Successfully Integrating Remote Care into an Audiology Practice with Dr. Michael Valente

Bob Traynor 0:10
Welcome to This Week in hearing. I’m your host Bob Traynor sitting in for David Kemp today with another episode with our honored guest, Dr. Michael Valente. Dr. Valente has been for many, many years, a clinical professor of Otolaryngology at Washington University in St. Louis, Missouri. He’s now a professor emeritus from that institution. Mike, I’ve learned so much from you over the years and reviewed many of the things and articles and presentations you’ve done over the years. So it’s my pleasure to be the host for this particular session of This Week in Hearing. And my understanding is that you’re going to kind of combine the the sessions together, do a little review from the first two, and then put things together into looking at the integration of remote fine tuning and other things we have we need to do in the practice to continue to be successful in our clinical endeavors. So it’s my pleasure and my honor to present my distinguished friend and colleague, Dr. Michael Valente.

Michael Valente 1:26
Hello, Rob, thank you so much for that introduction. It’s far longer than I deserve. But thank you so much at any rate, for doing that, and putting it all together for me. So I wanted to start it off with kind of a general sense of how I feel about all of this. And so, I feel that, you know, it’s easy to say that audiology is dedicated the seven years of their life to college, to provide high quality patient care, some 8 some of them longer but at a minimum seven. And due to this great care. I can I can speak for myself, I provided care for over 30 years. Many of our patients do think that audiologists are indispensable. However, I think most would agree that far more believe we are not, we are – we are not indispensable, just by the low adoption rates that we see around 30-32%. Because of our I think long held bundled model that create super super perceived barriers that led to the OTC hearing aid act, we were not as accessible, we are not assessable as patients would like, due to travel and ease of scheduling, were not as convenient as patients would like requiring multiple visits to retain hearing aids and getting into our schedules we’re costly, due to the bundled approach that we’ve taken for decades, and really didn’t educate patients about the importance of the extensive array of services that we supply along with the product, the hearing aid, as an example 2 cc couplers for quality control, real ear measures speech in noise validation, and so on and so forth. So we really haven’t been able to educate patients on the cost of the device, which is really equivalent to OTC and direct to consumer and the additional cost, which is bundled into that which is the service that we put in that can be depending upon the warranty anywhere between one to three years or four years. So these perceived barriers of accessibility convenience cost, led eventually to where we are now which is OTC and direct to consumer devices, which are more accessible and more convenient, and are often less costly than what we’ve been offering over the last several decades. But in spite of all of this, I firmly believe that OTC/DTC devices present audiology with an incredible opportunity that I dissected and presented in part two of this three part presentation. But I believe audiologists need to objectively that take the motion take the emotion out of it, objectively view the factors that has led to OTC and direct to consumer and implement changes within their practice to address these factors to help. I’ve put together this three part series, part one, I spent a considerable amount of time to demonstrate very carefully how one could calculate charge per hour to create an unbundled approach to address the issue of cost that led to OTC in part two, I discussed how we can integrate OTC type devices into our clinic, and use this as an opportunity to education that educate patients on the value of the services we provide, along with the product or the hearing aids. And I spent a considerable amount of time doing that in part two. In that lecture, I provide an example of an entry level hearing aid using an unbundled approach that we implemented two years ago. Today, if I were still directing the program, I would offer several OTC type devices in stock, again for convenience and accessibility, using the unbundled approach, again, demonstrating that we are not in a static, but in a dynamic environment. And you have to kind of change as information and experience dictate. Today, I’m going to take the last leg of that three tech three attack prong. And I’m going to discuss how audiologists today really need to think about implementing remote care and remote fine tuning, which then can address the last two issues, which is accessibility, and convenience that again, led to where we are today. Not to belabor the point. But if you go back to where we are, there were a series of meetings in 2015-16, and 17. To kind of set the stage as to why OTCs need to be made available. And if you read them, you’ll notice that they kept honing in on some three key points we need for our free with consumers greater accessibility, we need for them to have greater convenience, they have to cost less, because they felt that these three factors were causing the 70% of hearing, hearing impaired patients not getting hearing aids. Cost was another one in 2016. In 2017, access can convenience, affordability, all of these things led to the OTC hearing act, from mild to moderate hearing loss in 2017. That finally, finally is coming in October of 2022. So here we are. And let’s go through some of this. So just so that we’re all together on this one, this presentation is not how to do remote care and remote fine tuning. That’s a much, much longer presentation, but rather, why you should do it, and how this could be integrated into a clinical practice and share with you how this was done here in St. Louis.

So before we get to that I want to kind of define for you in my world, what is remote care, and how is that different from remote remote fine tuning, remote care, resolves problems remote, kind of like a secure Zoom. It doesn’t require manufacturer software, nor does it require a clinic visit. This addresses the issue of accessibility and convenience, audiologist. This is not new. audiologists have been engaging in some form of remote care for decades by either telephone or email communication with their patients. But Zoom adds the additional dimension of seeing the patient and the hearing aids at the same time. And this can significantly improve your ability to resolve problems without the need of an office visit. Remote fine tuning on the other hand, also resolves problems remotely. But it requires a smartphone using a strong Wi Fi and a smartphone with unlimited data plan. And it doesn’t require an office is it like remote care. This however, utilizes a manufacturer software, to reprogram the hearing aids, as well as provide additional services provided within that software. And it varies quite significantly across the different manufacturers. And I’ll share some of that with you later on. This also addresses accessibility and convenience. So these are examples in my head when I put this together, what would constitute remote care. So the way I thought about it was when I was providing clinic care. Oftentimes I would say to myself, really, does this patient need to be here for me to resolve this problem? I could have done this by a phone, I could have done it by zoom. So requiring an office visit addresses the issue of convenience and accessibility, which is part of what develop the OTC law. So by having a zoom, you could, I think significantly reduce the number of visits that a person would have to schedule to see you that could have been resolved simply by face to face communication. And here, you see just a litany of potential issues that I thought about when I was doing clinical service that I could have solved in my office, with the patient on their phone, or their PC. And by seeing them and the ear mold and the hearing aid, we could have resolved a lot of these problems, and prevent the patient from having to come into the clinic. And then also, oftentimes, I’m sure, and we’ll talk about that in a little bit, you’ll soon learn that there are things that you thought you could resolve by zoom, but you can’t. And during that Zoom, you apologize that you can’t provide you can’t resolve that problem, and advise them to mail the device to your office, or schedule an appointment. If the remote care doesn’t resolve the problem and have an example of that in a slide or two down the road. You can resolve feedback by a correct insertion of a dome or a mold or perhaps counsel the possibility that the feedback had been caused by cerumen. And again, if you can solve the problem by Re by counseling the patient on reinserting, that your milk was not inserted correctly. How many times have you seen a patient with shoe feedback they come in, and the ear molds are on the wrong ear, you could have resolved that problem with a zoom, or it’s in backwards, or it’s not in all the way I mean, there’s a lot of things that can cause feedback that you couldn’t resolve face to face. And if you can’t have all these strategies don’t resolve the problem. You can advise the patient we tried, it didn’t work. And now we need to have you come in and we can resolve the problem. So I think it’s important and this is what I would do to counsel patient in advance that it is possible that a remote session may not solve the problem. And as you gain more and more experience with this, you’ll begin to create a library of experience that in advance, you know, yeah, I can the Zoom will take care of this, or this has presented some challenges in the past or this is not going to work. So here’s an example. A patient calls me and says Mike, my aids are dead. And then

