What factors determine the use of audiological treatment services?
When dispensing hearing aids, audiologists engage in a number of activities to improve patient benefit and satisfaction. These activities include selection of appropriate hearing and assistive devices, hearing aid programming and acoustic modifications, cleaning, repairs, electroacoustic analysis, probe-microphone measures, formal and informal outcome measurements, cerumen management, teaching effective communication strategies, patient education, affective counseling, and more. Such activities are known as audiologic treatment (AT) or aural rehabilitation (AR). These AT/AR activities most often occur in the context of a relationship wherein the patient has purchased a hearing aid device from a hearing care provider (eg, audiologist) or the institution/practice in which the provider is employed.
The services provided by dispensing professionals are meaningful and important in the success of patients who utilize hearing instruments. Data have consistently shown that patients report high levels of satisfaction from the professionals who dispense hearing aids.1,2 Furthermore, in a MarkeTrak survey,3 consumers attributed high-quality audiology services as being beneficial to treatment outcomes, including higher hours of usage, subjective benefit, and handicap reduction. Interestingly, the only exceptions to improved outcomes included group activities and therapy-like activities such as “auditory retraining software therapy,” “referral to a self-help group,” and “aural education group.” This perceived lack of benefit by patients may explain why these particular types of activities are not typically sought by patients nor offered by providers in the context of audiologic treatment services.
The need for audiologic intervention also is highlighted in reports from consumers who do not use their hearing aids. The top four reasons cited for non-use included poor benefit, background noise, fit and comfort, and negative side effects. These reasons—as well as one-half of the 32 reasons given for non-use—have the potential to be corrected or improved via additional and appropriate AT/AR services.
AT/AR services are typically spread across the timeline of patient care. Some activities occur during the audiologic evaluation, or the hearing instrument evaluation and dispensing appointments, and others occur during follow-up care. In most cases, the costs for these services are bundled into a single cost to the patient, and these services are provided as needed for a given period of time. In some cases, the costs of goods and services may be unbundled, and the consumer is billed for each encounter or service.
Regardless of which model is used, the dispensing professional is typically reimbursed by the patient directly for these AT/AR activities. In fewer cases, reimbursement is provided through third-party payors, such as the Veterans Administration or private insurers.
Recently, some in the audiology community have advocated that third-party reimbursement for AT/AR services be extended to include Medicare. In addition, there has been increasing focus on unbundling of AT/AR services, particularly in light of the increase in direct-to-consumer sales of hearing aid amplification. Unfortunately, there is a dearth of evidence to inform these types of public and professional policy decisions.
The bundling of audiologic professional services serves as a form of “insurance” for AT/AR service. This is because, when a hearing device is purchased, neither the patient nor audiologist knows just how much audiologic intervention will be required or utilized by a given patient.
There is no substantial evidence-base to suggest which factors may contribute to increased patient utilization of AT/AR services. Because of this, it is difficult to predict the wide-scale financial effects of unbundling for providers, insurers, or patients. This question becomes particularly important when considering the financial implication of extending AT/AR reimbursement to a population as large as that covered by Medicare.
Understanding which patient, device, and cost factors predict AT/AR utilization can help inform policy decisions. In this study, we sought to understand what factors might influence the utilization of AT/AR services in the context of a hearing aid dispensing relationship. To accomplish this, we counted the number of follow-up appointments over a 1-year period following the initial hearing aid(s) acquisition and examined various patient, device, and cost factors to determine the relationship with number of visits. Our assumption is that a patient’s need and desire for services is reflected by the number of volitional follow-up visits.
In a retrospective analysis, medical record numbers were collected from the TrakAid Hearing Aid Data Management System of all patients who obtained hearing aids in the year 2009 at the Henry Ford Fairlane Medical Center (HFHS), part of the Henry Ford Health System. The health care billing system was then used to determine the number of hearing aid “follow-up” encounters for each of the 503 patients. The number of the encounters was tallied for exactly 1 year following the date of the hearing aid acquisition.
Records were sorted according to gender, age, hearing sensitivity, number of aids purchased, level of technology, and insurance coverage. The audiometric thresholds from each patient were collected from the electronic medical record system. Each factor was examined to determine if it related to differences in the number of aural rehabilitation encounters.
