Treating the Right Patient with the Right Service at the Right Time: Thriving in the Era of Managed Care and OTCs

Holly Hosford-Dunn
May 30, 2017

by Brian Taylor

Brian Taylor, AuD

“Signal & Noise” is a bimonthly column by Brian Taylor, AuD.

The first two installments of this series in Signal and Noise column were devoted to the use of some relatively routine clinical measurements as part of the practice of “good audiology”.  The basic message of those previous columns was this: Audiologists and hearing aid dispensers need to systematically evaluate the noise floor of the products they dispense, and take the time to carefully assess the information carrying capacity of the cochlea using speech audiometry. The main point being the results of these often neglected measurements can make a difference on patient outcomes when they are properly interpreted by the hearing care professional.

 As spring turns to summer, let’s focus our attention to another facet of practicing “good audiology” in an era of third party managed care contracts and the possible emergence of over-the-counter hearing aids. A combination of factors that is likely to see practices experience the further decline of their margins, and ultimately, their profitability.


Our Binary Service Delivery System


As most know, one way to combat declining hearing aid margins is to unbundle services from the sale of the device. From charging for hearing assessments to offering service packages, unbundling can be done in a number of ways.

This column, however, is not really about unbundling services per se. Rather, here are some thoughts on how the shortcomings of the current binary service delivery system and what we can do to provide the right kind of service at the right time for the right patient. (Note this phrase is a variation of the mantra many nurses and physicians use with respect to administering correct doses of medication.)  Perhaps if we rethink how we provide (and unbundle) services to adults with hearing loss we can uncover opportunities to deliver the right type of service.  

In most audiology practices, once an underlying medical problem has been ruled out, clinicians have a tendency to to treat all individuals with hearing loss as hearing aid candidates. We tend to sort them into one of two categories:

A. Hearing aid users (those that accept our recommendation to use hearing aids on the day of their appointment), or

B. Hearing aid candidates (those that have some type of objection to using hearing aids who often get labeled as “tested not sold”).

In this binary service delivery model the patient is either an immediate hearing aid user or a future hearing aid user who is likely to be flooded with letters, direct mail pieces and other forms of advertising until they eventually purchase hearing aids. 


Improving on the Model with Triage


A big flaw associated with our current binary service delivery system is inefficiency. When the same group of services and procedures (for example, the hearing aid evaluation) are bundled with the sale of a pair of devices, as they are today, the more routine cases subsidize the more complex cases. In other words, in a bundled model, patients who need just one or two relatively short appointments to become successful hearing aid users are paying more for the same thing than patients with more complex problems that require more time and expertise to successfully remediate. When the goal is simply to fit as many hearing aids as possible in order to generate sustainable revenue for a practice, as it is in the binary model, we lose opportunities to delivery more varied and sophisticated types of services that can be unbundled from the devices we fit.

One path to the provision of services that could be delivered separate from the fitting of a pair of hearing aids can be found in the work of Sophia Kramer and the late Dafydd Stephens. (An excellent starting point is their book, Living with Hearing Difficulties: the Process of Enablement). In much of their work they discuss the process of hearing enablement, which is loosely defined as the clinician’s ability to help a person with hearing loss become more active and engaged in daily living by overcoming the emotional obstacles associated with their chronic condition. Their work does a good job of focusing on the need to discuss with patients their particular communication problems, their reactions to their communication problems and the reasons behind such reactions. It is a significant departure from our current binary approach where we try to fit the individual into our service delivery model.

Stephens and Kramer suggest clinicians sort patients into one of four categories and provide the right kind of counseling and remediation, depending on how the clinician classifies their condition.

Type 1: Positively motivated without complicating factors

Type 2: Positively motivated with complicating factors

Type 3: Wants help, but rejects a key component of your recommendation

Type 4: Denies any problems with hearing or communication

According to Stephens & Kramer, about 80 to 90% of patients fall into the first two categories. Let’s look more carefully at each type, what each type looks like clinically, along with some of the service that need to be provided by the clinician for ear respective type.

Type 1: Positively motivated without complicating factors

        The individual readily accepts your recommendation for hearing aids and rapidly and effectively passes through the system, needing only one of two appointments.

Type 2: Positively motivated with complicating factors

The individual requires more time and attention to successfully use hearing aids or to acquire necessary communication skills. Thus, a Type 2 patient needs three or more appointments over a 6 month time period. Time spent at each of appointment would address issues related to complicating factors such as the patients’ lack of confidence, physical or cognitive decline, and/or lack of family support.

Type 3: Wants help, but rejects a key component of your recommendation

The individual requires additional personal adjustment counseling and involvement of significant others to improve their acceptance, understanding and expectations relative to the rehabilitation process. Type 3 patients are likely to need more “talk therapy” that allows them to gain confidence and independence with respect to accepting the clinician’s recommendation. Oftentimes because a device is not involved in the rehabilitation, but the clinician is providing guidance on the patient’s underlying reasons for not accepting treatment that may lead to behavior change .

Type 4: Denies any communication or hearing problems

Because the individual is in denial or unaware of a communication problem, no intervention can be started at this time.  Significant others may require support and advice during the time of the appointment. Type 4 patients likely need to be monitored over a long period of time, and with the support of family, encouraged to visit the clinic periodically for a re-assessment.


Triaging patients into one of these four categories has the potential to unlock new service delivery models that benefit more patients and allow clinicians to charge fees for specific services, many of which do not have to be coupled with the sale of hearing aids. The next installments of Signal & Noise will examine what specific skills, tests and procedures – both audiometric and non-audiometric – can be used to sort patients into these 4 categories as well as some thoughts on how to bill for these services.




Kramer S & Stephens D. (2009). Living with Hearing Difficulties: the Process of Enablement. Hoboken NJ: Wiley.


Brian Taylor, AuD

Brian Taylor, AuD, is audiology advisor for the Fuel Medical Group.  He continues to serve as Editor of Audiology Practices, the quarterly publication of the Academy of Doctors of Audiology. During the first fifteen years of his career, he practiced clinical audiology in both medical and retail settings. Since 2005, Dr. Taylor has held a variety of leadership & management positions within the hearing aid industry in both the United States and Europe. He has published over 50 articles and book chapters on topics related to hearing aids, diagnostic audiology and business management. Brian has authored three text books:  Fitting and Dispensing Hearing Aids(co-authored with Gus Mueller), Consultative Selling Skills for Audiologists, and Quality in Audiology: Design & Implementation of the Patient Experience.  His latest book, Marketing in an Audiology Practice, was published in March, 2015.  Brian lives in Golden Valley, MN with his wife and three sons.  He can be reached at or


feature image courtesy of Cambridge in Color (edit)

  1. There is some truth to the classification of patients explained above. The overlying method is common to all approaches, i.e. the hearing specialist needs to take over the show. To the patient, you are “God”, and should answer his prayers! Most patients are ignorant of the reality of progressive hearing losses, and cannot be in denial about something they cannot feel.
    Make the patient talk, and you observe and interject when emotions run high. Since all decisions are emotionally affected, the patient must go through the emotional journey to realize what he/she has been suppressing.
    Hearing correction is 80% psychology and 20% technology. Don’t ever flip this ratio if you want lasting good results with amplification.

  2. The model described seems is a re-hashing of the Goldstein-Stephens model (1980).

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