Author’s Note: My earlier 2 part blog has now been out for over two months. The majority of the responses I received have been favorable and largely supportive. I feel it is now appropriate for me to respond.
Maurice H. Miller, Ph.D.
By Maurice H. Miller, Ph.D.
Dr. Kevin Liebe, audiologist and editor of this blog, stated to me his belief that the “billing issue” is a major reason why many audiologists today are not providing the extensive rehabilitation services I believe the elderly population desperately requires. Auditory rehabilitation services, he states, are often “not covered” by insurance.
My lingering question is that if audiologists could bill, would they then provide substantive rehabilitation services–or are they so “hung up” in the fitting of amplification that they are convinced what they fit in the patient’s ears is all that is required? The manipulation of the hearing aid circuit–rather than the training of auditory behavior.
Another respondent sees the only answer as legislative changes that would allow audiologists to bill for these services.
My question remains: If rehabilitation services become “billable,” would most audiologists feel comfortable in performing them?
Having been closely associated for 50+ years with the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS), I read with interest a report of a presentation at its Annual Convention of a program designed to improve the “adherence to hearing aids” of a group of 90 elderly patients with hearing loss. The rehabilitation program they used, Active Communication Education (ACE), resulted in “a significant association between the rehabilitation intervention and the use of amplification.” A greater proportion of the treated group used amplification more than 8 hours per day than in the non-treated controls{{1}}[[1]]Felipe Cardemil; Patricio Esqjuivel, MD; Talmara Barria; Lorena Aquavo; Adrian Fuente; Maritza R Espejo. (2013) Randomized Controlled Trial to Assess the ACE Program for Rehabilitation in Patients with Hearing Loss. Summary of Annual Convention of the AAO-HNS on P 108 in Otolaryngology-Head and Neck Surgery 149(2S)[[1]].
An Outside Perspective
An interesting and important response came from a non-audiologist colleague, Dr. Ronald Tikofsky, a distinguished Speech-Language Pathologist (SLP) and neuroscientist. He states that{{2}}[[2]]Dr. Tikofsky’s complete comments can be found here[[2]] : “…it is clear that auditory function is an integral part of the total communicative process. There is no doubt that the correct selection and fitting of a hearing aid or cochlear implant is a necessary step in the treatment of hearing loss, particularly in the aging population. However, it is only the first step and needs to be followed by Auditory Rehabilitation.”
Audition, he correctly opines, is “a complex cognitive process, and the intensity of the speech signal is but a small part of the process.”
Tikofsky correctly and cogently states that persons with hearing impairment, “suffer from a loss of appreciation of the quality of spoken speech and music. Such “secondary” or “collateral” impairments have a negative effect on the individual’s quality of life.”
Despite advancements in hearing technology, hearing impaired music aficionados may be left wanting
Even when high-quality amplification is utilized, intelligibility appreciation is not immediately restored to their hearing-starved ears. Thus, reintroduction and retraining in a supportive rehabilitative structural environment is essential. This is one of my objections to “ear-starved listeners” making their own amplification adjustments. When they do so, they tend to attempt to reproduce the distorted amplification systems they have become accustomed to hearing. Often, in the case of high-frequency hearing loss, they are used to distorted or missing high-frequency sibilant and fricative sounds of speech.
These high-frequency sounds, critical to the understanding of speech especially in noisy background situations, need to be amplified in as undistorted a manner as possible. Their intelligibility in quiet and in varying noise backgrounds need to be presented to the patient in an audiologic rehabilitation situation.
Dr. Tikofsky also refers to the loss of appreciation of the “quality” of music by many persons with hearing impairment. Portable forms of amplification reproduce the range essential for understanding connected conversational speech.
Enjoyment of music requires a broader frequency response and greater dynamic range. Even the best modern hearing aids just “won’t cut it” for those seeking quality music enjoyment.
Tikofsky states, and I agree fully, “attaining and integrating good speech reading and listening skills at this stage will be invaluable to them as they begin to experience cognitive decline, which includes reduced attention span and memory.”
Finally, Dr. Tikofsky places the audiologist as holding the “primary rehabilitation role,” as it was during its inception and rapid expansion during and after World War II. In assuming that role, audiologists view service to patients in the context of how hearing impairment impacts “the total quality of life of the persons with hearing loss.” He concludes with the important statement, “now more than ever, audiologists must fulfill their role as essential professionals in the study and treatment of communication disorders.”
It has been a pleasure to have this opportunity to respond to the comments offered by readers of this blog and I thank the Editors for the opportunity to do so.
Maurice H. Miller, PhD, is Professor Emeritus of Audiology, New York University Steinhardt School of Culture, Education and Human Development. Throughout his career, he has directed programs in Communication Disorders at some of the nation’s leading medical and academic institutions. Dr. Miller has authored five books, over 120 articles in peer-reviewed journals, and numerous monographs and chapters in widely used audiology textbooks.
*featured image courtesy of clce.onmason.com
Thank you Dr. Miller for contributing another thought-provoking post for Hearing Views.
I’d like to share a few of my thoughts on auditory rehab with our readers and address why I see the “billing issue” being such a problem:
1) Many AuDs today are employed by ENTs, hospitals, etc., who want their employees to “produce” billable time. Since structured rehab, particularly group sessions, are not “billable”, many non-audiologist employers do not see the value and therefore will likely not support it. You could always bill patients for this time, but I can attest from personal experience that even when offered completely free of charge and ongoing promotion of the vast benefit to patients of these group sessions, the turnout is often dismal.
2) Personally, I believe that the majority of audiologists today are doing much more than simply manipulating the hearing aid circuit and “sending people out the door”. Most clinicians I talk to are seeing patients at least 3-4 times following the initial hearing aid fitting over the course of several weeks. During those visits, the patients and their families are typically counseled (and often re-counseled) on many issues well beyond just the use of their hearing aids, including: communication strategies, assistive devices, assertiveness and personal advocacy, lipreading, LACE, etc., etc. (many topics that would be traditionally be reviewed in a rehab context)
3) Structured rehab is the ideal and I don’t think anyone could disagree with Dr. Miller on the importance of auditory rehab. However, I think the modern clinic environment often doesn’t lend itself well to the traditionally structured format. Audiologists need to do a better job at conveying the value it (and they) provide and thus, patients will more clearly understand that better hearing is about much more than technology alone.