5

Improving Affordability of Services and Technologies

For many people cost can be a key factor in making health care decisions; for some people cost can be the driving factor in such decisions, including whether to forego the care entirely. Among respondents to the 2014 Survey of Household Economics and Decision Making who had a household income of less than $40,000, 45 percent reported going without some form of medical treatment in the preceding 12 months (Federal Reserve, 2015). The cost of hearing health care includes the cost of services and technologies, and these costs may be incurred multiple times over a period of many years in order to maintain and replace hearing aids and other technologies, to continue to monitor hearing status, and to retain the benefits from auditory rehabilitation and other services. In an ideal world, high-quality hearing health care would be easily and immediately accessible, and the costs would be fully covered. Opportunities for note-worthy improvement in affordability do exist throughout the U.S. hearing health care system. Lessons learned from individual health care systems and other health care models in the United States and internationally can shed light on appropriate paths forward to improve the affordability of hearing health care in the United States.

CONSUMER COSTS FOR HEARING HEALTH CARE

A key challenge to understanding the costs associated with hearing health care and how to make that care more affordable is the need to make accurate price comparisons (comparing technologies with similar technologies or services with equivalent services). As discussed in Chapters 3 and

4, there are several types of hearing health care professionals, services, and technologies from which an individual may benefit. The variety of options and the interest in meeting the unique needs and specific preferences of each individual make it all the more important that consumers be able to make informed decisions about what their personal expenses for hearing health care will be. The committee recognized this challenge throughout its deliberations, and it urges changes to ensure that the public is able to accurately interpret and easily compare the costs for hearing technologies and services in order to make more informed decisions. It was with this concern in mind that the committee considered how to improve not only the affordability of the hearing health care system but also transparency in pricing. Where data were available, this chapter contains references to the prices of hearing health care. Every effort was made to include information about what hearing health care was included—or not included—in a given price.

Professional Services

When consumers are provided with the prices for hearing health care services, they are often presented as a set price for each type of hearing aid they are considering (basic to advanced). It may or may not be obvious that the price includes not only the price of the device (primarily hearing aids, but sometimes other assistive products as well) but also the price for professional fees for services, which may include all or some of the following: a comprehensive assessment of hearing loss and hearing aid candidacy, a functional communication assessment, hearing aid fitting and programming, and other associated services such as routine maintenance for a defined period of time and accessories (see Chapter 3). This is commonly referred to as a “bundled” pricing model. This package price may also include an unlimited number of visits to the dispenser for programming adjustments until the consumer is satisfied and has adjusted to the hearing aids or other technologies. Visits for auditory rehabilitation services may also be included. These services are often needed to achieve optimal fit and maximal benefit from the device and for the individual to learn strategies to maximize communication abilities. An alternative model, unbundled or itemized billing, lists the price of each test, device, and service individually. Results from a 2012 billing practices survey of audiologists showed that 67 percent of respondents used a bundled pricing model;¹ in a 2015 survey

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¹ Personal communication. Letter to staff for the Committee on Accessible and Affordable Hearing Health Care for Adults, from Kim Cavitt, President, Academy of Doctors of Audiology; Judith Page, President, American Speech-Language-Hearing Association; and Larry Eng, President, American Academy of Audiology. Received August 27, 2015. Available by request from the National Academies of Sciences, Engineering, and Medicine Public Access Records Office. For more information, email PARO@nas.edu.

of hearing instrument specialists, approximately 52 percent responded that they used a bundled model.² Thus, the majority of hearing health care financial transactions are conducted using a bundled price; moreover, the consumer may not be aware that this price includes devices and professional services and may incorrectly attribute the price solely to the device. A subsequent section of this chapter focuses on transparency in billing.

Nature and Scope of the Hearing Technology Market

The market for hearing aids is often expensive and generally not transparent. The hearing aid industry has been characterized as having “considerable vertical integration, with manufacturers controlling the design, development, manufacturing, and distribution of their products, nearly to the point of sale” (Seelman and Werner, 2014, p. 401). Audiologists and hearing instrument specialists may sell one or several brands of hearing aids but may not sell the full range of products due to the associated costs for programming and other reasons. Additionally, the average hearing health care professional may sell only about 20 hearing aids per month, limiting access to volume discounts (Strom, 2014b), or sell only one brand of hearing aid. These marketing and sales strategies can restrict competition and the associated benefits that competition provides for consumers.

The average retail price for a pair of hearing aids in 2013 was $4,700 (bundled price which includes professional services) (range: $3,300–$6,000) (Strom, 2014b). According to an industry estimate, 2.9 million hearing aids were dispensed in the United States during 2013, with approximately 20 percent dispensed by the Department of Veterans Affairs (VA) (Strom, 2014a). This number was estimated to be an increase of 4.8 percent over the previous year (Strom, 2014b). Globally, hearing aid sales were estimated to be 10.8 million in 2012, with total sales of $5.4 billion on the wholesale market. Of these, 45 percent were sold in Europe, 29 percent in North America, and 26 percent in other regions (Kirkwood, 2013).

A 2013 survey of hearing health care professionals (179 responding from 42 states) found the total weighted average price to the consumer to be $1,657 per economy-level hearing aid, $2,196 for a mid-level hearing aid, and $2,898 for a premium-level hearing aid, resulting in an average price of $2,363 per hearing aid of any level (it was not specified whether services were included in these prices) (Strom, 2014b). The respondents

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² Personal communication. Letter to the Committee on Accessible and Affordable Hearing Health Care for Adults, from Kathleen Mennillo, Executive Director, International Hearing Society. Received January 15, 2016. Available by request from the National Academies of Sciences, Engineering, and Medicine Public Access Records Office. For more information, email PARO@nas.edu.

indicated that 37 percent of hearing aids dispensed were in the premium level, 44 percent in the mid-level, and 19 percent in the economy level. Respondents reported that 84 percent of fittings were for binaural hearing aids—the consumer purchasing two devices—with some providers offering discounts on the second hearing aid (Strom, 2014b). The pricing of “high end” hearing aids so that they are much more expensive than “basic” hearing aids implies a substantial benefit to the consumer for using high-end devices; however, few studies have been conducted to examine the benefit to consumers, particularly regarding effectiveness in real-world listening environments (see Chapter 4). A study by Cox and colleagues (2014) found little functional benefit to justify the price disparity between these two levels of hearing aids, which can be as much as several thousand dollars. Additional consumer price data for hearing aids are presented in Table 5-1.

