Medicine & Audiology: Moving Toward a Stronger Alliance in the New Health Care Landscape

Author: Robert Tysoe

According to the 2010 Census Bureau the U.S. population at 306,000,000,₁ and the Health Care industry consumes almost 19 percent of the total GDP, which equates to almost $2.7 trillion. There are approximately 260,000 primary care physicians in the United States, who to a remarkable extent help to direct and control this enormous expenditure. The U.S. Audiology industry with approximately 15,000 providers fits approximately 2,000,000 units annually, which produces about $6 billion. Clearly audiology is the “little brother” of medicine.

To date, physicians only generate about 15 percent of the total audiology market revenue. (See Figure 1 for details). In a recently published article, Lin et al (2011) estimated that 30 million, or 12.7% of Americans 12 years and older had bilateral hearing loss from 2001 through 2008, and this estimate increases to 48.1 million or 20.35% when also including individuals with unilateral hearing loss.

A Mandate from Medicine
Assessing health information collected from 5,700 Americans aged 20 – 69 years between 1999 – 2004 in the federal National Health and Nutrition Examination Survey, Agrawal et al (2008) found men twice as likely as women (21 percent versus 11 percent) to have speech-frequency hearing loss in one or both ears. Agrawal et al (2008) have called for annual hearing screenings for all individuals from young - adulthood onward, particularly for vulnerable groups.

Marketing research results show that 73 % of the U.S. population prefers to ask their primary care physician first about their hearing loss, and get recommendations for care. Audiology industry research estimates that only 20% of those with a treatable loss get care. It should be obvious that physicians are not readily diagnosing hearing loss or initiating significant patient referrals for hearing healthcare, yet.

What is wrong with this picture? If most of the potential growth for audiology referrals lies in the country’s primary care providers, what are the approximately 15,000 audiologists and hearing instrument specialists in those 11,000 store fronts doing to reach out to the 260,000 primary care physicians, (pediatricians, family practice, internal medicine, geriatricians) to change the way they practice medicine and encourage them to include hearing health care recommendations in their routine standard of care?

Figure 1. The various pathways hearing impaired “customers” find their way to an audiology clinic. Along with the pathway, the expected amount of revenue, expressed as a percentage is listed.
Kissing the Cheek
It is said that in most relationships there is the one who offers the cheek, and there is the one who kisses the cheek. The Audiology industry must accept the reality that it needs to kiss the cheek of the Medical industry by engaging in productive, mutually rewarding patient care and patient education and co-marketing strategies. Audiology may include Disease State Marketing, Physician Marketing, and Services Marketing in order to substantially grow physician referrals and increase their own hearing impaired patient case load.

The disease state of hearing loss includes conductive, sensorineural, mixed, and centrally mediated hearing loss, each with an array of causes, and vast patient populations with co-morbidities that substantially contribute to loss of hearing, and decreased quality of life. Diabetes, pre-diabetes, smoking/nicotine addiction, passive smoking, age related hearing loss with corresponding co-morbidities such as dementia and Alzheimer’s, noise-induced hearing loss, cardiovascular disease, ototoxicity and tinnitus are major contributing disease states that affect the patient’s ability to enjoy a hearing life.

Disease State Marketing by hearing health care specialists requires that they schedule time out of their clinics, and bring evidence based clinical research about the disease state of hearing loss, and it’s co-morbidities to the physician to explain cause and effect, with peer reviewed state-of-the art treatment modalities that lead to efficacy of care; provide patient educational materials to the nurse or medical assistant; deliver referral and billing process information to the referral coordinator, as well as detailed explanations of the services that they provide that may benefit the patient.
Kathleen F., 92 years old, upon being fitted with a new cochlear implant successfully returned to living independently with an active social life after suffering loss of self esteem, social withdrawal and isolation caused by profound hearing loss. Photo reprinted with permission of the patient.

Audiology can use substantial resources to create an effective dialogue with physicians so that they are educated about the complexities of making the diagnosis of hearing loss, encouraged to develop a treatment action plan that includes a referral to an audiology specialist. As Parker (2010) stated, “the audiologist should be a part of the comprehensive team of care givers striving to assist the patient to minimize impairment and achieve maximal function”. The onus is on both the physician and the audiologist to ensure they develop a committed, consistent, partnership of patient care. This can be achieved if audiology will altruistically reach out to medicine for the “patent life of their clinic ownership”.

Preventive medicine or preventive care consists of measures taken to prevent diseases, or injuries rather than curing them or treating their symptoms. Historically, preventive medicine has been the concern of public health activities while physicians focused on the treatment of established disease. However the concerns of public and private health and private practice are developing an increasing overlap, especially for primary care physicians. Today, the emphasis is on preventing or slowing the progression of chronic illness by optimizing other aspects of the patient’s health. Consequently, the treatment of hearing impairment becomes part and parcel medical preventive care. This is leading to a fundamental change in the relationship between audiology and traditional medical practice.

Some examples of preventive audiologic care that have positive outcomes are early treatment of hearing loss in the elderly so that the progression to depression and subsequent need for treatment is reduced. Treatment costs for the patient suffering with social withdrawal and isolation, hearing loss associated dementia, decreased functional status, poor communication skills that compromise patient safety. The impact of all these conditions can be significantly modified with early audiologic intervention. These patients may well lead lives of longer independence in their own homes with effective treatment of their hearing loss.

