Defining a Movement: What “18 by 18” Means to Audiology



Author: Kim Cavitt, Au.D.

On November 9, 2012, the Academy of Doctors of Audiology introduced an initiative described as “18 by 18”. This audiology profession initiative promises to fulfill the scope and destiny of the Au.D. movement. Some of you may be wondering what 18 by 18 means in practical terms or more specifically, “What does 18 by 18 mean to me?” This article’s goal is to define the terms, statutes, and regulations surrounding this movement and to outline what 18 by 18 means to audiologists.

The first 18 stands for amending Title 18 of the Social Security Act, to provide for the treatment of Audiologists as physicians for purposes of furnishing audiology services under the Medicare Program, to provide for a broadened scope of audiology services available for coverage under the Medicare program and to enable Medicare beneficiaries to have their choice of qualified audiologist.

Also known as Health Insurance for the Aged and Disabled, Title 18, is administered by the Centers for Medicare and Medicaid Services (CMS), which is part of the United States Department of Health and Human Services. The fact that Title 18 is under the Social Security Act means that it will require a change in legislation by the United States Congress to amend the current language.

The proposed 18 by 18 legislation would affect change on the Medicare system and redefine an audiologist’s classification within under Medicare. Title 18 is available for review at http://www.ssa.gov/OP_Home/ssact/title18/1800.htm. Please pay significant attention to section 1861 (http://www.ssa.gov/OP_Home/ssact/title18/1861.htm), which classifies and defines the role and responsibilities of health care providers within the Medicare system.

The second 18, as in “By 18” means that we, as a united profession, hope to achieve this goal by the year 2018. 2018 is significant because it will mark the 30th anniversary of the Au.D. movement. It also presents us with a realistic timeframe in which to work towards passage of legislation to achieve this goal.

You can learn more about the history of the Au.D. at http://www.audiologist.org/_resources/documents/publications/feedback/Feedback_17-1.pdf and http://audiology.advanceweb.com/article/a-brief-history-of-the-aud.aspx. As you will see, ADA and its members were the original torchbearers and founders of the Au.D. movement.

Now that we have defined 18 by 18, let’s talk about what passage of 18 by 18 legislation would mean for an audiologist’s day-to-day life.

First and foremost, amendment of Title 18 and passage of the legislation would allow for audiologists to be recognized as limited licensed physicians within the Medicare system. As such, audiologists would be allowed to practice, be recognized and be compensated for our current state-defined full scope of audiology and vestibular practice and care. Audiologists would be placed in the same classification and afforded the same latitude as other doctoring professionals including chiropractors, dentists, optometrists, and podiatrists within the Medicare system. The 18 by 18 legislation would provide audiologists with the autonomy to make clinical recommendations. As a result, audiologists could bill and be compensated for appropriately utilized evaluation and management codes. This change in status would also allow audiologists to opt out of the Medicare system.

It is important to understand that amending Title18 under the Social Security Act will have no impact on audiologists’ state defined scopes of practice or laws and regulations related to the state licensure of audiologists. Instead, an amendment of Title 18 will reinforce and recognize the full scope of practice as outlined in existing state licensure laws. Changing this federal statute would also have no impact on current state licensure laws and regulations. Achieving limited license physician status would not in any way expand audiology’s current scope of practice (as defined by each state). Audiologists would not be considered medical doctors. Further, the proposed legislation does not advocate for an enhancement of scope of care beyond that which typically exists in most current state licensure laws. For example, it would not allow for the addition of prescriptive or ordering rights for audiologists.

Several have asked, why are we not pursuing limited license practitioner status? The rationale is that this classification has recently been flooded with practitioners who are afforded an increased scope of practice and the recognition that accompanies it but are not doctoral level providers. Psychology currently has this level of classification but is attempting to be reclassified as limited license physician (http://www.apapracticecentral.org/update/2012/06-21/physician-definition.aspx and http://www.apapracticecentral.org/advocacy/state/leadership/slc-fact-congress.aspx).

“Direct Access” is the second component of the proposed 18 by 18 legislation. The language in the proposed 18 by 18 legislation largely mirrors the current American Academy of Audiology (AAA) language (www.audiology.org/advocacy/federal/congressionalissues/Pages/DirectAccess112thCongress.aspx) related to Direct Access.

The 18 by 18 movement reinforces and supports the importance of direct access to our collective profession. The term “direct access” solely applies to eliminating the Medicare requirement for a physician order for medically necessary, Medicare covered auditory and vestibular items and services. Passage of direct access legislation would not affect reimbursement or the continued need for medical necessity for Medicare coverage.

The final piece of the proposed 18 by 18 legislation is the inclusion of the comprehensive Medicare benefits as considered initially by the American-Speech-Language-Hearing Association: http://www.asha.org/Publications/leader/2011/110705/Medicare-Audiology-Coverage-Debate--ASHA-Supports-Comprehensive-Benefit-Over-Direct-Access.htm).

The comprehensive benefit would allow for the expansion of Medicare coverage for medically necessary, covered treatment services such as vestibular rehabilitation, cerumen removal and aural rehabilitation provided by audiologists, practicing within their state-defined scope of practice. Currently, Medicare does not cover treatment or rehabilitation services provided by an audiologist.

The proposed 18 by 18 legislation with the inclusion of the limited license physician status, would allow expanded coverage to be achieved in a way that is best for the patient, best for the audiologist and best for the Medicare system.

As limited license physicians under Medicare, audiologists would be recognized and reimbursed for the full scope of their current (state-defined) scope of practice, which includes treatment and rehabilitation, in addition to diagnostic services.

There are no recognized limited license physicians currently included in the current Medicare therapy cap. Therefore, concerns that audiology could be lumped into the therapy cap when providing therapy are alleviated under the proposed 18 by 18 legislation.

The 18 by 18 Movement is one that is poised to improve access to quality, evidence-based audiologic services to Medicare subscribers, while increasing efficiencies and cost savings within the Medicare system itself. Patients, payers, employers and our physician colleagues can benefit from the proposed 18 by 18 legislation, and I look forward to working with all of you to help achieve it.    
Kim Cavitt, Au.D. was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career. Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. She currently serves on the Board of the Academy of Doctors of Audiology and the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.