Angela Loavenbruck, Ed.D.

crabby-audiologist-small-2Prepare yourself for a really, really grumpy post. First of all the Yankees left the bases loaded far too often, thus considerably dampening my happiness that the Boston Red Sox were fighting for last place and secondly, I have just read a lot of the literature on PSAPS.

And then I listened to a webcast presentation by Dr. Christine Cassel.  Dr. Cassel is a distinguished gerontologist who is presently chairing a study group for the Presidents Council of Advisors on Science and Technology (PCAST) established in 2009 by President Obama.{{1}}[[1]]9/20/2015: Dear President Obama: 30 Million American’s Without Access to Hearing Care.[[1]]

PCAST Aging and Technology Study

Since 1933, each president has had an advisory committee of scientists whose purpose has been to provide scientific and technical advice to the President. The broader purpose of Dr. Cassel’s study group is to focus on ways that technology can help aging individuals with cognitive function, mobility, social connectedness, as well as with hearing.

Her study group considered the ways that technology can help individuals with mild to moderate hearing loss.  Dr. Cassel was reporting on the progress of the group prior to delivering its report and recommendations.

While there are a number of reasons to celebrate the work of this group, the presentation gets a mixed review from this crabby audiologist.

b44hbfo12912fvwfzd8dDr. Cassel pointed out that hearing loss is a major health and social problem and that only 15 to 30% of individuals with hearing loss use hearing aids. She identified four barriers to wider use of hearing aids:  the cost of technology – described as the number one issue, complexity of access, social stigma and limited awareness and the lack of engagement in this issue by primary care health professionals. My concerns began with many of her subsequent remarks.

Cost as a Barrier

In terms of cost, Dr. Cassel said that the average cost of hearing aids was $2400 per ear, and that some cost “$4000-8000 (not clear whether she meant for one or two aids), costs not covered by Medicare or most other insurance companies because they don’t consider hearing loss to be a medical problem.” As audiologists, we can all appreciate the irony of the fact that Medicare doesn’t consider hearing loss to be a medical problem, while hearing aids – the only treatment for the vast number of hearing losses – are regulated by the FDA because they are medical devices. Hmmm…..  Dr. Cassel then went on to say:

“Often you have to seek out an audiologist in a specific kind of arrangement with one or more hearing aid companies.  The choices are somewhat limited. By and large these are not available online or in other kinds of consumer venues the way people are increasingly accessing many aspects of healthcare.”

I don’t even begin to understand this remark.

Given that her summary came after hearing presentations by many experts, this quote made me realize the extent to which audiology gets lost in these high level study groups.  I wonder if there were any audiology practitioners among the people who gave presentations to this panel – there almost never are.

Missing the Best Part

Dr. Cassel’s entire summary presented hearing aids as a commodity – there was not a single sentence in the summary that indicated any understanding or recognition of the professional work that is included in the overall cost of hearing aids or of the expertise required in the process of evaluating, fitting, educating, adjusting, and verifying the devices.

Her statements about Costco’s ability to offer reduced prices came with no acknowledgement that they are indeed making a profit, and do so because manufacturers sell them products for 1/4 to 1/3 the price that private practices pay for identical products.

There are many services that are included in the device/service package that constitute the selling price of hearing aids in a bundled price scheme – yet no mention was made of this, nor was there any discussion of how critical these services are to solving the communication problems important to the patient. How do we as audiologists begin to change this conversation with “study groups”?

I keep wanting to videotape the process that goes on each and every day in our own office, and in many practitioners’ offices, as we take case history information, test hearing, evaluate lifestyle and communication needs, help people choose technology that is suitable and in their budget range, navigate any coverage provided by their insurance policies, order and fit and program the devices, teach them to insert, adjust, maintain the devices, provide months long trial periods with multiple time consuming visits to adjust, meet with family, validate and verify the fittings, recommend assistive devices and teach their use and benefit, recommend and provide aural rehabilitation therapy if needed – hours of work with each patient – all before the consumer makes a final decision.