The VA procures hearing aids for its beneficiaries directly from hearing aid manufacturers as part of large-volume contracts. According to one report published in early 2014, the VA paid an average of $369 per hearing aid, while one vendor’s retail price for a similar hearing aid in the open market was $1,400–$2,200 (VA Office of the Inspector General, 2014). The VA’s negotiation power may be due to their bulk purchasing of large numbers of hearing aids. As noted earlier, the VA’s hearing aid purchases made up approximately 20 percent of the U.S. hearing aid market in 2013 (Strom, 2014a); in fiscal year 2014, the VA issued nearly 800,000 hearing aids (Chandler, 2015). In addition to the effects of bulk purchasing on hearing aid prices, another key difference between the price paid by the VA and the price paid by the public lies in paying for professional services associated with the hearing aid purchase. As discussed above, the retail price for the general public is often bundled to include the prices for both the hearing aid(s) and the professional services. The VA, on the other hand, negotiates a price that is only for the hearing aid itself, with fitting and rehabilitative services provided by audiologists and other providers employed by or partnered with the VA; the expenses for these professional services are not part of the price the VA pays to manufacturers for hearing aids. The VA report referenced above did not specify whether additional services were included in the vendor’s open market price of $1,400–$2,200. The VA purchasing system provides a glimpse into what may be wholesale or bulk-purchasing prices and demonstrates the potential for and feasibility of lower priced hearing aids.

As discussed in Chapter 4, technologies are rapidly changing and lower cost technologies (e.g., over-the-counter wearable hearing devices) are being explored that could potentially meet the demands of many adult consumers with mild to moderate hearing loss. Currently, there are consumer electronic products termed personal sound amplification products (PSAPs; see Chapter 4) that range in cost from less than $50 to more than $500 (see

TABLE 5-1
Examples of Retail Prices for Hearing Aids and PSAPs

NOTES: Many of these prices are from studies funded by the hearing aid industry. Prices reported as per aid (i.e., for one ear) or per pair (i.e., for two ears) depending on the unit used in the referenced source.

^aPrice includes professional services and technologies.

^bNot specified what price includes in terms of services.

Table 5-1) and may overlap in some or many of the technological features that hearing aids have. Food and Drug Administration guidelines note that these products cannot be marketed for the intended purpose of addressing hearing loss. Product standards are being developed for PSAPs that may facilitate comparisons for consumers (see Chapter 4).

TYPES OF COVERAGE AVAILABLE FOR TECHNOLOGIES AND SERVICES IN THE UNITED STATES

Medicare

Original Medicare

Services Original Medicare (also known as Medicare Part A and Part B) covers costs associated with hospital stays and outpatient services and supplies considered medically necessary to diagnose and treat a disease or condition. As part of the Patient Protection and Affordable Care Act (ACA), Medicare beneficiaries are eligible for an Initial Preventive Physical Exam when they turn 65 years old (CMS, 2015b) and an Annual Wellness Visit every year thereafter (CMS, 2015a) performed by a physician or other qualified health care provider. These visits can include screening for hearing impairment at no additional cost to the beneficiary (Koh and Sebelius, 2010). Medicare also covers hearing testing only if it is ordered by a physician or nonphysician medical practitioner for the purpose of diagnosing a hearing or balance disorder (CMS, 2016e). Audiologists can be reimbursed for conducting this testing if ordered by a physician or nonphysician medical practitioner (see Chapter 3). However, beyond this hearing test, Medicare does not pay for any other services provided by audiologists to beneficiaries, such as counseling about hearing test results, conducting a functional communication assessment, management planning, or auditory rehabilitation, even though these services are within the scope of practice of audiologists.

Medicare does cover rehabilitation services related to hearing when the services are provided by a speech-language pathologist, however (ASHA, 2016a). Services provided by a speech-language pathologist generally include evaluation and treatment to regain and strengthen speech and language skills, including cognitive and swallowing skills. In the case of patients with hearing loss (but not balance disorders), evaluation for and treatment with auditory rehabilitation can be performed by a speech-language pathologist and be covered by Medicare. Medicare payment for these services provided by a speech-language pathologist must be billed using a general speech-language pathology Current Procedural Terminology (CPT^®) code, not a code that is specifically for rehabilitating these particular functions. Extending Medicare coverage of auditory rehabilitation to provide reimbursement to audiologists, whom many consumers and patients are already seeking out for other elements of hearing health care, would make this treatment more affordable for Medicare beneficiaries.

Technologies As stipulated in the Social Security Amendments of 1965, Medicare does not provide coverage for hearing aids. Section 1862(a)(7)

of the Act states, “Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services . . . where such expenses are for . . . hearing aids or examinations therefor.” This policy is codified in the regulation at 42 C.F.R. 411.15(d), which states that hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids are excluded from Medicare coverage. The question of whether Medicare should cover hearing aids has been raised (Whitson and Lin, 2014); however, some hearing health care and hearing industry professional associations discourage this measure for many reasons, including the projected loss of revenue from private and out-of-pocket payers (Wallhagen, 2014).

Medicare Reimbursement in Other Health Care Fields

Evaluating options for expanding Medicare coverage of hearing health care can build on other areas of health care where coverage is already provided.

