Surviving technical changes and diverse competitors

Harvey Abrams, PhD, is head of the Department of Audiology and Speech Pathology Service at the Bay Pines VA Healthcare System, Bay Pines, Fla; Brent Edwards, PhD, is the executive director, and Cheryl Eiler, MA, and William S. Woods, PhD, are research audiologists at the Starkey Hearing Research Center, Berkeley, Calif; and Laurel Olson, MA, is manager of clinical product research at Starkey Laboratories, Eden Prairie, Minn.

The future will be characterized by rapidly evolving technology in which the line between hearing care and consumer products becomes increasingly blurred, the size of the hearing loss population booms, and new businesses try to capture those patients through nontraditional channels like the Internet and telecommunications technologies. If hearing care providers wish to thrive as a private practice-based profession, it will be their expert services that allow them to do so.

A visit to most health care providers today involves a rather predictable series of steps:

  1. A physical examination and/or series of laboratory tests to determine the nature of the patient’s symptoms;
  2. The implementation of some prescribed treatment to resolve or mitigate the symptoms; and
  3. A return visit to monitor the results of treatment, at which time the patient is discharged or, in the case of unresolved symptoms, the process begins again.

For a patient presenting with hearing problems, the process follows a similar pattern. The clinician conducts a series of tests to determine the nature and extent of the problem. If it appears that the patient’s problem cannot be resolved medically, the focus of the evaluation moves from diagnostics to rehabilitation; that is, consideration of a series of therapeutic options that are likely to result in an optimum patient outcome. In cases where hearing aids are indicated, the features are determined on the basis of test results and patient needs.

Ideally, treatment also consists of some type of rehabilitation program that assists the patient in adapting to amplification, and better understanding the implications of hearing loss and the limitations of amplification. Finally, the patient’s progress is monitored during scheduled visits to evaluate success and make modifications to the instruments.

Provider-Centered Versus Patient-Centered Care

The model presented above describes a provider-centered approach to patient care. The patient accesses the provider through appointments at the provider’s practice. In addition, the goods, supplies, and services required to ensure a successful provider-patient interaction are delivered to the provider by manufacturers, retailers, and other suppliers.

In the hearing health care environment, the provider-centered model requires the patient to travel to the dispensing professional for examination, treatment, and monitoring. In the provider-centered environment, ear impressions are made in the clinic; the hearing instruments are ordered, manufactured, and sent back to the clinic, where the patient returns for fitting and follow-up visits. This has been the prevalent model of hearing aid dispensing, remaining essentially unchanged since the invention of modern hearing aids.

However, there are dramatic market forces at play that will likely revolutionize the way health care in general and hearing health care in particular are delivered. In the coming years, patients will likely segment into two distinct groups. One group will consist of patients similar to those we see today: retired, over age 65, not as active as they used to be, not as technically savvy as younger generations, with at least a moderate hearing loss. This group is concerned about their hearing loss and will likely continue to seek the services provided by today’s dispensing professionals. We will refer to them as the Traditional group.

The other group will be dramatically different. This group is younger and more ethnically diverse, with milder hearing loss, higher income, and greater technological savvy as frequent users of computers and wireless technology. They have a stronger sense of entitlement, and are more likely to admit to hearing loss. We will refer to them as the Tech-savvy group. This new patient group represents significant challenges, opportunities, and threats for today’s dispensing professional.

Hearing care 2017? Given the pace of technology, it is not difficult to imagine a hearing health care model in which hearing testing is conducted, and the results are remotely transmitted using self-test kits or biosensors connected to patients at their home computers or at shopping center kiosks. Hearing sensitivity, otoacoustic emissions, evoked potentials, speech recognition, central auditory processing disorder testing—all administered locally but transmitted and analyzed remotely—may be an inevitable change confronting our profession. Imagine a model in which not only testing but treatment—hearing instruments, rehabilitation, and follow-up care— can be prescribed, ordered, and delivered remotely. Imagine a model in which monitoring changes and actual adjustments to hearing instruments can be made through remote technology interfaces or, just as likely, through smart technology that adjusts the instruments automatically through sophisticated scene-analysis algorithms.

Such a model represents a shift from a provider-centered to a patient-centered health care delivery system. The Tech-Savvy group will likely embrace such changes much more than the Traditional group. All of these advances could be integrated into a modern hearing health care practice, providing opportunities to reach the Tech-savvy group through the advanced technology they have come to expect.