Indesk-frustration-300x296 close to 40 years in a dispensing practice, I can’t think of more than a handful of patients with mild to moderate hearing losses who did not need or benefit from these audiology services.

I’m still waiting for the influx of aging boomers who are comfortable with programming their own hearing aids.  I get really tired of hearing comparisons to eyeglasses, along with the obligatory remarks about hearing aids costing more than a sophisticated smart phone – really?

Say Something… Nice

I appreciate the attention given to untreated hearing loss by this prestigious group of scientists.  I also appreciated the acknowledgement that the requirement for a medical evaluation is probably an unnecessary barrier to access to technology.

While I agree that some consumers with mild hearing losses may only need the simpler technology in PSAP devices, I am not aware of any evidence that suggests that audiology input is unnecessary in that decision making process.

I am frankly surprised by the totally untested confidence expressed by the PCAST group that encouraging self-evaluation and wider use of PSAP’s will significantly lower costs, increase access, provide satisfactory results for huge numbers of consumers, increase insurance coverage and help the Yankees win the pennant this year.

We’ll consider the PSAP issue in more detail next time…




  1. Hello Mike – I’m sorry you’ve had some negative experience with audiologists you’ve consulted, but I would like to discuss some of your comments. There are hearing aids available that make quite a few self-adjustments available to the wearer. In my experience over the last 45 years, not many of my patients are interested in making their own software adjustments, including all of the “aging baby boomers” who come into my office now. Particularly in the beginning of a fitting with new technology, fine tuning the devices, measuring the changes to make sure targets are being met, etc. – all of that can best be done with input from the wearer’s experiences with the devices. And newer aids permit quite a few self-fitting possibilities for those interested.
    The other statement that really bothers me, and one that is made over and over again, is that “the markup is astronomical” – it is simply not true. The cost of the devices themselves is only part of what it costs an audiology practice to evaluate, fit, program and maintain those products. We aren’t handing over the device and waving goodbye at the door. There are equipment costs, training costs, personnel costs, etc., along with all of the other costs to keeping an office open and available and equipped, and those of us struggling to run offices according to the highest standards of care are not becoming millionaires in the process. I think if you look, you will find an audiologist whose knowledge and skill set, as well as his/her ethics, are what you would hope for. Most try to make office hours available that suit working people. And I would hope that most, when asked a question they can’t answer, would say “let me find the best answer to that question” and get back to you. I think in the future, there will be more devices that allow more sophisticated self-adjustment for those who want that feature – I’m just not convinced the audience will be very large.

  2. As a hearing aid consumer (not an audiologist), my experience has been that audiologists are a _barrier_ to healthcare – not an enabler. Especially after I’ve purchased my hearing aids, the fact that I have to schedule an appointment, take time off work, drive to an office all to make an adjustment to my hearing aids is silly. I’m certainly capable of making some adjustments to my hearing aids, but I’m not able to because the audiologist is the only one that has the programming software capable of making the changes.

    I agree that the audiologist has a role in diagnosing hearing loss and making device recommendations. Beyond that, I’d prefer to be left alone to manage my own device.

    Especially galling is the knowledge that hearing aid markup is astronomical, and variation in audiologist level of knowledge is HUGE. In my experience it was more common than not to have an audiologist make something up when faced with a question he or she didn’t know the answer to.

    As aging baby boomers who are more technically competent start coming into audiology offices, audiologists better be ready for technical questions. I don’t think that many of them are ready today.

    1. Mike… Are you planning to fabricate your own eyeglasses, fit and adjust your own dentures? Would you manage and adjust a prosthetic limb without professional oversight? What other medical professionals do you see that don’t require an appointment? Hearing loss is a complex medical condition. Your auditory system includes your brain. I, for one, want to provide my brain with the best input possible. Many people think that hearing aids need “adjustments” frequently. When properly fit, this is not the case. But when there is a change in auditory status that requires additional evaluation, programming and verification of accuracy, the audiologist is the highly trained professional to do this.

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