Down the Rabbit Hole

Angela Loavenbruck
April 19, 2016


“Who am I then? Tell me that first, and then, if I like being that person, I’ll come up: if not, I’ll stay down here till I’m somebody else.”

Lewis Carroll, Alice’s Adventures in Wonderland

I’ve just returned from the 2016 AAA conference in Phoenix. As usual, the days and evenings were a whirlwind of greeting old friends, making some new ones, attending meetings and workshops, marveling at the exhibit hall (even though some familiar exhibitors were missing from the floor), and alternately feeling exhilarated by the information presented – or like Alice in Wonderland in a world of craziness.


What is most puzzling to me is how quickly the PCAST recommendations have become a faits accompli in so many quarters.  In my opinion, a deeply flawed report and recommendations based on faulty analysis of data has suddenly become the reality that audiologists are supposed to accept as the new reality.  The PCAST report, which bears great resemblance to a report issued by the Consumer Electronics Association (since renamed Consumer Technology Assn, CTA), has been discussed by a number of editors on Hearing Health Matters and in many other association and industry journals.  The FDA begins hearings this week on the PCAST report and the Institute of Medicine (IOM) will be issuing its report soon.

A major PCAST conclusion is that the hearing impaired population can be divided into people with mild to moderate hearing loss and those with more significant hearing loss, and furthermore that people can self-identify the group in which they belong. Indeed, several presenters at a workshop I attended divided individuals with hearing loss into those who identify as having a health problem (who presumably would seek medical and/or audiology care and products) and those who identify as having a consumer electronic need (who would just head on down to the nearest drug store or other retail outlet to choose some type of over the counter personal sound amplification device). There is scant data to support these conclusions.

I don’t know – am I deluded or have I spent 40 some years working with people with significant hearing loss who insist all they need is to hear the TV better? And will those folks with presumably “mild” high frequency loss who struggle to hear in many everyday situations be led to self-identify as needing a PSAP too? Who assesses the validity of self-identification?

The Promised Land of Market Penetration

We are being told that manufacturers are just waiting in the wings for the FDA to eliminate many of its current hearing aid guidelines to unleash dozens of products which can be marketed directly to people with hearing loss and which will satisfy an unmet consumer need. We need not worry, however, because ultimately this will lead people to get professional help when they switch their self-identification from consumer electronic purchaser to health care purchaser. Presumably this will occur when these individuals realize that the stuff they purchased doesn’t really help them.

Managed Care Managers

And, lucky us, when that switch occurs, there will be lots of MBA types available who have marketed themselves to various managed care companies as experts in delivering capitated hearing health care products and services – which of course will not differentiate in any way between audiologists and hearing aid dispensers. These business minded folks will have decided what kind of products and professional services and time are needed, and exactly what that time and service are worth and they’ll be selling their networks of providers to managed care companies. Take it or leave it.

And never mind if these are patients that have been your patients for years, or that your marketing and public relations activities have brought them into the hearing health care market. Either enroll in the network, and provide the limited services your capitated fee allows, or say goodbye to your patient. Maybe you can convince the patient to purchase a better service package – but maybe your contractual agreement won’t allow any balance billing at all.

Who Are We

There is also an undercurrent among some of our audiology colleagues that the events unfolding represent enormous opportunities for audiologists. Finally, they say, audiologists will have to differeUnknownntiate themselves by providing the rehabilitative services that are essential to successful use of amplification. Finally, we will have to unbundle those services and actually identify them and bill for them. While some optimism is welcome in times like this, we would do well to remember that Medicare does not allow audiologists to bill for these treatment procedures and that when third party payers do allow these codes, the payment rates are abysmal. The fact that many of us already meet and exceed best practices for fitting amplification doesn’t seem to fit into the trending equations.

The CMS Bottleneck

It’s interesting to me that for years, audiologists have lobbied CMS to permit audiologists to see patients directly.  For the last several years, we have attempted legislative changes to Medicare law to define audiologists as limited license practitioners. Earlier in our history, our lobbyists recognized that changing the law was actually not necessary and that CMS could make a regulatory change without a change in the law. They were actually told to do that by Congress, but CMS refused and we were forced to try to change the law – an enormous and expensive endeavor even if you have a Congress that actually works. The CMS bottleneck has continued unabated.

CMS and the FDA have insisted that hearing loss is a medical problem and that consumers would only be protected if hearing diagnostic tests were provided on the recommendation of a physician – it was too dangerous for consumers to have direct access to audiologists. Manufacturers have had to jump through regulatory hoops before making claims about their products.

FDA regulations mandated physician visits prior to hearing aid purchase to protect consumers – again forcing everyone through an unnecessary and expensive physician funnel.  And physicians market their hearing aid businesses by insinuating that consumers are better protected if purchases are made in a physician’s office. We all know that direct access to audiologists would save millions of unnecessary healthcare dollars and that physicians are ill-equipped to supervise amplification procedures.

Future Dreaming

imagesSo here we are on the precipice of what may be sweeping changes in FDA regulations where, without anydata or demonstration projects, OTC products suddenly present no danger to consumers. Physicians and audiologists are suddenly not needed at all. What are the chances that these changes will convince CMS that patients can safely have direct access to audiologists?  Crazy talk for sure.




Angela Loavenbruck, aka The Crabby Audiologist, has been in private practice since 1975. She has served as president of both the New York State Speech & Hearing Association and the American Academy of Audiology.  She was awarded the Joel Wernicke Award by the Academy of Dispensing AudiolAngela Loavenbruck, Hearing Health Mattersogy for her work on behalf of the AuD.  Angela has been Associate Professor at Teachers College, Columbia University and has spoken widely about ethics, private practice and accreditation standards. She and her husband recently celebrated their 50th wedding anniversary and have three children and three wonderful grandchildren.  Angela is also renowned for her Italian cooking and award-winning blueberry pie.




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