Barbara Weinstein PhD
Barbara Weinstein PhD

Downstream Consequences of Aging is a bi-monthly series written by guest columnist Barbara Weinstein, PhD.  Today she dreams about Hearables and unbundling as a way to recover our calling as a rehab profession with our patients at the forefront. 


In her piece in the New York Times titled, No Hearing Aid? Some Gizmos Offer Alternative to ‘Speak Up, ’ Paula Span focused on “hearables” concluding that time, hassle, and stigma are major obstacles to hearing aid uptake.  Citing data from Dr. Frank Lin’s research group on efficacy of PSAPS, she opined that should the FDA establish a new product category for over-the-counter devices, consumers will be able to avoid the “bundling system,” responsible for making hearing aids available ONLY through audiologists.


Hearables, a Media Dream


Span went on to quote Dr. Nicholas Reed, an audiologist and member of the Hopkins research team, who said that while hearing aids remain the gold standard for treating hearing loss, PSAPs have an important place in the hearing health care system with audiologists playing an important role. The patient can purchase “hearables” on line and an audiologist charging an hourly rate can fit the technology.

Span concluded that treating hearing loss has evolved as an “all-or-none” proposition, with the hearing impaired having few choices which range from paying a large sum for hearing aids, blasting the television, or asking friends to repeat what they have said. According to her observations, FDA-regulated PSAPs might be a simpler and a far less expensive solution than hearing aids.

Span’s piece is one of many appearing in the media in response to the PCAST and National Academy reports.  The reports and media scrutiny create a situation in which audiologists must begin to reflect on how the increased attention to delivery of hearing health care interventions is an opportunity for action rather than inaction. 

Countering the “all or none”scenario which could be the undoing of our profession, as we know it, is critical. If we fit hearing aids in the context of a comprehensive management plan, and if CMS were to reimburse Medicare beneficiaries for person-centered auditory rehabilitation services to improve communication and life quality, the landscape might change to our advantage and that of stakeholders.

As described by Mamo et al. (2016), let’s take these critical steps to move that Dream to reality:

  • Raise the visibility of hearing health care as a low-risk intervention that may delay the negative health outcomes associated with hearing loss and promote our interventions as a potential antidote to unhealthy aging.

  • Consider offering an array of options designed to optimize function using technology as a means to the ends valued by our patients.
  • Consistent with goal number nine of the National Academy report,let’s focus our efforts on reversal of the negative consequences of hearing loss (e.g. the compromised social interactions and functional abilities) which derive from the impact of hearing loss on communication (Ferguson et al. 2016). 


The Key Word Here is “Unbundling”


Hearing aid use, education and counseling are the foundation and gold standard of intervention for age-related hearing loss. Persons with hearing loss should expect to pay for our expertise in delivering such intervention services (Table 1).  


Table 1.  Service Based Hearing Health Care Intervention Options (Couslon et al., 2016; Blazer et al., 2016).

A.     Technology Based Aspect of Intervention

1. Selection of Hearing Aids

2. Fitting, verification and validation of hearing aids

3. Device related orientation

4. Fitting of assistive technologies

5. Fitting of hearables

B.     Auditory Rehabilitation Based Aspect of Intervention

1. Functional Communication Assessment  (person with hearing loss and communication partner)

2. Motivational Interview Assessment

3. Assessment of Patient capabilities (e.g. executive function, coping skills, motivation, readiness, self efficacy

4. Behavior Change Intervention Assessment

5. Behavior Change Intervention

6. Baseline Assessment (pre-intervention)

7. Treatment benefit/outcome assessment  (6-week, 3- month)

8. Assessment of Residual Disability Using Technologies (6-month, 1-year)

9. Patient related orientation to hearing aids – communication strategies, expectations, goal setting

10. Auditory based cognitive therapy/brain training

11. Counseling based supportive rehabilitation

12. Integrative family counseling based (Habanec & Kelly-Campbell, 2015; Preminger & Meeks, 2010; Scarinci et al., 2013).

13. Internet based rehabilitation (Ferguson, et al., 2016)

14. Hearing protection and preservation

15. Technology assists – assistive technology, hearables, iPhone apps

The price of our services before and after the hearing aid fitting comprises 40%-70% of the total bundle charged to our patients (Mamo et al.,  2016). Advantages of an “unbundling model” are that it both improves price transparency and enhances our credibility.  A fee for service paradigm automatically highlights the many areas of proficiency unique to the skill set of audiologists (see Table 1, part B).  Patient centered care that supports the higher level psychosocial needs of our patients will return to the forefront as we deliver the services for which we have been educated (Keidser & Convery, 2016).

