Mr President: Your advisors were wrong about hearing aids
Editor's note: The following editorial was written by the president of Healthy Hearing. This letter was submitted to the President of the United States and members of the President's Council of Advisors on Science and Technology in regards to recent discussions regarding hearing healthcare reform.
Dear Mr. President,
As a licensed audiologist and the president of Healthy Hearing, it was with great anticipation that I looked forward to the President’s Council of Advisors on Science and Technology’s (PCAST) initial report on Aging America & Hearing Loss: Imperative of Improved Hearing Technologies.
After reading the report, I was disappointed and concerned to see that the recommendations made by PCAST completely missed the mark.
Summary of the PCAST report on hearing aid technology
The council reported hearing loss as a major health and social problem; and left untreated, hearing loss is associated with social isolation, falls, depression and cognitive decline. The council cited two factors as the major barriers to treatment: the cost of hearing aids (approximately $2400 per device) and the lack of coverage by Medicare and insurance. The study proposed the following recommendations to reduce cost to consumers, increase the number of people who use hearing aids and stimulate innovation and technology development:
- Designation of a basic, over-the-counter (OTC) hearing aid category, which would not require being dispensed by a credentialed dispenser.
- The FDA’s withdrawal of draft guidance regarding Personal Sound Amplification Devices (PSAPs) and labeling requirements that exclude the use of PSAPs by persons with more severe hearing loss.
- A new requirement that hearing care professionals share results of hearing tests with other providers.
- A new requirement that hearing care professionals provide a copy of hearing test results to the patient at no additional cost.
What the PCAST committee got wrong about hearing aids
I do appreciate the work of PCAST, and it’s encouraging to see hearing health being considered a serious matter. However, as a professional in the audiology field for almost 20 years, I can confidently say these recommendations will accomplish none of the stated objectives, for the following reasons:
- OTC hearing devices (such as PSAPs) generally contain comparatively poorer levels of sound processing technology to modern hearing aids. Persons who would use these OTC devices would be less likely to have a satisfactory experience due to the lower levels of technology. The analogy comparing PSAPs to reading glasses is flawed. Treating farsightedness involves refocusing an image on a retina that is still intact. Most hearing loss is sensorineural, which means that the hearing organ has been damaged and/or non-functional. Therefore, the job of a hearing aid is more complex than just increasing the volume of the sounds sent to the ear (Clason, 2015) as it is sending amplified sounds to a hearing organ that is not fully intact.
- The labeling of OTC hearing devices (such as PSAPs) is essentially a non-issue for consumers. Most consumers purchasing PSAPs are not aware of the exact amount of hearing loss they have, so the current system of warning consumers to avoid use with severe hearing loss is somewhat meaningless to start with.
- The vast majority of hearing care professionals already provide a copy of the hearing test results upon request. Those results can be taken to another clinic for hearing aid purchase and fitting. It is common practice for the second clinic to repeat the testing to confirm results, especially if the results are older than six to 12 months. This is part of the professional’s due diligence to provide the best hearing aid programming for the patient.
- As stated above, it is standard clinical practice for professionals to provide a copy of the hearing test to the patient at no additional cost. Spending taxpayer dollars to institute legislation to enforce what is already occurring as standard practice would be a waste of time and money.
It does not surprise me that I do not agree with the committee’s recommendations, as this specific PCAST committee was composed of a large number of computer technologists, biologists and physicists, with some additional experts on aging. There were no committee members who had any extensive experience in the hearing loss or hearing aid fields from industry, clinical, research or consumer perspectives. The PCAST committee therefore lacked any applied or scientific experience with hearing loss and treatment.
My recommendations for improving access to hearing aid technology
I respectfully suggest the following recommendations would make a more positive impact on persons with hearing loss and their families. These recommendations are based on scientific and economic data, as well as my experience as a practitioner and researcher in the hearing healthcare field.
- Mandate all health insurance to cover hearing aids as a preventative care measure. Untreated hearing loss has been linked to several other disorders, such as depression (Li, et al., 2014; NCOA, 1999), anxiety (NCOA, 1999), cognitive decline (Amieva, 2015) and heart disease (Bishop, 2012; Friedland, et al., 2009; Hull, et al., 2010). Insurance companies should include hearing health as part of their preventative health initiatives, as treating hearing loss early can improve the overall health of the insured, saving money in health care costs the long run.
- Support initiatives to promote hearing aids as a healthy choice. Hearing loss is a major health issue, as described above. While affordability is a barrier to hearing aid use, it is not the largest one. The negative perception that the general public has towards hearing aids, a.k.a the stigma surrounding hearing aids, is the largest barrier. A review of hearing aid adoption rates in countries that subsidize or provide free hearing aids to patients show roughly the same hearing aid adoption rates as the United States (HIA, 2015). Therefore, reducing the cost of hearing aids is not likely to increase hearing aid adoption (Amlani, 2010). We have to work together to change the public’s attitude toward hearing aids and their perceived value (Amlani, et al., 2011) in order to increase hearing aid adoption rates. The general public needs to understand that hearing aids are a healthy choice that treats hearing loss and promotes general wellness.
