Brian Taylor, AuD
“Signal & Noise” is a bimonthly column by Brian Taylor, AuD.
I recently had the privilege of listening to a panel of distinguished executives from the leading hearing aid manufacturers and retailers. Aside from the pointless squabbling about who, among their competitors has a stake in corporate retail, and the irony that a female-dominated profession was represented by an all-male cast of characters; this group did have a thoughtful appreciation for the professional’s involvement in meeting the needs of adults with hearing loss.
The Biomedical Perspective
Together, their expert opinions might be best labelled the biomedical perspective: They see the problem of the 5 to 10 year wait to seek services by 80% or more of adults with hearing loss as one that can be addressed with a better hearing aid predicated on multiple office visits with a hearing care professional. In other words, build a better instrument or provide a more engaging office experience centered on that device and people with hearing loss will beat a path to your door.
It’s a credible, yet myopic view, and one that could be trumped by the inertia of changing consumer demands and looming government policy changes in the near future: Is a traditional hearing aid wrapped around several face-to-face appointments with a professional enough to meet the needs of the majority of healthy aging adults, many with “normal for my age” hearing loss living without help?
No doubt, the opinion of these eight business leaders is valuable and worthy of our respect; after all, the number of adults over the age of 65 – individuals most likely to use the devices they manufacture – will essentially double over the next 20 years. However, we have a professional obligation to look beyond the status quo and carefully analyze what other key stakeholders may believe about what lies ahead. Here are two alternative perspectives warranting our attention.
The Public Health Perspective
Although there appears to be consensus across healthcare disciplines on the long-term consequences of untreated hearing loss and the relatively poor uptake of hearing aids, opinions vary on the underlying causes of the long gap between first noticing hearing difficulties and receiving care for it. One opinion comes from the realms of public health. These are professionals – mainly nurses, epidemiologists, primary care physicians and policy officials – tasked with maintaining the long-term health and wellness of a large swath of the population in the most cost-efficient manner possible.
Public health officials involved in the study of adult hearing loss have generated much of the research that indicates age-related hearing loss is not inconsequential; it is closely associated with several other long-term, detrimental conditions, like dementia, depression and social isolation. Given the consequences of untreated hearing loss, the long wait to seek help for hearing loss and low uptake of hearing aids, public health officials see this as an opportunity to address a potential huge public health problem by offering lower cost, off-the-shelf solutions.
Toward that end, on January 21, the Journal of the American Medical Association (JAMA) published a short opinion piece, co-authored by public health officials (and members of the now well-known PCAST committee). In the article, Christine Cassel, Ed Penhoet and Robert Saunders outline the consequences of untreated age-related hearing loss and barriers to wider patient uptake of hearing aids. The same article appeared in the February 9th print issue of the JAMA. Considering that the practice of medicine in the US is moving toward a population-based model in which physicians are incentivized to keep large pools of patients healthy, these opinions deserve our attention.
Public Policy Concern #1: Cost
In the two-page article, likely read by thousands physicians and healthcare providers immersed in this changing healthcare system, the authors echoed the sentiments of the PCAST committee by stating:
“that cost is the major impediment to seeking and obtaining care for hearing loss, especially because many people would have to pay the full cost out of pocket due to lack of insurance coverage, and many live on fixed incomes. The average price for a hearing aid is $2400, and most people need two.” and
“unlike other technologies in the consumer and medical electronics arena, advances in electronics have not reduced the price charged to consumers.”
Even more recently, public health expert, otolaryngologist Frank Lin, during a presentation at the American Association for the Advancement of Science’s (AAAS) annual meeting said, “Treating hearing loss could potentially help reduce the risk of cognitive decline and dementia, but hearing aids are out of reach for the vast number of Americans.”
It’s More than Better Devices and Lower Costs
Clearly, public health officials see cost as the primary barrier to increased assess. If cost is the number one concern of the public health perspective, how does the clinician, who now often spends several hours counseling the first time hearing aid user, factor into the equation when individuals might, in the near future, be able to buy their devices off-the-shelf without professional involvement?
Since the PCAST recommendations were published in the autumn of 2015, industry experts have weighed in on the causes of the long wait between awareness of hearing loss and the seeking of professional help. According to many of these thought leaders, cost is a small part of the poor uptake equation, and is overstated by PCAST.