As examples from Table 1(B), unbundled billing shifts the emphasis from product to professional knowledge and skills when we charge for functional communication assessment,  behavior change assessment, and assessment of residual disability.   Notice in Table 1 the service and billing opportunities for AR (15 options) as compared to technology (5 options).  Rather than audiology being synonymous with hearing aid sales, audiology should be synonymous with patient centered holistic and customized care, designed to improve communication, to promote independence, and quality of life. This is how we began as a profession and we should be true to our roots.


Focus on the Person with Hearing Loss not the Technology


Shifting our conceptual frame of reference by unbundling supports the life goals and daily living needs of our patients (AGS, 2016) by making our activities more patient-directed and patient-focused .  As Westphal et al. (2016) point out, people with chronic disease do not express the desired outcomes from health care interventions in terms of decreasing the negative effects of the particular disease. Rather, they ask how can they live and function as well as possible in spite of the disease and its symptoms.

With Medicare moving toward performance-driven payment schemes, it is incumbent on us to meet the person with hearing loss where they are, as whole people. We must see our patients as persons who we must help live with their functional limitations where the ability to communicate to achieve life goals and to remain socially engaged is critical (Westphal et al. (2016).


The Dream of a Services-Based Intervention Model


Extracting from recommendations described in the National Academy Report, I conceive of AR as a top down multifaceted process focused on helping people function more effectively and safely in their environments (Blazer et al., 2016). This is in contrast to a bottom-up technology based process which has become synonymous with sale of hearing aids.  As is evident from the decisional balance shown in Table 1, the benefits of the former far outweigh those of the latter.




Let’s reorient. Instead of thinking of hearing aids as the “gold standard for treating hearing loss”, let’s think of the skill set audiologists bring to the table as the standard of care.

What if we adopted a person-centered approach with the vision for success defined by the person with hearing loss (Westphal et al., 2016)? Begin with a functional assessment for which you should be charging.  From the outset, let’s not be the “decision maker in chief.”  Work with the person with hearing loss and a family member, to shape clear, specific, measurable goals in terms of their function rather than by a medically defined clinical outcome such as “meeting target.”

Think in terms of the indicator which defines quality in the person-centered care vernacular. Namely, being able to live life at the highest functional level possible and having a degree of self-confidence in navigating the care system which requires the ability to communicate successfully (Westphal et al., 2016).  Mark Ross, a true legend in audiology circles, said it best in an interview with Doug Beck (Beck, 2009):

“Aural rehabilitation is arguably the single most important thing we do as audiologists. When you think about it, when a professional picks a hearing aid and programs it for a patient, that’s very important and certainly a significant part of taking care of the patient—BUT frankly, that’s a technical skill that other professions share, such as hearing instrument specialists and maybe some physicians, too.  There is much more to being an audiologist. The thing that separates us from the pack is our training, knowledge, and education in aural rehabilitation and counseling, which, when applied to patients, produces incredible results— much like I experienced at Walter Reed Army Medical Center.”




AGS (2016). Person-centered care: A definition and essential elements. JAGS. 64: 15-18.

ASHA (2016). Adult aural/audiologic rehabilitation. (accessed February 24, 2016).

Beck, D. (2009). Aural Rehabilitation, the AR Value Proposition, and Cochlear Implants: Interview with Mark Ross, PhD.  Audiology.org.   . Retrieved August 2, 2016.

Blazer, D., Domnitz, S., Liverman, C. (2016). Committee on Accessible and Affordable Hearing Health Care for Adults; Board on Health Sciences Policy; Health and Medicine Division; National Academies of Sciences, Engineering, and Medicine (2016). Hearing Health Care for Adults: Priorities for Improving Access and Affordability. National Academy of Sciences

Couslon, N., Ferguson, M., Henshaw, H. & Heffernan, E.  (2016). Applying theories of health behaviour and change to hearing health research: Time for a new approach. International Journal of Audiology. 55: S99-S104.

Ferguson, M., Woolley, A., & Munro, K. The impact of self-efficacy, expectations, and readiness on hearing aid outcomes. International Journal of Audiology.  Retrieved August 2, 2016.

Ferguson, M., M. Brandreth, W. Brassington, P. Leighton, and H. Wharrad. 2016. A randomized controlled trial to evaluate the benefits of a multimedia educational program for first-time hearing aid users. Ear and Hearing. 37: 123-136.

Habanec, O. L., and R. J. Kelly-Campbell. 2015. Outcomes of group audiological rehabilitation for unaided adults with hearing impairment and their significant others. American Journal of Audiology.  24: 40-52.

Keidser, G. & Convery, E. (2016). Self-fitting of hearing aids: Status quo and future predictions. Trends in Hearing. 20: 1-15.

Mamo, S., Reed, N., Nieman, C., Oh, E (2016).   Personal sound amplifiers for adults with hearing loss. The American Journal of Medicine. 129: 245-50.

 Barbara E. Weinstein, Ph.D.
earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly.  Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.


feature photo courtesy of shannon christy

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.