time when audiologists were prohibited (per ASHA’s Code of Ethics) from profiting on the sale of hearing aids. An outstanding review of this fascinating era of our professional history is provided by Wayne Staab in a 3-part series of HHTM posts (part 1, part 2, and part 3). Following a Supreme Court ruling that found that a professional society (in this case, the National Society of Professional Engineers) was in violation of federal antitrust laws when they prohibited their members from submitting competitive bids and thereby suppressing competition, it became clear that ASHA could no longer legally sustain its own policy of restraining trade and competition among its members.
Overnight, everything changed for our profession. This was a critical decision point in our history. We could have created a hearing health care model unique to the profession of audiology. Instead, we simply adopted the prevailing and, at the time, successful bundling model used by the hearing instrument specialists.
Sticker Shock
The inevitable result of over 35 years of incorporating a bundling model is that, from the perspective of the hearing impaired community (and apparently from the perspective of senior health care policy experts) hearing health care is, and only is, the hearing aid and hearing aids cost too much. Their cost is beyond the ability of many to afford; the average cost is approximately $2400 with some hearing aids costing up to $10,000.
How many times have you witnessed sticker shock from your patients or heard them exclaim that they didn’t realize that hearing aids “cost so much” or ask, “Why do they cost so much”? The conversation is exclusively about the cost of the product, not the value of our services. We have, in essence, commoditized the rehabilitative component of our profession.
Resources and Recommendations from Membership Organizations
Our professional organizations have attempted to address the bundling/unbundling issue. ASHA created a white paper as part of its Practice Portal titled “Unbundling Hearing Aid Sales” (full disclosure: I was one of the contributors to this Practice Portal topic). The paper provides an excellent summary of the pros and cons of each model and provides valuable resources for those considering an unbundling model but does not recommend any particular approach.
Likewise, a AAA task force published two articles in Audiology Today{{1}}[[1]]Sweetow R (2009). Hearing aid delivery models: Part 1. Audiology Today, 21(5):48-58.[[1]],{{2}}[[2]]Sweetow R (2009). Hearing aid delivery models: Part 2. Audiology Today, 21(6):32-7.[[2]] describing current hearing aid delivery models but made no recommendation relating to bundling or unbundling. Instead, the task force recommended that “the Academy should reinforce the concept that a clear fee structure should be presented, or at least be made available, to the public whether bundling or unbundling is selected, so that consumers and other stakeholders might understand what the fitting of amplification entails.”{{3}}[[3]]Page 34, reference #2.[[3]]
What To Do?
I would like to think that the AAA task force’s recommendations will be universally followed and that:
- all audiologists who sell hearing aids will provide a “clear fee structure” to their patients which identifies the value of the professional services they are providing
- our patients and health care policy folks will understand and appreciate that the cost of hearing health care is more than just the device.
I’m afraid, though, that after 35 years of conflating the service with the product, we have created a perception of hearing health care as a product and this perception will be very difficult to overcome. And for that, we have no one to blame but ourselves.
Harvey Abrams, PhD, is a principal research audiologist in the hearing aid industry. Dr. Abrams has served in various clinical, research, and administrative capacities in the industry, the Department of Veterans Affairs and the Department of Defense. Dr. Abrams received his master’s and doctoral degrees from the University of Florida. His research has focused on treatment efficacy and improved quality of life associated with audiologic intervention. He has authored and co-authored several recent papers and book chapters and frequently lectures on post-fitting audiologic rehabilitation, outcome measures, health-related quality of life, and evidence-based audiologic practice. Dr. Abrams can be reached at [email protected]
This is Part 12 of the Peeling the Onion series. Click here for Part 1, Part 2, Part 3, Part 4,Part 5, Part 6, Part 7, Part 8, Part 9, Part 10, Part 11.
feature image by Ross Land/Getty, image of Dr. Cassel from healthcareitnews
No you have no one to blame, but yourselves. The USA is the worlds largest, richest hearing aid market. It’s audiologists’ could have beaten the manufacturers down on price.
They could have developed a business model based on selling a decent number of hearing aids and helping a decent number of people.
They could have fought stigma and advertised their products positively (no companies called Hidden Hearing and the like). They could have made a comfortable living helping lots of people.
But no, they decided to take the easy way out to join the bloated insane gravy chain that is the US health system.
But it was always going to fall apart because the health insurers are never going to pay $1000’s for over 50% of seniors.
And increasingly even well off HOH people aren’t going to either.
I hold in my hand £500 worth of iPhone, no way are you going to convince me a hearing aid is more complex and worth more money than that.
