4

Current Approaches to Hearing Health Care Delivery

The system for delivering hearing health care is undergoing dramatic changes. Traditionally, patients would be referred from a primary care physician to an ENT physician or an audiologist, who would examine patients and provide them with a hearing aid or other device. Today, the traditional system is being supplemented by sales over the Internet and through big-box stores, telemedicine, and direct-to-consumer advertising.

Three speakers at the workshop examined the hearing health care system in the United States and abroad. Innovations in the system are covered both in this chapter and in Chapter 6.

THE SPECTRUM OF HEARING IMPAIRMENT AND INTERVENTIONS

Theresa Hnath Chisolm University of South Florida

Age-related hearing loss, also known as presbycusis, can have many different impacts on a person, explained Theresa Hnath Chisolm, professor and chair of the Department of Communication Sciences and Disorders at the University of South Florida. It is associated with elevated hearing thresholds, so people cannot hear soft sounds. It reduces speech understanding in noisy and echoing environments. And it can interfere with the perception of rapid changes in speech, leading to such complaints as “I can



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4 Current Approaches to Hearing Health Care Delivery T he system for delivering hearing health care is undergoing dramatic changes. Traditionally, patients would be referred from a primary care physician to an ENT physician or an audiologist, who would examine patients and provide them with a hearing aid or other device. Today, the traditional system is being supplemented by sales over the In- ternet and through big-box stores, telemedicine, and direct-to-consumer advertising. Three speakers at the workshop examined the hearing health care sys- tem in the United States and abroad. Innovations in the system are covered both in this chapter and in Chapter 6. THE SPECTRUM OF HEARING IMPAIRMENT AND INTERVENTIONS Theresa Hnath Chisolm University of South Florida Age-related hearing loss, also known as presbycusis, can have many different impacts on a person, explained Theresa Hnath Chisolm, profes- sor and chair of the Department of Communication Sciences and Disorders at the University of South Florida. It is associated with elevated hearing thresholds, so people cannot hear soft sounds. It reduces speech under- standing in noisy and echoing environments. And it can interfere with the perception of rapid changes in speech, leading to such complaints as “I can 31

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32 HEARING LOSS AND HEALTHY AGING hear people talking but can’t understand what they are saying,” or “If they spoke slower (or clearer), I could understand what they are saying.” As previous speakers noted (see Chapter 3), age-related hearing loss is associated with sadness and depression, worry, anxiety, emotional turmoil, and insecurity, said Chisolm. What is interesting, too, she added, the symp- toms of untreated hearing loss are remarkably similar to those of Alzheim- er’s disease. As has been attributed to Helen Keller, “Blindness separates us from things, but deafness separates us from people.”1 Nevertheless, hear- ing loss can be effectively managed so that people can continue to live full and active lives. Managing for healthy hearing begins with identification, Chisolm observed. But it also is associated with having individuals believe that hearing is important and that hearing loss can be treated effectively. The American Academy of Audiology has produced a document titled Guidelines for the Audiological Management of Adult Hearing Impairment (Valente et al., 2006), and these guidelines have been supplemented by subsequent research. These evidence-based protocols begin with a compre- hensive assessment of the hearing impairment, functional hearing-related difficulties, and individual factors shown by research to affect intervention. Once any medically treatable hearing losses are ruled out, an integrated treatment plan is developed that has both technical and nontechnical as- pects. The outcomes of the interventions are then measured, and the result- ing information is used to modify the treatment plan. Assessing Hearing Loss As Chisolm explained, an audiogram shows how sensitive an individu- al’s hearing is to different sounds that range from low pitch to high pitch, with the degree of hearing loss ranging from mild to profound. Still, the pure-tone average, which is calculated by averaging sensitivity thresholds for specific frequencies, is only one component of hearing loss. Another component is distortion, which results in problems with the clarity or the cleanness of the signals. Making sounds louder does not necessarily increase their clarity. In addition, external factors such as noise and reverberation or echoing can obscure speech sounds and affect how well hearing aids and other devices work in a given environment. Reverberation off walls and other surfaces, for instance, can create a great deal of difficulty for listeners. And for every doubling of distance, a sound signal loses 6 dB in intensity. All these difficulties are exacerbated by the effects of hearing loss in aging and by age-related cognitive processing declines. Managing hearing loss requires not just an audiogram but a measure 1 See http://libguides.gallaudet.edu/content.php?pid=352126&sid=2881882 (accessed March 14, 2014).

