Hearing aid affordability in the United States.

PURPOSE: Substantial out-of-pocket costs for hearing aids constitute a barrier to hearing health care accessibility for older adults among whom prevalence of hearing loss is high. This study is the first to estimate the proportion of Americans with functional hearing loss for which out-of-pocket expenditures for hearing aids would be unaffordable at current average costs and determine how affordability varies by sociodemographic factors. MATERIALS AND METHODS: We utilized data from the 2016 American Community Survey to determine the proportion of adults with functional hearing loss for whom hearing aids would constitute ≥3% of annual income or have post-purchase income below a poverty standard. Chi-square tests were used to identify differences in affordability outcomes by sociodemographic characteristics. RESULTS: Results indicated that an average bundled cost of $2500 would constitute a catastrophic expense for 77% of Americans with functional hearing loss (N = 7,872,292) and would add an additional 4% of the population into poverty for the year (N = 423,548). Affordability outcomes varied significantly by age, race, sex, educational attainment and geographic location. CONCLUSIONS: Hearing aids were unaffordable for three-fourths of Americans with functional hearing loss, and their purchase would result in impoverishment for hundreds of thousands of individuals. Reductions in out-of-pocket hearing aid costs to $500 or $1000 would alleviate affordability issues for many Americans with hearing loss. Future federal and state policy should address poor rates of insurance coverage for hearing care, specifically among Medicare and Medicaid, to reduce out-of-pocket costs for hearing care particularly for older adults.Implications for rehabilitationAn average out-of-pocket hearing care cost of $2500 was unaffordable for over three quarters of Americans with functional hearing loss.Hearing care affordability varied significantly by demographic characteristics such as age, sex, gender, educational attainment and geographic region.Affordability constitutes a significant barrier to hearing care accessibility in the United States, where most costs of hearing aids and rehabilitation are statutorily excluded from insurance coverage, including the largest insurer of Americans, Medicare.

Defining Audiology through Occupational and Health Policy Action.

Many barriers to accessibility exist for Medicare beneficiaries seeking hearing and balance care such as availability of providers, coverage for services, and ability to pay. Other statutory and administrative barriers exist including the need for physician orders to have audiology services covered, the classification of audiologists as suppliers of "other diagnostic tests" under Medicare payer policy, and non-coverage of certain audiologic management and treatment services. Nearly two decades of legislative efforts have not resulted in any substantial changes to U.S. health policy, while the need for audiology services has increased due to a growing demographic of older adults. The Medicare Audiologist Access and Services Act (MAASA) has been introduced in the 116th and 117th Congress and proposes amendments to the Social Security Act that would address statutory barriers to accessing hearing and balance care among Medicare beneficiaries and would recognize audiologists for their scope of practice within the Medicare program. Objectives of the present review are to provide a summary of statutes in the Social Security Act and Standard Occupational Classification system which affect audiologists, audiology services, and Medicare beneficiaries and to discuss previous and current legislative health policy efforts to address these statutory barriers to hearing and balance care access.

U.S. Policy Considerations for Telehealth Provision in Audiology.

The demand for telehealth services will continue to grow alongside an increased need for audiology services among both children and adults. Insurance coverage policies for audiologic services are specific to each payer and vary widely in the level of coverage provided for both in-person and telehealth-based audiology services. While benefits for children are fairly comprehensive, coverage for audiology services for adults is generally poor. Traditional Medicare does not cover hearing aids or other rehabilitative audiologic services, and other payer policies vary widely. Lack of benefits for hearing and balance services is inconsistent with the evidence base and leaves many beneficiaries without access to meaningful care for hearing and balance disorders, which are highly prevalent among and disproportionately affect Medicare beneficiaries. The purpose of this article is to discuss regulatory and reimbursement considerations for telehealth provision in audiology and elucidate opportunities to influence related health policy at both state and federal levels.

Predictors of Hearing Aid Use in the Advanced Digital Era: An Investigation of Benefit, Satisfaction, and Self-Efficacy.

