Aaron C. Jones, AuD, MS, CCC-A
The hearing health care paradigm is rapidly shifting. It is becoming critical for audiologists in clinical practice to work at the top of their license because patients are changing, new competitors are entering the market, and profit margins are declining. What does it mean to work at the top of one’s license? For audiologists in clinical practice it means delivering services consistent with a doctoral profession and reducing work on things that could be done by someone else.
Audiologists must work at the top of their license partly because patients are changing. They are transforming into health-care consumers with expectations anchored by great experiences in other industries. Now more than ever, patient-centered care is needed to elevate the patient experience. In addition, competition in the hearing health care industry is changing. Legislation and technological advances are fostering new physical and virtual competitors that press audiologists to work at the top of their license. Consumers are gaining access to over-the-counter (OTC) hearing aids with an inevitable spectrum of features that leverage artificial intelligence to perform audiologic functions. Lastly, declining profit margins provide even more incentive. Lower reimbursements and the proliferation of third-party administrators force audiologists to rethink their business models.
In response to these changes, audiologists must clarify their professional value proposition in a way that motivates consumers to choose their services despite the availability of perceived alternatives.
Patients are transforming into health-care consumers. Many audiologists remember the way it used to be: patients were relatively uninformed about their hearing health care and often trusted their audiologists’ recommendations. Today, patients have a greater sense of empowerment. While they may still respect the recommendations of their providers, they often have their own preconceived notions, too. Right or wrong, they use the internet to educate themselves about both problems and potential solutions, and they have greater expectations for how their care will be provided.
To help understand what this transformation means to audiologists, Unitron surveyed 360 hearing aid owners and non-owners (Hayes, 2018). Of those participants, a whopping 92% of hearing aid owners who expressed dissatisfaction with their purchase indicated they “would like to be an active participant in the process and the decision” of purchasing their next hearing aids, as did 67% of those who were somewhat satisfied and 59% of those who were satisfied. Furthermore, this survey uncovered that 70% of very satisfied hearing aid owners recommended their provider to at least one other person, and that 38% of this group recommended their provider to two or more people. Only 37% of hearing aid owners who were somewhat satisfied recommended their provider, and 0% of dissatisfied owners made a recommendation. These data support the argument that maximizing satisfaction by engaging with patients in a process of patient-centered care can lead to word-of-mouth referrals, which are critical for the success of audiologists in clinical practice.
We are experiencing a rapid shift in the way people interact and consume. The transformation of patients, together with a proliferation of digital technologies, is the impetus for this shift. As smartphones and apps became ubiquitous, the transportation, entertainment, food, and consumer goods industries adapted. For example, in the transportation industry, Uber surfaced to give consumers unprecedented access to taxis. Entertainment companies like Spotify and Netflix entered to make massive libraries of audio and video content available on-demand. Starbucks brought an unprecedented level of personalization to retail coffee shops, and Amazon made a vast array of consumer goods available 24/7. Above all, these companies forged their identities by creating satisfying consumer experiences. They gave consumers a voice and choice in a way they now expect in other areas of their life, including health care.
The health-care industry is lagging. Only recently some health-care specialties began adopting digital technologies in attempts to improve the patient experience. Specialists in optometry, psychology, and dermatology, for example, have done this and raised the bar. They realized that to create and offer a remarkable patient experience, they must focus on patient satisfaction. It is the key driver. What does that mean in the context of health care?
A study was undertaken that helps us answer that question (West Corporation, n.d.). Health-care providers were surveyed to identify the things they think are most important to their patients’ satisfaction. The same survey was given to patients, who were asked to identify the things most important to their own satisfaction. An important finding was that patients prioritized satisfaction metrics differently than their providers did. While providers thought friendly and accommodating staff were the most important thing, no single metric stood out in the eyes of patients. Patients wanted it all with an emphasis on respect for their time, respect for their money, and expert care.
