How Audiology Got To Where We Are Today (my view from the cheap seats)

Anyone who knows me well knows that my long-standing mantra is actually from an Apple ad:

“Here's to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They're not fond of rules. And they have no respect for the status quo. You can quote them, disagree with them, glorify or vilify them. About the only thing you can't do is ignore them. Because they change things. They push the human race forward. And while some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do.”

I try to live this mantra in my life and work. My goals are simple: 1) For Americans to hear more and fall less, 2) for audiologists to provide the care and treatment necessary to make that possible, and to accomplish #1 and #2 in as honest, transparent, and research evidence-based manner as possible.

Over the past almost two decades, I have vehemently tried, through both my work and volunteer activities, to accomplish the goals above. It has never been easy. I have tried “nice”, supportive, and collaborative. ?But, in the end, honest has been the most successful approach. Honest isn’t always perceived as “nice”.

I have always seen itemized and unbundled pricing as the most honest, patient centered, transparent way to value and charge for care. ?It also is how insurance worked, which made it even more desirable and straightforward. I gave my first presentation on the topic in 2007. ?During the Q and A following the presentation and in the hallway after, I was screamed at by audiologists, buying group business development staff, and at least one president of a hearing aid manufacturer. They told me I was trying to destroy a successful hearing aid business model of high average selling prices and high margins. They told me I was ill-informed and wrong. There was little thought to the effect that this model had and would have on hard of hearing consumers.

I was introduced to Clayton Christensen and the idea of disruptive innovation a year later.?I saw, immediately, how our industry was ripe for disruption because so many consumer needs (access, affordability and care) were not being met by our current, 1980s/90s evaluation and care delivery and pricing models. 70—80% of the hard of hearing were not being served (and this number stands today). I gave my first presentation on the topic in 2009. I was again met with skepticism and pushback. The same year, the government got involved and the National Institute of Deafness and Other Communication Disorders (NIDCD) launched the first working group on accessible, affordable hearing care for adults with mild to moderate hearing loss (https://www.nidcd.nih.gov/research/workshops/nidcd-workshop-accessible-and-affordable-hearing-health-care/2009/participants). Still limited response from the masses.

Two years later, in 2011, the Hearing Loss Association of America (HLAA) made price transparency and unbundling its #1 advocacy initiative. Most of audiology ignored their plea. As we failed to respond, the movement on accessible, affordable hearing care gained traction and continued to grow. NIDCD put out a call for research proposals (https://www.nidcd.nih.gov/research/hearing-health-care-research-projects).?It is this resulting research (i.e. SCIENCE) that has brought about the changes we are seeing today, including over the counter (OTC) hearing aids and self-assessment. I hate when I see providers talk about the resulting research on the impact of untreated hearing loss on cognition and then simultaneously fight any action to expand the treatment of hearing loss. The disconnect is mind boggling and disingenuous.

During this time, I kept pushing forward on trying to get audiology to evolve and change and continued to get pushback from many practices, buying group staff and industry. They would say that they were going to lose money, that patients would not be willing to pay for services and that care would suffer.?None of this was based upon any data or fact and, to date, there is zero data that supports these assertions.

The years 2014-2017 were the years of many engaging into hearing care topics. NIDCD continued funding projects in this space. The Institute of Medicine (IOM)/National Academies of Science, Engineering and Medicine (NASEM), The President’s Council of Advisors on Science and Technology (PCAST), the Food and Drug Administration (FDA) and the Federal Trade Commission (FDA) all did research and deep dives into our profession and industry. Many of these entities did public meetings/seminars on the topic of accessible and affordable hearing care. They produced encompassing reports which outlined a path forward for care and treatment. Despite the science behind these findings, a majority of providers and industry poo pooed these results as out of touch, misinformed or unimportant. Industry blamed providers for the price of hearing aids to all who would listen and we let them.

It was also in this time frame that I started reading the research that was coming out of the NIDCD research pipeline. I became fascinated with emerging ideas and technologies. This is when I started buying, wearing and testing over the counter and direct to consumer hearable and wearable technologies, especially from new entrants, and trying out every self-assessment and remote assessment tool available. I learned a great deal, from personal experiences, about what is possible and available, good and bad. I even co-authored a study on this topic. Still, providers, by and large, touted these products and tools to be inferior, despite little personal experience or evidence.?They were socialized, by the five legacy hearing aid manufacturers, that anything not created by one of them is bad for consumers and even worst for audiology practices. Again, none of this was founded in actual data or science, just fear mongering and propaganda.

2016 and 2017 brought us the Over the Counter hearing aid legislative movement. I am proud to say that I have always been an advocate.?Research illustrated to me that the risks of non-treatment now outweighed the risks of inconsistently provided, research evidence based, audiologic evaluation and treatment. I knew that solid products existed. It also showed, if we follow the vision model, that this might allow us to finally expand the market and reach people when they are younger and more mildly impaired. See, the market that OTC is designed for is a market that is not currently engaging in the current audiology care delivery model. They do not have a $3000 problem; they have a $300 problem. They do not have the time, money, or inclination to devote to their condition as it currently exists. This market wants their hearing care journey to be on their terms and not ours. ?They want the accessible, self-directed care they see in other aspects of non-life threatening healthcare. But, instead of responding to consumer needs, we continued to fight against their desires under the guise of “protection and safety”. Oh the stories I could tell about the OTC fight on the Hill and the lies that were told along the way by people who knew better. I have lost faith and respect in many. Even after passage in August of 2017, this fight continued.?It has been a very long five years.?I have never seen another industry, in healthcare or beyond, fight so hard against expanding a market and helping those we serve. The final rule offered me a small victory but only a wisp of solace because the fight goes on.

The last almost two decades have left me older, wiser, and more informed. I respect science, truth and decency more. ?I have realized that my reputation does not have a price and that lying is not worth the cost to your soul. I now know who to trust and I cherish and value my true friends.

I have successfully trained or guided a few thousand audiologists over this time frame and have seen many of my colleagues and clients evolve and create more disruption proof, financially stable, patient centered care and pricing delivery models. These audiologists engage with and serve their communities and have seen many win the insurance game. From my client surveys, I know that the vast majority of my boot camp attendees and clients are happy with the outcome of our engagement and relationship. I could not be happier or prouder of the small role I have played in their successes.

I cannot though drag everyone to drink. These years have also left me more frustrated than I have ever been in my life. While many, many audiologists work hard, everyday, to the betterment of the profession and the individuals we serve, there is, unfortunately, a critical mass of providers who do not. They are why we cannot accomplish more and why we cannot have nice things. Their goals are greed and ego. They charge their patients premium dollars and do not provide premium care. They take kickbacks from industry, file false claims and scam patients and payers alike. Someone will say, “why are we so ugly to your colleagues”? My answer: I tried nice and it failed. Honesty and transparency are the ONLY way forward. We cannot fix ANYTHING until we acknowledge OUR role in where we are now. Only WE can change our collective future. ?

See, every industry is faced with disruptions. Audiology is not special. How we respond to the disruptions though is often disappointing.?We are no one’s victim. Much of what we are experiencing today are the byproducts of our own decisions and affiliations over the past twenty years. I have seen it time and time again. There is a path forward for us.?It is full of opportunity and growth. It allows us to practice to the top of our education and scope. It just requires action on our part. Until WE do things differently, we will be stuck in this cycle. I am available to give people a hand out of this.?Do you want to take it?