The State of the State of Audiology: Service Based Care, Delivery and Pricing Models

Audiology used to offer service-based delivery and pricing. Prior to 1977, audiology was fee for service; the patient was billed for the services rendered by the audiologist. The hearing aid dispenser dispensed the device and the audiologist provided evaluation and fitting.? The costs of the devices were decoupled from the costs of the audiologic care.

Then, we are allowed to dispense.? And, instead of maintaining our current medically focused, fee for service delivery and pricing model, we took on the bundled retail model of the hearing aid dispenser.? In this model, every service and cost are only represented by the total cost of the hearing aid itself. Sometimes that bundled delivery lasts one year and other times it lasts a “lifetime”.

I have been passionate, since early in my career, about assigning value and costs to all audiologic care.? Our expertise and its worth need to be illustrated to the patient.?

In 2007, I began, in earnest, presenting and writing, at the national level, on top of license, top of scope, research evidence-based care delivery and the itemized, service driven, unbundled pricing of that care.? I remember that first presentation vividly, where I was shouted down during the talk and after was surrounded by presidents of manufacturers and industry “icons” (all men, I should note), all telling me how I was about to destroy audiology. My takeaway, that day, is that they were all trying to maintain their OWN status quo, especially when many of them owned corporate owned and franchised clinics. They did not care about the long game and the next generation; they cared solely about the profit at the time. We are still paying for this.

Between 2007 and 2011, a few clinics began to transition to service based, unbundled pricing of care. More and more audiologists, such as Stephanie Sjoblad, Barbara Winslow Warren, John Coverstone, and Debra Abel, wrote and presented at professional meetings on the value of unbundled, service driven care. Despite this, the vast majority of audiology practices remained in their bundled model.? This approach was supported by industry.

As hearing aid prices began to rise, in 2011, the Hearing Loss Association of America (HLAA) launched the Campaign to Make Hearing Aids Affordable.? Most practices in the US continued to ignore this call to action.?Unfortunately, this inaction helped lead to the focus of the President’s Council of Advisors on Science and Technology, the Institute of Medicine/National Academies of Science, Engineering and Medicine, and the National Institute of Health on accessible, affordable hearing care, especially those with mild, untreated hearing loss. Despite the misinformation spread throughout the industry, over the counter hearing aids are not here because of lobbying monies; they are here because hearing care and hearing aids became too expensive for many consumers and we, as an industry, would do nothing to change that.

There is no evidence that bundled care, delivery and pricing produces greater profitability and significantly higher patient satisfaction, outcomes and performance. None. I would counter that bundled care, delivery and, most importantly, pricing have a large role in where we find ourselves today.? The growth of hearing benefit plans/third-party networks, the introduction of over-the-counter hearing aid, and the growth of big box retail sales of devices are the result of consumer ?demands for more affordability and accessibility and a direct byproduct of our collective refusal to provide greater transparency, a higher level of care in the evaluation and fitting processes, and various care, technology, delivery, and pricing options. ?

See, one thing that every audiologist and very practice controls, in most situations, are the items and services they provide, the level of care they provide and the items they dispense, the way they delivery their care, and the price they charge or bill their patients for items and services. YOU determine this, not a government entity, a manufacturer, or third-party. Your standard of care is yours.

Our collective future, first and foremost, lies in the practice of audiology. Audiologists should provide care to top of license, top of scope, and in complete adherence to the research evidence. THIS is what makes audiology, audiology.? THIS is what (hopefully) differentiates you from hearing aid dispensers. Every day, I see a market for this type and level of care.

The future also lies in alternate delivery models.? Telehealth offers evaluation and follow-up care options to solve staffing (especially in rural areas) and scheduling issues. You can staff a clinic, for evaluation and rehabilitation services, ?with a technician and a remote audiologist.? You can provide follow-up “touchpoints”, using extenders and by the means preferred by the patient, during the hearing aid evaluation and adjustment period or after fitting an auditory prosthetic device, often without face-to-face encounters.? ??This reduces the number of appointments where the patient comes in to report no issues or concerns. We should also use extenders (technicians, audiology assistants, and hearing aid dispensers) in our practices to provide care that does not require the education or skills of an audiologist. Every patient does not always need to be seen in person and by an audiologist.

Every patient does not require an annual hearing test (no data to support timing of re-evaluation for monitoring sensorineural hearing loss), premium hearing aid (no data to support this), bundled, inclusive, long-term, follow-up care, and multiple, face to face follow-up visits during the evaluation and adjustment period and first year of ownership. Some do; some don’t. We though tend to put every patient in the same delivery box, which leads to overpayment by some and underpayment by others.

And, finally, we should offer transparent, service based, itemized (unbundled pricing), where we notify our patients, before services are rendered, of their out of pocket costs, value our time based upon data, metrics, and our breakeven plus profit needs and goals, charge for our medically necessary, evidence based services as they occur, and offer numerous hearing aid and long-term care pricing options for management of hearing aids and auditory prosthetic devices. THIS respects our patients and their individual needs and desires, values our education and skillset, and illustrates that value to the patient and their family. THIS differentiates us from big box and direct to consumer retailers and those who decide to remain bundled.

I am mentioning nothing here that I do not see successfully currently offered and provided, in every type of practice setting, in the US.? While we have not done a survey in a while (my last was in 2019 and the number of unbundled practices was 34%), I would estimate that still only 40-45% of hearing healthcare practices offer service driven care, pricing, and delivery.? This means that 55-60% of you have an unmet opportunity.

Most practices cannot compete, on price, against $1499.99 for a pair of hearing aids, provided in a bundled delivery. We have to begin to compete more on the level of care and the delivery options provided (be everything they are not) and with transparent, more individualized pricing options. To get started you just need knowledge, skills, and data on your practice, its expenses and overhead, your breakeven rate, your financial goals, your time scheduled for each procedure and service, your third-party allowable rates, your costs of goods, and the metrics on the care delivered to your average patient. This data should exist and be available in your office management or electronic health record systems.

We can all evolve our practices.? It is something WE control. Right now, it is not too late. I teach people to successfully navigate this every day! ?I cannot promise though that it will never be too late. The industry is rapidly changing and what worked in 1990 really doesn’t work today in most situations and settings.