Back to the Future, part VIII: Bimodal Is as Bimodal Does

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

 Today’s post– the grand finale in this series–considers Dr. Kolind’s final prediction of a Brave New World that looks a good deal like a high volume version of the Old World.  We have arrived at this point after posts on Predictions I through VII, which covered  Audiologists as Retailers,Vanishing Practitioner AutonomyInternet DispensingConsumer ExpectationsVertical DistributionTechnological DominanceDispensers and Audiologists as BedfellowsRuthless Demand Curves,  Verification and Validation by regulation, and huge market expansion. Today’s post wraps it all up by considering the schizophrenia{{1}}[[1]]Not a universally-agreed upon diagnosis.  It’s my informal diagnosis, and one I’ve heard from others.  And yes, I am an Audiologist, not a physician.[[1]] endemic in our field since the beginning, with no end in sight:

Lars Kolind’s Prediction #VIII.   “Hearing healthcare provision will split into two major segments… I doubt that many audiologists will be successful in serving both:

  • Provision of hearing healthcare to people with mild and moderate hearing losses
  • Provision of hearing healthcare to people with severe to profound hearing losses”

Who’s Bimodal?

Hearing Aid Sales Are Bimodally Distributed

Well… we are and we have been since 1977 when Audiologists were finally allowed to dispense hearing aids.  From that time on, some consumers have purchased hearing aids from Audiologists, others have purchased through retail outlets.  That’s one way of being bimodal.  But Dr. Kolind’s assertion is that consumers will purchase through one or the other “mode” according to their degree of hearing loss.  The retail mode will compete on Price, the Audiology mode will compete on Knowledge.  Let’s consider that bimodal concept and see if it holds up.

The prediction suggests that people with mild and moderate hearing losses are going to be purchasing hearing healthcare.  This is not the clinical experience of most Audiologists, though it is certainly the dream of Audiologists and manufacturers.  MarkeTrak data support the clinical experience:  hearing aids are consumed by 40% of those with moderate to severe hearing loss, compared to only 9% of those with mild to moderate hearing loss.  To be sure, RICs have introduced hearing aids to a broader consumer base, which has contributed to market expansion.

To the extent that Table 3-a, MarketTrak 8 predicts actual future purchase decisions, there may be a good deal of truth to United HealthCare’s original assertion that their market entry was designed to service patients that our current industry model had ‘failed’ to reach. Responses of responsible consumer groups support the assertion.  Time will tell.  I do not know how the UHC program is faring and I do not know anyone else that knows.  Please chime in if YOU know!

Part b of Dr. Kolind’s prediction says Audiologists are going to have to choose between markets.  He goes on to say that people in the first group (mild losses) “will expect hearing healthcare to be much more … commercial, more pleasant, quicker” and that private practice Audiologists “will have only little to do in this segment.”  The prediction is already borne out by Costco, which has rapidly emerged as the second largest US retailer of hearing aids.  Though Costco does not provide demographics on its hearing aid sales, its Price and reputation (commercial, pleasant, quick) make it likely that that it is fitting a larger percentage of the mild hearing loss market than are private practice Audiologists.  Time will tell.

But that doesn’t mean Audiologists were shut out of that market.  One can make the valid argument that Costco employs a lot of Audiologists.  On the other hand, Costco does not bill insurance, which suggests to me that testing is not performed for the purpose of diagnosis.  Audiologists working at Costco–and in similar models (perhaps including UHC once they fully define their model)  DO make a choice — they choose to work as hearing aid dispensers rather than as Audiologists as we have traditionally been defined.  Please note:  this is an economic observation and in no way a critique of their professional choice.


Separate Beds, Strange Bedfellows

Recently, UHC has upped the commercial ante by offering mass distribution of product via online ordering.  Once consumers obtain a measure of their hearing ability (currently a controversial stumbling block), they can simply check off their desired style, color, number, and price of hearing aid(s).  The order is fulfilled by Hi HealthInnovations — a UHC group company and… I have no idea what happens next as far a the consumers’ use of what they ordered.  Time will tell.

But what has already happened is the improbable friending of Audiologists and ENTs as they find equally improbable common ground in the form of the old FDA Medical Clearance requirement for consumer protection:

A recent related development has introduced a potential patient risk about which physicians and audiologists are united in steadfast agreement.The company has the financial and organizational ability to reach a great many people. However, the decision to offer online diagnosis, treatment, and hearing aid distribution for hearing-impaired patients has raised major concerns among otolaryngologists and audiologists.

Shocking developments, considering that the FDA Final Rule story was one in which ENTs convinced the FDA in 1977 to move hearing aids into the medical camp, taking them out of the hands of dispensers just as audiologists gained the opportunity to start dispensing.  But, this is just the tip of the strange bedfellows iceberg — see David Kirkwood’s posts for complete bedside coverage.  

Who Ya Gonna Choose?

Dr. Kolind’s final prediction has come to pass, insofar as a bimodal distribution of hearing aid provisioning goes.  But, he envisioned  a dividing line based on degree of loss and that part of the prediction seems off.  Power aids are available through Hi HealthInnovations and other internet sources.  At present, Price and Access seem to be setting the bimodal distribution boundaries.  Dr. Kolind’s optimistic view that Audiologists’ knowledge and expertise would attract most of those with significant hearing loss hangs in the balance, which means Audiologists’ choices of employment are also in the balance.  

In the meantime, audiologists are choosing industry and big box employment rather than taking the risk of setting up autonomous practices.  The hearing aid industry shows signs of moving its dollars away from independent audiology, choosing instead to invest in vertical dispensing channels.    It’s worth noting that this demographic shift is mirrored in the “snowballing” number of physicians moving from independent practice to hospital employment while hospitals and clinics are expanding rapidly in networks of suburban outpatient facilities that “follow the patients.”  

In the end game, market forces will likely prevail, as economists would predict and as did Dr. Kolind over a decade ago.  The market forces do not exclude Audiologists from any part of the Demand curve, but they do suggest that “huge” market growth will drive many audiologists away from diagnostic centers and redirect them to large, retail dispensing environments where they will work side-by-side with dispensers and where Price will ultimately dictate terms of employment.  Audiology member organizations, together with other stakeholders such as physicians who have much to lose, will work hard to remain essential by efforts to adjust the market through regulations, licensure, Scope of Practice, and price floors.  Those efforts will doubtless by countered by increasing availability of lower priced, direct-sale “audio devices,” thus maintaining and promulgating the bimodal distribution of sales.  

 photo courtesy of cafe press and lady chestnut

About Holly Hosford-Dunn

Holly Hosford-Dunn, PhD, graduated with a BA and MA in Communication Disorders from New Mexico State, completed a PhD in Hearing Sciences at Stanford, and did post-docs at Max Planck Institute (Germany) and Eaton-Peabody Auditory Physiology Lab (Boston). Post-education, she directed the Stanford University Audiology Clinic; developed multi-office private practices in Arizona; authored/edited numerous text books, chapters, journals, and articles; and taught Marketing, Practice Management, Hearing Science, Auditory Electrophysiology, and Amplification in a variety of academic settings.


  1. I like this bi-modal concept. I can think of lot of things that we audiologists always considered to be single-modal that might be bi-modal after all. Or, perhaps, multi-modal. I suspect when too many “modes” are involved, there ceases to be any relationship at all. But, I really like the bi-modal thingie.

    1. Thanks Mike. What things come to mind that we thought were unimodal that might be bi-modal?

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