Habilitative and rehabilitative services by occupational therapists, physical therapists, and speech-language pathologists Medicare provides coverage for evaluation and treatment related to habilitative and rehabilitative services and related technologies including for physical therapy, occupational therapy, and speech-language pathology. These services may be provided as outpatient, inpatient, in-home when the person is homebound, or in a skilled nursing facility. There is an annual therapy cap limit to reimbursement (see Table 5-2), which means that Medicare may not always cover all rehabilitation services needed by an individual beneficiary before the therapy limit is reached.

Prostheses Medicare covers programming and follow-up after cochlear implantation. This is based on the classification of a cochlear implant as a prosthetic device and the surgical placement as a medical necessity. Medicare defines a prosthetic device as one that replaces a body part or function. Prosthetic devices covered by Medicare include cochlear implants, corrective eyeglasses or contact lenses provided after a cataract operation (coverage is 80 percent), breast prostheses, and ostomy bags (CMS, 2016g).

Medicare Advantage

Medicare Advantage (also known as Medicare Part C) is a program that allows those eligible for Original Medicare to opt out of Medicare itself and choose their own private insurance plan. For each beneficiary who opts out of original Medicare and opts into a Medicare Advantage program, the

TABLE 5-2
Reimbursement for Outpatient Auditory Rehabilitation and Other Related Therapies Under Medicare Part B

^aSee above discussion about speech-language pathology reimbursement for auditory rehabilitation.

SOURCE: CMS, 2016f.

federal government diverts the money it would have paid into Medicare to that enrollee’s Medicare Advantage plan; depending on the plan, the beneficiary may have to pay an additional premium. Medicare Advantage allows the beneficiary to choose a plan that offers specific benefits that meet his or her needs. Some Medicare Advantage plans include coverage for hearing health care services and technologies, or they may offer the option to purchase extra coverage for hearing health care. As such, Medicare Advantage plans can serve as a source of hearing health care coverage for Medicare beneficiaries. Medicare Advantage plans are becoming increasingly popular, with approximately 31 percent of Medicare beneficiaries enrolled in a Medicare Advantage plan in 2015, a number that has increased steadily since 2004 (Kaiser Family Foundation, 2015).

Medicaid

Medicaid Coverage for Adults

As of early 2015, only 28 states covered hearing aid purchases for adult Medicaid beneficiaries, and the extent of coverage varied widely between states, with it being very limited in some states (HLAA, 2015). Many states that provide Medicaid coverage for hearing aids for adult beneficiaries require that an individual obtain a medical exam and an audiological evalu-

ation to determine if a hearing aid is appropriate. Many states also have an established minimum hearing loss requirement for an individual to be eligible for hearing aids. Some states only cover certain types of hearing aids, and many have a limit on the number of hearing aids and accessories, such as batteries, that beneficiaries can receive within a given period of time. Some states set an annual cap on payments. Even when a state offers Medicaid coverage for hearing health care, finding a provider who will accept Medicaid can present another hurdle to overcome.

The Early and Periodic Screening, Diagnostic, and Treatment Program

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program is the child health component of Medicaid in which services are provided for children until they turn age 21 years (CMS, 2016a). As part of this program, each state must provide minimum hearing health care services to Medicaid beneficiaries under age 21 years, such as diagnosis and treatment, including hearing aids. When young adults covered by EPSDT turn 21 years old, they transition to the adult Medicaid program, if eligible, and receive the Medicaid hearing health care benefits provided by the state in which they reside. Thus, young adults may receive hearing health care benefits through the EPSDT program and then lose the benefits on their 21st birthday if their state Medicaid program does not provide hearing health care benefits to adults, which can make the transition to adulthood more challenging. It is important to note that states are not required to extend their EPSDT program to those who are covered by their Children’s Health Insurance Program, which supports uninsured children and young adults up to 19 years of age if their families have an income that is too high for them to qualify for Medicaid.

Affordable Care Act

The ACA established state-level health benefit exchanges that provide access to a marketplace of affordable health insurance coverage for people who were previously uninsured and did not qualify for Medicaid. The ACA also offers states the option to expand their Medicaid programs to cover more people—anyone whose family income is up to 138 percent of the federal poverty line (CMS, 2016d).

While the ACA has improved access to medical services for many people, it has not substantially improved access to affordable hearing health care for adults. Under the ACA, individual state marketplace health insurance plans and expanded Medicaid programs are required to cover 10 “essential health benefits,” including “rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities,

or chronic conditions gain or recover mental and physical skills)” (CMS, 2016b). The specific interpretation of what constitutes the benefit varies by state. Many states have chosen benchmark insurance plans that do not include hearing health care services or hearing aids for adults; if the benchmark plan does not include hearing health care coverage, then the expanded Medicaid program (if the state chose to expand) and the plans offered in that state’s marketplace are not required to offer hearing health care coverage. Out of 50 states and the District of Columbia, only 7 states (Arizona, Hawaii, Nevada, New York, Rhode Island, Texas, and Wisconsin) have chosen benchmark plans that offer hearing aid coverage for adults, with the amount of the benefit and coverage for hearing aid–related services varying by state (CMS, 2016c). Other states have chosen benchmark plans that include hearing aid coverage for children defined in a variety of ways ranging from newborns to individuals under age 24 years.

Employer-Sponsored and Private Health Insurance

Third-party payment for hearing health care is limited; only a small number of private insurance companies cover hearing health care for adults (Andrews, 2012; Consumer Reports, 2015). Employer-based coverage for hearing health care tends to be modest at best. Of those insurance plans that provide some coverage of hearing health care, some cover diagnostic and evaluation services, while others cover part or all of the costs for hearing aids, and some employers offer their employees the option to purchase hearing health care insurance similar to optional dental or vision insurance (ASHA, 2016b).