I say well, why don’t we schedule a zoom. And let we see, we’ll see what the problem is how many times if you had a patient with a RIC that’s dead. And you know, before the patient has sit down in the chair, it’s a wax trap that is clogged with wax, and you could have solved that in 10 minutes. But to make up the time as you should you clean the hearing aid your test them in the 2cc coupler. But the wax trap the the wax and the wax shape is probably the biggest cause of patients saying this aid is that that could have been a solved by zoom, as opposed to having the patient come in. And in our clinic, when we gave a patient we dispensed a behind the ear hearing aid, we gave them an air blower. So by seeing the tubing by utilizing that person’s camera, I could see if there is moisture in the tubing. And I couldn’t explain to them, show them how to use the air blower to get that out of that tubing. We give our patients dehumidifiers as part of our dispensing practice, have they been using the dehumidifier? does this solve the problem? It could be as you know, a dead battery. Is the battery? Is it correct battery? How many how many times I had a patient where it was a 312 and they tried to get a 13? Or vice versa? They have the wrong battery in there. Is it inserted correctly? How many times have you taken a dental pick to get a battery out of a battery compartment because it was it was inserted incorrectly? Corrosion of the battery or the contacts. A lot of this could have been resolved by zoom. Is there obstruction in the tubing? Is there a crack in the tubing, obviously, I can’t change the tubing. But I can say the problem is a crack in the tubing, you’ve got to come in so I can change your tubing. Or if it’s a broken receiver or some other component, I would tell the patient Well, I can’t fix it by the zoom. And this is why. Why don’t you call come in and we will take care of it and it completes the circle. And then you also must know that there are some remote finding software manufacturers that can actually test a hearing aid and it at home and it can depict whether or not the problem is in the microphone, the receiver or external excessive internal noise and that’s a technology you might want to think about. Taking advantage of and almost all of these manufacturer software’s can also do a feed back test. So there’s a lot of things you can do remotely, again with the goal, accessibility, and convenience. That’s that really is the goal. So these are just a small sample of parameters that can be resolved by remote fine tuning. And they are manufacturer specific, this is not the complete list, I just simply popped out in my head, the ones that I remembered the most common from the four manufacturers that we use. And several of these could be provided by a hearing instrument specialists if you should hire such a person within your practice, or by an audiology assistant, and we’ll talk about that later on in terms of how do you fit this into your schedule, that’s later on in the presentation. So you can do full programming capacity. It’s like being in the booth connected to the computer, directionality, time constraints, wind noise expansion, noise reduction, gain adjustments, program changes, phone streaming settings, I think a audiology assistant might be able to do accessory streaming settings I again, I think audiology assistant can do acceptance manager in-situ measures, this is an interesting one to me that I wish I would have still working and I would work on this one. I’m just giving an example. In our clinic, when we were dispensing hearing aids, we did the audiometric test through the hearing aid and coupled to the person’s ear. And the one that comes to my mind is the sensogram from Widex. And you have that in that patient’s chart.

Wouldn’t it be kind of nice as a screening tool, you reassess the hearing, utilizing the remote fine tuning software, and see if there is a significant change or not. And whether or not that person should be visited for a full comprehensive audiogram. Or tell the person Hey, you know what your hearing hasn’t changed just the last time and you can do that remotely. You can do a feedback test remotely. You can assess assess the functionality, the microphone, the receiver, an internal noise that can be done by an audiology assistant, or hiring a hearing instrument specialist as part of your team. There are a lot of different ways in which you can address this. So a couple of words about remote fine tuning, and we’ll get into this in greater depth later on. There are two different modes of remote fine tuning utilizing manufacturer software. One is synchronous, that means when you make the change, it’s made to the patient in real time. And in our clinic, we did this with a Widex Phonak Starkey and live assistance on the Resound. Another form which is not as widely used, or as popular is the changes are made. And at some point later on down the road, the patient downloads it to the hearing aid and it’s stored in the cloud resound offered this early on this particular method is problematic because the patient may be in a locality, other than the locality where I as an audiologist is licensed. And that presents a quagmire, which I’ll talk about later on the presentation. I can’t sell, I can’t tell a patient for me to do this, I need to be sure you’re in St. Louis or Missouri, and therefore the arch or Busch Stadium has to be behind you. Or if I see his or her on the on my monitor. And I noticed that there’s palm trees in the background, or there’s a mountain in the background or there’s an ocean in the background. Clearly that person is not in Missouri, and I would have to tell the patient, I’m sorry, you’re not in Missouri, I can’t do this. And I’ll touch on that in a little bit. So this particular method of remote fine tuning was clearly defined by the medical school. You cannot do this as you get into remote fine tuning or remote care. But there is help coming around the bend and I’ll share that with you later on in the presentation. So I think one good starting point on all of this and it also addresses another problem later on down the road is How popular is telemedicine that became really popular during the pandemic because all the clinics shut down? And we had to find -Not we- but the medical school and all healthcare professionals have to find a way to maintain relations with patients as maintaining relations and also as a form of revenue generation. So this is from the Government Accountability Office. And what they found was during the initial phase of the pandemic, which would be March 2020, Medicare had 325,000 telemedicine encounters. In mid March, which was the beginning of the pandemic, it shot up to 1.9 million. And then as the clinics began to open, it decreased to 1.3 million by June 2020. But still 1.3 million is a big number, compared to 325,000. They also reported that more beneficiaries who were less than 25, usually more than those who are greater than 65, I mean less than 65, and more than 65 more urban beneficiaries, people living in cities used telemedicine than rural beneficiaries and similar proportions of beneficiaries used TM across all racial and ethnic groups. I only mentioned this because of the popularity, and that will come on later on as to addressing one of the reasons why audiologists as a whole don’t seem to be embracing remote care and remote fine tuning.