In a world with these technological advances, however, there will be many others besides audiologists, hearing instrument specialists, and ENTs competing for and gaining access to this emerging group of patients. Who are these “others”? They will be new business competitors consisting of direct marketers, Internet providers, HMOs, large retail stores, telecommunication companies, and probably even new hearing instrument manufacturers and/or dispensing networks. The combination of changing technology and this new younger group of patients with hearing impairment provides the potential for these groups to access our patients through home and business computers and through telecommunication devices.

Further adding to the potential for other access methods to patients is the fact that the hearing impaired population will nearly double during the next 25 years, yet the number of dispensing audiologists is expected to decline. As access to technology for hearing health care becomes more difficult, the door opens for other competitors to fill that gap.

The Future, As Viewed by Stakeholders

Manufacturers and suppliers. From the manufacturers’ perspective, the order-manufacture-distribution process will undergo dramatic change and potentially threaten their business. In today’s environment, hearing instrument orders originate primarily in individual practices or large retail operations. In tomorrow’s environment, those orders may come directly from the consumer via direct Internet sales provided by new business competitors. This trend appears more inevitable as laser technology, open-ear fittings, and ready-fit products are decreasing the need for individual ear impressions.

Perhaps the most dramatic development to affect the future of manufacturing, and one that will have a ripple effect throughout the hearing health care industry, is the rapid change in telecommunication technology. We are already seeing the influence of “technology fusion” with the incorporation of Bluetooth and FM technology into today’s digital hearing instruments. It is not difficult to imagine the future “hearing aid” simply serving as a receiver for multiple inputs such as e-mail, phone, MP3 player, FM, Bluetooth, the Internet, real-time translator, and even as an amplifier for the hearing impaired. Indeed, products exist already that blur the line between a communication device and a hearing aid.

Instead of the universal, flat-frequency-response earbuds typically associated with MP3 players, our future patients will wear ready-fit wireless receivers individually programmed to their hearing preferences, or programmed to compensate for their hearing impairment—provided by manufacturers of consumer products such as Sony, Panasonic, and Nokia. The demand for these products will come from the Tech-savvy group. The technology compensating for the patient’s hearing loss from these consumer providers will likely not be nearly as beneficial to the patient as technology from traditional hearing aid manufacturers—but the patient may be oblivious to this fact, and/or the lower cost of the product may help compensate for its reduced benefit.

Consumers. Future patients’ expectations of hearing health care outcomes may not be too different from what they are today. The patient will expect improved audibility; speech understanding in noisy, reverberant environments; good cosmetics; affordable devices; and convenient access to technologically sophisticated staff.

The difference will be in their expectation of how the care is delivered: Tech-savvy patients will expect immediate and convenient access to hearing health care and to hearing instruments capable of product integration. They will also demand products and office environments that reflect their perception of state-of-the-art technology, and they will reject purchasing hearing devices from offices that do not seem to have modern technology or advanced procedures.

Dispensing professionals. From the dispensing professional’s perspective—particularly audiologists—the future presents considerable challenges. How can we position ourselves as the primary hearing health caregiver when so many are competing for the patient’s business? How will we address the different demands of the Tech-savvy group while also providing for the needs of the Traditional group? Clearly, whether evaluation and treatment continue to be provided in the office, through technology transfer, or through a combination of both, we will need to differentiate ourselves in an increasingly competitive marketplace.

Perhaps the most effective way to distinguish ourselves from the Internet providers, retailers, telecommunication companies, etc, is to separate ourselves from the devices and avoid being perceived as salespeople. This requires a focus on treatment. This is not to say that we will not have to maintain our knowledge and skills regarding the latest technologies; rather, we will need to embrace the concept that it’s the pretreatment counseling, advanced diagnostics, sophisticated fitting and validation tools, and postfitting treatment or rehabilitation that will differentiate us in the marketplace.

In an environment where the line between hearing instrument and ear-level consumer electronics becomes increasingly blurred, it is services such as the rehabilitative process that will define who we are as professionals. Furthermore, these processes must extend beyond the selection and selling of devices in terms of both the range of services offered and in the length of follow-up. Regardless of the manner in which the amplified signal is received by the impaired ear, that signal will need to be carefully prescribed. Once the device is fitted, we will need to determine the appropriateness of assistive hearing technologies and home-based auditory training programs, and we will need to monitor the patient’s progress through regularly scheduled return visits.