Many adult Americans under the age of 65 years (i.e., the age to qualify for Medicare) are covered by employer-sponsored health plans, which are regulated under the federal Employee Retirement Income Security Act of 1974³ (ERISA). There are two distinct types of ERISA plans: (1) those in which employers purchase health insurance coverage for their employees from a private health insurer or health maintenance organization (HMO), with the latter parties bearing the “insurance risk” of plan insolvency; and (2) employer “self-funded” plans in which the employer in effect “self-insures” the health care costs for its employees and bears the insurance risk itself but possibly engages an insurer to assist with claims administration or other non-risk-bearing functions for an agreed-upon fee. This distinction is important because it affects the degree to which state legislators and regulators can impose requirements—such as that employers must offer hearing health care insurance—on employer-sponsored health plans. States can

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³ Employee Retirement Income Security Act of 1974, Public Law 93-406, 93rd Cong. (September 2, 1974).

legislate benefits mandates that apply to commercially sold health insurance or HMO plans, and these mandates will affect employer-sponsored plans to the extent that employers purchase such policies for their employees. However, because of a legal doctrine known as “ERISA preemption,” states cannot impose benefits mandates on ERISA self-funded plans. Thus, employers that offer self-funded health plans are not subject to state-imposed benefits mandates. Large employers may elect to use self-funded plans because their large workforces may be diversified enough to make the insurance risk financially manageable.

As of 2014, only three states—Arkansas, New Hampshire, and Rhode Island—mandated that health insurance plans include coverage for hearing aids (with some specifically stating that related services were included) for adults (ASHA, 2016c). In addition, self-insured plans are exempt, meaning that large companies that have their own insurance programs and that may hire thousands of employees do not have to provide coverage to their employees even if they are in a state with mandated coverage.

Employees who have access to a flexible spending arrangement, regardless of hearing health care insurance coverage, can contribute pretax income (up to a prespecified amount, the maximum being $2,550 in 2015) to their flexible spending arrangement to cover the costs of hearing aids, hearing exams, and other audiological services—in addition to all other medical costs—during the year (IRS, 2016). With this type of arrangement, the employee bears some risk because he or she must use the funds during the calendar year, and if the employee does not incur medical expenditures during the year, he or she will lose the funds (although some employers give their employees a grace period of up to 2.5 months into the following year to use the money in the account or they may allow their employees to carry over up to $500 per year to use in the following year).

Some Federal Employee Health Benefits plans—which cover many federal employees and members of the U.S. Congress—other fee-for-services plans, and HMO plans provide coverage for hearing aids and other services for adults (HLAA, 2008). The comprehensiveness of the benefits depends on the individual plan.

TRICARE, which provides health care for members of the military, military retirees, and their families, covers hearing aids and hearing aid services for beneficiaries with hearing loss that meets specific parameters (TRICARE, 2015). Military retirees may be able to access VA services for hearing health care (see next section on benefits for veterans) or access the Retiree-At-Cost Hearing Aid Program, which is available at certain military hospitals and clinics (MAA, 2016; TRICARE, 2015).

Benefits for Veterans

Audiology is one of the highest demand services in the VA; hearing loss and tinnitus are the two most prevalent causes of service-connected disability for U.S. military veterans (Chandler, 2015; VA Office of the Inspector General, 2014). These conditions affect veterans of all ages and may not be apparent until years after military service has ended. The VA provides diagnostic audiology services for all veterans enrolled in the VA’s health care system, and hearing aids are provided at little or no cost to veterans who have a predefined minimum hearing loss that is determined to be the result of active military service (Beck, 2015) (38 C.F.R. 3.385). In some cases, veterans can receive hearing aids if their hearing loss is not directly related to their military service (38 C.F.R. § 17.149).

The VA’s audiology services include the assessment, evaluation, treatment, and management of hearing loss and tinnitus; the fitting and programming of hearing aids and hearing assistive technologies and rehabilitation with cochlear implants and other bioelectric auditory implants; hearing screening and prevention services; and auditory rehabilitation services to optimize residual hearing.

Vocational Rehabilitation Programs

The Rehabilitation Act of 1973⁴ authorizes and funds state vocational rehabilitation programs to assist individuals with a physical or mental disability that is a barrier to gaining part- or full-time employment or engaging in post-secondary education. Furthermore, it must be determined that vocational rehabilitation will help the individual with gaining employment or post-secondary education. Eligible individuals work with a counselor to create an Individualized Plan for Employment.

The program provides services, such as counseling, and devices to assist eligible individuals of all ages with disabilities. In 2014 the Workforce Innovation and Opportunity Act⁵ amended the Rehabilitation Act of 1973 to require that all state vocational rehabilitation agencies dedicate at least 15 percent of their federal funds to services for young adults transitioning from secondary education to post-secondary education or employment. Efforts to aid young adults include summer programs for students with hearing loss transitioning to college (see Chapter 6).

For individuals with hearing loss or deafness, vocational rehabilitation services can include the provision of hearing aids and other hearing health

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⁴ Rehabilitation Act of 1973, Public Law 93-112, 93rd Cong. (September 26, 1973).

⁵ Workforce Innovation and Opportunity Act, Public Law 113-128, 113th Cong. (July 22, 2014).

care services if needed for obtaining employment. Vocational rehabilitation services are administered by state programs with funding primarily through the Department of Education’s Rehabilitation Services Administration (RSA, 2016). State vocational rehabilitation agencies can and do differ in the way they operate, including how they operate when they have insufficient funds to support all eligible individuals. During these times, by law a state vocational rehabilitation agency determines priority for clients by a process called Order of Selection for Services. Under this process, individuals determined to have the most significant functional limitations are given the highest priority for benefits, while others who are determined to have less severe disabilities may be placed on a waiting list to receive services. The determination of which functional limitations should be given the highest priority is left to the state. Order of Selection for Services may reduce access to vocational rehabilitation services for people with hearing loss as they may not be seen as having as significant a functional limitation as other individuals (University of Arkansas Rehabilitation Research and Training Center, 2008).

