About 17% of American adults report some degree of hearing loss, yet fewer than one-fifth of them seek help for their condition (National Institute on Deafness and Other Communication Disorders, n.d.-a, n.d.-b). In fact, most hearing aid users live with hearing loss for more than 10 years—letting their impairments progress to moderate-to-severe levels—before seeking a hearing aid (Davis, Smith, Ferguson, Stephens, & Gianopoulos, 2007). Clearly, there is a need for expanded hearing health care (HHC) services. But first, we need answers to persistent questions surrounding the accessibility and affordability of HHC.
There are no readily accessible, low-cost, hearing screening programs in the United States. Although the Internet provides access to online procedures for hearing screening, and numerous smart phone apps are also available for hearing screening, most of these tools are not validated. HHC access—inclusive of hearing screening/assessment, acquisition of an appropriate device, and services tailored to a person's needs—can be confusing due to multiple entry points, such as family practitioners, audiologists, hearing aid specialists, otolaryngologists, and direct Internet access, as well as magazine, newspaper, and television offers.
Affordability is an open question as well, because "affordability" is difficult to define. There are likely different price points for different segments of the population, and limited scientific data are available on how cost affects hearing aid adoption rates. But hearing aids can be among an American's biggest expenses, after the mortgage and car payments—and paying for them is often a challenge, or simply impossible.
There are programs that provide free or reduced-cost hearing aids, but on a limited basis. Thus, without help from Lions Clubs, hearing aid loaner banks, and other such philanthropic organizations, many people who need hearing aids must forgo them—unacceptable for individual life functioning and for public health in general.
The cost associated with hearing aids, and the lack of or limited insurance/Medicare coverage, is one of the most obvious barriers to HHC, but there are many others that need additional research. What are the barriers for accessing HHC: availability of services, cost, location, health care insurance coverage, and/or the referral network? Are there unique concerns across the lifespan, and among different cultures or special populations—for example, perceived need, personal attitudes, stigma, socioeconomic status—that influence HHC? And finally, does every individual with hearing loss need the most advanced—and expensive—hearing aid technology? Let's begin by looking at some external factors related to HHC.
In the examination of the current state of HHC, four external factors that influence accessibility and affordability emerge in sharp focus: changes in demographics, socioeconomics, emerging technologies, and evolving service-delivery paradigms.
Changing demographics. America is aging—by 2026, 30% of the U.S. population will be over 55 and 18% will be over 65 (U.S. Census Bureau, 2009). We expect to see a simultaneous increase in people with hearing loss and hearing aid candidates. We need more information to understand the characteristics of older adults who benefit most from hearing aids and the demographic variables—such as age, degree of hearing loss, cognitive abilities, or socioeconomic status—that contribute to the penetration rate of hearing aids.
Changing socioeconomics. Americans living in rural areas are more likely to be older, have lower incomes, be in fair or poor health, and have chronic health conditions. People living in inner cities are also underserved, and many Americans have limited disposable income. Acquiring appropriate HHC may be especially challenging for the working poor. Our limited knowledge in this area is noteworthy; the size and composition of unserved and underserved populations are not well defined. How can we increase access and decrease cost for those with limited incomes? We need more information on special populations—those with comorbid diseases/conditions, intellectual disabilities, cultural or language differences, or advanced age—and whether they have unique requirements.
Changing Technologies. The increasing use of telehealth is making health care services accessible in ways other than face-to-face meetings. Audiological assessment and hearing aid fitting and management processes are moving toward automation. Automated hearing tests—telephone-, computer-, or Internet-based—including speech-in-noise testing, are more viable now than in the past. Technological advances make it likely that one day audiometry, real-ear measurements, and hearing aid programming and fitting can be packaged and performed on one chip. Can we develop a quality self-testing, self-fitting hearing aid, one that considers demographic and audiologic characteristics, selection, fitting, and aftercare? Which technology-centered factors—for example, cost, appearance, or performance—determine the adoption rate of hearing aids, and do these vary among age, cultural, and socioeconomic groups? What technology-related variables predict success with amplification?