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CURRENT APPROACHES TO HEARING HEALTH CARE DELIVERY 33 of a person’s ability to understand speech in noise, Chisolm continued. Many objective measures of speech-in-noise are available, but they are not always used in the clinic. These measures yield a signal-to-noise ratio that an individual needs to understand about 50 percent of the speech. A person with normal hearing typically needs the speech to be 2 dB louder than the noise for 50 percent correct recognition. A person with hearing loss might need speech to be 12 dB or more above the noise for 50 percent correct recognition. Unfortunately, this measure cannot be predicted just from an audiogram. In addition to an audiogram and a signal-to-noise ratio for 50 percent correct recognition, functional hearing-related difficulties need to be as- sessed. This assessment can be done through a detailed case history, but that case history should not necessarily focus on the medical aspects related to the person’s hearing loss, Chisolm said. Rather, the case history should center on what it is like for that person to live with the hearing loss daily and the social and emotional impact of that hearing loss. Many psycho- metrically valid self-report measures can provide useful information for documenting and identifying the restrictions in activity limitations and participation restrictions that are associated with hearing loss; one of the most widely used measures is the Hearing Handicap Inventory for the Elderly (Ventry and Weinstein, 1982). Other individual factors also need to be examined. For example, research shows that cognition, expectations, motivation, willingness to take risks, assertiveness, manual dexterity, visual acuity, general health, tinnitus, occupational demands, and the presence of support systems can impinge on decisions for intervention and the out- comes of intervention. Once the results of a comprehensive assessment are available, ap- propriate treatment goals for a person can be developed. These treatment goals must be individualized, said Chisolm. “One size does not fit all for a person with hearing loss.” Chisolm uses the Client Oriented Scale of Improvement (Dillon et al., 1997). This tool, which was developed at the National Acoustic Laboratories in Australia, calls for establishing three to five realistic and achievable intervention goals. Progress toward these goals then can be measured after the intervention has been initiated and used to modify the plan. Kinds of Interventions Interventions can be technical or nontechnical. In the former category, most people with mild to moderate hearing losses can be effectively helped through the use of hearing aids. Fitting a hearing aid is not a simple pro- cess, Chisolm reminded the workshop participants. Many evidence-based decisions involving features, style, signal processing, and so on need to be

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34 HEARING LOSS AND HEALTHY AGING made. Then, once an individual is fitted with a hearing aid, the fit needs to be checked in terms of both the amplification characteristics and the physi- cal fit and comfort to the individual. As described in the previous chapter, hearing aid interventions can improve emotional, social, cognitive, and communication functioning (Mulrow et al., 1990). Davis et al. (2007) also demonstrated a higher quality of life as a function of hearing level in new referrals before and after being fitted with a hearing aid. Hearing aids provide limited help for most people with more severe to profound hearing impairments. Cochlear implants, however, which bypass the defective cochlea of the ear and directly stimulate the acoustic nerve, provide a very efficacious intervention, said Chisolm. These devices are sur- gically implanted electrode arrays with external signal processors, and they have been shown to improve speech perception and quality of life (Klop et al., 2007). Still, even with the best hearing aids or cochlear implants, the combined effects of noise, reverberation, and distance continue to repre- sent challenges for listening and communicating for many individuals with hearing loss. Intervention with assistive listening technologies, such as the loops used in public spaces (these technologies are discussed in more detail in Chapter 5), are important in meeting the challenges of listening in poor listening environments. These technologies can be used alone or combined with hearing aids and cochlear implants to supplement performance in a variety of difficult listening conditions. With these devices, sound is picked up and transmitted directly to the listener, thus overcoming deterioration resulting from noise, reverberation, and distance. They catch the sounds that are important to a person, carry the sounds through a hard wire or wireless link to the listener, and couple the sounds to the listener’s ear. A variety of alerting devices that convey either a visual or tactile signal are also available. But effective use of any technology requires systematic device orientation and instruction regarding use and care, either individually or in groups. And usually this instruction needs to occur more than once, because only about 50 percent of medical information is typically remembered by individuals, said Chisolm. Nontechnical intervention is often called aural or audiological reha- bilitation. Typically, in group-based aural rehabilitation programs, partici- pants learn about communication strategies, problem-solving approaches, assistive listening devices, information and advice to give their significant communication partners, and relaxation techniques. Ideally, after getting to know about these techniques, people can try out the various approaches and report back to the clinician about what was successful and what was difficult. Chisolm and Arnold (2012) recently reviewed the evidence for the effectiveness of group-based aural rehabilitation and found good evidence