- Mandate a national best practices protocol for hearing aid fittings. An individual’s success with hearing aids depends on the appropriate fitting and proper verification (Abrams, et al., 2012). Recent surveys of professional practices (Mueller & Picou, 2010) show that professionals do not always follow best practices for hearing aid fittings. Additionally, the typical “first fit” algorithm from the hearing aid manufacturer generally needs to be adjusted using those best practices (Abrams, et al., 2012; Sanders, et al., 2015). OTC hearing aids with self-fit protocols are even less likely to be fit properly.
- Mandate package labeling for risk of hearing loss. If you want to update the label on something that will make an impact, add hearing loss risk labels to speakers at concert venues. Add hearing loss risk labels on the outside of the boxes of the millions of iPods and iPhones sold every year versus being where they currently are; buried in the user manuals that no one reads. Require lawn mower, leaf blower, chain saw and other related power tool sales to include protective earmuffs and regulate the sale of excessively noisy toys. Support initiatives that build awareness of hearing loss by informing consumers when they will be exposing themselves to potentially dangerous noise levels. Americans currently value their hearing, but do little to protect it and this needs to change (Packer & Dybala, 2015).
I am thankful for the initial work PCAST has done to shed light on hearing loss awareness. I would like to see the discussion reframed with input from practicing hearing care professionals, experts in the field of auditory research and persons with hearing loss. Together, we can recommend policy on this important health issue that could actually improve the lives of over 30 million Americans with hearing loss.
Paul Dybala, PhD
President, Healthy Hearing
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Amieva, H., Ouvrard, C., Giulioli, C., Meillon, C., Rullier, L., Dartigues, J. (2015). Self-Reported Hearing Loss, Hearing Aids, and Cognitive Decline in Elderly Adults: A 25-Year Study Journal of the American Geriatrics Society 63(10): 2099–2104. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/jgs.13649/abstract
Amlani A.M. (2010). Will Federal Subsidies Increase the U.S. Hearing Aid Market Penetration Rate? Audiology Today 22(3):40-46. Retrieved from http://www.researchgate.net/publication/235290235_Will_federal_subsidies_increase_the_US_hearing_aid_market_penetration_rate
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Bishop, C.E. (2012). The Ear is a Window to the Heart: A Modest Argument for a Closer Integration of Medical Disciplines. Otolaryngology 2:e108. Retrieved from http://www.omicsonline.org/the-ear-is-a-window-to-the-heart-a-modest-argument-for-a-closer-integration-of-medical-disciplines-2161-119X.1000e108.php?aid=10646
Clason, D. (2015, October 26). How hearing loss is different than losing your vision. Healthy Hearing Retrieved from http://www.healthyhearing.com/report/52555-How-hearing-loss-is-different-than-losing-your-vision
Li, C., Zhang, X., Hoffman, H.J., Cotch, M.F., Themann, C.L., Wilson, M.R. (2014). Hearing Impairment Associated With Depression in US Adults, National Health and Nutrition Examination Survey 2005-2010. JAMA Otolaryngol Head Neck Surg. 140(4):293-302. Retrieved from http://archotol.jamanetwork.com/article.aspx?articleid=1835392
Mueller, H.G., Picou EM. (2010). Survey Examines Popularity of Real-Ear Probe-Microphone Measures. Hearing Journal 63(5):27-32. Retrieved from http://journals.lww.com/thehearingjournal/Fulltext/2010/05000/Survey_examines_popularity_of_real_ear.5.aspx
Friedland, D.R., Cederberg, C., Tarima, S. (2009). Audiometric pattern as a predictor of cardiovascular status: Development of a model for assessment of risk. The Laryngoscope 119(3):473–486. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/lary.20130/abstract
Hearing Industries Association (HIA) (2015). Patient care & positive outcomes: The focus of hearing health. White paper Retrieved from http://www.hearing.org/uploadedFiles/Content/HIA_Updates_and_Bulletins/HIA%20White%20Paper%20on%20Hearing%20Health%20-%202015.pdf
Hull, R.H., Kerschen, S.R., (2010). The Influence of Cardiovascular Health on Peripheral and Central Auditory Function in Adults: A Research Review American Journal of Audiology 19: 9-16. Retrieved from http://aja.pubs.asha.org/article.aspx?articleid=1757459
National Council on Aging (NCOA) (1999). The Consequences of Untreated Hearing Loss in Older Adults. White paper Retrieved from https://www.ncoa.org/resources/the-consequences-of-untreated-hearing-loss-in-older-adults/
Packer, L., Dybala, P.D. (2015, November 10). Survey shows most Americans are hearing hypocrites. Healthy Hearing Retrieved from http://www.healthyhearing.com/report/52570-Survey-shows-americans-are-hearing-hypocrites
Sanders, J., Stoody, T.M., Weber, J.E., Mueller, H.G. (2015). Manufacturers’ NAL-NL2 Fittings Fail Real-ear Verification; One more reason why probe-mic verification is crucial in any Best Practice protocol. Hearing Review 21(3):24. Retrieved from http://www.hearingreview.com/2015/02/manufacturers-nal-nl2-fittings-fail-real-ear-verification/