Sea of Change—Are Audiologists Ready for the New World of Hearing Health?
Autonomy. Direct access. Physician status. These have become buzz words in audiology and are frequently touted as the only means by which audiology can remain relevant. Doctor of audiology (AuD) students and audiologists often buy into this because it is appealing. A lot of money is spent—and debt incurred—to obtain an AuD degree, so why should audiologists NOT have autonomy, direct access, and be recognized as having "limited license physician" status under the Medicare program? In a vacuum, it makes perfect sense. But no matter how logical it seems or how much autonomy is desired, the reality is that it is nearly impossible for this to happen in the context of the current and rapid waves of reform in health care delivery models and consumer choice.
Here are the facts:
- Health care is moving toward integrated systems of care, with complex requirements for reporting quality and outcomes, and the use of this data to determine reimbursement. Those remaining in private practice will see increased administrative burden and overhead costs, and the potential for decreased reimbursement.
- With the rapid explosion of technology, including the proliferation of personal sound amplification products (PSAPs), baby boomers who embrace technology are searching the web for lower-cost options to what they perceive as expensive hearing aids. They are also turning to big-box stores for their hearing health needs.
- The perception of consumers and health care payers is that consultation with an audiologist equals purchasing a device. Free hearing tests and bundling are commonplace. The result is that consumers and payers do not see the value of audiology services.
- Given the focus on the device by many audiologists, consumers and payers also may not realize the difference between hearing aid dispensers and audiologists in terms of education and training.
Audiology is going through a sea of change, as seen in the illustrations in the Resources section below. In order to weather—and emerge from—the current storm of change in health care, audiologists would be best served by reviewing their current business models to ensure that they remain competitive in today's market.
Relevance. Transparency. Value-based services. Outcomes. Professional Services. These must be new buzz words for audiology.
Medicare Moving Away From Fee-for-Service Model
Last year, Congress passed sweeping changes related to Medicare Part B payments, which moves payment away from the fee-for-service (FFS) model to alternative payment models (APM) such as accountable care organizations and bundled payments. These policy changes will move away from a volume-based reimbursement approach to one based on quality and value. The Centers for Medicare & Medicaid Services (CMS) has established a goal of tying 30% of Part B FFS payments to quality or value through APM by 2016, increasing this to 50% by 2018. Additionally,
Medicare is currently conducting a bundled payment demonstration project that includes audiology services.
Audiologists choosing to remain in private practice will most likely be required to participate in a Merit-Based-Incentive Payment System (MIPS)—a hybrid FFS system that includes payment incentives for quality, outcomes, and deficiency. MIPS scores—based on the provider's performance in four categories—will be used to modify the provider's payments and to encourage quality improvements.
MIPS payment will either be an incentive or a penalty, depending on where the provider ranks among their peers. The program is designed to be budget neutral; that is, it provides financial winners and losers based on performance. High performance will see payment increases, and lower performers will receive penalties.
Providers who already participate in Medicare-recognized APM, such as accountable care organizations and demonstration projects, will automatically receive the maximum MIPS payments as a way to encourage providers and health care systems to adopt APM.
In any of these models, in order to ensure quality patient-centered care, care coordination will continue to play an integral role. Audiologists will need to share plans of care and treatment information with other health care providers to ensure continuity and quality of care.
Hearing Aid Dispensers
Given the current practice of some audiologists to focus solely on the dispensing of the device, the professional lines between a hearing aid dispenser and an audiologist have blurred in the eyes of consumers and government officials. Over the past several years, there has been a concerted push by hearing aid dispensers to expand their scope of practice at both the federal and state level, and to increase their relevancy in the provision of hearing health care services.
