Clinical Time and Hearing Aid Technology



Author: Dan Quall, M.S., and Brian Taylor, Au.D.

Triaging and Billing Patients Based on Complexity

For generations audiologists have not effectively differentiated their treatment and management of sensory neural hearing loss in adults. Regardless of the magnitude of hearing loss, cognitive ability and other non-audiological variables, audiologists have traditionally offered the motivated adult patients hearing aids, striated along three or four technology levels, as the sole treatment option. Besides the multiple levels of technology, which according to recent independent research indicates premium technology may not result in superior patient outcomes for common “typical” hearing losses1, 2, the professional time needed to manage all aspects of their hearing handicap is usually bundled into the price of the products dispensed. Essentially all patients who are receiving treatment from us are paying for the same thing - even those individuals that don’t want or need the additional professional clinical time. To confuse matters, there are individuals on the other end of the spectrum, many of them older with multiple chronic disabilities, which require additional clinical time due to the complexity of their treatment plan. This undifferentiated approach, where the audiologist’s clinical time is bundled into the fee for products offered to all patients desiring treatment, has led many outside the industry to question the value of the professional services we provide3.

In addition to not seeing the value of professional services when they are bundled into the sale of hearing aids, there is at least one other reason to question the traditional approach of exclusively offering multiple levels of hearing aid technology to adults with hearing loss: Patients with mild loss and normal cognitive and physical ability require less clinical time than patients with greater hearing loss and/or significant cognitive or physical impairments. In order to appreciate this shortcomings of the current service delivery model, consider these two examples that many audiologists routinely encounter:

Patient A: A 65-year-old male with no history of ear disease or noise exposure, a mild high frequency hearing loss and normal cognitive and physical function is offered a choice of three hearing aid technology levels. The cost of the devices includes unlimited office visits for one year. Given the situational communication problems of Patient A, a pair of $6000, premium hearing aids are recommended because he is an active individual and needs aggressive noise strategies for his primary communication complaint. He utilizes three clinical hours of your professional time in the first year.

Patient B: A 75-year-old male with no history of ear disease or noise exposure, a moderate loss and declining cognitive and physical functioning is offered a choice of three hearing aid technology levels. The cost of the devices includes unlimited office visits for one year. Because our 75-year-old is less active a set of $5000 mid level hearing aids are recommended. Considering the long-standing hearing loss, combined with memory problems and other physical ailments, Patient B and his family believe they are receiving a great value, especially for all the time you will be spending with him. He utilizes 6 clinical hours of your professional time in the first year.

The inefficiency of our delivery model is reflected in the fact that Patient A, purchasing a high end hearing aid and utilizing only 3 clinical hours provides an extremely high return per clinical hour on a treatment plan that is not complex. Patient B, a considerably more complex treatment plan, requires twice the clinical time and provides a relatively low return per clinical hour. It could be argued that Patient A subsidized part of Patient B’s treatment. That being said, the real tragedy occurs when Patient A rejects the recommendation of high tech hearing aids based on life style because he doesn’t feel he has a $6000 problem—a problem which he considers normal for his age. In this common clinical scenario, Patient A loses and the clinic is left with a potentially unhealthy economic situation: A person who shops around and perhaps buys less expensive hearing aids on-line.

Today’s inefficient delivery model treats both patients in the example above in the same way: A clinic-based model in which both patients (or a third party payer) are buying the same thing, even though some of the technology or services may not be needed. Patient A with a mild loss, for example, is likely to require audibility of missing high frequency speech cues. And, since Patient A has normal cognitive and physical functions, chances are good you can resolve his communication difficulties with relatively little professional time. Further, relatively traditional amplification schemes, designed to provide optimal gain for soft and average inputs, may be appropriate for someone like Patient A4. Today, this technology can be found in a high quality PSAP (or low end hearing aid) and could be purchased over-the-counter or on-line.

On the other hand, Patient B has a more complex problem requiring more professional time and perhaps more sophisticated technology. Patient B will need more assistance learning how to insert his hearing aid and to understand how to use automated wireless technology—features needed to improve their declining signal-to-noise (SNR) loss and/or reduced cognitive or physical ability. He will need to be counselled on how their hearing loss and cognitive deficits affect his ability to communicate. No doubt, the typical patient is not as straightforward as these examples. There are plenty of patients with milder losses and poor cognition or severe losses and normal cognitive ability. Our point is that additional testing that evaluates downstream, non-audiological variables would help to stratify treatment approaches along both the professional time and hearing technology domains.

A different approach that adds remote tele-audiology services or alternative products such as high quality PSAPs might look like this: A comprehensive diagnostic and functional communication assessment is completed on all patients. This battery of procedures includes traditional audiological tests to rule out medical problems, as well as tests that screen for cognitive decline and physical conditions. Cognitive screeners, commonly used by primary care nurses and physicians, should become a routine part of the audiologist’s functional communication assessment. The Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) are two popular, scientifically validated cognitive assessment tools that could be added this functional communication assessment. We encourage audiologists to learn more about the pros and cons of each of these screeners and to establish a referral network for patients that “fail” these tests and need more elaborate care.

In addition to screening for cognitive decline, audiologists could quickly and accurately screen for physical decline by using the 12-Item Short Form Health Survey (SF-12). The SF-12 was developed for the Medical Outcomes Study (MOS), a multi-year study of patients with chronic conditions, and research has shown that it can be a viable tool for identifying individuals with physical and cognitive decline. Results of the SF-12 could be used in the triaging process to identify individuals who may require additional clinical time from the audiologist. Clearly, more research is needed in this area. We don’t know, for example, exactly what therapeutic approach used by the audiologist would be the most beneficial for patients who score poorly on the MMSE, MoCA or SF-12. However, the lack of clear evidence on how to use the results shouldn’t be a deterrent for not employing some type of scientifically validated screening of cognitive and physical health. Audiologists must look for new ways to responsibly and ethically triage (or sort) patients that need additional clinical time.

