Robert Burkard, PhD, CCC-A, and Stuart Trembath, MA, CCC-A
By way of research for this article, we Googled the phrase "practicing at the top of the license" and found a handful of websites that were penned by professionals (physicians, nurses) complaining about the inefficiencies of having skilled professionals spend a lot of time engaging in unskilled (and non-reimbursable) activities. The basis of this catchphrase appears to have arisen from the 2011 Institute of Medicine Report, The Future of Nursing: Leading Change, Advancing Health . In this report, the first recommendation states, "Nurses should practice to the full extent of their education and training" (p. 4). This recommendation appears to have morphed into the current phrase, "practicing at the top of the license." We also searched the ASHA website to determine whether this phrase had been used in the context of speech-language pathology and audiology.
Alex Johnson used this wording during his presentation at the Researcher-Academic Town Meeting at the 2012 ASHA Convention. "Practicing at the top of the license" was also used in the December 2013 final report by the ASHA Ad Hoc Committee on Reframing the Professions. This committee's report, Reframing the Professions of Speech-Language Pathology and Audiology, specifically stated: " Work at top of license: SLPs should engage in only those patient care activities that require their level of expertise and skill" (p. 10). With our current model of service delivery, however, SLPs spend a great deal of therapy time "practicing" new skills that have been taught to the patient. This can and should be done by less skilled individuals (e.g., assistants and/or the patient and family members). This would greatly decrease the cost of achieving outcomes (and also increase family satisfaction by decreasing the inconvenience, cost, and overall burden of care; ASHA, 2013). Alex Johnson, in his 2012 Town Meeting talk, put it more telegraphically: "Top of the license practice; skilled at delegation to others" (slide 13). The idea behind this mantra is that we should limit our professional activities to those services that are within our scope of practice and that are considered skilled services. Let us now turn to what services are within the scope of practice for audiology.
The current ASHA scope of practice document (ASHA, 2004) summarizes the professional roles and activities of audiologists. In brief, the document indicates that audiology practice includes the identification, assessment, and rehabilitation of those with auditory, vestibular, and balance dysfunction, as well as the prevention of hearing loss and vestibular/balance dysfunction. The scope of practice tells us that our education and training as audiologists prepare us to deal with both the diagnosis and the (re)habilitation of hearing, vestibular, and balance problems.
If a patient walks in with a complaint that he or she is having difficulty hearing, what reflects the top of the license? According to Medicare guidelines, audiologists are not considered physicians, and we cannot really treat any medical problems. Such activities would truly be "over the top" of the license for audiologists. Is aural rehabilitation in an audiologist's scope of practice? Do the skills and training required to do this competently argue that this is at the top of the license? In our opinion, the answer to these questions is an unambiguous "maybe." Audiologists have the expertise to perform aural rehabilitation, and this is truly a skilled clinical service. In this regard, aural rehabilitation is truly top of the license. However, audiologists cannot be reimbursed by Medicare for treatment, and many private insurance companies follow the Medicare rules. Hence, engaging in aural rehabilitation—not reimbursable in current clinical practice—may be a very ineffective business practice. For many practicing audiologists, it would appear that, until Medicare reimburses audiologists for aural rehabilitation (and for treatment in general), it would be unwise, from a fiscal standpoint, for audiologists to consider aural rehabilitation to be at the top of their license.
There are several areas of clinical audiology practice that are reimbursable and that could be included as coming under the rubric of top of the license. We believe that the following areas should be included under this header: vestibular/balance assessment, the collection and analysis of sensory evoked potentials, mapping cochlear implants, intraoperative monitoring, pediatric audiology, and site of lesion testing. Many of these areas can be considered medically necessary and are not treatment modalities, meaning they are generally reimbursable under Medicare and are often covered by other insurance.