In its model scope of practice, hearing aid dispensers are advocating for a scope that includes, among other provisions,
- eliciting case histories, including medical, otologic, pharmacological, and previous amplification histories, and patient attitudes and expectations;
- administering otoscopy for the purpose of identifying possible otologic conditions;
- administering cerumen management;
- administering and interpreting tests of human hearing, including appropriate objective and subjective methodology measures; and
- determining candidacy for hearing instruments, hearing assistive devices, or a referral for cochlear implant evaluation or other clinical, rehabilitative, or medical intervention.
The International Hearing Society was recently successful in getting its apprenticeship program recognized by the Department of Labor Apprenticeship. As part of the 2-year program, individuals would have the opportunity to gain experience in cerumen removal, interpreting tests of middle ear function, determining candidacy for cochlear implants, conducting rehabilitative and medical intervention, designing and modifying auditory equipment, providing aural rehabilitation, and providing tinnitus management. ASHA, along with other audiology organizations, has challenged this program and is working with the Department of Labor to revise the apprenticeship program to better reflect the scope of practice for the dispensing of a hearing aid.
U.S. Department of Veterans Affairs, Veterans Health Administration
Hearing aid dispensers are also making a case for their ability to independently work at the Veterans Health Administration in dispensing hearing aids to veterans. In an article for Hearing Health Matters, an International Hearing Society executive is quoted as saying that
hearing aid specialists, who number about 9,000 in America, are fully qualified to serve veterans:
"Contrary to outdated and inaccurate perceptions," she stated, "hearing aid specialists do not simply fit and ‘sell' hearing aids," but are full-fledged hearing care providers. In fact," she argued, "as they move into independent practice, hearing aid specialists typically have as much, if not more, experience performing hearing evaluations and fitting and dispensing hearing aids than an average new AuD (doctor of audiology) program graduate."
More data on outcomes and consumer satisfaction are needed for audiologists to continue to affirm that their education and training make them the most qualified to provide a full scope of audiology services—which may include the dispensing of a hearing aid. Unfortunately, until such data are available, consumers may be led to believe that hearing aid dispensers and audiologists are comparable not only in terms of training and education but also in terms of the quality of the services that they provide.
Affordable Access to Hearing Health Care: Federal Government Review
Consumers continue to express frustration at the high cost of hearing aids. Additionally, there is a perception that hearing aids are equivalent to over-the-counter (OTC) eyeglasses referred to as "readers" that consumers can easily purchase. This analogy has created a perception that no health care intervention is necessary in the dispensing of hearing aids for mild to moderate hearing loss.
Three federal entities are currently reviewing access to hearing health care services, and one—the President's Council on Science and Technology (PCAST)—has issued a pivotal report that recommends OTC access to hearing aids. The reality is that OTC hearing aids and PSAPS may soon be accessible to consumers with mild-to-moderate hearing loss absent any intervention by audiologists. Now, more than ever, audiologists must educate consumers on the importance of audiologic intervention and aural rehabilitation in the successful adaptation of a hearing aid.
This council is chartered by the administration to advise the President on issues related to science and technology, and their recommendations are nonbinding. In October 2015, PCAST released its report, Aging America and Hearing Loss: Imperative of Improved Hearing Technologies, which focused strictly on consumer access to hearing aids. The council made four specific recommendations:
- FDA should approve a class of OTC hearing aids that does not require consultation with a health care professional and should approve OTC tests appropriate for self-fitting and adjusting of devices.
- FDA should withdraw its guidance on PSAPs and allow for labeling of these products as appropriate for age-related mild-to-moderate hearing loss.
- FDA should require audiologists and dispensers to perform standard diagnostic hearing tests and hearing aid fitting and should provide consumers with a copy of their audiogram and the programmable audio profile for the hearing aid at no additional cost—and in a form that can be used by other hearing aid vendors.
- The Federal Trade Commission (FTC) should define a process by which in- and out-of-state vendors can obtain, at the consumer's request, a copy of a hearing test for the purpose of dispensing a hearing aid at no extra cost to the consumer.