BACKGROUND: Untreated sensorineural hearing loss (SNHL) has been linked to depression, social isolation, anxiety, and a reduction in health-related quality of life (QoL), and is independently associated with cognitive decline. Only one in five persons with SNHL pursues amplification; 76-97% of those having hearing aids report regular or occasional use. Although hearing aid use during all waking hours is advocated for children, recommendations for adults are not as clear. Treatment outcomes, including benefit, satisfaction, and self-efficacy with hearing aids, may be predictors of self-reported hearing aid use, which is useful in clinical practice. PURPOSE: The aim of this study was to determine average hours of self-reported daily hearing aid use by adults and if treatment outcome measures of benefit, satisfaction, and self-efficacy with hearing aids can predict self-reported daily hearing aid use in adults. RESEARCH DESIGN: The present study was a prospective cross-sectional survey with retrospective chart review. STUDY SAMPLE: The study sample consisted of 152 experienced adult advanced digital technology (ADT) hearing aid users between 18 and 90 years of age who were patients in a two-office private practice in California. DATA COLLECTION AND ANALYSIS: A postal survey was sent to 500 experienced adult ADT hearing aid users. Participants completed the Visual Analog Scale for Daily Use of Hearing Aids (VASuse) and validated measures of (1) self-efficacy, (2) satisfaction, and (3) benefit. Retrospective data were collected for all respondents via chart review. Multivariable linear regression was used to explore relationships between treatment outcomes and hearing aid use. RESULTS: Experienced hearing aid users wore their hearing aids an average of 12.0 h/day. Daily hearing aid use was significantly associated with residual participation restriction (RPR) on the International Outcome Inventory for Hearing Aids (IOI-HA) item 5 (p = 0.02). The VASuse was significantly associated with the IOI-HA factor 1, "Me and My Hearing Aids" (p = 0.03), an aggregate measure of satisfaction, benefit, and QoL. CONCLUSIONS: Participants reported wearing their hearing aids an average of 12.0 h/day. Self-reported daily hearing aid use was associated with a combination of satisfaction, benefit, and increased QoL, and with RPR. The interconnectedness of satisfaction, benefit, and QoL positively affected hearing aid use, and greater levels of RPR seemed to discourage hearing aid use. If hearing aid owners are inconsistent or nonusers, then counseling and outcome measures should be used in the domains of satisfaction, benefit, and QoL. Future research should involve additional ADT hearing aid users with different experience levels across various study sites.

Large Vestibular Aqueduct Syndrome: Parents' and Audiologists' Perspectives.

BACKGROUND: Large vestibular aqueduct syndrome (LVAS) is an auditory disorder that is difficult to diagnose and manage; it is confirmed when the vestibular aqueduct is >1.5 mm in diameter. Diagnosis of LVAS in children can devastate parents and challenge healthcare professionals who serve these patients and their families. PURPOSE: This study surveyed parents of children with LVAS about their knowledge of and experiences with LVAS and their attitudes about the support provided to them by healthcare professionals. This study also surveyed audiologists about their knowledge of and experiences with LVAS and their level of confidence in serving families with children having this disorder. RESEARCH DESIGN: Cross-sectional survey. STUDY SAMPLE: 100 parents, mostly mothers, and 144 audiologists responded to invitations to participate in surveys designed to elicit information about their knowledge of, experiences with, and attitudes toward LVAS. DATA COLLECTION AND ANALYSIS: Invitations via links to participate in a survey on surveymonkey.com were posted in LVAS support group pages on Facebook.com for parents and sent to audiologists randomly selected from the American Academy of Audiology Membership Directory. Descriptive statistics were used to analyze trends in parents' and audiologists' responses. RESULTS: A response rate could not be obtained for the parents' survey because it was impossible to know how many parents actually viewed the invitation to participate via Facebook.com. The response rate for the audiologists' survey was 10%. Most of the parents reported that their children had clinical trajectories similar to those of cases reported in the literature, and said they needed more information from their healthcare providers, especially pediatricians and primary care physicians. Most of the audiologists felt confident in their knowledge of and/or skills in aiding in the diagnosis and/or treatment of LVAS, except for issues surrounding cochlear implants. Audiologists were interested in obtaining continuing education about LVAS from multiple sources. CONCLUSIONS: Parents of children having LVAS need greater support from their healthcare providers, who in turn need additional information on the topic and should collaborate for supportive and appropriate interprofessional care.

Disruptive Hearing Technologies and Mild Sensorineural Hearing Loss I: Accessibility and Affordability Issues.