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CURRENT APPROACHES TO HEARING HEALTH CARE DELIVERY 35 that some of these approaches could improve outcomes for individuals with hearing loss. In particular, the group produced reduced perceptions of disability and improvements on many quality-of-life measures. Group aural rehabilitation programs can bring benefits much quicker than if an individual were given a hearing aid without the provision of such follow-up care. In addition, communications partners benefit if they participate in the programs; for example, they can come to understand why they should not talk to a spouse sitting in the living room watching television while they are in the kitchen washing the dishes. Providing information and counsel- ing about communication strategies can be helpful even for those with mild hearing losses who might not be ready to use hearing aids or other forms of personal amplification. Another type of aural rehabilitation involves listening or auditory training. Many commercially available computer-based auditory training systems are available. Nonetheless, even though some evidence suggests that these approaches might be helpful, the latest systematic review of computer-based auditory training systems for adults with hearing loss found that the efficacy of these programs is not robust enough to recom- mend this approach for all patients (Henshaw and Ferguson, 2013). Further research is needed for optimizing auditory training for adults with hearing loss, Chisolm observed. A Public Health Perspective From a public health perspective, the optimum situation would be for individuals to recognize that they have impaired hearing, for society and individuals to believe it is important and should be treated, and for ef- fective treatments to be readily accessible, Chisolm said. Today, however, age-related hearing loss is not understood to be an important public health issue. Studies of cognitive, functional, and social-emotional effects need to continue, she said, along with studies examining health beliefs and attitudes about hearing loss and intervention. Evidence-based interventions are available, but they need to continue to be improved, Chisolm said, especially as more is learned about the effects of cognitive aging. In addition, studies are needed that examine the potential for systematic hearing intervention to influence cognitive, functional and social-emotional status. Each person with a hearing loss is different, and each will require a different solution. All clinics should conduct speech-in-noise testing and a functional assessment to determine how the hearing loss affects a per- son’s everyday life, Chisolm said; clinics should not just use audiograms. Thresholds are important, but they are “not the be all and end all.” Hear- ing rehabilitative devices and services are usually not covered by insurance,

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36 HEARING LOSS AND HEALTHY AGING and Chisolm urged that this issue be addressed. Well-controlled studies of both technical and nontechnical interventions could demonstrate the cost- effectiveness and value of interventions. Finally, Chisolm pointed to an overemphasis on devices rather than comprehensive integrated hearing rehabilitation for older individuals. This workshop could help “change the landscape,” she said, so that people can learn to live well with hearing loss as a part of healthy aging. THE CURRENT U.S. HEARING HEALTH CARE MODEL Margaret I. Wallhagen University of California, San Francisco Hearing loss is seen by many to be a communication disorder, but it may have much more wide-ranging consequences. It could increase the risk of falls and injuries, lead to increased functional limitation and subsequent disability, and reduce one’s activity and participation, leading to decreased quality of life. People who have hearing loss often delay seeking hearing health care. Aspects of the hearing health care system help explain why this is and how it might be changed, said Margaret Wallhagen, professor of gerontological nursing at the University of California, San Francisco. Many stakeholders are involved in the hearing health care system, including the following: • Consumers and their support associations • Health care providers • Hearing health care providers • Industries and manufacturers • Centers for Medicare & Medicaid Services (CMS) • Other health care payers • Legislators and other policy makers • Public health professionals The Healthy People 2020 goals for hearing and other sensory or com- munication disorders2 include the following: • ENT-VSL-3: Increase the proportion of persons with hearing im- pairments who have ever used a hearing aid or assistive listening devices or who have cochlear implants 2  See http://www.healthypeople.gov/2020/topicsobjectives2020 (accessed July 8, 2014) for a full listing of objectives. Also, refer to Chapter 7 of this summary for more on Healthy People 2020.