Institute of Medicine (IOM)
A study by the IOM is expected to be issued this summer. The IOM study will look at the public health significance of hearing loss, rehabilitative strategies, and innovative models of care.
As a result of the PCAST recommendations, the FDA conducted a public workshop titled "Streamlining Good Manufacturing Practices (GMPs) for Hearing Aids" in April 2016. The workshop outlined the agency's perspective on the current GMPs and gathered stakeholder and public input on balancing patient safety with encouraging advancements in hearing aid technology and accessibility to devices. Specifically, FDA is looking at information and advice on the following questions:
- Can consumers self-diagnose, self-treat, and self-monitor mild-to-moderate age-related hearing loss?
- Should FDA designate as a distinct category ("basic") nonsurgical, air-conduction hearing aids intended to address bilateral, gradual onset, mild-to-moderate, age-related hearing loss?
- Should OTC devices be exempt from GMPs?
- What would be the implications of widely available OTC hearing aids for patients with age-related, mild-to-moderate hearing loss on other patients with different types and degrees of hearing loss (e.g., pediatric patients, patients with conductive hearing loss, or moderately severe to profound hearing loss)?
Insurance coverage plays a critical role in consumer access to health care services. Although some can afford to pay for concierge care—where everything is out of pocket—many cannot. Insurance coverage is the only means by which many consumers will access vital hearing health services.
As Medicare and private insurance companies move to new systems of care, it is important that both audiologic diagnostic and treatment services be reimbursed. Absent coverage for treatment services, should OTC hearing aids come to fruition, the consumer may not have the financial means to seek assistance from an audiologist.
Now, more than ever, audiologists must fight to demonstrate their role and relevance in being included in payment models related to hearing health services—and separate themselves from solely dispensing a device. This is best achieved through legislation such as the Medicare Audiology Services Enhancement Act of 2015 (H.R. 1116), which would allow for coverage of both diagnostic and treatment services provided by audiologists. The legislation is achievable and moves the profession forward in data collection related to treatment outcomes, which can be further used to ensure our place in hearing health care.
Currently, health care is moving away from autonomy and direct access. If it was deemed achievable, ASHA would stand behind such legislation. The reality is that, over the years, other professional organizations have tried to achieve Medicare direct access and physician status for their members (some of whom also hold clinical doctorates)—with no success. In fact, 1986 was the last time the physician definition of the Social Security Act was successfully amended. Related to direct access, a 2007 CMS report to Congress indicated concerns with direct access for audiology services. Congress will always seek CMS input in moving forward with legislative efforts. We have not heard that CMS has changed its stance on this report, nor do we believe that CMS would support changing the physician status for audiology—which would then open the floodgates for all other clinical doctorates to request physician status.
In addition to the legislation's lack of direct access, concerns have been expressed related to the bill's requirement of a plan of care for audiology services. Care coordination is becoming an integral part of health care delivery. The legislation's requirement for the audiologist to use his or her clinical judgment in the development of a plan of care—and to share that plan with the Medicare beneficiary's primary care physician—is not specific to audiology. It's a Medicare requirement. Medicare works under a medical necessity model; physician referral and care coordination through a review of the plan of care are a condition of payment for many provider groups. Other clinical doctorate professions are working very successfully under this Medicare model. In some Medicare managed care plans, a referral is needed from the primary care physician to see a physician specialist. Therefore, this is not a specific legislative mandate for audiologists—but, rather, the way the Medicare program works for most health care providers.
There are many changes in the world of audiology, from payment models to possible OTC hearing aids. In order to remain competitive in these waves of change, audiologists must be willing to adapt to reimbursement models as well as to provide transparency in their billing practices.
About the Author
Ingrida Lusis is director of federal and political advocacy at the American Speech-Language-Hearing Association (ASHA). She oversees ASHA's Washington, DC, satellite office and is ASHA's chief congressional lobbyist. She directs activities to support the inclusion of ASHA's public policy agenda priorities in federal legislation and regulations.