Limited accessibility to and affordability of hearing health care (HHC) and hearing aids (HAs) are two reasons why people do not seek treatment for their hearing losses. This article is the first in a series of two and discusses affordability issues (i.e., billing models, cost-effectiveness, insurance coverage, and reimbursement) related to and provides a historical context for the Over-the-Counter Hearing Aid Act of 2017. This piece of legislation supports development of a new class of over-the-counter HAs that represents a disruptive technology that may transform the HHC industry by reducing costs specific to the device. A discussion of ethical issues and the importance of using evidence-based practice guidelines set the stage for the second article in this series, which reviews relevant research on issues pertaining to persons with mild hearing loss.

Disruptive Hearing Technologies and Mild Sensorineural Hearing Loss II: Current Research on Affordable Hearing Technologies and Direct-to-Consumer Models.

Recently, President Trump signed into law the Food and Drug Administration (FDA) Reauthorization Act of 2017, which included the Over-the-Counter Hearing Aid Act designed to provide greater public accessibility to and affordability of amplification for individuals with self-identified mild and moderate hearing loss through the provision of over-the-counter (OTC) hearing aids (HAs) with a direct-to-consumer (DTC) delivery model. American Speech-Language-Hearing Association and American Academy of Audiology Position Statements on OTC HAs state that these devices should only be used for adults with mild hearing losses. DTC amplification and service delivery has been available to consumers in a variety of forms for a significant period of time. However, FDA-regulated OTC HAs will not be available as described in the new law until the FDA publishes the required guidance related to the technology, safety, and labeling of such devices. With the clear similarities in mind between present and future amplification options, a literature search was conducted to review studies assessing outcomes for low-cost and DTC HAs and service-delivery models to inform what we may expect as OTC HAs enter the market. Nine studies were identified which assessed: (1) electroacoustic capabilities of low-cost and DTC HAs, (2) use of these devices in field trials, or (3) efficacy of DTC models. None of the studies reported outcomes specifically for participants with mild hearing loss. The studies had poor external validity because none included all factors that would exist in realistic uses of OTC HAs within a DTC model. Additional research will be needed as OTC HAs become available and different delivery models are proposed.

Benefits from, Satisfaction with, and Self-Efficacy for Advanced Digital Hearing Aids in Users with Mild Sensorineural Hearing Loss.

Little evidence is available regarding outcomes of advanced digital technology (ADT) hearing aid wearers with mild sensorineural hearing loss (MSNHL). The purpose of this article is to report the characteristics of and outcomes for this population. A cross-sectional research design was employed with 56 participants from a private practice setting. The International Outcomes Inventory for Hearing Aids (IOI-HA), Satisfaction with Amplification in Daily Life (SADL), and the Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids (MARS-HA) were completed, scored, and compared with normative data. Results revealed that ADT aids were worn 10.5 hours/day, were mostly advanced to premium (55%), had an average cost per aid of $2,138 (SD = $840), and provided significant benefit (IOI-HA overall score: mean = 4.1; SD = 0.6) and satisfaction (SADL global score: mean = 5.4; SD = 0.8) to users who had good overall self-efficacy (MARS-HA composite score: mean = 81.7; SD = 12.8). Patients were most dissatisfied with and had the least self-efficacy for managing background noise and advanced handling of their devices. ADT hearing aid users with MSNHL achieved excellent outcomes, but ongoing follow-up and counseling from hearing health care providers may be important for successful management of background noise and mastery of advanced handling skills.

Toward the Future of Early Intervention for Adult Hearing Loss.

This issue of Seminars in Hearing has focused on the early intervention of adult sensorineural hearing loss (SNHL). Contributions to this monograph have taken a contemporary issues approach to the prevention, diagnosis, and treatment of mild SNHL. This article looks toward the future and discusses clinical and research implications for the early intervention of adult SNHL.

Developing Foundational Counseling Skills for Addressing Adherence Issues in Auditory Rehabilitation.

