Data Driven and Determined
What can audiologists, as service providers, expect with respect to the changes all health care providers will face? Tomorrow's audiologists will be diligent practitioners of patient-centered care, more accountable than ever before in requesting reimbursement for services and regularly pursuing new and different types of professional education. Their education will include an interprofessional approach to patient care. They will become members of health care teams addressing complex medical issues where the result is a patient-centered approach to care.
They will lend their care and expertise to resolving acute cases as they always have, but they will also expand their involvement to include long-term management of patients' hearing health. And they will be data driven—routinely recording treatment outcomes and patient progress—and at the ready with statistical evidence that validates the care they provide. Failure to pursue approaches like these will put practices at significant risk. As audiologists, we will be asked for evidence that the procedures we use produce significant positive outcomes for our patients. Patients also will be asked for feedback about the effectiveness of their respective providers' services.
So, how will audiologists demonstrate that they have provided the most appropriate and effective services for the conditions presented? We must find or collect data (i.e., evidence) that the procedures we use result in positive changes in function. Large datasets that take into account the diagnosis, patient's functional level, patient demographics, co-morbidities, and likely additional factors must be collected and continually modified.
Does that sound like an exaggeration? Think again. Forces of change have been gathering for a while. Health care costs are at unsustainable levels that drive the nation's mounting deficit. Health care—Medicare and Medicaid costs—is the number one cause of our fiscal and debt problems. The United States spends the largest proportion of its GDP on health care, yet ranks lowest on measures like quality of care, access, efficiency, equity, long and healthy/productive lifespan, and health expenditures per capita. Transformation of the infrastructure currently supporting health care is necessary to develop new payment systems that can sustain affordable and accessible quality health care. Health care spending continues to grow more rapidly than inflation and population growth, despite initiatives implemented to curb this growth. Indeed, those who hold the fate of health care practitioners in their hands—lawmakers and policymakers, regulators, health care rating organizations, accrediting bodies, employers, commercial payers, and, last but not least, the public—are insisting on improved patient care at lower costs. In anticipation of these changes, last summer audiology organizations co-signed a communication to put their respective members on notice.
How far away are these changes in reimbursement based on outcomes? For audiologists, probably not far. For other health care providers, the time has already arrived. Some professions are required to document expected outcomes, and payment for their services depends on how well those outcomes are achieved. There is little comfort knowing that we are required to become a part of this change. The comfort may come when we are on the other side of the desk. When we pursue health care services as patients, we will want to know the likely outcome—or documentation of success—of the proposed treatment, not only in general terms, but in terms of its successful use by our individual practitioner. The demands for change are neither a policy fad nor the agenda of any one group; rather, they are widely accepted goals. Every indication is that they will be required indefinitely. Practitioners who do not make changes will likely find the road ahead of them pretty bumpy, if not a dead end.
What is needed if practitioners are to position themselves to operate viable practices in the future? That question arose for a cross-section of thought leaders, experts, and advocates at the Summit on the Changing Health Care Landscape, hosted by the American Speech-Language-Hearing Association (ASHA), October 5–7, 2012. Summit participants included representatives from all major audiology organizations. For audiologists and students of audiology, Summit attendees highlighted a number of points, including the following:
- A top priority must be patient-centered care that reflects the patient's wants, needs, and goals and features measures of care value, outcomes, and best practices.
- Audiologists and students will have to be continually educated about a variety of topics in a variety of ways. Subjects should include outcome measures for evaluating intervention steps and demonstrating value of care; reimbursement models; and areas of care, such as hair cell regeneration, vestibular prostheses, and cell and gene therapy. Also, interprofessional education should be encouraged; student education should feature models of preferred practice patterns, while online courses about the changing health care landscape and reimbursement issues need to be available to faculty and students alike.
- Data must drive the practice of audiology. Attendees cited the critical need for an extensive and accessible registry of anonymous patient data related to audiological services. By bringing best practices to light, documenting outcomes, and justifying costs, this registry of data would provide a much-needed evidence-based source of defensible arguments to present to reimbursement officials.
- A learning health care system can result in improved outcomes, reduced and unwarranted practice variation, reduced medical cost, continuous quality improvement, and improved health care value.
- Payment systems will be built on predictive modeling—based on large-scale datasets—that can be used to predict the rehabilitation potential of individual patients (based on historical data from similar patients).
These points reverberate in the recommendations from the Summit conference. Ultimately, attendees called for practitioner tools for collecting and mining data related to patients' auditory and vestibular impairment as well as for providing classification of impairment severity as it affects quality of life. They also recommended an informative model for determining the amount of care an audiologist should deliver.
Other recommendations from the Summit include funding of a multi-centered controlled study to show quality-of-life improvement, developing a means for making hearing aids available to everyone in need of them, and prompting changes in Medicare reimbursement as it pertains to comprehensive care and audiology telepractice.
The impact of such recommendations remains to be seen. For its part, ASHA has appointed a committee to consider the Summit report and suggest a course of action. Areas to be addressed are: education and interprofessional education, core competencies, reimbursement models, reframing the professions, and outcomes/databases/quality improvement.
Nonetheless, I believe, current and future practitioners of audiology already have encouraging news. It lies in things such as last summer's co-signed letter and the ASHA-sponsored Health Care Summit, where a wide range of participants addressed the future thoughtfully, realistically, and, above all, proactively. All were keenly aware of their responsibility to play a role in shaping the future of audiology and in equipping their members and constituencies accordingly.
Of course, in the end it will be up to every practitioner of audiology to be in the know, prepared, and adaptive. But for now we all can take comfort that collaboration and pro-action are a proven prescription in cases of uncertainty, especially when strong winds of change are forecast.
What might tomorrow's audiologist look like? Consider the example of the elderly individual just treated at the ER for congestive heart failure. The patient lives alone, has documented hearing impairment, and some cognitive deficits. He leaves the ER with several prescriptions and recommendations from hospital staff, including the need to return in 2 weeks for follow-up. He returns home, ill, tired, and with several medications. He is having difficulty recalling the events of the day, including what the hospital staff told him; he questions whether he heard correctly the instructions from the pharmacist. Five days later, he is readmitted to the ER, again experiencing difficulty breathing; he is treated for congestive heart failure. What is the audiologist of the future's role on a team in a patient-centered care model? Audiologists are experts in understanding the limitations imposed by impaired hearing. Their role on a health care team can go beyond providing amplification in this patient's case. Audiologists can educate team and family members about the unique needs of the patient with hearing loss, which can lead to better communication, and enhanced understanding of recommendations as they are explained. In concert this can improve overall health outcomes and quality of life. The knowledge and experience audiologists possess must be shared with all members of the team, from the physician prescribing medication, to the ER staff, to the pharmacist, to the neighbor monitoring the patient's medication schedule.
It is known that improved disease management and care coordination can reduce hospitalizations. How can audiology fit into this patient's health care plan? Do other health care professionals have a place? Can paraprofessionals or neighbors play a role in monitoring this patient? I believe that, as members of the audiology profession, we need to become part of the team whose collaboration results in improved patient outcomes and helps to reduce the cost of medical care. This is just one example. I believe that we as a profession can find many opportunities to prove the value of becoming an integral part of an interdisciplinary health care team. The future is here. Let's be sure we are a part of it.
Neil J. DiSarno, PhD, CCC-A
ASHA Chief Staff Officer for Audiology
A 'Sea Change' in Health Care Reimbursement
Executive Summary: Changing Health Care Landscape Summit [PDF]
Practice Considerations for Dispensing Audiologists