For gender and number of aids obtained, t-tests were used to determine statistical significance. ANOVAs were used to determine statistical significance for age, degree of hearing loss, and level of hearing aid technology.
In the HFHS system, audiologists do not receive commissions based on hearing aid sales or returns, and they follow a relatively similar hearing aid dispensing protocol. Costs of hearing aid devices and services are bundled, so there was no greater direct cost to patients for increased return visits.
Approval from the Institutional Review Board of Henry Ford Health System was obtained prior to data collection.
Results and Discussion
Overall Utilization. The total number of post-dispensing encounters was 1,567 for an average of 3.12 encounters per patient in the year following the hearing aid acquisition. In some cases, patients came to a walk-in clinic for services and were seen by a hearing aid technician who was supervised by an audiologist. These types of services accounted for 545 or 35% of the encounters. In most cases, patients were scheduled with an audiologist for an appointment of at least 30 minutes duration. This type of service accounted for 1,022 or 65% of cases. The distribution of number of appointments is shown in Figure 1. It can be seen that the bulk of patients were clustered in the range of 0 to 5 encounters, while a few patients returned as many as 15 times in the year following hearing aid acquisition.
Kochkin et al3 found that consumers reported an average of 2.6 visits required “to get your hearing aid sounding just right to me” (ranging from 2.4 visits for patients who received verification and validation [V&V] to 3.6 for those receiving no V&V4). Thus, the respondents may have included the initial “dispensing appointment,” which was excluded from our count. However, the MarkeTrak data were reported by the patient for hearing aids that had been dispensed in the past 4 years with a maximum of “6 or more” visits, while the present study was confined to a 1-year time period, and visits were objectively counted by the clinic. Further, it is unclear whether the visits reported by MarkeTrak included follow-up for expected hearing aid maintenance and other dynamic issues related to hearing aid adaptation or merely an initial perception of completion of fitting.
Patient factors. We hypothesized that certain patient populations might be more likely to utilize AT/AR services. Gender, age, and hearing loss were considered as potential factors.
Gender was not found to contribute to utilization of services. Males had an average of 3.09 visits and females 3.14 (Figure 2).
Similarly, no significant differences were found in the number of follow-up visits as a function of age. The average number of visits ranged from 2.47 for the 20- to 59-year-old group to 3.46 for the 60- to 69-year-old group, but no discernible trend was found among the age groups (Figure 3). This is consistent with data reported by Kochkin4 that age of patients did not correlate with number of visits to fit hearing aids.
Hearing loss also was not found to contribute to utilization of services. The average number of visits ranged from 2.79 for the minimal (<30 dbhl=”” pta=”” hearing=”” loss=”” group=”” to=”” 3=”” 21=”” for=”” the=”” moderate=”” 50-69=”” but=”” no=”” discernible=”” trends=”” or=”” significant=”” differences=”” were=”” found=”” sensitivity=”” figure=”” 4=”” this=”” is=”” consistent=”” with=”” data=”” reported=”” by=”” kochkin=”” sup=””>4 that degree of hearing loss did not correlate with number of visits to fit hearing aids.
Of the patient factors that we examined, none was shown to indicate that certain patients were more likely to utilize audiologic services than others.
Device factors. We hypothesized that the nature of the devices acquired by patients could contribute to audiologic treatment utilization. Factors of number of hearing aids (binaural vs monaural) obtained and the “technology level” of the hearing aids purchased were considered.
It could be argued that people who have only one hearing aid might utilize services more than those with two, due to increased communication difficulties. However, we expected that patients who obtained bilateral amplification versus a unilateral fitting were more likely to have a higher number of audiologic treatment encounters due to the fact that device problems or failures would be twice as likely to occur with two aids than with one. This was shown to be the case. Patients who acquired two aids had an average of 3.28 visits while patients who acquired one aid returned for an average of 2.38 visits (Figure 5). This difference was significant at the p<.05 level.
Within our health system, hearing aid technology is grouped into one of four categories of bundled cost. Nearly all styles of hearing aids are available at each cost level. The hearing aids from a number of different manufacturers are available in our system. The pricing levels tend to follow the four-tier system that is currently commonly used by the majority of these manufacturers. Of the 503 patients sampled, the majority (366 or 73%) acquired Level 1 technology. Level 2 technology was acquired by 88 (17%) patients; Level 3 by 30 (6%); and Level 4 by 19 (4%).
