President's Message: A Private Practice Clinic Experience in Cochlear Implants

The first time I heard my (now) colleague state that private practice audiologists could be successful cochlear implant centers, I was skeptical. The two things that immediately went through my mind were: 1.) cochlear implants are not profitable, and 2.) the relationship with ear, nose, and throat (ENT) surgeons would not progress beyond the hospital walls. I was sure wrong! In fact, Dr. Kim Cavitt’s article “The Original Unbundled Delivery: Auditory Prosethetic Devices” (page 46) and Dr. Brian Taylor’s featured article “Changing the Course of Care at the Local Level if Adults with Severe Hearing Loss: Debunking 5 Cochlear Implants Myths” (page 10) address my two initial thoughts.
History (and Future) of Cochlear Implants
Similar to other technologies that private practice audiologists work with daily, cochlear implants have vastly changed since their introduction by William House, M.D. in the United States in the early 1960s. The first microelectronic, (8) multi-channel cochlear implant is often credited to Med-El Corporation’s Ingeborg and Erwin Hochmair and initially implanted in adults with severe to profound hearing loss in the late 1970s. Body worn speech processors were introduced in the 1980s with behind-the-ear (BTE) processors launched in the early 1990s. Current technology allows for off-the-ear (OTE) processors, rechargeable batteries, accessory and hearing aid compatibility, and iPhone connectivity.1 Additionally, the candidacy criteria has grown to include children, infants, moderate to profound hearing loss, and hybrid candidacy.

Figure 1. Med-El Corporation Candidacy for their EAS Cochlear Implant2


The significant changes still underway in the cochlear implant space can easily be seen with the 28 patents already granted to Cochlear Limited in 2018.3 In fact, the IEEE Journal of Solid-State Circuits in January 2015 published an article about fully-implantable cochlear implants4 indicating great possibilities for cochlear implants in the future.
Implementing Cochlear Implants
Towards the end of the meeting with my colleague, I was intrigued and ready to add cochlear implants to my private practice. The idea of offering a full spectrum of treatment options: assistive listening devices/personal sound amplification products to hearing aids, to cochlear implants appealed to me as a provider and the additional profitability was welcomed as a small business owner. Fortunately, my colleague had strong connections to one of the (three) cochlear manufacturers and the neuro-otologists in Maryland. The initial connection was made from the manufacturer and often took two or more weeks before any additional information was relayed back to me. All three surgical sites eventually agreed to a business meeting dinner, in-person, and/or phone interview to further discuss the relationship with my private practice. After these meetings, everyone was comfortable, and the relationship moved forward. Protocols were discussed, communication was cemented, and preferences were all determined. Once the relationship with the surgeon was established by one cochlear implant manufacturer, another manufacturer came to me to ask if I would be willing to join their provider network. This was an easy addition, as the protocols are the same; learning another software system and obtaining the equipment was as easy as adding another hearing aid company. With two cochlear implant manufacturers offered at the office, I then lobbied the third cochlear implant manufacturer to obtain their equipment and software. The last company was difficult to obtain, as I had to convince the local representative that private practices could complete the candidacy criteria, active, and follow-up care for years to come. Reluctantly, the company agreed (perhaps from concern that they would not have any new users) and all three relationships were cemented.
A Personal Story
As a fourth-year extern, I was introduced to all three cochlear implant manufacturers and the complete process at the Mayo Clinic Arizona. My education did not adequately prepare me for cochlear implants, but the hands-on training prepared me to integrate them in a private practice. My first cochlear implant patient found me through my practice website. She had been evaluated at another private practice office and was not happy with the (lack of) options presented to her. With a progressive, bilateral hearing loss and limited hearing aid benefit, she had been through all of the candidacy testing and knew she was a candidate. However, the initial practice only offered her one cochlear implant surgeon and one manufacturer. Being younger than 40 years, she knew there were more options in the Washington, DC/Baltimore area and three cochlear implant manufacturers. Presenting to my office, the initial appointment mainly consisted of counseling, presenting device options, and explaining surgical sites. After making her decision to move forward with implantation and staying with the practice, she was scheduled for a head scan and required information was sent to the surgeon’s office. Another appointment was completed to finalize the manufacturer and pick sound processors (the surgeons and clinics in the area are a two-processor clinic), colors, cable lengths, and accessories. Additionally, the patient upgraded her opposite ear’s hearing aid and obtained new earmolds. Two weeks after surgery, with the medical follow-up appointment completed, the patient was seen for activation. She presented with her family member and the session was videotaped, at her request. Activation of an adult is just as fun, emotional, and rewarding as a child/infant. At one month, testing was completed to start measuring the pre- and post-candidacy improvement. Testing and mapping appointments are completed using the evidenced-based protocols by Renee Gifford, Ph.D.5 and continue to be an improvement from the hearing aid benefit. The patient is so happy with her outcome to date, that she scheduled her opposite ear for implantation later this year.
Conclusion
While no cochlear implant patient (or their support system) is “typical,” the above story shows how cochlear implants can help private practices and patients. Payment is received, either through reimbursement from insurance or via private pay (depending on the procedure and coverage) making it a profitable service. Additionally, the relationship with area surgeons has helped provide more than cochlear implant referrals to the office and afforded all patients another option for medical management, when needed, without any threat that the patient will not return. After implementing cochlear implants, auditory osseointegrated devices (e.g. BAHA) is next!    
References
1 http://www.medel.com/us/history/
2 http://www.medel.com/us/eas-hearing-implant-system
3 https://patents.justia.com/assignee/cochlear-limited
4 https://ieeexplore.ieee.org/document/6910323/
5 https://www.amazon.com/Cochlear-Implant-Patient-Assessment-Performance/dp/159756446X