Audiologists in clinical practice can be perceived as the experts by working at the top of their license in ways that stand out from the competition. The growing list of competitors includes brick-and-mortar businesses staffed by other audiologists and hearing instrument specialists, ones staffed by other service professionals, OTC product retailers, and artificial intelligence. What can an audiologist do in their clinical practice that is most unique and challenging for all of these competitors? The answer is to provide evidence-based, patient-centered care.
Competitors employing clinical audiologists and/or hearing instrument specialists abound; independent practices, otolaryngology practices, and large retailers are just a few types. Practices employing other service providers like physical therapists have even entered the market as their professional scopes of practice allow. Obviously, not all practices are the same. Hearing health-care providers have uncovered numerous ways to differentiate their practices: patient age, audiologic function, risk factors and disorders, geographic location, referral sources, and more. Importantly, sustainable differentiation requires more than unique service offerings. It requires distinguished care that resonates with patients both emotionally and financially (West Corporation, n.d.). This patient-centered care helps build lasting relationships that lead to the repeat and referral business audiologists need for successful clinical practice.
When the Over-the-Counter Hearing Aid Act was signed into law in 2017, the door opened for consumers with mild and moderate hearing challenges to obtain aids without the assistance of hearing health care professionals. Clinicians and practice owners alike remain justifiably skeptical about the implications since the U.S. Food and Drug Administration has yet to provide guidance, but audiologists can start planning for OTC competitors who are eagerly waiting to enter the market through brick-and-mortar and online channels.
Online competitors with direct-to-consumer business models have been around for years. With little or no accompanying services, consumer interest in these products has been and will continue to be driven by price and accessibility. Of course, there will always be consumers who are most motivated by price, but this is not a call for alarm. Recent research reveals significantly lower consumer satisfaction with pre-programmed devices that lack an audiologic delivery model (Humes et al., 2017). Direct-to-consumer hearing aids and OTC devices may leverage advanced technologies just like traditional hearing instruments, but they are not bundled with all the services that differentiate audiologists. Their prices may not include a hearing aid orientation, verification, or custom ear molds, for example. In this case, audiologists can differentiate themselves by itemizing their services and products, and unbundling them when appropriate, to clarify their value proposition and compete with relatively low-cost competition.
Andrew Ng, a renowned computer scientist and former Chief Scientific Officer at Baidu, once said that tasks a person can do with no more than one second of thought may be automated with artificial intelligence now or in the near future (Ng, 2017). This suggests that in hearing health care, some tasks may be ripe for automation. In fact, there have already been attempts to automate routine audiometry. Advances like these are unlikely to replace human professionals, however, and some may actually help audiologists be even more successful. Counseling is one crucial aspect of hearing health care that seems beyond the near-term reach of automation. While virtual personal assistants may leverage language models and acoustic models to function in simple use cases, and emotion detection may mature to reliably recognize extremes, the empathetic top-of-license counseling provided by audiologists ensures their job security. Complex decision-making based on subtle cues among a highly variable spectrum of patients will keep audiologists in clinical practice for years to come.
Despite a clear need for audiologists in clinical practice, review of the Medicare fee schedule reveals reimbursement rates for their services generally have been steady or declining for more than ten years (Centers for Medicare & Medicaid Services, 2018). Simultaneously, we have seen increases in rent and utilities, minimum wages, and our own health care expenses. In addition, patients have increasingly sought hearing aids through third-party administrators that typically share profits with audiologists in exchange for patient leads. Audiologists in clinical practice are faced with declining profit margins.
Jack Welch, ex-CEO of General Electric, once wrote, “When the rate of change inside an institution becomes slower than the rate of change outside, the end is in sight.” (General Electric, 2000). The sky is not falling, and one need only look at other health-care specialties to see where this is headed. In pharmacy, for example, declining profit margins pushed pharmacy organizations to become more operationally efficient through the use of pharmacy technicians. Single-pharmacist practices have evolved to reduce their overhead expenses and employ technicians to perform routine tasks. The same can be said of dental practices, which use hygienists to triage patients, and optometry practices, which use opticians to increase their practice efficiency. By delegating some tasks to audiology assistants and other staff as allowed by state licensing boards, audiologists in clinical practice may be able to offset their declining profit margins.