We hypothesized that level of hearing aid technology might play a role in utilization of AT/AR services for a number of reasons. On one hand, higher levels of hearing aid technology might be expected to decrease the utilization of AT/AR services due to potentially better hearing outcomes for patients and greater satisfaction, resulting from the more sophisticated features available on the aids. On the other hand, higher levels of hearing aid technology might be expected to increase the utilization of AT/AR services because patients have higher expectations for outcomes with these devices and/or because they paid more for them.
Results showed a systematic increase in average number of visits for audiologic services with increases in hearing aid technology level. An average of 2.73 visits occurred for Level 1 (the lowest level) technology. Those with Levels 2 and 3 had 3.97 and 4.13 visits, respectively, and those with Level 4 had an average of 5 visits. Differences between Levels 1 and 2, and 3 and 4, were significant at the p<.05 level. The average results are shown in Figure 6 and the distributions for the different levels are shown in Figure 7.
Clearly, the technology level of the device played a significant role in the utilization of AT/AR services. It is unknown whether this effect is related to the technology itself or to covarying factors, such as cost. Although not a measure of treatment utilization, data from Kochkin1,2 showed that consumer satisfaction was higher for “dispenser” services when more advanced hearing aid technology was used for programmable versus analog aids, and aids with directional versus omnidirectional microphones. It is also possible that consumers perceived greater satisfaction from dispensers as a result of greater time spent with the professional.
Cost and insurance coverage. In interpreting the technology-level data, it is important to understand the role of insurance coverage, and, by extension, cost to the patient, for the devices. In the state of Michigan, there is an unusually high portion of patients who have private insurance coverage for hearing aids and associated hearing health care. This situation gave us the opportunity to examine the utilization behaviors of patients who acquire hearing aids with different levels of hearing aid coverage—specifically those with full or no coverage for hearing aids.
Records were sorted according to Level and then according to payment method. Two groups of payment methods were examined. The “patient-pay” group consisted of patients who paid the entire cost of their hearing aids and related services. The “full-coverage” group consisted of patients who had full coverage for binaural hearing aids and related services and paid nothing for the devices and services. Only patients who obtained binaural Level 1 hearing aid technology were examined for this question, because this group presented the cleanest means of answering the question. Essentially, in the full-coverage group, Level 1 hearing aids and all services were of no cost to the patients. In the other group, the patient paid the entire cost of the devices and services. This is in contrast to higher levels of hearing aid technology wherein patients with insurance coverage for hearing aids pay a portion of the cost when upgrading. The full-coverage group accounted for 198 (86%) of the Level 1 technology group and the patient-pay group for 32 (14%).
Patients who had full coverage for hearing aids had an average of 2.68 visits, while patients who paid for their devices had an average of 3.63 visits (Figure 8). This difference was significant at the p<.05 level.
When the technology of the hearing aid was held constant, insurance coverage for devices and, by extension, patient payment for the devices influenced patient utilization. Patients who paid for their devices utilized AT/AR services more than those patients who did not pay for the devices and related services.
This study demonstrated that patient factors, including gender, age, and degree of hearing loss, did not impact utilization of AT/AR services. In contrast, hearing aid device technology and associated patient cost appear to play a significant role in the utilization of AT/AR services. Acquisition of higher levels of hearing aid technology resulted in greater utilization of services. When level of hearing aid technology was held constant, insurance coverage for hearing aids and, by extension, elimination of cost to the patient reduced the utilization of AT/AR services.
These findings are related to previous research conducted within our health system, showing that insurance coverage for hearing aids resulted in complex patterns of hearing aid acquisition behavior.5 Specifically, patients who had full coverage for hearing aids obtained them at an earlier age and with less hearing loss than people who paid any amount, including a discounted amount via partial insurance coverage. In addition, few of the patients with full hearing aid coverage upgraded devices (23%), compared to those patients who paid privately (59%). This meant that patients who paid the most of the “base” cost of hearing aids were more likely to purchase increased hearing aid technology than those patients who paid less or who paid nothing at all.
