by Brian Taylor, AuD, Editor-at-Large
Two recent significant developments have the potential to upend the status quo of the profession: over-the-counter hearing aids and Medicare coverage for hearing aids and related services.
Below are summaries of three recent articles that clinicians can use to formulate an informed opinion about anticipated changes in how persons with hearing loss seek help, pay for services and self-direct their care.
Study Uncovers Key Drivers of Inaction
It’s been almost four years since the Institute of Medicine, now known as the National Academy of Medicine released a seminal report, titled Hearing Health Care for Adults: Priorities for Improving Access and Affordability. The multidisciplinary report outlined why and how key players within the industry could better manage the ill effects of hearing loss of adult onset.
Since the influential report was released in June 2016, several studies have been published that underscore the scope of the problem resulting from untreated hearing loss and some of the potential positive health-related outcomes stemming from early identification and treatment.
A recent study, published ahead of print at Ear and Hearing, shines a light on just how common it is for middle aged and older adults to ignore their hearing difficulties. Using data from the English Longitudinal Study of Aging (ELSA), Chelsea Sawyer and colleagues at the University of Manchester reviewed hearing screening data from 2845 adults, aged 50 to 89 years (mean age = 74). Screening results worse than 20 dB HL at 1000 Hz and 35 dB HL at 3000 Hz were considered a hearing loss.
Hearing screening results for each participant was compared to their self-perception of help seeking, stratified into one of seven possible help seeking categories, as shown in Table 1.
Of the 9666 adults participating in the ELSA, about one-third (2845) had probable hearing loss per the hearing screening procedure. For the approximate one-third (29.4%) of adults, aged 50 to 89 with probable hearing loss, the percentage, sorted into one of the seven self-reported help seeking categories, is shown in Table 2 below.
The study shows that 40% of individuals with measured hearing loss fail to recognize difficulties with their hearing, while approximately one-third (31%) of individuals with hearing loss exist somewhere on the help seeking journey between acknowledging hearing difficulties but not reporting them to their health care provider (Category 2) to being offered a hearing aid but declining it (Category 5). The results indicate that a modest percentage of individuals with measured hearing loss have taken all the necessary steps to receive and use hearing aids, as 28.6% of the total number of respondents with probable hearing loss reported they wore hearing aids regularly. Also, of note, the researchers found approximately one in five individuals (22.4%) of individuals who obtained a hearing aid reported they were no longer wearing it.
Through their correlation analysis, the researchers were able to assemble a profile of the typical individual with probable hearing loss who does not seek help. Individuals who 1). closer in age to 50 (perhaps because of the stigma associated with hearing loss), 2). female (perhaps because they have better coping strategies for dealing with hearing loss), and 3). less socially active (since they might be less reliant on their hearing ability during their daily routine) are, on average, more likely to have hearing loss and not report hearing difficulties or seek help.
Because the study involved British participants within their National Health System, where hearing aids are subsidized, the results may have limited carryover to other markets, and should, therefore, be interpreted cautiously. Nevertheless, the results are noteworthy as they suggest two in five adults between the ages of 50 and 89 have a mild loss or greater and do not seek help. Further, individuals within this group are more likely to be less socially active, female and on the younger side.
Given these findings, audiologists, physicians, as well as public health experts, would be wise to encourage all adults over the 50 to get their hearing screened and to target individuals at-risk for not reporting hearing difficulties with educational materials that help them become familiar with signs of hearing loss, consequences of untreated hearing loss and to promote corrected hearing as part of a healthy lifestyle.
Are Medicare Advantage Plans Moving the Needle?
Unlike the United Kingdom, where the previous study was conducted, hearing aid wearers in the United States have limited government (Medicare or Medicaid) or private insurance coverage for their hearing aid purchases. To fill the gap, Medical Advantage (MA) programs – a supplemental program for Medicare eligible individuals include a hearing aid benefit to about one-third of their members.
Researchers at John Hopkins University used 2016 survey data, collected from Medicare beneficiaries, to better understand access and spending patterns for dental, vision and hearing services. Their article was published in the February issue of Health Affairs, a peer reviewed health policy journal, also reviews some of the current federal legislation that could open the doors to additional hearing coverage for older Americans.
Results of their analysis provide us with several important insights about how older adults utilize MA services, including hearing aid benefits.
According to their results, 45% of all Medicare beneficiaries report some trouble with their hearing, even when wearing hearing aids. Additionally, 14% higher income individuals (>400% of the federal poverty level) have seen an audiologist for services, while only 7% lower income individuals (<100% of the federal poverty level) have seen an audiologist for services.