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CURRENT APPROACHES TO HEARING HEALTH CARE DELIVERY 37 • ENT-VSL-4: Increase the proportion of persons who have had a hearing examination on schedule • ENT-VSL-6: Increase the use of hearing protection devices Far too few health care providers know about these goals, said Wallhagen. Medicare uses three conditions to determine coverage: does a service fall within the defined Medicare benefit category, is it reasonable and necessary for diagnosis and treatment, and is it not statutorily excluded for coverage. Unfortunately Medicare has a statutory exclusionary clause prohibiting payment under Part A or Part B “for any expenses incurred for items or services [for] hearing aids or examinations.” Said Wallhagen, “I always tell my students, ‘We will give you a new heart, but we won’t be able to give you glasses, dentures, or hearing aids.’” Various legislators have tried to change the exclusionary clause in Medicaid prohibiting reimburse- ment for hearing aids, but these efforts have yet to yield results. The hearing health care system can roughly be characterized as pro- gressing from the consumer to the primary care provider or other provider to the hearing health care specialist. A consumer can go directly to a hear- ing health care specialist, but referrals are needed to obtain coverage of the assessment by the audiologist. Consumers tend to attribute hearing loss to normal aging, to be un- aware of the extent of hearing loss because of slow onset, to not accord hearing loss a high priority, and to be very concerned about cost. Stigma can also be a factor with hearing loss, especially when the media advertise hearing aids that are “so small no one will know,” as Wallhagen put it. A better message would be that people with hearing loss really want to hear what others are saying. Providers in the primary care setting could overcome many of the bar- riers to accessing good hearing health care. Yet most do not screen for, pay much attention to, or even know much about hearing loss. According to the U.S. Preventive Services Task Force, between 40 and 86 percent of health care providers admitted they did not screen routinely, with barriers noted including a lack of time, the perception that there are more pressing clinical issues, and a lack of reimbursement (Chou et al., 2011). In an interview of 91 patients conducted by Wallhagen and her colleague, 85 percent of those who had good recall of a clinical encounter said that their practitioners never talked to them about having a hearing screening unless the patient specifically mentioned a hearing problem (Wallhagen and Pettengill, 2008). “We had one woman who kept talking about the fact that she went to see her practitioner who knew she had hearing loss, and [the practitioner] looked in her ears and said, ‘They are very nice and clean.’ Another [asked

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38 HEARING LOSS AND HEALTHY AGING his practitioner], ‘My wife thinks I have hearing loss,’ and the practitioner said that wives say that. Needless to say, the wife was not happy.” This lack of screening is a major problem, Wallhagen said. It was re- inforced by the U.S. Preventive Services Task Force, which concluded that “the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults aged 50 years or older” (USPSTF, 2012). What is needed from their perspective, Wallhagen stated, is additional research to gain an understanding of the effects of screening compared with no screening on health outcomes and to confirm the benefits of treatment under conditions likely to be encountered in most primary care settings. The Hearing Health Care System Once a person is referred for hearing health care, they enter what can be a very confusing system, Wallhagen said. Hearing health care specialists are far from a unified whole. Audiologists may have a Ph.D. or be a doctor of audiology, because that is the requirement for entry into practice. Other practitioners include speech-language pathologists, otolaryngologists (ENT physicians), and hearing instrument specialists (hearing aid dispensers). Some of these categories overlap, and practitioners offer different services to different patients. Specialists and their corresponding professional as- sociations can also disagree among themselves about the types of services practitioners should offer, how services should be reimbursed, and the ways services are accessed by patients. Furthermore, the tension among special- ists “is getting larger,” said Wallhagen, “because of the new models that are coming out and the various challenges they are facing in terms of their own practices.” The ways in which services are charged also are changing. Many audi- ologists are arguing that costs should be unbundled because the cost of a hearing aid is not really the cost of the hearing aid by itself but the cost of the hearing aid plus that of surrounding services. Medicaid provisions are also a consideration, though coverage is very state specific and more ser- vices are covered for children than for older adults. One model that might be useful, said Wallhagen, is the national Program of All-Inclusive Care for the Elderly (PACE), a model of care which includes integrated medical and social services. The PACE model is based on the On Lok Senior Health Services model started in San Francisco, California, in the early 1970s.3 Such programs could deal with a patient’s greatest needs, including hearing, without worrying about reimbursement issues. The bottom line, said Wallhagen, is that the hearing health care system 3  See more about the PACE program at www.npaonline.org (accessed May 9, 2014).