So, my, my entrance into this began in the pandemic, where telemedicine became crucial to maintain relations with presents patients and generate income, but the school the medical school, and like almost everybody else, was totally unprepared. As a footnote, I actually approached the medical school in 2019. To discuss audiology, providing remote care and remote fine tuning is before the pandemic. But the medical school simply would not allow audiology to do that, because they were concerned about provision of care with a patient and a locality, other than the state where we had licensure, which was Missouri, so they just shut it down. So due to the closing of all clinics, and we did we closed everything ent audiology. I mean, we just shut it down, like everybody did around the country. And medical school was forced to rethink this. And in a really rapid timeframe. They implemented telemedicine and of course, audiology became part of that we were finally allowed to do it. But we’re prohibited again from offering to patients who were not physically in Missouri, unless we obtained a license in that other state. So we could not use asynchronous fine tuning, which at that point was resound. So, to prepare for this presentation with Bob, I contacted our manufacturer reps, which again, no particular reason. Widex Phonak Resound and Starkey, and I wanted to find out from them, how popular was remote fine tuning with their accounts. All 4 reported that remote fine tuning was not being used, less than 10%, as predicted, given what they felt was a tool to improve patient care, accessibility and convenience. They thought that this tool would improve patient satisfaction, increase the number of appointments and increased revenue. But in spite of all of that, less than 10% of their accounts, and in many of them less than 5%. Simply were not doing it. And so I asked them, which doesn’t take a genius to figure this one out. Why? Why would you think this was the reason and they gave me the following answers. And it was by either their hunch or direct communication with the staff of their accounts, which is quite large. What they came out with and this was consistent across the four manufacturers. There was a hesitancy to adopt and learn new technology. Okay, and I’m going to expand on that lower on in this slide. They were the staff hesitant to counsel on its availability and the advantages that this might provide. They lacked -how do we integrate this into their practice? Because this is something that’s entirely different. And I’ll expand on that later on. They lacked any knowledge of how do you charge for this? Or do you charge for this? They will concern is this can we do this with within our scope of practice, and abide by all state and federal laws? The most important one out of all of it was this feeling that if we did remote care, the patients were never going to come back to the clinic and see us. And we’ve lost them. They also expressed not uniformly but quite a bit, that they didn’t think that patients could handle this technology or have access to this technology.

And then I just want to put the last point down here, because it’ll kind of dovetails to something I have to say later on. We, as a presenter – me- we have to understand that the software for remote fine tuning for some manufacturers, can be initially overwhelming. And I’ll share that with you a little bit down the road. And the other thing we have to bear in mind, unlike manufacturers of direct to consumer devices, where the staff have to learn one fine tuning software package, in our clinic, we have to learn for and that’s quite a bit of information for staff who are doing other things, in addition to hearing aid care. And so we have to, you know, we have to kind of bear in mind that we’re asking a single audiologist, who is part of the dispensing practice, told her in several software packages. And again, some of these are, and I’ll show you later on the a quite extensive, require a lot of steps, and to do it on one. But to do it on for quite quite, quite the task. And again, you have to bear in mind, and I will later on when you have an example Lively, which is direct to consumer, those audiologist only need to know and operate one fine tuning software package. Whereas audiologists have to do is many manufacturers that they use that they dispense, just bear that in mind. So what I’m going to do now is I’m going to address four of the concerns that audiologists have expressed why they’ve not adapted remote fine tuning. But before that I just want to share with you this is an article that was on the next slide, you’ll see it was just published in AJA on on their website by doctors Harvey Abrams and Christina Callahan in AJA, the American Journal of audiology that literally addresses some of the behavioral reasons why audiologists are reluctant to provide telemedicine and then they offer several strategies on how to come overcome and change that behavior. I was emailing back and forth with Harvey, and he introduced me to this article, and I read it over the weekend. And I would urge you know, people are interested in this topic, to go to the AJA website, pop up that article and read it. It’s it’s it’s quite interesting. And there’s the article just came out literally last week. Health Behavior and motivational engagement models can explain and modify tele audiology uptake. And then Harvey also introduced me to another area that I was simply not aware of, and I’m, I’m going to share that with you in a little bit. And I’m gonna kind of give you the reason why I contacted Harvey. Number one, he and I have been friends for quite some time. And I always you know, there’s something that just befuddles me, I’ll contact him. So I asked him, Harvey, this was an email, it wasn’t communication. How is it? I think I knew the answer, but I wanted to get the answer. How can audiologist at lively provide remote care and remote fine tuning to their customers who come from all 50 states and God knows where else? How do you overcome this, this statewide, you have to have a license your own state quagmire? And he provided me the answer. And that’s exactly what I thought the answer was going to be. But he also introduced me to something really special that I’m going to share with you in a few moments. And I want to give him credit for that and I’ll share with that a little bit. So what what I’m going to do Now for the next several slides is I’m gonna go out on the limb, this is Mike Valente talking. And I’m going to go over what seems to be the four reasons audiologist are not embracing remote care and remote fine tuning and provide a counterpoint, an opposite argument, or some kind of reasonable argument to that. So here we go. So if anybody is going to get mad at this, at the end, you’ll see my email address and you can contact me, I have really thick skin. And I can take it, I think. So the first one is fear of losing patients, that if a patient does remote care, or remote fine tuning, they’re going to be so happy. Because of the accessibility and the convenience, they’re not going to come