One of the challenges identified by state vocational rehabilitation agency staff is raising awareness in the general public, particularly among individuals with hearing loss, that vocational rehabilitation programs exist and may be able to provide them with needed hearing technologies and services.⁶ Opportunities to disseminate this information more widely include collaborations among state and local disability agencies and through hearing health care professionals, as well as through advocacy organizations.

LESSONS LEARNED FROM HEARING HEALTH CARE BENEFITS PROVIDED IN OTHER COUNTRIES

Several countries with comparable development and resources to the United States provide some form of public hearing health care funding, which offers a number of funding models from which the U.S. hearing health care system can learn (see Table 5-3). The extent of coverage for technologies and services varies widely, including the extent to which maintenance, batteries, and repair are covered. Wait times to see a professional for the purpose of accessing hearing health care can be several months in some public health systems, which may lead some individuals with hearing loss to choose self-pay options to avoid long wait times.

In some countries that subsidize the cost of hearing aids or provide them free of charge, use of the devices is greater than in the United States (see Chapter 4), but market survey data indicate that the rates of use are still

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⁶ Personal communication, B. Bell, Alabama Department of Rehabilitation Services, February 16, 2016.

TABLE 5-3
Examples of Countries with Publicly Funded Hearing Health Care for Adults

SOURCES: Anovum, 2016a,b,c,d; Australian Government Office of Hearing Services, 2016a,b; Bisgaard, 2009; Egbert et al., 2012; Hear-it.org, 2016a,b,c,d,e; National Health Service, 2015.

low even in these countries (see Table 5-3). Population-based epidemiological studies of hearing loss have similar findings: In the Age, Gene/Environment Susceptibility–Reykjavik study (Iceland), hearing aids were found to be used by 21.9 percent of the participants with hearing loss (Fisher et al., 2015). Use was strongly related to the severity of hearing loss and ranged from less than 10 percent usage among those with mild loss to more than 90 percent of those with severe hearing loss (≥ 65 decibel hearing level). In addition to the severity of hearing loss, another, independent predictor of whether an individual used a hearing aid was self-reported hearing loss.

A similar effect was seen in the Blue Mountains Hearing Study (Australia), where the cost of hearing aids was subsidized for older adults with limited means. The 5-year incidence of hearing aid use was 18 percent and 48 percent, respectively, among participants with mild and moderate/severe bilateral hearing loss, was 6 percent among those with unilateral hearing loss, and was 23 percent overall. This was slightly higher than the 15 percent utilization rate reported in the Epidemiology of Hearing Loss Study (Wisconsin, USA) (Fischer et al., 2011; Gopinath et al., 2011). As in the study by Fischer and colleagues (2011), self-reported hearing loss was an independent predictor of the incidence of hearing aid use (Gopinath et al., 2011). Uptake rates in non-U.S. countries that provide subsidized or free hearing health care indicate that the cost of hearing aids is one of a complex combination of factors that contribute to an individual’s decision of whether to seek help for hearing loss and is not necessarily the sole reason that some of those who could benefit from hearing aids do not get them (see Chapter 4 for other contributing factors).

INNOVATIVE APPROACHES TO IMPROVING AFFORDABILITY

Improving Transparency in Hearing Health Care Billing Practices

Over the past several years, questions have been raised about the use of a bundled model for hearing health care billing (described earlier in this chapter). First, there is a lack of transparency for the consumer regarding the itemized costs of professional services and technologies. Fees for services are included in the purchase price of the device, which raises the (apparent) cost of hearing aids to the consumer. Second, in the bundled model, prices include a package of services that the individual consumer may or may not use. In the bundled model, prices for services are generally set by computing the average number of appointments across a large number of patients for a specific time period (typically within the manufacturer’s warranty period for the hearing aid or other technology or for a certain number of months after fitting). This calculation estimates the fee for providing services and running the business for the average patient in the practice, and this fee is

then added to the retail price of the hearing aids. Third, bundled models may include services that are advertised as “free,” such as hearing tests to determine candidacy for hearing aids and follow-up appointments. The advertised “free” hearing test may not include a comprehensive audiologic evaluation and functional communication assessment (see Chapter 3 for detailed description) but rather a screening-type evaluation, with a comprehensive exam included in the bundled cost presented to the consumer (if this exam is not covered by the consumer’s insurance or Medicare as being a medically necessary evaluation). Thus, in a bundled billing system, individuals may be paying for services that they do not need (or may need but do not use), while not paying for or receiving additional services that they do need.

There is some evidence that improved transparency in health care services pricing can lead to substantial reductions in the prices paid by consumers (Reinhardt, 2014). For example, employers with self-funded health plans have used reference pricing to reduce health care costs; if an employee chooses a health care provider that charges more than a given price limit (i.e., the reference price), the employee then pays the difference in price for obtaining the device or service. Reference pricing has proven effective in lowering the price of orthopedic surgery, imaging, and laboratory tests (Robinson and MacPherson, 2012), and it proved to be an effective mechanism for lowering health care expenditures per capita for hearing aids in Germany (Baumler et al., 2008; Schreyogg et al., 2009).

Transparency in hearing health care billing could help to differentiate the cost of the technologies from professional fees for hearing tests, professional services to fit the device, and services to provide follow-up care as needed. This type of “fee-for-service” model is familiar to patients in other areas of health care where they are accustomed to paying for visits to health care professionals, including those providing a combination of devices and services, such as in the cases of physical therapy and dental care, or the separate costs associated with a procedure versus professional services, such as often occurs when billed for visiting a primary care provider and receiving a vaccination or laboratory test.

