Patients who purchase hearing aids are underwriting the substantial costs of those patients who either exchange their aids or return them without a purchase. When patients exchange their hearing aids for other devices, the number of visits goes up by 61%, and the time spent by clinicians with these patients goes up by 56%. The clinic in this study incurred an average cost of $204-$252 more per patient exchange or return respectively, and this does not include the cost of the hearing evaluation, earmolds, next-day shipping, and many other related fitting and administrative services.

Most states mandate a trial period for patients obtaining hearing aids, and the vast majority of audiologists and hearing instrument specialists offer a trial, regardless of the law. At least two-thirds of states allow hearing health care professionals to retain a fixed fee or a percentage (5%-20%) of the purchase price when patients return hearing aids for credit.1 Other states, such as California, prohibit retention of any costs or fees associated with the sale of hearing aids. Specifically, laws such as California’s Song-Beverly Consumer Warranty Act2 require that the dispensing professional refund all fees including the cost of earmolds, batteries, and fitting fees.

While the intent of this legislation was to protect consumers, the effect has been to penalize not only professionals by not allowing them to charge for professional time, but also consumers—by driving up the retail cost of the product because of the expense of providing “free” additional services to those patients who return or exchange hearing aids.

Previous studies have documented the amount of time and expenses associated with dispensing hearing aids.3,4 The purpose of this investigation was to perform a time-cost analysis on patients who purchase and retain hearing aids, exchange the aids for other devices, or return the aids for credit.

Methods and Procedures
Subjects: A large database of patients purchasing hearing aids at the University of California, San Francisco between 2000-2003 was used for this study. All patients included in this review were 18 years or older and all were self-pay (ie, no third-party insurers). Only patients purchasing programmable analog or digital hearing aids were included in order to maintain a fair comparison regarding time spent. The database was subdivided to create 3 categories of patients, and subjects were randomly selected from these groups:

n Group A: Patients who purchased hearing aid(s) and kept the device(s). None of these patients returned or exchanged their hearing aids. The total number of patients in Group A was 57. Of these, 34 (60%) purchased binaural instruments.

n Group B: Patients who purchased hearing aid(s) but exchanged the device(s) between 3 weeks and 3 months of the original fitting date of the devices. The total number of patients in Group B was 40. Of these, 30 (75%) purchased binaural instruments. To be included in this analysis, patients purchasing binaural instruments also exchanged their hearing aids for different binaural instruments. Ten subjects (25%) in Group B exchanged devices and tried more than 2 sets of hearing aids.

n Group C: Patients who purchased hearing aid(s) but returned the device(s) for full credit. The total number of patients in Group C was 52. Of these, 35 (67%) purchased binaural hearing aids. Forty-five of the 52 subjects in Group C returned their hearing aid(s) within a 3-month period. The 7 who did not either tried multiple sets of devices or had their trial extended due to extenuating circumstances. It should be noted that the UCSF Audiology Clinic initially authorizes a 1-month trial period, but for 65% of the Group C patients, the trial was extended in an effort to optimize the fitting. Five subjects in this Group also exchanged devices, tried more than 1 set of hearing aid(s), and ultimately did not complete a purchase.

Visits: Billing and medical records were reviewed to obtain the number of visits and the time allotted for those visits. Each live encounter, including the fitting (but not the evaluation), was counted as 1 visit. Battery purchases or minor issues requiring less than 10 minutes were not counted.

Time Allotted: Because this was a retrospective study, there was no means of determining the exact amount of time spent on each visit. Therefore, the fitting appointment was allotted 60 minutes. Follow-up hearing aid checks and additional audiologic testing visits were logged as the actual time spent rounded to the closest 15-minute increment, as determined by the billing records. These appointments generally entailed some or all of the following: re-programming, probe microphone measures, re-casting, shell or earmold modification, and counseling.

All no-shows, missed appointments, or cancellations made less than 24 hours in advance were assigned the time that was allotted for the appointment; however, those missed appointments were not counted as additional visits. Fifteen minutes were added to the total time for each return for credit (Group C) since processing time from the professional or clerical staff was required. Thirty minutes (15 minutes each for processing the return and placing the new order) were added to the time allotted for the exchange patients (Group B). However, additional visits were not counted for any group unless the professional was scheduled for that time. Time spent on emails and telephone contacts was not formally analyzed.

figureFigure 1. Mean number of visits over a period of 12 months. Group A represents those patients who purchased and kept their hearing aids; Group B represents those who exchanged their hearing aids for another; Group C represents those who returned their hearing aids and chose not to make a purchase.

Full-Year Analysis of Data
Figure 1 shows the data for the mean number of visits for the three groups. For Group A, the mean number of visits was 4.78 (SD 2.54); the minimum number of visits was 2 and the maximum number of visits was 11. For Group B, the mean number of visits was 7.83 (SD 2.76); the minimum number of visits was 3 and the maximum number of visits was 22. The mean number of visits for Group C was 3.96 (SD 1.98); the minimum number of visits was 1 (ie, the subject dropped off the returned hearing aids at the front desk) and the maximum number of visits was 13.

figureFigure 2. Mean time allotted to individuals in each group of patients over 12 months.

