With Friends Like These, Continued….

By Angela Loavenbruck, Ed.D.

crabby-audiologist-2Let’s have a talk about Medicare and Medicaid. If you are not crabby now, you will be by the time you finish reading this.

The relationship between Medicare/Medicaid and audiology is not a pretty story. Way back in the early 60’s when the Medicare law was being written, audiology was a tiny profession – probably no more than two or three thousand practitioners in the country, most of whom worked in hospitals or community clinics. The only mention of hearing testing in the original Medicare law came under a section called Other Diagnostic Tests.

Medicare law covers diagnostic audiologic testing provided by a qualified audiologist only when a physician (or non-physician practitioners such as nurse practitioners, clinical nurse specialist or physician’s assistant) orders the evaluation for the purpose of informing the physician’s diagnostic medical evaluation or determining the appropriate medical or surgical treatment. Since audiologists were not yet licensed in 1965, the original definition of a qualified audiologist included the ASHA Certificate of Clinical Competence (CCC).

Changing Definitions

In a totally out-of-character initiative in 1994, ASHA led the effort to change the Medicare definition of a qualified audiologist and qualified speech-language pathologist to include state licensure rather than ASHA’s CCC certification. When the new law was published in the Federal Register in 1994, Congress noted that the original law was written at a time when no statutory definitions of the two professions existed and that it was inappropriate to continue to use a private proprietary certificate when licensure laws provided a statutory definition.

After initially opposing licensure, ASHA helped state after state to get licensure laws by testifying to the necessity of strong licensure laws as the best consumer protection for both audiology and speech-language pathology.

ASHA’s magnanimity stopped there, however, since their model licensure law included a requirement for the CCC’s, which many state licensure laws adopted.

It should be noted that virtually all states eventually replaced this requirement with a generic description of educational and clinical requirements. It’s important to remember that at this time in our history, university audiology programs were only responsible for the academic requirements and for providing a limited number of clinical hours. The bulk of clinical hours were obtained in the Clinical Fellowship Year, which was the responsibility of individual students.

As a matter of course, employers were expected to provide jobs and supervision for master’s degree graduates and therefore were providing the bulk of clinical and professional education and training without recompense. As I’ve discussed in previous posts, this anomaly was a major incentive for the AuD degree which more properly placed these educational responsibilities within academic programs.


Medicaid and Medicare

mdcIn 1998, the American Academy of Audiology began an effort to bring the definition of qualified audiologist in the Medicaid program in line with the definition in Medicare law. At that time, Medicaid law continued to require the CCC for participation in the Medicaid system. AAA correctly noted that it was confusing to have differing definitions of the profession.

Medicaid at that time covered 19 million children, 8 million adults, and 6 million individuals with disabilities. In addition, Medicaid often covered rehabilitative audiology procedures and hearing aids, which were specifically excluded by Medicare. Furthermore, Medicaid covered early hearing screening programs for children as well as a number of treatment services provided to school-age children.

Simultaneously AAA and ADA were petitioning the health department to broaden its definition of audiology services to include treatment services as well as diagnostic services. The Medicare definition of a qualified audiologist was particularly important because it defined covered diagnostic audiologic services as those “within their legally defined scope of practice as would be covered if provided by a physician” – language used to describe health care practitioners such as optometrists, chiropractors, psychologists, and others who had attained limited license practitioner status under Medicare.

Defining Audiology: Change turned out to be more difficult than once anticipated.

The Medicaid administration informed AAA that it did not have the statutory power to change the definition of a qualified audiologist and that only Congress could do this. AAA then initiated the Medicaid Audiology Act (HR 1068) to accomplish the task. Not only did ASHA refuse to support this legislative initiative, but it joined the American Academy of Otolaryngology–Head and Neck Surgery in actively lobbying against the bill in Congress.

ASHA’s president called the Medicaid Audiology Act “a direct attack on its certification program.” ASHA’s lobbyists went to Congress and stated that they represented audiologists, that audiologists did not support the bill, and that it would permit unqualified individuals to practice audiology.

Why would ASHA do this when it had so enthusiastically supported identical language in the Medicare law? The answer lies, as it always does with ASHA, with 1) the dollars it gets for certification and 2) protecting their speech-language pathology members.


Fear of Change?

Using the old definition of qualified speech-language pathologist, Medicaid payments for school-based speech-language pathology services could only be provided by SLPs paying for the CCCs. ASHA was afraid that a change in the definition of audiologists would lead to the same change in the definition of SLPs.

ASHA-cartoonSince schools are exempt from licensure laws, ASHA was afraid that the services of “teachers of the speech and hearing impaired” who did not meet the licensure definition of a qualified SLP would be eligible for Medicaid payment. Since school-based SLP’s represent the largest contingent of ASHA membership, ASHA was afraid it would no longer be able to force SLP’s to buy their certificate. It was perfectly determined to throw audiologists under the bus in order to hang onto that particular stick.

Because of ASHA’s activities, it took until 2003 for the CMS to finally agree to make the Medicaid definition of audiology  consistent with the Medicare definition.  It’s important to remember this history when we try to understand what ASHA is now doing with its combined AA0-ASHA effort to extend physician supervision of audiologists under the Medicare law. More crabbiness to follow…

*title image courtesy Rocko’s Modern Life Wiki