Separating out the price of the technologies from the price of associated professional services educates the consumer about the retail prices of hearing aids and facilitates a direct comparison of similar devices across manufacturers. A better understanding of the retail prices of hearing aids also makes it easier to make an educated evaluation of the added costs of special features and technologies, such as directional microphones, noise reduction, and multiple programs. In addition, transparent pricing allows consumers to distinguish among the many components of hearing health care services, and it can promote informed decision making by allowing individuals to make informed comparisons and choose the care appropriate and afford-

able for them. Itemized and transparent lists of prices for technologies and professional services may help consumers understand all of the facets of services that may be helpful in addressing their hearing loss, including assessing the individual’s functional communication abilities and the need for intervention, selecting and fitting of the hearing aid or other technologies as needed, auditory rehabilitation services to enhance communication, and ongoing care and support. Price transparency for hearing aids and hearing assistive technologies, professional services, and follow-up care is particularly relevant under new health insurance and health care financing models that are increasing consumer exposure to health care costs (HFMA, 2014).

With transparent pricing options available, consumers can choose to itemize and pay using a “fee-for-service” model. Alternatively, consumers may opt to pay for a separate “service plan” over a fixed period of time, but this package can be billed separately from the fees for pre-fit evaluations and the cost of the devices. Because in an unbundled model individuals are paying only for the services they need and use, unbundling has the potential to reduce the total cost of services for the individual. To further enhance transparency, individuals purchasing technologies should be notified by the seller that additional visits for more services may be necessary and whether the cost of any of those visits is included in the initial purchase price. This model may also lessen the need for a large upfront investment by the consumer because the fees are collected as services are used, which occurs over an extended period of time.

Increased transparency and itemized billing may also be of benefit to consumers who use a direct-to-consumer model of delivery (e.g., online ordering), who are traveling and may want assistance with their hearing aids, or who may want to seek assistance in learning how to use the devices to their full potential, to acquire needed accessories, or to obtain assistance with ongoing maintenance and repairs. Itemized billing provides a means for dispensers to establish a unique fee schedule for these services to provide care for individuals who already own their devices but still require assistance, thus reaching more people and increasing the likelihood that those who have hearing technologies will have opportunities to learn how to get maximal benefit from those technologies. It also provides the means for individuals who purchased technologies from one dispenser to obtain service from another dispenser should the individual move, become dissatisfied with the original dispenser, or have some other reason for wanting to see a different dispenser (see Chapters 3 and 4). Although increasing transparency in pricing can help consumers make more informed decisions, some consumers and their family members still might not know exactly what services they need and will require additional help. Consumer education that accounts for an individual’s health literacy level will be needed to complement transparent pricing and itemized billing (see Chapter 6).

Alternative Care Delivery Systems

As described in Chapter 3, a number of alternative and innovative systems for delivering hearing health care exist and continue to be tested. For example, telehealth models of care have been tested as ways to expand access to various types of health care services, including audiology, and can be particularly useful for patients living in rural areas (see Chapter 3). The use of community health workers is also being tested as a potentially cost-effective mechanism for expanding access, and it may be especially beneficial in bridging access gaps caused by health professional shortages and in providing culturally sensitive care in underserved communities. Additionally, retail clinics are being used to improve access and reduce the growing demands on primary care providers. These alternative approaches to care delivery have the potential to increase access, reduce disparities, promote efficiency and value, and reduce costs for consumers, insurers, and health care as a whole. This section will focus on the potential costs and reimbursement factors related to the provision of care under these models, as Chapter 3 already described these innovative models and considered how they could affect access to care while reducing disparities.

Community Health Workers

The World Health Organization—which supports the use of community health workers in low-income countries as a cost-effective approach to greatly expanding access, maximizing finite resources, and improving health outcomes—describes how community health worker programs can be integrated into larger health care systems (Global Health Workforce Alliance and WHO, 2010; McCord et al., 2013). As noted by McCord and colleagues (2013), the resulting close connections between the community health worker programs and the health care system can lead to such benefits as timely referrals, sufficient supervision, and evidence-based information and processes. Although the specific costs associated with community health worker programs (e.g., HIV and tuberculosis screening, nutrition, pneumonia care) in low-income countries are not relevant to this discussion (McCord et al., 2013), the types of operating costs for a community health worker–delivered program for hearing-related services are likely to be similar. For example, costs might include training, salary, and benefits for the community health workers; equipment for basic screening and education; consultation time for community health workers with health care professionals (e.g., audiologists); and other overhead costs (e.g., transportation, community engagement and outreach).

In the United States, information on the costs and cost effectiveness of community health worker–provided services is limited. A systematic review

of evidence related to community health worker programs concluded that the available evidence was insufficient to assess and compare the cost effectiveness of the services provided (Viswanathan et al., 2010). Of the 53 studies identified for the review, only six featured data relevant to the cost or cost effectiveness of community health worker programs. The studies—which included interventions related to children’s health, cancer screening, and the management of chronic health conditions (e.g., asthma and mental health)—found a large range of annual costs per patient ($52–$6,200) depending, in large part, on the intensity and follow-up requirements of the program (Viswanathan et al., 2010).