What about threshold determination? Is performing pure tone audiometry a skilled service? Computerized audiometry can produce a valid and reliable audiogram from most cognitively intact adults. In infants, young children, and those with developmental delays, psychiatric/psychological disorders, and dementia, computerized audiometry might not produce results as valid and as reliable as those obtained by an experienced audiologist. Therefore, if we want to practice at the top of our license, we might want to delegate this activity to an audiology assistant who could monitor computerized audiometry. Computerized audiometry is a Tier 3 Common Procedural Terminology (CPT) code and, in most instances, Medicare (and many other insurance programs) will not reimburse for computerized audiometry (or for the use of audiology assistants). We would still have to use our clinical skills to interpret the audiogram. Despite our goal of practicing at the top of the license, in this instance, we might keep doing "unskilled" or "less-skilled" labor (i.e., collecting the audiometric data), so we can be reimbursed for the skilled activity (i.e., interpreting the results). With continued downward pressure on reimbursement by Medicare and other third-party payers, practicing at the top of our license may not be sustainable financially.
In the recent past, in large part due to an effort to contain health care costs, interprofessional education and practice (IPE/IPP) have been popular topics at meetings and in professional reports. A recent series of Institute of Medicine reports addressed IPE/IPP. It is useful to begin with a definition of IPE: "Interprofessional education occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes" (World Health Organization [WHO], 2010, p. 13). If the various professions are educated together and understand the scope of practice and the culture of the other professions, then it follows that, once practicing together (IPP), they will work better as a team, and this efficient service delivery will (hopefully) improve quality of care and drive down costs. Most clinical audiologists have been trained interprofessionally and often practice interprofessionally. Audiology students are typically educated and trained with speech-language pathology students. Depending on our work setting, we often collaborate as part of a team. In diagnostic audiology, we work closely with physicians. For site of lesion testing, audiologists often work with otolaryngologists or neuro-otologists. Other specialists with whom audiologists collaborate include neurologists and psychiatrists. For school-based audiologists, this interprofessional team might include speech-language pathologists, classroom teachers, social workers, psychologists, occupational therapists, and physical therapists.
Who is Alex Johnson, and why do we care what Alex says?
Alex is a past president of ASHA. He participated in ASHA's 2012 Changing Health Care Landscape Summit. He was the Interprofessional Education and Practice topic chair for the 2014 ASHA Convention. As topic chair, Alex helped produce a major focus on IPE/IPP at the 2014 ASHA Convention. He is the provost and vice president of academic affairs at the MGH Institute of Health Professions. In this role, he integrates the interprofessional education and training of speech-language pathologists, physical therapists, occupational therapists, physician assistants, and nurses.
If audiologists have historically been trained and practice interprofessionally, was the profession of audiology a leader in the movement to promote IPE/IPP?
The short answer to this question is no. For example, a 2011 conference/report, Core Competencies for Interprofessional Collaborative Practice. Report of an Expert Panel (Interprofessional Education Collaborative Expert Panel, 2011) was sponsored by the American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Association, Association of American Medical Colleges, and Association of Schools of Public Health. This IPE/IPP event focused on physicians, nurses, pharmacists, dentists, and those in public health. Notably absent were audiologists, speech-language pathologists, occupational therapists, and physical therapists. However, through more recent professional efforts, audiologists and speech-language pathologists are getting more involved. In ASHA's 2012 Changing Health Care Landscape Summit (ASHA, 2012), IPE/IPP was addressed. Subsequent to the summit, the ASHA Board of Directors formed an Ad Hoc Committee on Interprofessional Education, which published a report in 2013 that made numerous recommendations regarding IPE/IPP. Notably, this committee included not only audiologists and speech-language pathologists, but also a nurse and a physical therapist. The input of those outside of our professions was invaluable.
Can audiologists practice interprofessionally AND at the top of the license?