This study raises a number of important issues regarding utilization of AT/AR services. One question is whether insurance coverage for AT/AR services will increase access to these services for patients. It is commonly assumed that this is the case, and the current study cannot help us to understand how many patients would obtain hearing aid devices and utilize AT/AR services if these services were covered by insurance. However, the finding that patients accessed AT/AR services less when they did not pay for them compared to those patients who paid for services should at least give us pause if we assume that increased insurance coverage automatically leads to increased access to audiologic services. These results would suggest that third-party coverage for hearing aids may actually decrease utilization of AT/AR services.
Another question raised by this study is why insurance coverage for hearing aids and elimination of cost to the patient result in a decrease in utilization of services. One answer may come from the relationship between insurance coverage for hearing aids and the age and degree of loss at which patients obtain aids. If patients obtain hearing aids earlier and with less hearing loss simply because they can do so without incurring any personal expense, might they obtain hearing aids when they in fact do not perceive the need for them? If this scenario occurs, perhaps lack of utilization of AT/AR services may be due to lack of use of the hearing aids—a reflection of “hearing aids in the drawer.” Another possibility is that patients who do not pay for hearing aids themselves may value the devices and associated AT/AR services less than those who pay for them.
It is commonly believed by dispensing audiologists that successful hearing aid outcomes require a period of adaptation and active engagement, learning, and effort on the part of the patient. Patients who do not pay for services may be more willing to “give up” earlier when challenges in device utilization occur because of less financial investment in the devices and services on their part.
In considering the number of visits, it seems reasonable to question whether more treatment necessarily relates to better outcomes. Kochkin et al3 found that requiring more than three visits to “fit” hearing aids was strongly related to “below average” real-world success with devices. In our sample, approximately 20% of the patients accounted for 50% of the utilization of services. The only trend observed from inspection of our data is that these high-utilization patients typically obtained higher levels of hearing aid technology. It is possible that perceived upgrades to technology resulted in unrealistic expectations for hearing aid performance. It is otherwise unknown what particular needs of this group contribute to high rates of service utilization.
The relationship between number of visits and patient benefits appears to be complex. On the one hand, the Kochkin et al3 data suggest that “too many” patient visits results in poorer outcomes. On the other hand, the same study found that the most comprehensive fitting protocols (up to 12 protocol steps performed) resulted in greater patient success. These data are somewhat paradoxical in that it simply takes time to perform each activity and patients may be reasonably expected to need to visit the hearing professional several times in order to complete the protocols.
In addition to initial hearing aid dispensing activities, hearing ability, hearing handicap, patient abilities, and hearing instrument function are all dynamic components of a patient’s experience with hearing instruments. Of course, hearing ability can change over time. Cognitive abilities, dexterity, vision, and other patient function and health factors may require changes in the approach to hearing aid amplification and communicative function. Patients’ hearing needs and consequent expectations for devices can change over time. Hearing aids may require maintenance and repairs. These factors may require a greater than typical number of visits to the audiologist to cope with such changes.
Audiologists and dispensing professionals are well aware of the benefits of customized AT/AR services to patients. In order to increase access to these services to promote better patient outcomes, it is important to understand which factors contribute to utilization of audiologic treatment and, most importantly, how these factors and treatments impact user outcomes.
When considering the impact of policies regarding the benefits of bundling versus unbundling of services and the application of insurance coverage for AT/AR services, it is important that we rely on an evidence base of patient behavior, rather than assumptions, to support our decision-making. Further studies regarding utilization of services—particularly more large-scale evidence of how utilization of services impacts patient outcomes—would be helpful in better understanding how to improve audiologic treatment.
Correspondence can be addressed to Virginia Ramachandran, AuD, at .
- Kochkin S. MarkeTrak V: “Why my hearing aids are in the drawer.” The consumers’ perspective. Hear Jour. 2000;53(2):34-41.
- Kochkin S. 10-Year customer satisfaction trends in the US hearing instrument market. Hearing Review. 2002;9(10):14-25,46.
- Kochkin S, Beck DL, Christensen LA, et al. MarkeTrak VIII: The impact of the hearing healthcare professional on hearing aid user success. Hearing Review. 2010;17(4):12-34.
- Kochkin S. MarkeTrak VIII: Reducing patient visits through verification & validation. Hearing Review. 2011;18(6):10-12.
- Ramachandran V, Stach BA, Becker E. Reducing hearing aid cost does not influence device acquisition for milder hearing loss, but eliminating it does. Hear Jour. 2011;64(5):10-18.