Headquarter's Report: MAASA Means Medicare Policy Parity for Audiology Services and for Women as Clinical Doctoring Professionals

Author: Stephanie Czuhajewski, MPH, CAE, Executive Director

Women make up approximately 85 percent of practicing audiologists in the United States.1,2 While tremendous strides have been made to increase the percentage of women in medicine and other clinical doctoring professions in recent years, there continue to be significant disparities.3,4 Audiology is well ahead of other clinical doctoring professions in terms of female representation—and way behind in terms of salary and stature, despite the high demand for audiology services, and the scarcity of audiologists. These disparities are borne out in Medicare reimbursement policies.
Beneficiary Direct Access is More Readily Achieved, and with Fewer Restrictions for Male-Dominated Professions
Medicare Part B regulations impose fewer restrictions on beneficiary “direct access” to clinical doctoring professions that have low percentages of females as shown in Table 1. Further, additional requirements and restrictions increase proportionately to the percentage of females in the profession.
Medicare Provider Classification Favors Male-Dominated Professions
  • Physician: The clinical doctoring professions that Medicare recognizes as physicians coincide exactly with professions that are predominantly male.5 Of those professions, optometry has the highest representation of females in clinical practice at 43%.6 Optometry was also the last profession to be categorized among Medicare physicians in 1987.7
  • Practitioner: Clinical psychology is classified by Medicare in the practitioner category. Women account for 65% of practicing clinical psychologists today, up 10% from 1990 when Medicare first added them as eligible providers.8
While not included in the physician category, clinical psychologists are eligible for reimbursement of medically necessary, Medicare-covered services at 100% of the Medicare Physician Fee Schedule. 9
  • Supplier: Medicare classifies physical therapy and audiology, the clinical doctoring professions with the highest percentage of women (68%10 and 85% female respectively), as suppliers. Suppliers are frequently left out of important policy advances—for example, they are not included among the providers who are eligible by statute to deliver services via telehealth.
    Medicare Reimbursement Restrictions Disproportionately Impact Audiology and Other Female-Dominated Professions
    Archaic Medicare reimbursement restrictions disproportionately impact audiologists, other clinical doctoring professions with a high proportion of females, and the Medicare beneficiaries who need their services. While we do not know whether the association between the gender composition of the profession of audiology and the overregulation of audiology services is a causal relationship, it is nonetheless concerning.
    What We Do Know
    • What we do know is that while the OTC Hearing Aid Act allows consumers greater autonomy to self-assess and self-treat their perceived hearing loss—Medicare Part B coverage rules continue to prohibit beneficiaries with perceived hearing loss from going to their audiologist for a professional diagnostic examination, without first obtaining a physician order.
    • What we do know is that Medicare Part B continues to categorize audiology services as “diagnostic other,” outright prohibiting reimbursement to audiologists for the Medicare-covered treatment services that they are licensed to provide. This policy is anti-competitive, expensive for beneficiaries (in both time and money), and a wasteful use of Medicare system resources.
    • What we do know is that the Center for Medicare and Medicaid Services (CMS) continues to classify audiologists as suppliers, despite their education and training, which is commensurate with other clinical doctoring professions recognized by Medicare as physicians and practitioners, and despite evidence and outcomes from other government programs and commercial insurance that supports broader deployment of audiologists within the Medicare program.
    The Medicare Audiologist Access and Services Act (MAASA) will help close the gap between the outdated Medicare policies governing audiology and the Medicare policies that apply to clinical doctors in male-dominated professions.

    MAASA (H.R. 1587/S. 1731) will provide streamlined beneficiary access to audiologists by eliminating the physician order requirement, will authorize CMS to reimburse audiologists for the treatment services that they are licensed to provide, and will reclassify audiologists from suppliers to practitioners. MAASA supports Medicare policy parity for the profession of audiology and with it, parity for women in clinical doctoring professions.
    TABLE 1: SELECTED CLINICAL DOCTORING PROFESSIONS BY PERCENTAGE OF WOMEN AND MEDICARE POLICIES
    Clinical Doctoring Profession Percentage of Women Practicing in the Profession Medicare Direct Access Classified in Medicare as Practitioner or Physician
    Audiologist 85% No, the beneficiary must have a physician order. Neither
    Chiropractor 32%11 Yes Physician
    Clinical Psychologist 65% Yes, but must consult with the patient’s primary care physician (Psychiatrists do not have do this for reimbursement). Physician must sign off on plan of care.12,13 Practitioner
    Dentist 36%14 Yes Physician
    Medical Doctor 36% Yes Physician
    Optometrist 43% Yes Physician
    Physical Therapist 68% Yes, but plan of care must be filed and signed off by a physician.15 Neither
    Podiatrist 25%16 Yes Physician


    Contact Stephanie Czuhajewski at sczuhajewski@audiologist.org for more information.    
    References
    1. Hearing Health Matters (2017) https://hearinghealthmatters.org/hearingviews/2017/sex-and-audiology/
    2. American Speech-Language Hearing Association (2019) https://leader.pubs.asha.org/doi/10.1044/leader.AAG.24082019.32
    3. Newman C, Templeton K, Chin EL. Inequity and Women Physicians: Time to Change Millennia of Societal Beliefs. Perm J. 2020;24:1-6. doi:10.7812/TPP/20.024
    4. Searing, Linda. The Big Number: Women Now Outnumber Men in Medical Schools. The Washington Post. December 23, 2019. https://www.washingtonpost.com/health/the-big-number-women-now-outnumber-men-in-medical-schools/2019/12/20/8b9eddea-2277-11ea-bed5-880264cc91a9_story.html
    5. https://www.ssa.gov/OP_Home/ssact/title18/1842.htm
    6. American Optometric Association (2019). https://www.aoa.org/news/inside-optometry/aoa-news/the-future-is-female?sso=y.
    7. Garland N. Optometric parity legislation under Medicare. J Am Optom Assoc. 1987 Jun;58(6):518-9. PMID: 3305674.
    8. The Feminization of Psychology (2018)http://psychology.iresearchnet.com/counseling-psychology/multicultural-counseling/feminization-of-psychology/
    9. Social Security Act, Title 18. https://www.ssa.gov/OP_Home/ssact/title18/1842.htm
    10. American Physical Therapy Association (2020). https://www.apta.org/contentassets/5997bfa5c8504df789fe4f1c01a717eb/apta-workforce-analysis-2020.pdf
    11. American Chiropractic Association (2021) https://www.acatoday.org/news-publications/aca-roundtable-explores-the-experiences-of-women-chiropractors/
    12. American Medical Association (2020)https://www.ama-assn.org/practice-management/scope-practice/congress-plays-name-game-redefine-physician-under-medicare
    13. Centers for Medicare Medicaid Services Reimbursement Handbook https://www.cms.gov/files/document/medicare-mental-health.pdf
    14. American Dental Association (2021)https://www.ada.org/resources/research/health-policy-institute/dentist-workforce#:~:text=How%20many%20dentists%20are%20female,2021%2C%2035.9%25%20are%20female.
    15. Web PT: https://www.webpt.com/blog/medicare-and-direct-access/
    16. Kent State University, Women in Podiatry.https://www.kent.edu/cpm/news/women-podiatry#:~:text=According%20to%20the%20American%20Podiatric,cited%20in%20Delzell%2C%202016).