Using community health workers to extend access to hearing health care services is still in the very early phases of testing and implementation. In terms of cost, researchers affiliated with the Access HEARS program⁷ in Baltimore, Maryland, have reported affordable preliminary outcomes, with the complete cost of the service provided plus the hearing product averaging approximately $200 per person served (Leaderman, 2015). If proven effective, this approach to basic care and treatment options could offer a significant reduction in costs for individuals with mild hearing loss when compared to the much higher cost (discussed earlier in this chapter) that might be required for clinical hearing health care services, which may be a barrier for some individuals. In Arizona, a partnership between academia, a local community, and a private, nonprofit Federally Qualified Health Center serving a mostly rural, low-income population employs Promotoras de Salud (i.e., community health workers) to deliver a hearing health education program in Spanish (Colina et al., 2016). Researchers from the University of Arizona are currently conducting a randomized controlled trial to evaluate the efficacy of this community health worker program to expand access to culturally and linguistically relevant hearing health care education and support. It is important to note that within each of the above-cited examples under research and development, mechanisms for referral and access to clinical care are embedded within the program. There is an ethical responsibility to provide underserved populations with equitable access to quality health care from well-trained professionals. Community health worker programs present novel ways to facilitate this access and make pathways to care more efficient. Currently, coverage and reimbursement for community health worker–provided services through

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⁷ The Access HEARS program (http://accesshears.com) was launched from the Johns Hopkins University and initially funded through a grant from the AARP Foundation. The program recently completed the proof-of-concept trial and hopes to achieve sustainability through fund raising and employ two full-time community health workers (Leaderman, 2015).

Medicare, Medicaid, and other insurers are limited. However, the ACA has expanded reimbursement and funding opportunities for community health worker–provided services. For example, the ACA authorized the Centers for Disease Control and Prevention (CDC) to administer grants for various types of evidence-based interventions, including efforts to “educate, guide, and provide outreach in community settings regarding health problems prevalent in medically underserved communities,” (CDC, 2015, pp. 4–5), which may represent an opportunity for hearing health care. The legislation also led to an amendment to the Centers for Medicare & Medicaid Services’ rules regarding who may be paid for preventive services under the Medicaid program; although this ruling was not directly relevant to audiology, it may open a door for other types of services to be added in the future. Effective October 2013, nonlicensed care providers, including community health workers, may be eligible to receive payment under Medicaid, as long as these services are recommended by a licensed health professional (CDC, 2015; CMS, 2013). States are also establishing a more defined place for community health workers within the health care system through Medicaid. A policy brief from the CDC describes how individual states are authorizing Medicaid reimbursement for community health workers that goes beyond preventive services to integrate community health workers into team-based approaches to health care (CDC, 2015), which could lead to improved access and outcomes for individuals in underserved communities. Leveraging existing models of community health worker–provided services across the United States may provide opportunities for the hearing health care field.

Telehealth and Tele-Audiology

The use of telehealth has been promoted as a mechanism to expand access, improve care continuity and coordination, ensure quality, and increase value and efficiency (AMA, 2016; Klink et al., 2015). Telehealth can also save patients time and money on travel and transportation. For example, the Alaska Federal Health Care Access Network, which provides telehealth services in a state where approximately one-third of the population lives in a rural area, estimated a savings of $8.5 million in travel costs for Medicaid beneficiaries in 2012 (AHRQ, 2013; U.S. Census Bureau, 2012). However, the overall potential for costs saving and the cost effectiveness of telehealth is less certain and will depend on the type of care being provided, the health professionals providing the care, and the types of equipment and other resources needed to provide the care. A systematic review of literature concluded that telehealth services appear to be no more cost effective than conventional health care delivery mechanisms (Mistry, 2012). Despite these

findings, telehealth, like retail clinics (described below), holds the potential to reduce expenditures on more expensive forms of care (e.g., emergency department visits), which would result in a net savings for payers and the health care system.

Inconsistencies and limitations related to reimbursement regulations have been cited as barriers to the wider adoption of telehealth (e.g., AMA, 2016; Klink et al., 2015). For example, Medicare coverage of telehealth services is currently limited to beneficiaries who live in rural areas; a defined set of services provided by specific providers;⁸ and live, synchronous interactions between the patient and provider (CMS, 2015c). Legislation has been introduced in Congress to update Medicare’s coverage of telehealth services: the Medicare Telehealth Parity Acts of 2014 and 2015 (H.R. 5380 and H.R. 2948), if enacted, would have expanded coverage beyond rural areas; included reimbursement for audiologists, speech-language pathologists, and other types of health professionals; and allowed remote patient monitoring for some chronic health conditions (Lacktman, 2015).

Many states have also enacted laws which provide for reimbursement through Medicaid and private insurances (Bachrach et al., 2015). Almost every state allows some form of reimbursement for telehealth services through Medicaid (48 total), and almost half have parity laws covering private insurances (24 total). However, the legal frameworks in many states set limits on the provisions of telehealth. For example, nine states have reimbursement restrictions related to distance or population density (e.g., distance between patient and provider, use in rural areas), and four states forbid the use of cell phone videos for the purposes of telehealth. Additionally, many states limit reimbursement to only cover live, synchronous interactions, prohibiting the use of remote patient monitoring, store-and-forward interactions, or transfer of saved images (Thomas and Capistrant, 2015). In its most recent gap analysis, the American Telemedicine Association, an advocacy organization that supports the broad implementation of telehealth in the United States, ranked Alaska as the most telehealth-friendly state in numerous categories (e.g., Medicaid reimbursement, the use of eligible technologies) (Thomas and Capistrant, 2015).

With regard to hearing health care in the United States, the use of telehealth services is currently limited due, in part, to reimbursement restrictions. As noted above, Medicare regulations do not include audiologists and speech-language pathologists as eligible providers of telehealth services (AAA, 2016; CMS, 2015c). However, Medicaid programs in some states do allow reimbursement for audiology services that can realistically be provided remotely. For example, earmold impressions cannot be taken

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⁸ I.e., physicians, physician assistants, specific types of nurses, registered dieticians and nutritionists, and clinical psychologists and sociologists.

remotely, but teleprogramming of hearing aids could be covered in some states (AAA, 2016; ASHA, 2012). Beyond expanding access to care and reducing travel costs for patients, other possible cost savings associated with tele-audiology remain unclear. Given the uncertainties about time requirements, administrative and technical costs and requirements, and reimbursement coverage and rates, some hearing health care professionals may be reluctant to offer telehealth to their patients. Further investigation and policy changes will be required to ensure the widespread adoption of tele-audiology services that satisfy the needs and preferences of both patients and providers.