Perhaps the most illuminating aspect of their report are the utilization rates and out-of-pocket costs and how they differ for various types of insurance coverage. Not surprisingly, 76% of all Medicare beneficiaries do not have hearing aids or services as a covered benefit. For this group, 8% of them visited an audiologist within the past year. In contrast, 52% of Medicare enrollees were MA enrollees with a covered hearing benefit, with just 8% of this group seeing an audiologist within the past year.
Spending on hearing care was highest among traditional Medicare and MA enrollees without hearing coverage ($1,526 and $1,569, respectively). Spending was about $400 lower among MA enrollees with hearing coverage, compared to those without ($1,163 versus $1,569). Medicare Advantage enrollees with a covered hearing benefit paid 79% of the bill out-of-pocket, compared to MA enrollees without hearing coverage who paid 89% of the bill out-of-pocket.
Together, the two studies reviewed above suggest that a relatively high number of middle aged and older adults are unaware of hearing difficulties, and for many that do recognize a hearing problem, they fail to see an audiologist for services. The problem may be more acute in the U.S where supplemental MA programs with a hearing benefit lessen the out-of-pocket burden by an average of about $400.
One way to improve access and lower costs could be the availability of self-fitting hearing aids. Sold directly to consumers via the internet or dispensed by a licensed professional, there are many questions about the effectiveness of such devices. The next study provides some answers to these questions.
Is the Audiogram Needed to Fit Hearing Aids?
Although most clinicians don’t complete all the steps outlined in many best practice protocols, they have relied on the prescriptive method to fit hearing aids for more than 30 years. Now, that process, which requires, at a minimum, clinicians enter a patient’s hearing thresholds into computer-based fitting software is being challenged.
In a paper published January 31 at the open access journal, Trends in Hearing, researchers demonstrated adults with mild to moderate hearing loss could select hearing aid parameters similar to those derived from a vetted prescriptive approach, such as NAL-NL2.
In their study, conducted at Northwestern University’s hearing aid clinic, a group of 75 adult patients with mild to moderate hearing loss were split into two groups. One group wore hearing aids with acoustic parameters selected by an audiologist following conventional best practice fitting methods and the ability to adjust gain-only in the device, while the second group wore a device allowing them to directly self-adjust the hearing aid’s acoustic parameters using a smartphone-like interface.
After the entire group of 75 participants were initially first fit using conventional prescriptive methods and allowed to wear the Bose prototype hearing aid for about one week as a practice session, they returned to the clinic for some fine-tuning, and then split into the two groups.
- The “audiologist selected” group left the clinic for a 30-day at-home trial with gain set to closely match their prescriptive target and the ability to adjust gain-only (+/- 8 dB) using the smartphone-like interface.
- In contrast, the “self fit” group left the clinic for the 30-day at-home trial with a starting point of 0 dB insertion gain (REIG) and the ability to self-adjust two sliders on the smartphone-like interface that were tied to compression, gain and frequency response parameters of the hearing aid.
During their at-home trial both groups were able to randomly report, using a real time assessment feature on the hearing aid, their satisfaction with sound quality during various types of listening situations. At the same time, the researchers were able to record the participants’ hearing aid settings when they made their self-reports.
At-home use of the devices showed, regardless of the group, that participants with greater hearing loss selected greater amounts of gain, with the “self fit” group selecting slightly lower amounts of gain compared to the “audiologist selected” group. Further, preferred gain levels for both groups were remarkably similar. The deviation from the initial prescriptive starting point in the clinic was calculated two different ways: Overall gain and gain per band.
The gain selected by the “self fit” group was within 1.8 dB for overall gain and 5.6 dB per band, on average, compared to the gain selected by the audiologist at the initial fit in the clinic.
While wearing the devices, participants were able to make A/B comparisons between their own self-selected parameters and those selected by the audiologist during the initial fit in the clinic. Both groups preferred their own self-selected settings more than the settings they received during the initial fitting in the clinic, but the preference for their own self-selected fitting was stronger for the “self fit” group.
Following the at-home trial, a series of standardized measures of outcomes were conducted in the clinic on all participants following their at-home trial, including the APHAB, SSQ-12 and aided QuickSIN. The average scores on these outcome measures did not differ between the two groups, as both groups derived benefit from their respective fitting approach.
Given the similar preferred gain settings and outcomes between the “self fit” and “audiologist selected” groups” the researchers surmise that adults with mild to moderate hearing loss, when provided user friendly tools, can successfully fit their own hearing aids with minimal or no involvement from an audiologist. Also, it’s worth considering if the fitting method employed by Sabin and colleagues could be used by patients with severe or asymmetrical hearing losses – groups that were not included in this study.
Considering the remarkably similar outcomes between the two groups in this study, consumers may soon have a choice between two different fitting procedures: One driven by the clinician using traditional threshold-based principles and another that places the control firmly in the hands of the wearer.