As reimbursement rates have declined, audiologists in clinical practice have become increasingly dependent on revenue from hearing instruments. A trick has been to get qualified patients in the door with inexpensive marketing. One study, for example, revealed the average cost of acquiring a single new patient was as high as $450 (CallSource, 2014). In some local markets, patient acquisition has been particularly challenging, especially as patients and the way they consume information change. Third-party administrators entered the mix to provide leads at no direct cost in return for shared profits.
Depending on an audiologist’s business model and patient demographics, participation in this system of managed care may or may not make sense. Some audiologists may be able to inexpensively acquire sufficient leads without involving a third party while others may not. In some local markets, audiologists may find it necessary to contract with one or more third parties simply because their competitors have already done so. Regardless, it remains critical for audiologists to establish a value proposition so health-care consumers will seek their care despite the availability of relatively low-cost alternatives.
Changing patients, new competitors, and declining profits are conspiring against the hearing health-care profession, but audiologists can work at the top of their license to provide something that differentiates themselves: patient-centered care. By giving patients the positive and satisfying experiences they expect, audiologists in clinical practice can get more of the repeat and referral traffic they need. What patients want is easy, empathetic care from an expert. They want the ease and affordability of online products with the personalization encountered in consumer industries.
For audiologists in clinical practice, working at the top of one’s license means delivering doctoral-level services and reducing the amount of work spent on things that could be done by someone else. Certainly in the case of hearing aids, the low prices of online and OTC devices and third-party payers are compelling to some, but data suggest patients also value audiologic services. Therefore, it is incumbent upon audiologists to make their value proposition clear. They must provide comprehensive patient-centered care that includes empathetic counseling, personalized evidence-based services and products, and unique offerings in their local markets.
Audiologist and entrepreneur Aaron Jones has worked in a variety of clinical settings, including a private practice EAR Audiology, which he founded, dynamic ENT offices, and the U.S. Department of Veterans Affairs. He is passionate about patient-centered innovation and has spent his career making products and processes better for users, both in and out of the health-care industry. Aaron is Senior Director of Product Management and Practice Development at Unitron and a hearing science instructor at San Diego State University. Previously an engineer, his experience includes programs in genomics at Illumina, automatic speech recognition and augmented reality at SRI International, anthropometrics at NASA, and acoustics at Boeing. Aaron earned an MS in management from Stanford, where he specialized in patient-centered innovation. He can be contacted at firstname.lastname@example.org.
CallSource. (2014). Hearing Industry Case Study: CSG Better Hearing Care Inc. Retrieved from http://www.callsource.com/wp-content/uploads/2016/04/csg-case-study.pdf [PDF].
Centers for Medicare & Medicaid Services. Physician Fee Schedule. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ (accessed July 31, 2018).
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Hayes, D. (2018, July 25). The New Healthcare Consumer. Hearing Health & Technology Matters. Retrieved from https://hearinghealthmatters.org/hearingeconomics/2018/new-hearing-loss-hearing-aid-healthcare-consumer/.
Humes, L. E., Rogers, S. E., Quigley, T. M., Main, A.K., Kinney, D. L., & Herring, C. (2017). The effects of service-delivery model and purchase price on hearing-aid outcomes in older adults: A randomized double-blind placebo-controlled clinical trial. American Journal of Audiology, 26(3), 53–79.
Ng, A. (2017, January). Artificial intelligence is the new electricity. Presentation at the Stanford Graduate School of Business, Stanford, CA.
West Corporation. (n.d.). Prioritizing the patient experience: Consumerization of healthcare brings patient satisfaction to forefront for providers. Retrieved from https://www.televox.com/downloads/west_prioritizing_patient_experience.pdf [PDF].