In a January 15 Hearing Review post, audiologist, Dave Smirga, challenged the PCAST findings on cost prohibitions. According to analysis, Norway and the UK, where hearing aids are offered for free to those who could benefit from them, the adoption rates are 42.5% and 41.5%, respectively. Further, Smirga presented data from a 2012 report indicating hearing aid ownership in industrialized countries as a percentage of population ranged between 1.5% in Japan and 4.2% in Germany with the ownership rate in the United States at 2.8%. Considering these hearing aid market penetration statistics, there is more to the unmet need equation than cost.
Which brings us to the third perspective, The Psychosocial Perspective, to be addressed in part 2.
feature image courtesy of Cambridge in Color
I think that if Audiologists were trained to actually adjust aids so people could hear, it would be the best thing to promote hearing aid use.
My audiologist adjusted my aids so that it’s more of a practical joke than an actual aid to hearing. Then, when I couldn’t hear, blamed it on me by telling me that I’ve just forgotten what things sound like. I haven’t forgotten, I just can’t HEAR with the aids.
When I first went to her, everything sounded loud enough and OK, but I was having trouble understanding speech. There was certain frequencies I wasn’t hearing, so part of the sounds of speech were missing.
Now, without an aid, I couldn’t hear anything at a rock concert!
And she claims my hearing is exactly the same as when I first went to her.
The problem for new patients is that they ask someone they know with an aid if it helps them, and because of bad judgement,on the part of the audiologist, the person tells them that it’s really not helping much and wasn’t worth the money, so the prospective client decides it’s not worth getting an aid.
I would have changed audiologists, but I got my aids through the VA. They let me change audiologists, but the new one knew the old one and was angry at me for saying I couldn’t hear, and refused to even test me because she said the other audiologist was right.
I wound up buying a generic aid on Amazon and adjusting it myself, and I can actually hear and recognise sounds with it. It’s 100% better than the mess the audiologist made of my expensive aids.
It is because of the long established reputation of expensive aids that do not properly compensate for a hearing loss. The EQ is wrong, the sound processors adversely affect the sound quality and are distracting, so the aids get tossed in a drawer. Then when that person tells the next person shopping for aids “they all sound like crap”, then there is another HOH person who goes without. Hard of hearing people do talk to one another about aids, audiologists and service. The boards are full of people asking why, when they spent so much money, their aids sound terrible, and the audiologist says, “you’ll just have to get used to them”.
The whole process of determining the correct compensation EQ is wrong from the start and the very idea of beginning with a bad EQ then throwing a bunch of noise reducers, speech enhancers, Automatic program changers, environmental sound adjusters, etc., on top of that to fix it, is simply nuts. Any audio engineer will tell you that. I am a musician with my own studio, I adjust my own aids and I am speaking from decades of experience from self adjusting at least 5 pairs of aids. I run my aids “bare” with no anti feedback (I don’t care if it says “music” it still kills the highs) and no other processing, and I hear well without them.
Solution: Concentrate on getting the EQ right, first, before they leave the factory. Audiologists should be the last step in fine tuning the aids and fitting of ear molds. They should not be the fall guy for factory mis – settings.
I’m in the UK, I have free and as far as I can tell, pretty well set up, relatively basic, pretty purple hearing aids.
I regret it took 3years of driving my family nuts and frustration for me before I got them.
Why the delay
1) because everyone hopes health worries will go away (at 46ish I rather young for age related hearing loss)
2) Bad and my experience inaccurate press NHS hearing services get “Don’t work”, “Only fit one”, “Big, Ugly, Beige”
3) Thus I assumed I’d go through all the hassel of NHS waiting lists, waiting rooms and diabolical car parking to end up going private anyway.
4) COST COST COST!!!!!
I’m a stay at home mum, had I hated my NHS aids it would have been family money that bought me private ones.
Yes my husband earns enough and he wouldn’t mind at all, but that doesn’t stop me minding and feeling with two teen daughters it’s more than my ‘share’
5) Equal to 4) VALUE FOR MONEY.
I’m a scientist married to the geek to end all geeks! I live surrounded by computers, radios, electrical test gear, signal generators, spectrum analyses, Rasberry Pi and other small processor chips. I can’t move without tripping over sodding cables.
Not one item in this collection nor three iPhones, husbands Andiod phone, lap tops tablets etc. cost more than £600
The hearing aid Tloop amplifier in my living room cost £25 on eBay (plus one power transistor and some wire out the shed)
Quite simply the mark up, between the manufacturing costs and the end price of hearing aids is obscene and immoral and I’m not prepared to pay it!
I’d be happy to buy HAs plus soft wear and set them up my self or pay a sensible amount for a private audiologist along the lines of what opticians/dentists cost BUT I am not prepared to support the stigma reinforcing, hidden hearing, low sales high margins model that exists today!