By Angela Loavenbruck, Ed.D.
Trying to understand the various contributors to the commoditization of audiology practice has led me in a number of different directions. Most recently I interviewed a number of AuD students about their academic and rotation experiences with private practice. This week, after publication of the 2015 US News and World Report Best Hospitals edition, I wanted to understand whether audiology departments in these award winning hospitals were experiencing the same pressures from commoditization as those of us in private practice. I also wanted to compare the everyday work experience of hospital based audiologists to those in private practice.
I interviewed eight audiology directors whose hospitals were in the Top 15 in the US News report. I asked questions about autonomy, relationships with otolaryngology and administration, working conditions, case loads, continuity of care, standard procedures in hearing aid evaluation and dispensing, turnover, pay scale and job satisfaction.
There was considerable variation in the administrative structure of audiology services in these institutions. Some were considered independent Divisions of Audiology and had equal standing with other medical divisions, such as the Division of Head and Neck Surgery, the Division of Otolaryngology, etc.
Audiologists who were Division Directors often had audiology directors of departments within the audiology division who reported to them. Others were considered departments within the Division of Otolaryngology and reported to the Chief of ENT.
In a few hospitals there was no overall audiology director. Many of the hospitals had multiple audiology clinic sites both within the hospital and in various parts of the outside community. Regardless of the administrative structure, every director I spoke with reported that audiology functioned autonomously in their institutions.
Several expressed concern that non-medical administrators were going to impose unreasonable limitations on which hearing aid manufacturers could be used, for example, or on the amount of time that could be devoted to various clinical activities, without any input from audiology staff.
Many spoke of having equal, collegial and collaborative standing with their physician counterparts and of mutual respect for their various roles and competencies. However, in two instances, the audiologist reported that physician staff sometimes countermanded the audiologist’s recommendation for amplification, and that patients were more likely to follow the physician’s advice to delay treatment.
In institutions where Audiology had division status, there seemed to be more awareness of the impact of healthcare changes imposed by the Affordable Care Act and integrated health care initiatives on audiology services.
I was particularly impressed by several community hearing healthcare initiatives developed by audiology departments to expand the reach of audiology services to assisted living and nursing home populations.
My first step in contacting the audiology departments was to go the hospital website. Finding the audiology department was not always easy, and finding the names of the directors and the audiology staff was also difficult. In several instances, the only way to contact the audiology department was by calling an appointment line and asking to be connected to the audiology department.
Although many of the websites contained good information about audiology services, contacting the director or an individual audiologist was virtually impossible.
All of the departments were well equipped, often with state of the art diagnostic equipment. However, staff audiologists frequently did not have their own office space. Patient counseling took place within the test booth or in a shared office space.
Some spoke of the difficulties imposed by large systems where patients were treated impersonally. These systems made it more difficult to ensure that patients would always see the same audiologist for follow-up visits.
In general, it appeared that adequate time slots were allotted for testing and consultations. In many hospitals, the need to schedule same day referrals from ENT staff makes it more difficult to schedule hearing aid consultations and fittings.
Diversity of the caseloads in their facilities was highlighted as one of the primary advantages of a hospital-based audiology practice. Many of these major hospitals draw patients from all over the world who present with difficult or unusual diagnostic problems. Additionally, most of these hospitals housed adult and pediatric cochlear and other implant centers where teams of specialists collaborate to work with patients.
Most directors reported that their staff audiologists were very satisfied with the work settings, although some did report turnover due to audiologists sometimes feeling like “a number” in a large system, with opportunities for advancement or to pursue individual interests not always available.
Directors reported that they certainly were aware of the pressures caused by retail incursion into hearing aid sales and that price shopping was a counseling challenge in their facilities. While adult and pediatric amplification services were an important part of the work of these departments, the diversity of the diagnostic and treatment work available seemed to dissipate at least some of the effects of commoditization in other practice settings.
Lessons to be Learned?
A number of these large hospitals are continuing to buy physician practices and also diversifying beyond traditional medicine and purchasing assisted living and long term care facilities, as part of their development of integrated health services. In many ways, these activities would help ensure a stable, locked-in referral system for both audiology diagnostic and treatment services.
What lessons can be learned?
I think that hospital settings cannot compete well with the personalized services delivered by private practice audiologists to adult hearing aid patients. While some are engaged in creative community outreach, many are not. Private practices generally do this quite well.
Private practice settings would do well to emulate the integrated health system model as a way to diversify their services and insure a steady source of referrals. That means outreach activity to primary care physicians and other generalist health care practitioners should be a priority.