The successful hearing care practices of the future will be those that have moved from product-based to service-based, with the service focusing on all aspects of the patient’s hearing loss and treatment, including rehabilitation. To this end, the more that patients can understand that hearing instruments in and of themselves do not provide a complete solution to their hearing difficulties, the more they will value the additional services not found through nontraditional hearing instrument channels, such as the Internet and consumer electronics stores.

The Orthodontics Model

How can the field of hearing health care begin to implement these changes? The profession of orthodontics provides a compelling model for separating the device from the service, and the orthodontic model has particularly interesting implications for hearing health care professionals.

In an orthodontics practice, the cost of the appliance is separated from the cost of service, and in many cases, the length of that service is expected to last several years. Orthodontic care requires the patient to return for scheduled visits to determine progress, ensure compliance with the treatment plan, and to adjust the appliance as the jaw changes in response to the appliance. The patient pays for 1 to 2 years of service provided by a team of highly skilled professionals.

Hearing aid users are getting older and more affluent. MarkeTrak VII suggests that the average age of a hearing aid purchaser in 2004 was 69.7 years old (up from 68.8 years in 2000) with an average household income of $56,000 (up from $46,000). See the full report in the July 2005 HR Archives.

Patients with hearing impairment should be similarly followed, because the auditory system also changes in response to an appliance—the hearing aid. It may be argued that the comparison between a metal appliance in the mouth and a highly sophisticated DSP instrument in the ear is not valid. It could also easily be argued that, just as the metal is useless until shaped and adjusted by a highly skilled professional, the hearing aid is of little value until its output is shaped and adjusted by a highly skilled professional. In both cases, successful outcomes are about an enhanced quality of life.

The orthodontics model can even suggest a solution to the problem of how our profession—with a static or decreasing number of practitioners—can meet the demand from an increasing population of hearing-impaired patients. Orthodontists typically see patients only at critical points in office visits; all other management is handled by technicians employed by the orthodontist. Audiologists could increase the number of patients they see and increase the extent of their care with additional services by utilizing trained technical staff to manage such areas of service as validation and rehabilitation.

In this way, the multifaceted aspect of hearing health care service can be expanded effectively beyond the dispensing of the hearing aid, with the additional benefit of increased patient satisfaction and the ability to meet the demands of both the Tech-savvy and Traditional patient groups.

Summit Recommendations

Attendees at the summit identified the following questions to consider so that we can better address potential changes in hearing health care delivery:

  1. How are the characteristics of our patients changing?
  2. How will new types of patients access hearing health care?
  3. How will the relationship between hearing aid technology, information technology, and changing demographics affect hearing health care delivery?
  4. What will the role of the hearing care professional be in this environment, and how should the profession change to meet changing demands?
  5. How can traditional manufacturers assist dispensing professionals in meeting these demands?
  6. Do we need to provide different services and technologies for those with mild losses (Tech-savvy group) versus those with moderate or severe losses (Traditional group)?
  7. How can our field change the consumer’s belief that hearing health care relies on a product (eg, “I need a hearing aid”) rather than a service (eg, “I need professional hearing help”), and how can our profession enact a more service-oriented approach to hearing health care?
  8. Is the orthodontics-care model viable for audiology? Patients see and therefore appreciate an improvement over time from their orthodontic treatment; can we provide evidence of such an improvement over time from audiologic services, and can we enable our patients to appreciate that evidence and value audiologic services?
  9. To what extent do we treat hearing health care as a consumer product model rather than a rehabilitation model, and does it depend on what type of patient (Traditional or Tech-savvy) is being treated?
  10. How can we enact a fieldwide modernization of technology and procedures to improve the patient experience when he or she seeks and receives hearing health care?
  11. How can potential patients be better educated about hearing health care so they understand that it requires a complete service solution and not just a hearing instrument? Should manufacturers assist in this education?


The future of hearing health care will be characterized by rapidly evolving technology in which the line between health care and consumer products becomes increasingly blurred, the size of the hearing loss population booms, and new businesses try to capture those patients through new channels. Dispensing professionals, particularly audiologists, need to separate the product from the service, capitalizing on specialized education, training, and offerings in such areas as diagnostics, fitting, counseling, patient benefit verification, and rehabilitation.

Correspondence can be addressed to HR or Harvey Abrams: .