Service delivery paradigms. Traditional sources of hearing aids include audiologists, hearing aid specialists, and otolaryngology offices. But now there are storefront—as well as Internet—hearing aid sales and services, including direct-to-patient and referral/consolidators. Internet and telehealth opportunities for remote audiometric testing, and for hearing aid fitting and management, are available, although not all are well studied and validated. Professional workforce demographics also are changing (i.e., shortage of primary care physicians and audiologists), and professional organizations are considering the training and certification of audiology assistants and technicians in an effort to maximize productivity of the most highly trained individuals. Convenient care clinics, providing access to basic care for the most common acute conditions, are now an integral part of the health care landscape (Mehrotra et al., 2009).
It may be possible to modify current delivery systems—including the system and the provider—to increase HHC accessibility and affordability. Many key questions remain, such as the knowledge, skills, and abilities of HHC professionals (audiologists and audiology assistants) and other persons providing HHC (e.g., nurses, nurse practitioners, trained volunteers, caregivers, students, physician assistants) in traditional and nontraditional settings.
Interrelated issues, tensions, and conflicts across provider groups have contributed to the current HHC situation. The willingness of manufacturers to produce lower-cost hearing aids, and the willingness of audiologists to sell them in the traditional distribution system, are debated within and among the professions. Direct access for older adults with hearing loss has long been a tension between otolaryngologists and audiologists, as have differing educational qualifications and credentialing of those who dispense hearing aids. Professionals and professional organizations have not uniformly supported Medicare reimbursement for hearing aids.
The value of current federal regulations that require a medical evaluation is also under debate. Some consider these regulations burdensome. Some individuals seeking hearing aids sign a medical waiver—essentially circumventing the medical evaluation—but exact numbers are unknown.
More research is needed to determine the appropriate medical evaluation to rule out contraindications for using a hearing aid. For example, it would be valuable to know whether existing U.S. Food and Drug Administration requirements for medical evaluation and clearance prior to hearing aid procurement provide significant protection to hearing aid users or create a significant barrier to access. What percentage of hearing aid recipients opt for the medical waiver and of these, what percentage is subsequently diagnosed with medically treatable hearing loss? How many of those adults seeking hearing aids have hearing loss with a medically or surgically treatable cause?
The field of audiology needs research to answer these and other questions to provide accessible and affordable HHC. To date, few studies have addressed the HHC system.
Outcomes & Health Services Research
Outcomes and health services research provides important new opportunities for research audiologists. Researchers investigate the degree to which a given intervention works in patients and populations in real-world settings, such as in diverse populations and among varied providers and clinical practice settings. This research is geared toward quality of life, the patient's experience of and satisfaction with health care, and the social and economic consequences of care. Outcomes and health services research also examines how the organization, financing, and management of health care services affect the delivery, quality, cost, access to, and outcomes of such services. These investigations are often multidisciplinary and require collaboration among members of various fields.
The National Institute on Deafness and Other Communication Disorders (NIDCD) held a small focus group on outcomes and health services research in June 2011 to discuss methods to increase the number of researchers and research in this area. Several national organizations—including ASHA and the American Speech-Language-Hearing Foundation—were invited to participate, along with scientists from the NIDCD research community and the Department of Veterans Affairs, which already has a robust health services research agenda.
Several follow-up activities have already occurred as NIDCD seeks to increase the number of researchers addressing HHC. In the spring, NIDCD solicited administrative supplements from currently funded NIDCD grantees to encourage and expand collaborative research on outcomes and health services. The NIDCD also published a Request for Information, seeking information on the availability of existing resources and strategies to encourage and expand NIDCD outcomes and health services research. Finally, NIDCD co-sponsored a working group in March 2012 on the collaboration and consolidation of databases for research evaluating hearing health care.
Problems surrounding access and affordability of HHC can be solved, and audiologists should play a crucial role in solving these issues. The solution requires research—which the NIDCD is eager to support—and requires the willing engagement of individual audiologists and the field as a whole.
Finding solutions also requires engagement of organizations involved in hearing health care, including industry, consumer advocacy organizations, professional organizations, and government. The ultimate goal—an increase in the number of adults with hearing impairment who receive quality hearing health care—is a mandate we can all support. Let's work together to achieve it.
This article is adapted from "Research Needs in Accessible and Affordable Hearing Health Care for Adults With Mild to Moderate Hearing Loss," which appeared in ASHA Access Audiology.