Lin et al (2012) recently published findings which show that patients with high frequency hearing loss have a higher incidence of falls. A recent report of a cohort of older Finnish female twins demonstrated a strong association between audiometric hearing loss and incident falls (Lin et al, 2012). Early treatment of hearing loss may prevent falls that cause injury, hospitalization and even death, not to mention the health care costs that could be avoided. Audiology is obligated to educate primary care physicians in how to effectively intervene, prevent or reduce hearing loss associated with known morbidities and mortalities.

Changes in Health Care Policy Has Positive Effects for Both Audiology and Medicine
The traditional medical care paradigm was based on treatment of overt illness. Physicians were basically passive in terms of initiating patient contact. They used their knowledge, experience and judgment to diagnose, treat, and or refer. If problems developed, it was up to the patient to determine when those problems necessitated a call to the doctor, or a return to the hospital.

A new paradigm of medical care is rapidly taking hold in the American healthcare system. In this new approach:
  • Providers, especially primary care providers and their patients have an interactive relationship that is continuous. Providers are expected to periodically initiate contact with patients who have complex and/or chronic illnesses in order to detect clinically relevant signs and symptoms at the earliest possible time.
  • Diagnostic processes, referral protocols, and treatment regimens are evidence based; providers are actively tracked for adherence to evidence based guidelines with reimbursement based to a significant extent on evidence supported performance standards.
  • Provider reimbursement is based on care quality, (the real value of the service in terms of helping the patient) rather than service volume (the number of visits, tests, procedures and treatments).
In the traditional paradigm, audiologists addressed the patient’s desire for improved hearing. Physicians generally did not test or refer the patient with mild, moderate, or even severe hearing loss unless the patient or his or her family members defined it as a problem and wanted it taken care of. The treatment of hearing loss is considered to be elective medicine rather than necessary patient care.

In the new model of medical care, the patient’s active understanding and participation in their medical treatment is far more important. If the patient does not understand their discharge instructions when they leave the hospital or the physician’s office, and potentially fails to take a medication correctly or does not attend a follow-up visit, and as a result has an adverse health event due to that failure to understand, it is now the provider who will suffer a financial penalty. The provider (hospital or physician) will be paid less, or not at all, for the care necessary to address the avoidable event. If such events happen to a given provider more often than average, they may soon find that they are no longer a “preferred provider” by insurers and that they are receiving fewer referrals from other providers.

Thus, it is the physician/provider’s responsibility to make sure that the patient’s ability to communicate, and interpret their physicians instructions effectively so that the most desirable possible outcome is achieved. Verbal contact between the patient and physician is the most effective way to communicate the critically important aspects of care for the frail and elderly and chronically ill. If hearing loss impairs this communication, that hearing loss becomes a threat to the patient’s health and a threat to the provider’s income.

The audiologist’s value in their partnership with primary care physicians with this objective is going to become a very important issue. According to J. Bakke M.D. MBA Senior Consultant, Zolo Healthcare Solutions, audiologists who provide high quality patient centered care should expect to be become an integral part of the medical care team.

The Newer,Younger Patient Market
Pre-diabetes mostly occurs independently of age, so there needs to be an increased education and marketing focus on the younger patient population with metabolic diseases. Tobacco use is growing around the world. Among 15 year old Germans, 25 percent of all German males and 27 percent of females, now smoke on a regular basis. With evidenced based research proving that tobacco smoke causes hearing loss at twice the rate of non-smokers, audiology marketers can be agents of positive social change, as well as helping to decrease overall health care consequences.

Noise related hearing loss in the younger patient population is growing unabated, while those who are devoted to marketing the “attributes of sound” devise ever more recklessly clever ways for youth to have the ultimate in listening entertainment.

Audiology's Mandate
As previously noted, Frank Lin M.D. and Yuri Agrawal M.D. from Johns Hopkins University state that hearing screening must begin in young adulthood. The Audiology industry now has a mandate from Medicine to confidently ask primary care physicians to refer their all their patients from early adulthood to the aged, for routine annual audiologic evaluations. This is not just good medicine, but preventve medicine as well.

Figure 2. An example of a Disease State Marketing schedule implemented by one audiology practice.
Audiology Marketing Efficiencies
A basic plan of action for audiologists that “reaches more patients, by reaching more physicians more frequently” involves organizing a four week call cycle to consistently educate the physicians and nurses about the negative consequences of untreated hearing loss, to promote the benefits of care, and explain why they should refer the patient to their clinic for compassionate, quality care, the latest diagnostic and treatment technologies, and friendly, efficient customer service.

This example of a “Disease State Marketing Schedule,” shown in Figure 2, demonstrates how to alternate the educational priorities for your target market of physicians, by co-morbidities. These are the largest patient populations who are likely to test with loss, and who will require the most educational emphasis by audiology providers. When this is done effectively over time, patient referrals will increase, marketing costs will decrease, a reliable revenue stream will be created, and the audiology clinic profitability will be enhanced.

Many audiologists require understandable, quality training programs, and a proven process before they commit to a long term practice development program that involves physician marketing, disease state marketing, and services marketing. Those who see the opportunities that await them by entering into a stronger working relationship with the medical community now will prevail in the current healthcare environment, as well as in the new health care landscape in the years ahead.    
Bob Tysoe, Marketing Consultant with Hearing Healthcare Marketing Company can be contacted at [email protected]. Phone: 503 863 9250.
Lin, F. et al. (2011). Hearing Loss Prevalence in the United States. Arch Intern Med. 171, 20.

Agrawal, Y. (2008) Reuters

Parker, P. (2010) Diabetes and Hearing Loss, Audiology Practices. 2, 2.

Lin, F. et al (2012). Hearing Loss and Falls Among Older Adults in the United States. Arch Intern Med 2,172, 369-371.