in. I said, limiting access and convenience by requiring numerous office visits is why we are what we is why we are where we are audiologists however, fear losing patients using remote care and remote fine tuning were offered in spite of innovating accessibility and convenience. They actually believe that if the patient tastes that Kool Aid, they’re not going to come back. So my argument to that is, if this concern is legitimate, why are so many health care professionals scheduling remote care, and don’t think their patients won’t return to the office? When we started remote care at the university, every faculty and nurse, nurse practitioners are also doing the same to their patients. And I would talk to them about this issue. And if I didn’t know this was an issue. And none of them expressed a concern that somehow this would turn off the faucet and these patients are not going to come back again. This is a really big one. This is the next one. Remote care. And remote fine tuning is used as a marketing tool. By many, the direct to consumer and OTC manufacturers as a way to attract consumers to purchase their products and abandoned the brick and mortar clinics because this addresses accessibility and convenience. The people that you’re most concerned about it negatively impacting your practice, are doing this. And you need to think about that. Finally, this concern. This is you know, where was this concern during the pandemic, when you utilized telemedicine that didn’t seem to be an expression of our concern that the patient is not going to come back. And then as the clinics kind of opened up the number of people using remote care decreased. Harvey beautifully explains this in his article. So if that was a concern, why was it not a concern during the pandemic and after the pandemic, at least my experience was these patients came back to audiology. So I think the fear of losing patients by implementing this is questionable at best. So, the next seven slides what I did is I took screenshots from seven different manufacturers and hearing health care providers on their website remote remote care and remote fine tuning as part of their package to induce them to come into their their link their website. So half of our customers use the video interface on our app while the other half prefer by phone. And this is med hearing MD hearing that I got from their website in August 2022 so that it doesn’t seem to bother them to do remote care and remote fine tuning. Here’s lively, professional follow up care included for three years. Remote follow up care along with easy adjustments through our app on more convenient and affordable than repeated office visits. It’s your competition. This is Lexie lumen. Your professional Lexie expert in the comfort of your home, available by video or by phone. Remote adjustments to your hearing aids experts Some are able to make remote adjustment. Your competition is promoting something that you have access to right now. And 90% of you or more are not doing it. Here’s UHC. This is the healthcare provider through their new program called right to you. Remote Access hearing healthcare to members of United Healthcare who have this particular policy, helping expand access, reduce the need for in person appointments for fittings and adjustments. The capability known as our you two builds on home delivered hearing health care developed by UnitedHealthcare, adding the virtual care component that is designed to help reduce the need for in person appointments.

There’s a health care insurance better doing it. Here’s Adicus unlimited telehealth support from audiologists here’s Eargo remote care provided by hearing instrument specialists or audiologists, lifetime professional support. GN Jabra enhance Pro, again, remote care, video appointments and remote fine tuning. So I couldn’t find a more powerful tool to urge you to think about this than the competition that was created by the fact that we did not do this for decades. And we have the capacity to do it now. But yet, 90% to 95%, I’m told, Do not integrate this kind of technology into the hearing healthcare. So another one is fear of violating scope of practice, as well as state and or federal laws by doing this, this is a legitimate concern. But by the click on a website, which I’ll share with you in a moment, you can resolve whether or not this is a problem. You can go to AAA website, you can go to the ASHA website. We when we did it, we went to the Missouri licensing board for advice on re implementing remote care and remote fine tuning. They did not get back to us. This is at the height of the pandemic. So to circumvent this obstacle, I sought the advice of General Counsel, which is an office within the university that deals with anything that even remotely relates to legality and put forth the proposal. And they advise us what we can do and what we couldn’t do about as an aside. Because we live in a very litigious society. I routinely sought legal advice before implementing anything just over three decades that I felt needed to be resolved before moving forward. So it’s always a good thing to check, double check, triple check. Before you say, okay, I’m good to go. There are no problems here that I can be in violation of any federal state, or equally as important third party contract for hearing aids. So this is the top two. Those are links to ASHA, on tracking state laws and regulations for telepractice and licensure. And then payment and coverage considerations for telepractice. During the COVID, a pandemic. The one below is the AAA website to get to this page, which is telehealth and licensure. So there’s a lot of sources out there that can answer your questions to resolve that fear of somehow by entering into remote care or remote fine tuning, you might be in violation of scope of practice, or federal or state law. This is something I was absolutely unaware of. And this is something that Harvey tuned me into. And there is an organization that is known as slep. I’m guessing IC, which is audiology and speech pathology interstate compact. And it can be accessed through the ASHA website that you see on the top line. Or you can go directly to the website, which you see on the line below it. So I’m going to show you some screenshots from the actual website and kind of share this with you. This is in for you. So here is the ASHA website, on the Audiology and Speech and Language Pathology interstate compact. And there is a short video. And I mean short by two minutes that you click on and it tells you what this is all about, as does the verbiage inside this website. And then I clicked on the actual website, and this pops up. And then I’m going to show you in a little bit on the bottom on the menu, there’s a thing called compact map, which I’m going to share with you in a few moments. What this is, is a national effort

so that I in Missouri, am licensed as an audiologist, I can provide service to my patient, who happens to be in Arizona, Florida, California, Maine, and I no longer have to worry about does the patient have the arch behind their back when I see them on the monitor, and I don’t get concerned if I see a mountain, palm trees or an ocean. And when you go to the compact map, as of today, there are currently 23 states that have joined this compact. Illinois and New York are pending. And the ones in gray again as of this morning, have not. And if you go through and you read the website, their goal is for this to be in place in 2023 next year. So it is entirely possible a year from now. You don’t have to worry about where does that patient reside when you’re providing this service. And one other thing. I’m in Missouri, so I went to this map. And I clicked on Missouri. And he told me, it showed me and I can click on that the three bills in Missouri that support this. And every one of those states that in blue, you can do the same thing. So this was introduced to me by Harvey, and I’m indebted to him. And I learned I didn’t I didn’t even know this was available. And I thought I would just share it with you on the assumption, you don’t know that it’s available. And I think this is very, very exciting. So here’s another one. Number three patients can handle remote care, or more fine tuning. This is my blurb on this one. During the pandemic. Zoom encounters with friends and family were very common. I personally, every month on a Sunday, get together with three high school friends of which to live in Florida. And one lives in Cape Cod. I get together weekly, my wife and I Maureen with our daughter, son in law and grandson who live in upstate New York. So this fear of patients not handling remote care is- Are you kidding me? Every body and his mother, it seems, has been using zoom for the last two years in some form. FaceTime as an example, on iPhones is a form of zoom. This presentation is by zoom. Yes, there will be patients who do not want to use this technology or are unable to use this technology. But as reported earlier, audiologist or hearing instrument specialist of seven manufacturers of direct to consumer products provide the service surely, is when we get in trouble. Surely the audiologist and hearing instrument specialist providing remote care and remote fine tuning and their patients using the services can be different or smarter from the patients you see in your clinic on every day. I mean, there isn’t this pot of patients in Missouri, that can’t do this when the rest of the nation can. So this idea that patients can handle this, I think is more of an assumption than a fact. Also, the patients of other health care professionals routinely use remote care. Almost all of the and key staff utilize remote care. My own personal physician and my dentist of all things just offer this option when we schedule appointments. They think I can do it. And you know what I can. And I take advantage of it. And then going back earlier in the presentation, data from the Government Accountability Office cited earlier 1.3 million Medicare recipients use it. So why would we think that audiology patients can’t do this. And then here’s

