The American Academy of Audiology (AAA) is, by far, the largest professional organization in Audiology, but the much smaller Academy of Doctors of Audiology (ADA) is gaining members at a record pace. According to ADA, the group has gained more than 120 new members this year. A probable cause of this sudden growth in ADA membership is a schism between AAA leadership and some of its rank & file members over support of the Audiology Patient Choice Act (APCA) of 2018. A prickly issue, often pitting members of both professional organizations against each other, which has been, under various forms, in Congress’ legislative pipeline for several years.
Recall that the latest iteration of APCA bill, introduced in Congress earlier this year, is to remove the requirement that Medicare recipients must receive authorization from a physician prior to seeing an audiologist for a hearing evaluation. Today for an audiologist to receive Medicare reimbursement the hearing evaluation must be “ordered” by a physician who also charges Medicare for an office visit. This extra visit with a physician is widely believed to increase the cost of care to the taxpayer-funded Medicare program.
Currently, approximately 44 million Americans, some 15% of the population rely on Medicare for their healthcare coverage. That number is expected to markedly rise over the next decade as the Baby-boomer population ages. Given the average age of Medicare recipients is well over 65 years, a high percentage of them have hearing loss and likely could benefit from direct access to hearing care provided by audiologists.
Endorsement of the Audiology Patient Choice Act
The bill, HR 2276/S.2575, has been endorsed by the Academy of Doctors of Audiology, but AAA did not provide an endorsement of the legislation. The American Academy of Audiology did agree, however, to not actively oppose the direct access bill. Given the size of AAA membership, this equivocating position is tantamount to opposing it, according to several AAA members HHTM contacted. (The bill, unsurprisingly, is strongly opposed by the American Academy of Otolaryngology, although some individual AAO members do support the bill).
To understand the frustration of some AAA members, it helps to recount the events at their recent meeting in Nashville. Soon after the annual meeting of the American Academy of Audiology in April, in which reports suggested contentiousness among members about AAA’s stance on the American Patient Choice Act, the AAA’s leadership posted this detailed FAQ to address the issues surrounding the APCA. Shortly after AAA posted their FAQ, the Academy of Doctors of Audiology, fervent supporters of the current APCA legislation, issued a detailed brief that addressed several questions concerning AAA’s FAQ document on the bill.
Although AAA was founded more than 30 years ago on the principle that Audiology be an independent doctoral-level profession, the organization – more than four months after their contentious membership meeting in April – continues to have concerns about the current bill, which has frustrated many of their members.
Audiologists in favor of the legislation believe the potential to lower Medicare costs for the most expensive healthcare system in the world and improve access to care – the intended benefits of the bill, outweigh the risks associated with its passage. In addition, many supporters cite that directly billing Medicare for hearing testing is fully within their scope of practice and results in superior care because patients without medical contraindications on their test or case history do not have to make an unnecessary appointment with a physician.
Although HHTM could find no one willing to speak out in opposition to the bill, according to the FAQ on the AAA website, those wary of the APCA legislation point out audiologists may have difficulty opting out of the direct billing of Medicare. In addition, there are concerns that Medicare wouldn’t reimburse for a full range of benefits, including evaluation and management (E/M) services, not just hearing evaluations. Beyond those reasons, which are posted on their website’s FAQ sheet, it is difficult to know why some members are wary of the bill because HHTM could find no audiologists willing to go on the record opposing it.
Members Weigh In
Several AAA members were queried by HHTM and for those willing to express their opinion, support for the APCA was unanimous.
As one member, Sheri Gostomelsky, an Illinois audiologist told HHTM,
“The APCA is the only way to move Audiology forward. If our profession is to survive and grow roots, we need to change. Direct access, billing for what we are licensed and trained to do and changing our taxonomy within the Medicare system is vital to the future of Audiology. I don’t understand why AAA will not back the complete act and look at the big picture. We should be allowed to bill and be reimbursed for services that are already recognized by Medicare and fall within our scope of practice.”
While there is evidence suggesting audiologists (most of which now have a doctoral degree) possess ample training to diagnose and treat most hearing and balance problems — and know when to make a necessary referral to a physician when indicated by test results, patient symptoms or case history — several AAA members were rankled by what they perceive to be AAA’s seemingly inchoate position on the APCA bill.
According to a press release posted on their website, AAA has not taken a position, and, instead, is doing “due diligence” by asking for the opinion of members and listening. However, of the more than a dozen AAA members contacted by HHTM, it is reasonable to conclude that the APCA bill is supported, often enthusiastically, by many rank and file members.
“Currently I am an active member of all three organizations so I have contacted AAA and ASHA about my disappointment in their choices and lack of support, although we all know that didn’t change their minds,” said Stacey M. Baldwin, an audiologist in Overland Park, Kansas. “I am thrilled to say that more than half of the state AAA chapters have already formally endorsed APCA and we are starting to pick up more ASHA chapters, too.”
Other audiologists were even more blunt in their assessment of AAA’s handling of the APCA.