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CURRENT APPROACHES TO HEARING HEALTH CARE DELIVERY 39 is not well coordinated at most levels. Currently it consists more of a menu of offerings, with access restricted by the lack of coverage by Medicare and other insurance companies, consumer beliefs about hearing loss, the cost of hearing aids as currently sold, and a lack of screening and referrals by primary care physicians. Most health care practitioners receive little educa- tion around hearing loss. And those involved more directly with issues of hearing loss have a wide range of views about payment strategies that will support their practices and professions. Wallhagen called for studies that would generate data on the benefits of primary screening and the effectiveness of hearing aids on outcomes and would evaluate models of care that may be targeted to individuals with varying levels of hearing loss. In addition, she said, programs are needed that address the following goals: • Inform older adults about hearing loss, available options, and how to be educated consumers when seeking treatment; • Educate health care practitioners (including physicians, nurses, and physician assistants) about hearing loss and available resources; and • Continue to emphasize that hearing loss is a public health issue. Screening is particularly an issue in low-income communities, said Wallhagen, where practitioners are often reluctant to screen patients be- cause of the difficulty patients would have in getting hearing devices. In such settings, health care practitioners could at least make patients with hearing loss aware of the communications issues they face and the kinds of devices that could help them stay engaged. AN INTERNATIONAL PERSPECTIVE Nikolai Bisgaard GN ReSound A/S The six leading hearing aid manufacturers—Oticon, Phonak, ReSound, Siemens, Starkey, and Widex—account for more than 85 percent of the world market, according to Nikolai Bisgaard, vice president of intellectual property rights and industry relations at GN ReSound A/S. All are repre- sented in the European Hearing Instrument Manufacturers Association (EHIMA). This association has standing committees that deal with such issues as standardization and market development. The latter committee, which Bisgaard chairs, seeks to develop and grow the size of the market. For example, its Hear-It website (www.hear-it.org) has been operating for a decade and has been translated into six languages.

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40 HEARING LOSS AND HEALTHY AGING The world market for hearing aids in 2012 was about 10.7 million units, Bisgaard said, with a total wholesale revenue of around $5 billion. It is not a huge industry, he added, and, with a steady growth rate of about 2 percent per year, will grow slowly, given current trends. Europe is the largest current market, followed by North America, Asia, and the rest of the world, respectively. Objective data about the use of hearing aids are generally unavailable, said Bisgaard, but he said estimates based on the number of units sold suggest that about 20 percent of the adult population with hearing impair- ments in the United States and Europe use hearing aids, falling to 11 percent in Japan, 6 percent in Russia, 2 percent in China, and less than 1 percent in India. Hearing care is clearly associated with a higher standard of living. “If you live in a developing country and get some money, hearing aids are not the first thing you think about,” said Bisgaard. “You would rather have cell phones, refrigerators, TV sets, and the like.” The use of hearing aids varies widely within Europe, Bisgaard observed, from a high of 56 percent of the hearing-impaired adult population in Denmark to single digits in many countries of southern and eastern Europe. The general standard of living among countries accounts for some of these differences, he said, but so do differences in accessibility to hearing health care, subsidy levels, and general historical factors. “Some countries have had free hearing aids for ages. Other countries introduced it recently, and some don’t have anything of the sort.” The delivery systems for hearing health care also differ within Europe. High-use areas are characterized by public hospitals with audiology de- partments, Bisgaard observed. Many of these areas offer free, good-quality hearing aids for all citizens with a recognized hearing loss, though some may only partially cover hearing aids purchased from a private dispenser. In Denmark, for example, patients receive vouchers from the government that will cover the cost of a hearing aid with basic features from a private dispenser. The Netherlands offers a 75 percent refund from the public health care system for a hearing aid from a private dispenser. In the United Kingdom, the government does not offer a subsidy to private dispensers. The central European model is more insurance based, Bisgaard noted, though people are required to carry insurance. This insurance will cover 10 to 20 percent of the best possible hearing aids. As in high-use areas, patients need to see an ENT physician, who will refer them to a hearing aid dispenser. The ENT physician then verifies the results before the insur- ance money is released. The southern European model has minimal public support and features private dispensing, reasonable accessibility, and partial public coverage of costs for challenged groups. In eastern Europe, public support tends to be even more limited, and accessibility tends to be low. In 2007 a French initiative created a standard for services offered by