the one that I really gave a lot of thought to. And I don’t really have what I would consider the definitive answer, but I’m just throwing stuff against the wall and see what sticks. But it’s based upon a premise, if the goal is to address accessibility and convenience, doing it spot meal, within a clinical schedule, is really not solving the problem. In other words, when we had a patient coming into what we called the hearing aid check, it was embedded in my schedule. That was before an audiogram, after an audiogram, on another hearing aid fit whatever it might be. But that was the pod. And if I’m gonna get into remote care, and remote fine tuning, I got to think of those seven or more manufacturers that say, you don’t have to wait for two o’clock in the afternoon on a Tuesday, or four o’clock in the afternoon on a Monday, because that’s where my opening is. We’re open five days a week, from eight o’clock in the morning to four o’clock in the afternoon, you pick the time, and we’ll send you the link, and we’re good to go. That’s where I think audiology needs to go. So what I did is, I asked five colleagues in private practice, and it was actually five different states. two were from the south, and three were from the Midwest. Number one, do you do remote care? And do you do remote fine tuning because you know, it’s less than 10%? So our thinking the answer to all five would have been no. And if you do, how do you do it? Well, as you might imagine, with five practices, there was a lot of difference. But three out of the five use audiology assistants to do it. I never really got into is this a spot thing? Or is it offered, you know, my vision full time. So I’m just throwing out the possibility in these next several slides of things you might want to think about, and how you might want to handle this if you decide to get into this arena. So my first thought to you is you got to think out of the box. Because what we’re doing, obviously, it didn’t work or else we wouldn’t be in the quagmire that we’re in, in terms of accessibility and convenience. And what you do is what I did you collaborate with colleagues with an outside of your organization, on how this service is provided. There are really two good Facebook groups that I’m a member of that is really, really helpful. One is called audiology, antics and anecdotes for all hearing professionals. And the other one is audiology best practice. And I’m there are hundreds of things thrown out and hundreds of comments that are provided to the person who were asked the question, one question you might want to ask as an example, if you will part of these two groups, how do you handle remote care? How do you handle remote fine tuning? Who does remote care? Who does remote fine tuning? Do you offer it full time? Do you – How do you do it? And it was through those kinds of interactions that my thought has changed. And I’ll show you a slide later on when I’m getting ahead of myself. The way I would do it today with the information that I have in hand is not the way we did it two years ago when we started this because technology has changed. A lot has changed and you’ve got to be able to kind of go with the flow. So these are potential thoughts for you to do this. I don’t think substituting an invoice for an in office visit will be useful. We still do my hearing aid carries the answer this spot on because that doesn’t get you convenience. He needs to think about having one audiologist or more than one scheduled an entire day. Wear that day A, that’s why that’s why my physicians do it with a day is just remote care appointments, my physician sets aside Friday to do remote care. Or you can do morning or an afternoon, the point being you set aside a block and not the sporadic thing.

When you do it physically, it’s exactly the same as you would be if you were in the clinic room with the patient. But only now you’re in your office. And you’re not utilizing your opening, you’re freeing a clinic space. It’s not any different. And I’m gonna talk about charge about this later on in the presentation. The last one here, think about this. Let’s just assume you decide not to charge. And we know, audiologists are marvelous in not charging, as I said in one of my two other presentations, or sometimes think audiologists are as close to social workers as you can be without getting a degree in social work- an MSW. But that’s a whole different thing. But let’s just assume you did that. Okay. Because the person that you’re seeing is in the bundled approach, and we provide this care as part of the warranty, just by the mere fact that you offer it. And by the way, and you’ll see later on offering it is not the answer. It’s only part of the answer, you have to offer it, and you have to promote it. You just can’t say well to this patient, of course, yeah, you know, we can do this, this should be part of your, your routine. When you, you, yoyou counsel patients, on why they should want to go to Washington University as opposed to someone so down the road or so and so in this state, because you know, if the data is correct, there are many people who are doing this, and this is going to set you aside, you’re not going to be separate from your competition by just doing it. And you don’t get the remote fine tuning, we can get that later on. Because it’s more complex, just a zoom with your patients set aside a morning and afternoon or a whole day. dip your toes in the water, and start simple, remote, remote care via zoom to the patient’s laptop, computer or smartphone. I do zoom, as I said with my friends once a month. And if you know, one of the concerns audiologist have is oh my god, you know this thing is set for 30 minutes and this person is going to talk over. And then I got a problem here. For those of you who use Zoom, it shuts down. I mean, it just shuts down. And you can set it for 30 minutes, and you can set it for 40 minutes, and there’s a timer. And you can tell the patient, we have three more minutes to say what we got to say, and then you’re not going to see me anymore. So you can resolve that endless conversation by zoom. You can inform patients, if there’s a charge or not as an example, it could be no charge. If these charges were no charge as part of your bundled model. Or you might consider hiring a full time hearing instrument specialist or an audiology assistant to offer this service full time to truly address the issue of accessibility and convenience. Now I know if I hired an audiology assistant or a hearing instrument specialist, this was their thing. I know early on, that the amount of time they’re actually going to be doing this is relatively small. But the hope is in time it’s going to grow, it’s going to grow, it’s going to grow, and it’s going to grow. And they have a multitude of other tasks that they can do to fill in that quote unquote dead spot. And then the goal is three months, six months, nine months, whatever it might be the number of people because it’s being promoted, who take advantage of the service will grow and grow and grow. And that’s what you want. You want this to be you want to address what it is that got you in the problem in the first place, which is accessibility and convenience, and also being used by the people who’s your competitor. And doing this spot meal is just not going to do it. And showing you what I did in part one of this presentation, you charge for that service for 30 minute increments. If you’re using an unbundled model, which I explained in the first and in the second presentation. You can use this time whoever this person will person’s might be to learn the ins and outs of the manufacturer, remote fine tuning, and then spur over time kind of overlap. Over time, as the comfort level gets better, you can can expand into that service, you’re just trying to, as it says on the top of the slide, dip your toes in the water and work your way up.