Sorry guys it simply doesn’t wash any more.
To those of us in the UK who get free (rumored to cost about £90) perfectly adiquate NHS digital hearing aids the cost of private hearing aids is just utterly totally and completely ridiculous.
Yes I’d like directional mikes, a bit better performance in background noise and hands free iPhone streaming without £10 worth of wire round my neck would be cute, but not faintly worth £2-3000.
Quite simply, on both sides of the Atlantic and I suspect in Australia, the game is up
I always argue that bundling has been necessary, as Medicare will not ALLOW audiologists to bill for our professional component. How can we bill otherwise without being able to bill an “office visit” charge.
I would like to make a few points, from the position of a musician with a a decades old progressive loss, that has bottomed out at profound, and has been self programming through 5 pairs of aids:
But first: “To those of us in the UK who get free (rumored to cost about £90) perfectly adequate NHS digital hearing aids the cost of private hearing aids is just utterly totally and completely ridiculous.”
Is utter codswollop- I have several musicians from the UK call me about aids and going through the NHS. What the NHS does is give you the cheapest aids possible, give you at most two follow ups and thats it you’re on your own quit annoying me. That is if they survive the demeaning process of apply to get aids. And they come wildly out of adjustment, and they don’t get better. They do not care one whit if you are a musician and you need them to properly amplify live music – they just fit for over amplified speech and that’s it. One Manchester muso told me that she would have been better with a microphone around her neck and a pair of ear buds.
When I started self programming, it was because the HA industry had no clue about fidelity and was concentrated on speech recognition, using a set formula. Of course that didn’t work, but I managed to work around it, considering the limitations. The primary issue was input stage headroom – it was so low that some aids would go into digital distortion rather quickly, and others would simply engage an input stage limiter that killed the dynamics. The second was the target mode – at that time, it was based upon the audiogram. An audiologist had complaints of his own, things that I recognized from my own experiences: 1- the aids were arriving out way of adjustment – usually over amplification of speech frequencies around 1.5K, which upped his return visit count, and his hearing aid return count, too, and 2- whatever formula that was being used as a target, was wrong. 3 – And exasperated audiologists were stuck in the middle.
Eventually I wound up with a pair of aids that had plenty of headroom and would not distort on stage, but were so full of sound processors that they sounded terrible, and the constantly changing sound was a major distraction. I found these aids had multiple target modes and I changed that, then went in and turned off all of the noise reduction / speech enhancers / auto directional switchers / wind noise reducers / grand children’s’ voice enhancers and whatever gobbledygook, then dropped anti feedback to minimum and lo and behold, fidelity! I could hear and music sounded good again! Then, when my hearing made the final (I hope) drop to the point of profound, the next aids were even better sounding, and, not only that, the in situ, was near dead on. So after two follow ups, I was very pleased. The point here is that, rather than focus on good amplification and proper adjustments, the aids were using a band aid approach to compensate, and the band aids were causing more problems than they were supposed to fix.
The issue here is not sales and marketing at all. It is the makers understanding that people do not want speech amplifiers, they want high fidelity sound amplification instruments, delivered “right”. So do it right from the very beginning. The aids makers need to deliver with the aids properly adjusted, or refine their in situ set up so it it is more accurate. If an audiologist knows that it will only take a couple of visits to fine tune aids, (maybe talk about getting the earmolds right another time?) then that can be reflected in a retail price reduction and greatly increased patient satisfaction. Further, if word gets around that buying aids is a drastically less stressful process, I am quite sure that more HOH people will buy aids. Yes, the makers need to drop their prices. Yes, the US government should recognize hearing aids as a medical device. But the audiologist will always be needed. However, if the US audiologists should not circle the wagons, to protect an outdated business model. Time to look forward.
I’m not a musician, speech in meetings was what I needed.
My NHS aids (new Oticon Spirit Synergies) manage that perfectly well. Also hearing family in the car, around the house and on my iPhone.
(Cheap T coil less dec phone is still hopeless).
I also mostly manage in cafes and restaurants, yes they are an assault on the ear drums, but so are over excited teen daughters.
Agree with many of Barry’s points However, let’s not forget that the sale of hearing aids is regulated by the Federal Govt.which has viewed audiologists and dispensers as one group. It gives overriding authority to the medical doctor preferably one that specializes in diseases of the ear to give medical clearance AND allows anyone 18 years and older to sign a waiver if they believe it is in their best interest. So, why would anyone be surprised or shocked at the PCAST recommendations.