With hard work, some flexibility on the part of all professionals, and a collaborative mindset, this is definitely possible. In a 2014 ASHA Convention presentation, Neil Shepard provided a clear example of a multidisciplinary team at the Mayo Clinic. The team works with patients who have vestibular/balance problems, and the team audiologists are clearly practicing at the top of their license. The Mayo Clinic's Integrated Balance Team includes professionals in audiology, otology/neuro-otology, neurology, physical therapy, psychology, gerontology, psychiatry, and neuro-ophthalmology, although not all of these professionals necessarily work with each patient. What makes this integrated approach successful is not only the diversity of practitioners involved; it is equally important that members of the team understand (and respect) the roles of their fellow team members and that patients are triaged and centrally scheduled, which enhances the integrated approach of the team. As Medicare and other third-party payers move to alternative payment models that will demand quality patient outcomes, we must ask ourselves the following question: What will the role of the audiologist be in the delivery of care? The simple answer to this question is that we do not know.
What can I do to empower audiologists to practice interprofessionally AND at the top of their license?
As audiologists, we have spent a lot of time determining what we want to be doing professionally (as specified in our scope of practice documents, clinical competencies, and educational criteria). We aggressively safeguard those skilled activities and, in the process, often practice in a professional silo. Audiology, over the past several decades, has focused on diagnostic audiology and hearing aid fitting. Consequently, it appears we have managed to remove ourselves from the treatment part of our scope of practice and frequently cannot be reimbursed for the treatment we provide (e.g., aural rehabilitation). Today, many private practices in audiology are critically dependent on the revenue from hearing aid sales. Alternative models of hearing aid sales (such as online sales) threaten these practices. But any threats may be offset by what appear to be the opportunities arising from changing models of health care delivery. We are intrigued and encouraged by the interprofessional approach used by the Mayo Clinic in the Integrated Balance Center. This particular example allows audiologists to practice at the top of the license and to work as part of an interprofessional team.
There are other examples of interprofessional teams that include audiologists, such as cochlear implant teams and intraoperative monitoring. We need to learn to be less defensive of our scope of practice and to work as part of an interprofessional team to deliver high-quality health care most efficiently at an affordable price to individuals with hearing, vestibular, and balance issues who are in desperate need of our care.
Robert Burkard, PhD, CCC-A, is professor and chair in the Department of Rehabilitation Science, University at Buffalo. His research interests include calibration, auditory electrophysiology (in particular, auditory evoked potentials), vestibular/balance function/dysfunction, functional imaging, and aging. His professional interests include acoustic/audiologic calibration standards and health care economics. Contact him at email@example.com.
Stuart Trembath, MA, CCC-A, has been a clinical audiologist for over 30 years. He graduated with a master's degree in audiology from Northwestern University. He is currently the owner of Hearing Associates, P.C., an audiology private practice. He has been active in the Iowa Speech-Language-Hearing Association and served as its president from 2000 to 2002. He served on ASHA's Legislative Council from 2004 to 2005. He is currently the co-chair of ASHA's Health Care Economics Committee and is ASHA's American Medical Association CPT advisor. He was named an ASHA Fellow in 2014. Contact him at firstname.lastname@example.org.
American Speech-Language-Hearing Association Ad Hoc Committee on Reframing the Professions. (2013). Reframing the professions of speech-language pathology and audiology. Rockville, MD: Author.
American Speech-Language-Hearing Association Ad Hoc Committee on Scope of Practice in Audiology. (2004). Scope of practice in audiology. Available from www.asha.org/policy/.
Burkard, R., Shepard, N., & Moore, R. (2014, November). Interprofessional education and audiology: What it is, a good example, and the (perceived) barriers . Presentation at the 2014 annual convention of the American Speech-Language-Hearing Association, Orlando, FL.
Institute of Medicine of the National Academies. (2011). The future of nursing: Leading change, advancing health . Washington, DC: Author.
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative.
Johnson, A. (2012, November). Preferred educational future in CSD. Presentation at the American Speech-Language-Hearing Association Researcher-Academic Town Meeting, Atlanta, GA.
World Health Organization. (2010). Framework for action on interprofessional education & collaborative practice. Geneva, Switzerland: Author.