Clinic says I think clinic should start offering remote care as soon as possible. And add remote fine tuning later on as the bugs specific to your practice are worked out another possibility, you might have an audiologist who really likes this. And that person would be the person doing this. So I’m just throwing ideas out and to have the listeners kind of think about ways in to address this issue of how do you schedule this. So again, it’s got to be full time, in my mind, and again, you want to verify state licensure, for what a hearing instrument specialist and or an audiologist can or cannot do. And I’ll show you a website about that in a few moments. So what I did here, I just, I took my Excel spreadsheet from number one, and I created an artificial budget. What would it cost my practice, if I added an audiology assistant? Now, mind you, I have no idea what a salary is for an audiology assistant. But it doesn’t make a difference. You can pop this stuff into the Excel spreadsheet, and it’ll calculate whatever you put in there. For my example, I assumed that I would offer this person $45,000. I just threw that out. And then I assumed an additional $11,000 for fringes. And other things, which the cost is 76,000. For the purposes of what we’re going to talk about, it really doesn’t make a difference. I put this increased cost into my Excel spreadsheet that I talked about in part one. And it increased my that that row to 2 million $106,344. And I added the number of staff from nine to 10. So you gotta go back to number one, in order to get the gigs of all of this stuff. The spreadsheet recalculated and a millisecond, the increased cost the change in the cost per hour as a result of hiring this person. So my cost per hour was actually reduced from 195 to 180. I added somebody why, because of the increased number of available billable available hours. So my number of available availability was from 18,720 to 20,800. Remember, part of the formula of cost per hour is your cost minus your costs for devices divided by billable hours. And that’s included in this spreadsheet. So what it told me when I inputted this was that it decreased my charge per hour, from 235 to 216. And that would give me comfort to suggest that their services could be offered at no charge and it wouldn’t affect it wouldn’t affect the profit of my division, but it would increase my convenience and accessibility. I’m not suggesting no charge, I’m simply suggesting it’s conceivable. And it would require a lot of work. Not a lot some work. So if you’re interested in an audiology assistant, this is the website and you click on the state and it will tell you the law in that state on what an audiology assistant can or cannot do, what they can bill and what they can’t go for. It’s a wonderful website.

So how did we do it? And again, keep in mind that this service will be revised as experience and information changes. I mentioned early on, I already would have changed what I did two years ago, based upon what I’ve learned in the last two years. Also keep in mind that remote fine tuning was adopted in our clinic two years ago. And there’s number of changes I would make to that based upon what I know. Now that I didn’t know then also on some of the manufacturers stock is an example that I know to really fine tune their remote fine tuning, and it doesn’t have nearly as many steps as it did two years ago. And so the software in your booth that allows remote fine tuning with your patient has also changed. And that would be incorporated into how you implement this in your in your practice. So, like anything that I did in the 34 years, when I was in, I just didn’t jump into it. I never adopted something because it was the thing. I would get together with staff and say, Okay, we’ve been approached about this. What do you think about it? And the examples that came to mind was ear lens that I really wanted to do. But the otology staff didn’t come on board. Lyric, we did 3D scanning by Lantos. They came to me incredible technology. They did scans of my ears and made for me, the best ear molds I’ve ever had in my entire life. But at that time, I said no, because it was so cumbersome, and so expensive to do, that it didn’t make any sense to get into it. That would change now, because their model has changed. And I would revisit it. We implemented stack ABRs, because one of the audiologists wanted to introduce that was a bust. And we put that I wanted to do it because one of the audiologists wanted to do it. We took time out for her to train, we bought the equipment, so on and so forth. That was one that didn’t work out so well. And we just bit the dust on that one. I had two audiologists that wanted to do tinnitus, retraining and misophonia. Therapy got into that did very well with that. The point is, before we got into anything remote care, remote fine tuning, we did a lot of work up front before we said, Yep, it’s a go, nope, this is not going to work out. So I’m saying just because I’m saying to do is you really need to research, can your clinic do or not do this and not just do it, because it’s the thing to do. Then we looked at when we decided this remote care of this remote fine tuning this makes sense. We had to go back and look at the resources to do it. Did we have the staff? Was it profitable? Did we have the equipment? How do we schedule this thing? How do we bill and collect for this thing? And then if we didn’t have it- What did it take to get it? And what is the cost? And then create a proposal, put it into my spreadsheet And then we’ll calculate quickly the impact on profit and loss and use that as one tool to determine whether or not we wanted to do this. Is it profitable? Or should it be charged? If we do charge- How do we charge for it? Does it improve patient care. And finally, seek legal advice to be certain that the service and adheres to all policy procedures of the institution, as well as state and federal laws and third party contracts. I don’t want to be the one my biggest not my biggest fear. But one of my biggest fears as the director at the medical school was me getting a phone call or an email from the Dean asking me to come visit him. That that that gave me cold sweats at night, because I did something that I shouldn’t have done. And fortunately, in the 35 years, I never got that email. I never got that phone call. That doesn’t mean I was a good director. I just was under the radar. So when remote care, and remote fine tuning was finally approved by the medical school. Again, we could not use asynchronous fine tuning. And here’s the problem, then and now.

That red circle is St. Louis. All of our staff have licenses as audiologists in the state of Missouri. But we live right on the Mississippi which means we have a lot of patients from Illinois. We could not offer at all remote care and remote fine tuning to a large bulk of our patients because they physically reside in a state where we did not have a license. Now of course we could have gotten a license in Illinois, but we elected not to do that. But during the course of a year, remember this is an elderly population. They had had awful. That’s Illinois. We had a lot of patients went to Arizona. We had a lot of patients that went to Florida. We even had one patient that went to Maine and we told these patients if you’re in our Arizona, if you’re in Florida, if you’re in Maine, have a great time. But as far as remote care or remote fine tuning is available to you can do it. Now, again, hopefully in 2023, this problem will be resolved. But this is the where it stands right now as far as I’m concerned. So what steps did we take, we recognize that many of the resources were already in place didn’t have to do much. We recognize the importance of offering a new service, competing with direct to consumer, addressing the issue of accessibility and convenience. And being current and competitive with other clinics in the in the region. We identified other factors that would need to be addressed in order to implement, we addressed each factor. So we could go forward as an example, and have a slide of this later on. All of our fitting computers were desktop. So we had to go out and invest in a microphone, and a camera to put on the monitor to do this minimal cost. But we had to do that to make this work. None of our software were on laptops, if I were to hire another audiologist, who’s exclusive purpose was this, I would purchase a laptop. And that would be set aside for that person. So that all the other computers that are required for hearing, if any, are free, and you don’t run into this issue of double use of a scheduling problem. Here’s another request of the institution I was in. Will this technology advanced the education of the interns and the externals that we had every semester? Obviously, the answer is yes. How much time is required? 30 minutes. And we communicated this with our departments, schedulers and our clinic schedulers.How do we bill?

