Back to the Future, Part VI: Slogging Through the Mine Field

Holly Hosford-Dunn
April 10, 2012

Editor’s note:  This series follows predictions by Lars Kolind[1] in the 1990s.  

So far, this series has negotiated all sorts of land mines, chief among them Audiologists as Retailers, Vanishing Practitioner Autonomy, Internet Dispensing, Consumer Expectations, Vertical Distribution, Technological Dominance, Dispensers and Audiologists as Bedfellows, and Ruthless Demand Curves.  Where’s the love?  Unfortunately not in today’s post, which looks at a Prediction that plunges this series deeper into enemy territory–smack into gigantic land mines which that cleave our profession down the middle.

Lars Kolind’s Prediction #VI. Patients and regulators will only be willing to deal with those hearing healthcare providers who can document total patient care.

By “regulators,” Dr. Kolind was referring to government and managed care entities.  His prediction was well in the making by the mid-90s and is firmly entrenched nowadays.  Back then, Medicare set the tone because it recognized Audiologists as contingently reimbursable providers, albeit often via physicians who employed them.  Managed Care moved Audiologists up a notch by putting some of them on Provider Panels and, in some cases, streamlining through direct access that eliminated the physician referral step.  Seizing the autonomous moment, Independent Professional Associations (IPAs) circled the Audiology wagons by aggregating Audiologists and initiating a form of collective bargaining with insurers.

Those successive selection processes shared a common factor: quality was documented by credentialling.  Thus, graduate degrees from ASHA-approved programs and CCC certification were prerequisites for obtaining Audiology licensure in most states.  That ruled out hearing aid dispensers as Medicare providers, which was not a big deal since they did not perform diagnostic procedures under their state licensures.{{2}}[[2]]This sounds right, but I have not read all of the different licensing laws for dispensers in different states. If it is not right, I would appreciate better-informed readers providing specifics and on what education requirements accompany any diagnostic privileges for a given state, beyond the obvious audiogram to fit instruments.[[2]]   The main point from an economic view is that provider entry was controlled by degree-based, membership-organization-regulated documentation.{{3}}[[3]]Economists call such controls “barriers to free trade.”  Generally speaking, this is not a desirable situation.  It’s a good topic for the promised series When Economics and Ethics Collide, which will come later this year.[[3]] Quality documentation evolved under Managed Care to include office inspections, Quality Manuals for individual offices, quality control conformity agreements with IPAs and managed care groups, and price discounts for patients.  The AuD replaced CCCs, which made the regulators’ documentation job easier by equating quality with “doctor.”

Credential-based documentation had good face validity.  But beauty is only skin deep: being a member, a panelist and a doctor does not automatically guarantee quality, much less the quality envisioned by Dr  Kolind as total patient care.  That vision requires content validity as well, and that is where the land mines lurk.  Consider these shocking statements paraphrased from Dr. Kolind’s chapter twelve years ago:

  • Many practices accept real-ear measurements  as a relevant criterion for successful hearing care.  Hearing care professionals still stick to the real-ear method despite the fact that it works equally well whether the patient is dead or alive.
  • The only relevant criteria in the future are objective speech recognition data and the subjective satisfaction of the patient.

Fighting words then and fighting words now.  The old land mine of using verification methods as final documentation confuses quality control with quality outcome.  It still pops up in articles that cherry-pick best practices to single out real-ear as the gold standard for hearing aid fitting.  You’d think we were stuck in a 1990s land mine fields unless you took the time to read the outstanding Best Practices document from the American Academic of Audiology entitled Guidelines for the Audiologic Management of Adult Hearing Impairment. If those guidelines were followed in every hearing healthcare service delivery system, the vast majority of hearing health consumers would experience total patient care. Here’s an excerpt from the document’s overview:

Measurement of treatment outcomes is assuming greater importance on the national healthcare stage… outcome measures and …clinical trials… build a foundation for evidence-based clinical practice…[which] minimize variability in outcome, maximize treatment efficacy, reduce risks, decrease waste, improve patient satisfaction…. Only by measuring the outcomes can audiologists be assured that treatments make a difference and patients have benefited from their care.

Here Here.  Not all of Dr. Kolind’s Prediction has come to pass:  objective speech tests and customer satisfaction measures have not assumed the central roles that they eventually must in a retail environment. Those are big land mines up ahead, but they are quibbles in the larger view right now.  The Prediction’s demand that our profession step up to the plate and grapple with total quality is on track.  It is manifest in the AAA Guideline–out there in writing–a touchstone  for the Prediction that “Patients and regulators [who] will only be willing to deal with those hearing healthcare providers who can document total patient care.

This is good, encouraging stuff, but it’s not the whole story.  Earlier in the post the comment was made that the land mines have cleaved the profession in two.    That’s because creation and implementation are two different things.  The Talk is Talked, but who is Walking the Walk?  Cleavage is the topic of the final posts in this series, coming up soon.

Photo courtesy of cellobello

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