An Imperfectly Designed System for the Times

Holly Hosford-Dunn
August 16, 2016
Harvey Abrams PhD

Harvey Abrams PhDb

by Harvey Abrams, PhD.


“Peeling the Onion” is a monthly column by Harvey Abrams, PhD.


If your time to you
Is worth savin’
Then you better start swimmin’
Or you’ll sink like a stone (Bob Dylan)

In a recent post  (in response to the PCAST report and pending FDA decision on creating a new classification of OTC hearing devices) I highlighted the availability of insurance programs and discounted benefit programs that provide hearing aids for considerably less than the “average price of one hearing aid” of $2363 and a $2898 premium hearing aid price tag cited by the PCAST. In one example I gave, a partnership between the GEHA health insurance plan and TruHearing has make high-end hearing aids available for under $1000 a pair (and as low as $0 if you purchase the TruHearing brand of hearing aid). This price includes batteries, a 45-day trial, follow-up visits, manufacturer warranty and loss and damage replacement.


The Times are a Changing


At about this time, I heard from several colleagues as well as audiologists posting on the American Academy of Audiology’s General Audiology listserv, expressing concerns that these benefit plans with deeply discounted hearing aids coupled with lower cost hearing aids provided by large retailers such as COSTCO, were creating an unsustainable competitive disadvantage for many private practice audiologists. Most of you are familiar with the expression that every system is perfectly designed for the results it gets, and for many years the revenue achieved by many small private practices was directly attributable to a perfectly-designed system that was (and still is) characterized by the audiologist providing individual attention to each of their patients throughout the entire evaluation, treatment, and follow-up processes.

While this “system” resulted in typical sales of only 20 hearing aids a month, the bundled fees paid by the patient assured that the practice would succeed. And after all, what could be better than providing each patient with our complete and undivided attention throughout their entire journey? Sadly, it’s becoming clear that the current system characterized by providing many hours of 1:1 care by the audiologist is no longer “perfectly designed” and may not be sustainable – particularly if prices continue to fall in response to discounted programs and large retail competition.


Admit that the Waters Around Us Have Grown


It’s time to create a new “perfectly-designed system”, one that will allow us to successfully compete in this environment. I will argue that going forward,  we need to incorporate two design innovations into our practices.

 I. A greater use of support personnel

As I noted in a previous post, if the audiologist takes full responsibility for the evaluation, treatment and follow-up, s/he will likely spend 4-6 hours over the year with each patient. Compare this to any other health profession where patient care responsibilities are shared among several staff (optometrist and optician; dentist and hygienist; physician and nurse; pharmacist and pharmacy tech).

There’s a reason for this division of labor – it allows each staff member to practice at the highest level of their license while increasing office efficiency and optimizing the time spent by the most critical (and most highly compensated) member of the team. Imagine how the cost of eyeglasses would be impacted if the optometrist not only performed the exam but ordered the glasses, performed an initial quality check, fit the glasses at the return visit, and performed repairs and adjustments at subsequent visits. These strategies also help family medicine practices keep their doors open despite, in many cases, decreases in insurance and Medicare payments.

Our profession is taking steps toward this division of labor, too:

  • I was pleased to see that the upcoming ADA convention program is including an entire track directly targeting audiology assistants. Topics include infection control, hearing assistive technology, and strategies to increase retention and recall among others.
  • The VA has successfully utilized assistants (health technicians) for many years which has helped that system meet the ever-increasing demand for audiology services.
  • Both ASHA  and AAA  have developed guidelines for assistants, and training programs are available at Utah State University and Nova Southeastern University.


II. Automation


Another way to drive down the cost of services as a function of time is to automate. Of course most practices do this for office management purposes but how about automating what we do clinically?

I understand that many audiologists object to the idea of automating the audiometric examinations because they feel that accuracy is improved when they can see the how the patient responds, which allows them to determine if responses are reliable. However, the literature is very clear on the value of automated testing according to a systematic review and meta-analysis of 29 studies comparing automated and manual audiometry. The authors conclude that the accuracy of automated air conduction audiometry is comparable to manual audiometry (average difference between the two being 0.4dB, 6.9 SD). The test-retest difference for automated audiometry is actually smaller (0.3 dB, 6.9 SD) than for manual audiometry (1.3 dB, 6.1 SD). The authors report that validation data are still somewhat limited for automated bone conduction testing, testing in children and other difficult-to test populations, and different types and degrees of hearing loss.

This is not to say that automated audiometry is not an appropriate alternative in these cases but only that an adequate evidence-base has not yet been established to determine how well automated audiometry compares to manual audiometry in these cases.  At a minimum, automated audiometry could certainly be the method of choice for periodic reevaluations and cognitively normal adults. 


Don’t Stand in the Doorway Don’t Block Up the Hall 


Bob Dylan, "Einstein of pop music" and audiology

Bob Dylan, “Einstein of pop music” and audiology

Don’t forget what Bob Dylan told us years ago.  A judicious use of support personnel and automated audiometry can reduce the amount of time the audiologist spends with each patient by two thirds which will allow an increase in the number of patients seen, hearing aids sold and revenue produced even in the face of discounted benefit programs and competition from large retailers.        


This is Part 18 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 9Part 10,Part 11,  Part 12, Part 13, Part 14, Part 15, Part 16, Part 17.


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]

Feature image by Ross Land/Get
  1. In addition to personnel, support should also come from technology. I would also suggest that there is a great deal more work to be done in measuring the hearing loss. Surely, increased investigative testing could supply an increase in revenue.

  2. I’m sick of health care professionals putting money and profits ahead of my welfare. I should at least be able to choose the level of care I can afford. Some people only want to hear the TV, so let them buy hearing aids at Walmart. Hearing well is vital to me, important enough to spend what it takes to get the expert care of my audiologist. Yes, premium hearing aids are expensive, but I understand that the cost includes all adjustments, tests, insurance, even batteries. My audiologist understands my needs and does all he can to personalize the programs in my hearing aids. I’m glad to give up such things as vacations, expensive fashions, etc., just to be able to hear music again! Other professionals do not work this way. I’ve been a “patient” of a medical doctor for 5 years, but have yet to meet this doctor because I’ve never been sick enough to see anyone but the nurse!

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