Successfully getting patients with confirmed hearing loss to use hearing aids is a major challenge for hearing health care professionals. Treatment adherence has been defined as the active involvement of patients in collaborating with health care providers to plan and manage treatment regimens. Counseling patients with hearing loss on adherence to recommendations of hearing aid uptake and utilization is dependent upon building a patient-centered therapeutic relationship during the initial diagnostic evaluation. The purpose of this article is to provide resources, tools, and engaging learning activities for training students on the development of a hierarchy of counseling skills: informational counseling (e.g., checking comprehension and problem clarification), communication skills (e.g., promotion of shared-communication space, congruence, listening with the third ear, unconditional positive regard, and empathy), and health behavior change (e.g., Motivational Interviewing and the Teach-Back Method) that are prerequisites for addressing treatment adherence.

Teaching Patient-Centered Counseling Skills for Assessment, Diagnosis, and Management of Benign Paroxysmal Positional Vertigo.

Audiologists are an integral part of the management of those with dizziness and vestibular disorders. However, little research has been performed on counseling approaches for patients who present with dizziness as a primary concern. Accordingly, it is important that audiology students are provided with didactic and experiential learning opportunities for the assessment, diagnosis, and management of this population. Benign paroxysmal positional vertigo is the most common vestibular disorder among adults. Doctor of Audiology students, at a minimum, should be provided with learning opportunities for counseling patients with this particular disorder. Implementation of patient-centered counseling is applied across various parts of the patient encounter from initial intake to treatment and patient education. The purpose of this article is to present the available evidence and to apply widely accepted theories and techniques to counseling those with benign paroxysmal positional vertigo. Didactic resources and experiential learning activities are provided for use in coursework or as a supplement to clinical education.

Didactic Content and Experiential Aging Simulation for Developing Patient-Centered Strategies and Empathy for Older Adults.

The number of people over 65 years of age is increasing, and many of those individuals will have sensorineural hearing loss in addition to other chronic health conditions. Future hearing health care providers need to be sensitive to the needs of elderly patients. The purpose of this article is to describe an experiential learning curriculum used in the Doctor of Audiology program in the Department of Communication Sciences and Disorders at the University of Oklahoma Health Sciences Center. The curriculum uses simulations of sensory disorders common in the elderly to transform knowledge and active experience into patient-centered, empathetic counseling skills and strategies to use with older adults with hearing loss.

Hearing Aid Benefit in Patients with Mild Sensorineural Hearing Loss: A Systematic Review.

BACKGROUND: Untreated sensorineural hearing loss (SNHL) is associated with chronic health-care conditions, isolation, loneliness, and reduced quality of life. Although hearing aids can minimize the negative effects of SNHL, only about one in five persons with SNHL seeks help for communication problems. Many persons wait 10 yr or more from the time they first notice a problem before pursuing amplification. Further, little information about the benefits of amplification is available for persons with mild SNHL (MSNHL), who likely defer treatment even longer. PURPOSE: To conduct a systematic review to weigh the evidence regarding benefits derived from the use of amplification by adults with MSNHL. RESEARCH DESIGN: Systematic review with meta-analysis. STUDY SAMPLE: Adult hearing aid wearers with bilateral average pure-tone thresholds ≤45 dB HL at 500, 1000, 2000, and 4000 Hz. DATA COLLECTION AND ANALYSIS: PubMed, Cumulative Index to Nursing and Allied-Health Literature, Cochrane Collaboration, and Google Scholar were searched independently by the authors during September 2013. The authors used a consensus approach to assess the quality and extract data for the meta-analysis. RESULTS: Of 106 articles recovered for full-text review, only 10 met inclusion criteria (at least Level IV of evidence and involved and reported separate pre-/postfitting hearing aid outcomes for patients with MSNHL). Included studies involved mainly middle-aged to elderly patients using hearing aids of various styles and circuitry. Results from all of the studies indicated positive benefits from amplification for patients with MSNHL. Data from five studies were suitable for a meta-analysis, which produced a small-to-medium effect size of 0.85 (95% confidence intervals = 0.44-1.25) after adjusting for a small publication bias. This evidence confirmed benefits from the use of amplification in adults with MSNHL. CONCLUSIONS: Evidence exists supporting the notion that adults with MSNHL benefit from hearing aids. This information is important and useful to audiologists, patients, and third-party payers, even considering that most of the studies in this systematic review were limited, somewhat dated, and used analog and early digital technology available when the studies were conducted. Clinical recommendations may be even stronger as future studies become available for patients fit with modern styles and high-technology hearing aids.