Recent demographic research indicates there is a potential market for an approach that triages patients based on hearing loss as well as cognitive and physical health. Given that 71% of individuals over the age of 80, a group comprising of a significant portion of many audiologist’s caseload, has a disability5, it seems logical to screen for some of these other co-morbid conditions. A new approach, one not based so heavily on pure tone thresholds and patient lifestyle to determine hearing aid candidacy might look like Figure 1.

Figure 1. The variability in professional time spent with patients as a function of degree of hearing loss (pure tone and SNR loss) and cognitive/physical function.


Level 1: mild hearing loss and/or normal cognitive & physical function
The goal of audiological intervention is to optimize audibility and improve the listener’s signal to noise ratio using the most cost-effective approach possible. Many of these patients could be good candidates for high quality, off-the-shelf solutions with minimal interaction with the hearing care professional.
Level 2: moderate hearing loss and/or mild decline in cognitive & physical function
The goal of audiological intervention is also to optimize audibility and improve the listener’s signal-to-noise ratio across all relevant situations. However, considering the increasing complexity of the problem, advanced hearing aid technology might be needed. In addition, given their cognitive and physical decline in function, more professional time might be needed to manage their communication problem.
Level 3: severe hearing loss and/or marked decline in cognitive & physical function
Like a Level 2 patient, the goal of audiological intervention is to optimize audibility and improve the listener’s signal-to-noise ratio across all relevant situations, which often requires advanced hearing aid technology. A Level 3 patient, however, because of their markedly declined auditory and cognitive systems is likely to require substantially more professional time. This increase in clinical time for a patient suffering from a combination of significant cognitive, physical and auditory deficits, compared to a patient with mild communication issues and good cognitive and physical capabilities, should be reflected in the cost to deliver an effective treatment plan for each individual.

Recently published hearing loss prevalence data indicate there is a large potential market for Level 1 service delivery. According to the analysis, more than 66.5% of the American population with bilateral hearing impairment (38.17 million) has loss mild in nature5. Since it cannot be determined from this study the number of individuals with mild hearing loss who suffer from cognitive or physical decline, the prevalence of these co-morbid conditions could be determined during a comprehensive evaluation, like the kind we suggest. Clearly, more research is needed to understand the interconnectedness of hearing loss, cognition, physical decline, aging and the most appropriate course of audiological treatment and management for patients.

Using a striated approach to treatment and management of communication difficulties, one based on the three levels outlined here, is an opportunity for audiologists to specialize. Using this model, it is possible to envision a future in which Level 1 patients are treated with on-line, virtual assistance by technicians, while Level 2 and Level 3 patients receive more comprehensive care from audiologists who specialize in delivering sophisticated treatments like cognitive behavioral therapy or personal adjustment counseling.

Ophthalmology has successfully striated their approach to patient care. By not focusing so heavily of the delivery of a device or surgery, they have managed to create a set of billing codes that are used to generate more revenue when they spend more time with cases they have deemed complex. Their billing codes are shown in Figure 2 and should serve as a model for how audiology could differentiate their services (and get paid for them by third parties) based on complexity of the case.

Figure 2: Coding Procedures for General Ophthalmologic Services
(N) Overview of Coding Procedures: General Ophthalmologic Services
92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
92015 Determination of refractive state


Adding additional measures, beyond our traditional audiological testing, could help provide a better picture of what is required clinically and technologically to provide the most effective treatment plan for our patients. With a better understanding of the complexity of the treatment needed for a good outcome, a plan can be developed that is both cost appropriate for the patient and cost efficient for the professional. Given the changes in healthcare and advances in technology, as a profession, we need to constantly review our treatment delivery systems and look for models that enhance outcomes for our patients and advancement of our profession.    
References
  1. Cox, RM, Johnson, JA, & Xu, J. (2016) Impact of hearing aid technology on outcomes in daily life I: The patient’s perspective. Ear & Hearing.
  2. Johnson, JA, Xu, J. & Cox, RM (2016) Impact of hearing aid technology on outcomes in daily life II; Speech understanding and listening effort. Ear & Hearing. 73, 5, 529-540.
  3. Hearing Health Care for Adults: Priorities for Improving Access and Affordability. Report from the National Academy of Science. June 2, 2016. Accessed at http://www.nationalacademies.org/hmd/Reports/2016/Hearing-Health-Care-for-Adults.aspx
  4. Killion, C & Firket-Pasa, S. (1993) The 3 types of sensori-neural hearing loss: Loudness and intelligibility considerations. Hearing Journal. 46, 11, 31-36.
  5. Jorgensen, LE, Palmer, CV, Pratt, S, et al (2016) The effect of decreased audibility on MMSE performance: A measure commonly used for diagnosing dementia. Journal of the American Academy of Audiology. 27, 4, 311-323.
  6. Goman, AM & Lin, FR Prevalence of hearing loss by severity in the United States. American Journal of Public Health. Published-ahead-of-print. August 23, 2016.
Portions of this article will appear in an upcoming special issue of Hearing Review, guest edited by Dr. Taylor.
Dan Quall is the Director of Managed Care for the Fuel Medical Group. He can be reached at dquall@fuelmedical.com.

Brian Taylor is the Editor of Audiology Practices and a consultant for the Fuel Medical Group. He can be reached at brian.taylor.aud@gmail.com.