and we communicate that with billing and collection is all self pay. It had to be approved by General Counsel to be sure that what we were doing was in compliance with all regulations. Did we protect patient privacy and security HIPAA? How much time is going to be required to train the staff and I’ll briefly touch on that later on. We had to develop new materials to promote this and counsel patients on the advantage and the disadvantage of this technology. And what we would charge or not charge. And we had to develop detailed cookbook guides for each of the manufacturers to give to the page to give to the audiologist so that when they had a patient with so and so they could do a quick, oh, this is what I got to do. Step Step, step, step step. And it literally was step, click, Step Click step, it was literally step by step with screenshots. And this was handled by one staff, audiologist, and one extra, they did a superb job and putting all of this together. And I’ll share a little bit of that later on. So other considerations on charging for remote charge and remote fine tuning. Know your state licensure law. For example, I didn’t know this. But I was told by an audiologist in California, that if our policy is that these visits are no charge in the clinic, we can’t charge this if we offer it remotely. Again, always seek legal advice before you move on won’t move forward on anything. If you’re using a bundled approach, and the policy is not to charge for office visits during the warranty, I think it’s reasonable that it should be provided at no charge, because that’s what you would do in the clinic. You could consider which we did, offering it as an added value, which I’ll talk about in a few minutes to be charged either by a pre visit or by a subscription, which I’ll share with you in a little bit. Again, obtain legal advice on all of this before you move forward. If you’re using an unbundled approach, which I talked about in part one and part two, absolutely. This is a item from the menu that you would charge for in 30 minute increments. And I explained you know how to go about calculating that. So if you’re going to charge and unbundled going back to lecture number one, know your cost per hour, converted to charge per hour. In 30 minute increments, and this should be included in your menu of services. Now, I thought about this, because it was it was actually given to me by somebody else, you provide a service, but you charge for it, that you might not ordinarily charge for it, because it’s an added value for convenience. And I thought about that, I don’t do this, but I have a lot of friends, when they go to a restaurant, they do valet parking. And, believe me, it’s gonna cost you more to do valet parking than if you took the time to park your own car. Because of the convenience. Marina and I were big St. Louis Cardinals fans. And we live three and a half miles from Busch Stadium. I know you’re gonna think this is nuts. And if marine was here, she would back me up on this one. But I’m so frugal that we walked to Busch Stadium to buy our tickets at the window. Rather than spend the 20 or $30 per ticket online. Again, you’re paying that money because you’re clicking on a website to order the tickets, and you can download it to your phone, you pay it you see in the same game. But you’re paying for it the convenience. How many people during the pandemic used Instacart, we did. And you knew you know that your ability using Instacart is not the same than if you went to the supermarket and bought your own food. Food delivery. You know your order pizza they delivered to you. You, I assume you give them a tip, it’s going to cost you more. Now here’s something else to think about. And I don’t have it in my slides. And I thought about it this morning. And I should have put it down. But I didn’t. I’m going to give you two examples of this.

Let’s say you have a remote care. And it’s to solve a problem that the hearing aid is dead. But you find that you can’t do it for the reasons I showed before. I would bet you that there is an audiologist or somebody listening to this presentation, the one person who decides to listen to this one who will say well, you know you couldn’t solve the problem, therefore you shouldn’t charge for it. And I would say nonsense. I’ll give you two examples. We have a security light in the back by I’ll garage that went out. I’m not an electrician. There are two things I hate fixing around the house. One is electricity, and one is plumbing. So I called an electrician to come in to fix it. He couldn’t do you think he went back in his truck and didn’t charge me for the visit? I got a bill and I I should get a bill and I paid the bill. So I’m saying if you’re an audiologist and you’re offering the service and you can’t fix it, don’t default to no charge. You don’t do it as a consumer. Another example we had a leak down in the basement. And for the life of me I couldn’t figure it out. A plumber came on my way. electricians and plumbers are not cheap. The Plumber came spent 45 minutes here, couldn’t figure out what was causing the leak. So the water kept tripping. Did I did he not charge me for his time? He did. And I expected it to. So the point I’m trying to make here is if you have a remote session, and it’s an unbundled and you charge for it, you do it. But it doesn’t solve the problem and the patient has the ice to come in or whatever it might be. That’s not a no charge. That’s a charge. So we created a patient information packet geared towards convenience and accessibility. And part of the package outlines what that means you minimize your exposure to infectious disease. You don’t have to travel. You don’t have to deal with traffic. You don’t have to pay for parking. You don’t need when you come in to go to a desk and they ask you who you are, and what insurance do you have. And then you’re in the waiting room. And by the way, it’s called the waiting room for some reason and that’s because your weight and your weight and your weight. You can schedule around work childcare or other medical appointments. It’s convenient, you complete it at home. No concern about masks social distance, impact on your health, ease of use, you’ve been doing zooms This is a zoom, please bring your hearing aid, increased access and And if you read the article by Harvey and Christina, evidence shows that outcomes using telemedicine is equivalent to face to face. So if somehow you think they’re going to lose something, because you’re doing this remotely, evidence has to put that additional factors to consider, you want to tell patients, we’re not open 24 hours a day, we can schedule these in half hour increments Monday through Friday, eight to four. Again, now we have to determine if the patient is residing in Missouri. Hopefully this will stop by the 2023. I’ll show you in a little bit. We counseled them on the advantages and disadvantages of remote fine tuning, and remote care. And again, this was all development, we had to put this all together because we decided to do this. And then again, we had to order cameras, and microphones, because we were using desktops and we didn’t we’re not using a laptop. And then in our packet, we remind the patient when we do this, please be sure you have a secure and stable Wi Fi. If you don’t have Wi Fi and you have a phone, make sure you have a unlimited data because it can suck up a lot of data. Do you have a smartphone? That probably should be on top Do you have a smartphone, it’s important that you be in a well lit environment like I am here. This would be a perfect spot to do remote fine tuning. And it’s quiet. There’s nobody here except for my cat. And my cat is sleeping in a sink here to the right. It’s actually quiet. Here’s the microphone that we there’s a camera we bought that has a built in microphone that we put on top of the monitor of each of our fitting boots. We offer this with Widex Resound Starkey, and phonak,