Retail Clinics

The number of retail clinics in the United States has increased by more than 9-fold in the past 10 years (from 200 in 2006 to more than 1,800), and estimates suggest that the number of visits to these clinics increased between 4- and 7-fold during roughly the same timeframe (Bachrach et al., 2015; Mehrotra and Lave, 2012). As described in Chapter 3 and in previous reports from the Institute of Medicine, these clinics offer a convenient and efficient alternative to some primary care services, which may also result in savings to patients, payers, and the health care system as a whole (IOM, 2010, 2011). For example, a 2010 study by Weinick and colleagues (2010) estimated that approximately 13 to 27 percent of emergency department visits could be managed safely and effectively in retail and urgent care clinics, representing a possible overall savings of approximately $4.4 billion dollars per year. However, questions remain about whether the increased availability of retail clinics in the last decade is reducing unnecessary emergency department visits or driving an increased utilization of health care services overall and thus increasing cost (Mehrotra, 2015).

In setting costs for patients, the retail clinic model uses a transparent, fixed pricing scheme in which prices for services are readily available or clearly posted in stores and online. The costs for most services range from $30 to $75, representing a significant savings to patients and insurers when compared with the cost of a visit to a physician’s office or an emergency department (IOM, 2010; Mehrotra, 2015). For example, the cost of care in physicians’ offices or emergency departments for the three most commonly treated conditions in retail clinics (i.e., otitis media, pharyngitis, and urinary tract infections) ranges from approximately $160 to more than $550, whereas care for those conditions in a retail clinic cost approximately $100⁹ (IOM, 2010; Mehrotra, 2015; Mehrotra et al., 2009). Although

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⁹ These estimates include the cost of the consultation with the health care professional(s), pharmacy/prescription services, and laboratory expenses (Mehrotra et al., 2009).

most retail clinics accept health care insurance—Medicare, Medicaid, and private insurance—and some insurance companies encourage the use of retail clinics by reducing or waiving copay fees, approximately 35 percent of patients choose to pay for services out of pocket (IOM, 2010; Rudavsky et al., 2009). The lower costs for these services can be attributed to the use of less costly health care professionals (e.g., nurse practitioners, physician assistants); efficient models of care that implement clearly defined care protocols, algorithms, and clinical practice guidelines; and new technology.

The services offered through retail clinics are evolving to include management for some chronic health conditions, and more retail clinics are being integrated into health care systems as a way of ensuring timely referrals, improving care coordination, and possibly lowering costs for payers (Bachrach et al., 2015), further opening the possibility of including hearing health care services. Just as community health workers can be trained to administer basic audiometry services and technologies in underserved communities, so too can health care professionals in retail clinics, as is currently being considered by the partnership between the Walgreens Boots Alliance and Connect Hearing (Sonova) (see Chapter 3). Costco Wholesale warehouses offer another retail example with approximately 500 hearing aid centers located in Costco Wholesale warehouses across the United States. These hearing aid centers offer hearing tests and sell hearing aids from four of the six largest hearing aid manufacturers at prices lower than average retail prices (from $499.99 per hearing aid) (Costco Wholesale, 2016b; Kirkwood, 2014; Stock, 2013) (see Table 5-1). Costco Hearing Aid Centers also provide free follow-up care and assistance with cleaning (Costco Wholesale, 2016a). Although this model offers more affordable options to those who have a Costco membership, there are concerns about the lack of training some Costco Hearing Aid Center employees have (e.g., Kasewurm, 2014). In conjunction with companies that operate retail clinics, researchers, health care professionals, health care systems, and regulators, the hearing health care field needs to determine which services and treatments can be provided in retail clinic settings and still ensure high-quality, cost-effective care that is integrated with other hearing health care professionals and services.

NEXT STEPS AND RECOMMENDATIONS

In the hearing health care system that serves adults, nearly all costs are out of pocket and the costs are relatively high. The vast majority of employers do not provide hearing health care insurance. Few state Medicaid programs offer hearing health care benefits without strict limitations. Vocational rehabilitation programs offer a tremendous benefit for those with hearing loss who are seeking employment, but wait times can be long, and

those with hearing loss who are seeking assistance can be skipped over in order to help those who have disabilities considered to be more prohibitive for gaining employment. Given the high number of Americans who have hearing loss and the high cost of hearing health care, changes to the cost of hearing health care are needed.

Recommendation 10: The Centers for Medicare & Medicaid Services, the Patient-Centered Outcomes Research Institute, the Agency for Healthcare Research and Quality, the National Institutes of Health, the Centers for Disease Control and Prevention, the Health Resources & Services Administration, the Department of Defense, the Department of Veterans Affairs, researchers, and health care systems should prioritize and fund demonstration projects and studies, including randomized controlled trials, to improve the evidence base for current and innovative payment and delivery models for treating hearing loss.

Specifically,

• Innovative models to be evaluated should include, but not be limited to, community health workers, telehealth, mobile health, retail clinics, and self-administered hearing health care. These projects and studies should include outcomes that are patient centered and assess value, comparative effectiveness, and cost effectiveness.
• Demonstration projects should evaluate the health impact of beneficiary direct access to audiologist-based hearing-related diagnostic services, specifically to clarify impact on hearing health care accessibility, safety, and the effectiveness of the medical home. This excludes direct access to audiologic testing for assessment of vestibular and balance disorders and dizziness, which require physician referral. Successful outcomes would provide evidence of effective communication and coordination of care with primary care providers within a model of integrated health care, and evidence of appropriate identification and referral for evaluation of medical conditions related to hearing loss and otologic disease.
• Models that are found to be most effective should be widely implemented.

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