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CURRENT APPROACHES TO HEARING HEALTH CARE DELIVERY 41 hearing aid professionals, which was adopted as a European standard in 2010 (CEN, 2010). This EN 15927 standard establishes requirements for education, facilities, equipment, the fitting process, and quality manage- ment systems. Its scope is for typical age-related losses, and it acknowledges that children, cochlear implants, and multiple disabilities require further efforts. A country-by-country analysis by Bisgaard revealed that subsidies for hearing health care and hearing devices increase hearing aid use. Bisgaard described the case of Denmark, which in 1960 introduced free hearing aids for anyone in need; the aids were provided by audiology clinics at public hospitals. Each clinic had a wide choice of products from preap- proved suppliers. In 2000 the coverage was among the best in the world, at around 25 percent. Waiting lists for the eighteen auditory clinics were normally from 3 to 8 months, however. In 2001 a new system opened up for private dispensing, with vouchers that allowed for a hearing aid with basic features for fitting in private shops instead of hospital clinics. The client could choose to upgrade to products with more advanced features for private payment. Many private dispensers were established, resulting in a considerable drain of staff from public clinics and even longer waiting lists. Meanwhile, advertising in newspapers and on television exploded. In response, the total market grew by 80 percent over 11 years. Today, more people get hearing aids through private sources than public ones, and a re- cent survey has shown that people on average are happier with the service they receive in the private outlets than in public clinics, said Bisgaard. Increased accessibility and visibility of hearing aids increase their use, Bisgaard suggested. Furthermore, when more people have hearing aids, it reduces the stigma surrounding their use. “You will not have the feeling that it is something special. This is not evidence or science. It is just my personal reflection on what we have seen happen here. It has accelerated in Denmark partly because you see more people with hearing aids, and you think they look okay with it.” Hearing aids are also less obtrusive and function better than they did 10 years ago, both of which, Bisgaard asserted, have helped increase coverage. Bisgaard added that early interventions could pay immense social divi- dends by allowing older people to remain at work and contribute to society in other ways. People might think that hearing is not affecting their jobs or their relations with others, but when a large sample was interviewed about their conditions at work, those with hearing loss reported far more difficulties even when they said that their hearing was not a factor at work. Furthermore, when people come in to get a hearing aid after many years of denial, they tend to have much more difficulty adapting to a hearing device than people who come in when they begin to have problems. Bisgaard also pointed to some challenges on the horizon. As the popu-

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42 HEARING LOSS AND HEALTHY AGING lation ages, the overall total cost for hearing devices will increase, which has already led to some pushback from insurance companies and public systems. At the same time, hearing aids are getting better every year and becoming increasingly attractive, so more people want to use them. Supply- ing large segments of a population with hearing devices can be expensive, Bisgaard pointed out. The populations of some countries may be willing to pay for such services through taxes and other means, whereas others may not. “This is an equation that is not easy to solve.” Subsidies could be reduced and patients differentiated, Bisgaard ob- served. For example, a child with a hearing loss may receive better services than an older adult. The bundling of services into hearing aids might also change, though this is a “delicate matter,” Bisgaard said. But “it is inevi- table that it is going to come up some day and that we need to work with that dimension.” People are accustomed to paying for part of their dental and vision services, Bisgaard concluded, and they will likely need to do so with hearing as well, though subsidies will improve their likelihood of moving forward.