Colorado audiologist Julie Link shared:
My support for the APCA is simple. Even in just 4 years of practicing, I have consistently observed that my patients who receive early diagnosis and treatment are the most happy and satisfied patients. These are the patients who stick with their treatment plans because they can actually appreciate the improvements. Drs. Campbell’s and Sharma’s 2016 research1 regarding the cross-modal re-organization in adults with early stage hearing loss could lead one to argue that the delay in access to care is actually a safety risk to our patients. There are already so many barriers to timely audiologic care for our patients (stigma, financial, transportation, misinformation, etc.), they do not need one more barrier to keep them from getting the audiologic services that they need.
With LLP status, comes new responsibilities. I believe that AAA is concerned that audiologists will not be properly educated for this new role and they themselves do not feel confident that they can provide the proper education to their members. If dentists, optometrists, and chiropractors can be prepared for these responsibilities in a 4-year degree, so can we.”
- Campbell J, Sharma A. Cross-modal re-organization in adults with early stage hearing loss. PLoS ONE. 2014; 9(2): e90594. doi:10.1371/journal.pone.0090594.
Private practice audiologist, Cliff Olson, owner of Applied Hearing in Anthem, Arizona, also weighed in on the issue:
“I’ve been an audiologist for only two years and within that time, we are already on our second piece of critical legislation that could have a massive impact on the future of our profession. I support the APCA act for two reasons. First, it clearly benefits patients with Medicare by allowing direct access to audiologic care. Second, Limited License Physician status will be an advancement of the profession, and I believe that if we are not growing as a profession, we are dying. It’s about time that we achieve professional parity with other doctoring professions and are allowed to function within the full capacity of our state mandated scope of practice.”
Another audiologist and AAA member who expressed unwavering support for the APCA is Sam Vaught, a practice owner in Georgia:
“I am, and always have been, very passionate about supporting direct access legislation every time it has been introduced in the U.S. Congress. I am supporting the APCA because it is time that CMS recognizes audiologists as an entry point into hearing healthcare. Our profession has evolved since its inception and CMS simply has not kept pace with our state licensure laws and our change in scope of practice as we have become doctoring professionals. There really is no need for a physician referral and that is evidenced by the Federal Employee Health Benefits Program and Medicare Advantage plans that do not require a physician referral. It would save CMS millions of dollars by eliminating the office visit to a physician for a referral (unless a patient prefers to see an M.D. first). While the APCA does not change our scope of practice, it would allow us to perform some treatment procedures on patients instead of having to refer them to another professional who can bill CMS for the same procedure, and it is much more convenient for the patient not to have to make another appointment somewhere else! And it would recognize us as the doctoring profession that we are for CMS purposes along with the other non-physician doctoring professions. These are three very legitimate reasons that I support the APCA and so should AAA.”
Other AAA members who support the APCA expressed astonishment that AAA leadership also wavered on pending over-the-counter (OTC) hearing aid legislation. They point to the Academy’s statement on OTC devices, posted on their website, which seems to offer tepid support of OTC devices, but falls short of endorsing current OTC legislation.
The AAA members HHTM spoke to expressed concern that AAA is vacillating on pending regulatory changes that are important to the future of the profession. The Academy’s OTC statement is available here.
Audiology & LLP Status
Opinion leaders within the field like to compare Audiology to other similar professions such Optometry and Dentistry, which both have Limited License Physician (LLP) status and the ability to directly bill Medicare patients. An HHTM query of a handful of dentists and optometrists, however, suggests that neither profession is willing to relinquish their LLP status because it helps reduce barriers for patients in need of their services and enhances their professional autonomy.
Another important constituency with a huge stake in issues related to professional autonomy are students and those who have recently graduated. Many of these students and newly minted Doctors of Audiology are expected to graduate with a significant amount of student loan debt, sometimes more than $100,000. Yet audiology remains one of the lowest paid doctoral level professions, according to data presented at the April 2018 AAA membership meeting.
Direct access to Medicare patients is believed by some to play a role in improving the compensation of audiologists.
Although several students have voiced their support of the APCA, the American Academy of Audiology recently reminded ADA that the Student Academy of Audiology, which is an official organization of AAA, cannot independently endorse the bill per a recent correspondence from Amy Miedema, Vice President of Communication and Membership for AAA.
For more on student loan debt in audiology, see this recent HHTM Hearing Economics post.
Like any piece of US Congressional legislation, there is expected to be some unintended consequences resulting from its implementation. And, a careful reading of AAA’s FAQs “Regarding the Academy’s Position on the Audiology Patient Choice Act” suggests their leadership is indeed concerned some unintended consequences will result from the legislation. Beyond their posted FAQ on the subject, however, AAA leadership is opaque about their uncertainty towards the APCA bill. This statement is based on HHTM’s attempt to reach AAA leadership for comment. As of July 28, queries to AAA leadership by HHTM have gone unanswered.
Although academy leadership does not endorse the APCA, on July 17, AAA posted on its social media accounts endorsement of the Medicare Telehealth Parity Act of 2017. It is an act that identifies audiologists as appropriate providers of telehealth services and authorizes Medicare to reimburse them for providing patients with audiology services via telehealth.
*Disclosure: Brian Taylor is a member of AAA and is the editor of ADA’s Audiology Practices publication.