I did not But Catherine Collopy. And our externput together beautiful step by step instructions on all four of these with screenshots and test this out on each other to make sure it works with their smartphone. And then I’ll share I’ll show you in a moment where we put this. And then we also develop patient counseling handouts for each one of the four manufacturers, because what they offer is different. And we wanted to share that. So on my desktop, my my my face is here and so is Bob’s. But if you look all the way to the right, you can see the size of each one of those files. These are the step by step procedures in a PowerPoint presentation or they get printed out on how to use remote fine tuning and phonak resound Starkey and widex. Again, each one of these were created by Katherine and are externally and they are fantastic. So it’s a kind of a quick guide. And the hope is, as you use it more and more, you’ll need less to go back to this. And even better than that. We hire somebody and they do this full time. And then on the next page. These are the handouts. These are Word documents. Explaining Starkey, widex Phonak. And resemble that we give to the patient at the time of our visit. And then each handout says the following what is remote care and this blurbs you know each one of these headings. What is remote care and what is remote fine tuning. How does it benefit me? What are the advantages? What are the limitations? What do I have to do? What’s the next step? How do I schedule? What’s the next step? What do I need to do this? And again, this is manufacturer specific, and what is the charge? And this is patient specific depending upon is it bundled or unbundled, it could be no charge. As I mentioned before, we offered an annual package of three appointments using the charge for our discussed in part one, or and I’ll menu of services pay as you use based upon an unbundling model that I talked about in the first visit, and then we provide them with the manufacturer brochure for their hearing aid. So this is what we give them if it’s a Starkey hearing aid that we have dispensed. And again, these have changed over time. This is the white x that we give them and they Has verbiage on the inside on what it can and what it cannot do. This is phone EQ we give them and this is resound. And then in some cases, we took the Resound instructions to the patient, we didn’t think it was sufficient. And on the left side, this is what we gave the patient. And on the right side, that’s what they got when they looked in that resound brochure. So we looked at that, and we do it on all of them, can a patient reasonably do what they have to do by looking at that right side, ie, the manufacturer, brochure? Oftentimes not. So we went into greater detail, step by step, how the patient accesses the remote care. That’s another example. So we created the form, you got to have forms that was approved by the General Counsel and signed by the patient states that the service is self pay when appropriate. They can select an annual or they do pay as you go, and it’s in the sheet. They’re informed that the service is not covered by Medicare or third party payer. It’s offered between eight and four. And he or she must be in Missouri. When we do this, and they sign this and it goes into the patient’s electronic medical record. The bottom is the challenge. OTC and direct to consumer, I believe, by the three presentations because I believe that way, it’s a three prong approach. First, you got to think about converting from a bundled to an unbundled approach. That’s what I talked about in part one. I think, as I described, in part one, you’re really need to offer both, and let the patient decide which way they want to go.

Number two, you got to think about patient comes to you. Why would you send them someplace else? Keep them in house, integrate OTC type devices in your clinic. When I did this, back two years ago, it was a entry level hearing aid. And that was it. If I were to do it now, and I and they were in stock, so we could dispense it rapidly. I would order for the three clinics, a multitude of different types of OTC that was based upon the literature to provide quality care as an example. I don’t know if you can see it. But this recently came out in the New York Times by a young lady by the name of Lauren, drag it. It came out October 26. 2022. And it goes and it basically does. What are the what are the best direct to consumer? What are the best PSAPs? What is a PSAP? What is it a recognition so more and more things like this are going to be coming out to kind of guide you that if you’re going to introduce an OTC device in your clinic, you want it to represent your quality. You don’t want to you don’t want to put it in your clinic a piece of garbage. That’s my Eastern dialect garbage. You want to put something that represents the quality of your clinic. I’ll give you another example. If you go to YouTube, and also it’s in the literature, and you look up, how do I program an eye pod two as a hearing aid. I did that.

I have iPod twos and I went to YouTube and I program my iPod to airpod in the air pod 2 as a hearing aid. Pretty darn good. And the data from resound from the NAL said its about as good as a hearing aid in the tests that they ran. And that’s also available online. And then I went one step further. You know because the audio coming out of my TV, not so good. And rather than buy a streamer, I went out for $78 and I purchased because my Sony TV which is as big as my house. Doesn’t have Bluetooth. I showed him the iPhone, got Bluetooth. My air pod 2 has Bluetooth, this big TV, doesn’t have Bluetooth, did a little research I around a device that is an adapter for a TV, it goes into the optical output of the back of my TV. And it sends out a Bluetooth signal. And I paired my air pod to to this adapter, and my Bose headset to this adapter. And the quality of the sound for 78 bucks is incredible. So I took my air pod pro tube, converted it to a hearing aid and the ability by bluetooth to stream from my TV, the air pod cost me $180 With a bilateral set. The adapter cost me 78 took a little time on how to do it all of it. So if I were in practice and somebody wanted as my service to program their AirPod Pro and adapt, set up the adapted their tv I can do it also I couldn’t do it, but I’m gonna charge you for my time who can do this remotely as possible. So here it is last one. audiologist can’t bury their heads in the sand hoping that this is going to disappear. audiologist need to recognize that somewhere I’ll pass behaviors contributed to this challenge. The challenge is real and strategies much beetelite be developed to prosper. This three part series this is number three is my humble attempt to show how to meet that challenge by integrating unbundling OTC type devices, remote care and remote fine tuning into clinical practices. Thank you for your interest. If you have any questions or need clarification, please do not hesitate to contact me at [email protected]

Bob Traynor 1:26:50
Thank you. Thanks so much, Mike. Now as with the other two, I have a fistful of notes, which I plan to implement in my courses that I that I teach as well, but also just for my own information and as usual when Mike Valente speaks, I listen and take copious notes. Thank you so much for your presentation today. And the other two presentations that are integrated into into this discussion. Thank you as the audience for putting up with us for just a little bit longer today than then you are used to this week in hearing. But again, my thanks to Mike for all of his thoughts, energy and effort that went into his series of discussions here at this week in hearing