Figure 2 shows the data for the mean time allotted for the three groups. For Group A, the mean allotted time was 4.42 hours (SD 2.09); the minimum time allotted was 1.5 hours and the maximum was 8.75 hours. For Group B the mean allotted time was 7.81 hours (SD 3.13); the minimum time allotted was 3 hours and the maximum was 16.75 hours. For Group C, the mean allotted time was 4.2 hours (SD 2.59); the minimum time allotted was 1.5 hours and the maximum was 12.5 hours.

Both the time spent and number of visits for Group B were significantly greater than for both Groups A and C (p<0.001, one way ANOVA with Bonferonni multiple comparisons test). Groups A and C did not have a significantly different number of visits or time spent (p>0.05).

Three-Month Analysis of Data
Group A subjects were seen in the clinic and had data analyzed over a full 12-month period, but the vast majority in Group C (45 of 52) only returned to the clinic over a 3-month period. Therefore, it is appropriate to compare the visits and time allotment for data for this time interval. Group B subjects were not typically finished with the second trial period by 3 months, and therefore were not included in this analysis.

figureFigure 3. Mean allotted visits per Group A and Group B patients over first 3 months.

Figure 3 shows the data for the mean number of visits for these two groups. For Group A, the mean number of visits was 3.53 (SD 1.57); the minimum number of visits for subjects was 2 and the maximum number of visits was 8. For Group C, the mean number of visits was 3.36 (SD 1.69); the minimum number of visits was 1 and the maximum number of visits was 8.

figureFigure 4. Mean allotted time per Group A and Group B patients over first 3 months.

Figure 4 shows the mean time allotted for these two groups. For Group A, the mean allotted time was 3.39 (SD 1.53). The minimum amount of allotted time for Group A subjects was 1.5 hours and the maximum was 7.5 hours. For Group C, the mean allotted time was 3.54 hours (SD 1.57). The minimum amount of allotted time for Group C subjects was 1.5 hours and the maximum amount of allotted time was 9 hours. Differences between these two groups for both time allotted and number of visits were not statistically significant (p >.1, t-test).

Sweetow & Shelton3 analyzed the time and number of visits required by patients receiving and keeping either programmable devices or conventional devices. They reported an average of 3.9 hours and 3.4 visits (for the more sophisticated programmable devices) over the first 12 months. They also indicated that the more sophisticated the product, greater amounts of time and visits were required. Comparisons can be made for the 1996 subjects receiving programmable instruments to the Group A “keepers” in the present study (4.40 hours and 4.78 visits). The greater amount of time allotted and greater number of visits found in the current study may support the view that patients now demand more time and visits because of the increased cost and expectations brought forward by digital technology. In addition, it may reflect the additional flexibility afforded dispensing professionals and their willingness to refine the fitting.

The findings of this study indicate that the amount of time and the number of visits for individuals who keep versus those who return devices for credit are essentially equal. Also, recall that we did not account for the emails and phone calls as time spent with patients (limited data shows a trend toward more emails and phone calls from Groups B and C versus Group A).

It is also relevant that the mean length of time allotted for the visits for Group C was greater than that allotted for either Group A or Group B. This was calculated by dividing the 12-month total hours by the 12-month total visits. Specifically, Group A required 55.5 minutes per visit, Group B required 60 minutes per visit, and Group C required 63.6 minutes per visit. Analysis reveals that the time spent per visit was significantly greater for Group C than for Group A (p<0.01, one-way ANOVA, Bonferonni post test). Group B did not differ significantly in time spent per visit from either of the other groups.

This investigation reviewed only the number of visits and time spent for procedures related to the fitting of amplification. In order to establish the cost associated with these procedures, each clinic or business would need to multiply the time spent by their own operating costs. For example, in our clinic we calculated the hourly rate per audiologist to serve a patient to be $60. Therefore, considering the mean time allotted of 4.2 hours for the “returners” (Group C), the mean cost to the clinic was $252. Moreover, that does not count the time spent on the evaluation and it does not include the non-refundable fees for earmolds, batteries, or shipping.

Similarly, when patients exchange for other hearing aids (Group B), the number of visits relative to the number of visits for the patients who keep the original devices (Group A) goes up by 61% and the time spent goes up by 56%. Calculated as above, the mean additional time spent on the “exchange patient” is 3.4 hours (recall that an additional 1-hour fitting appointment was required for the exchange group). With the above-mentioned $60 overhead, the additional expense to the clinic is $204.

There is clearly an urgent need to limit the number of “no-charge” visits to which the patient is entitled. Consider, for example, that one subject in Group B returned for 22 visits, and one subject in Group C returned for 13 visits. Interestingly, the maximum number of visits for any subject in Group A was 11. These figures support the concept that patients keeping their hearing aids are subsidizing the patients who either return or exchange devices.

Unbundling versus bundling might be one manner that would allow for a more equitable paradigm without penalizing “keepers” for the practices of the “returners”; however, certain laws (ie, the Song-Beverly Act in California) may preclude this as a possibility. If consumer costs are reduced because of fewer “no-charge” visits, there is a possibility that market penetration could increase. The argument against limiting the number of “no-charge” visits, of course, is that some patients will not return for needed adjustments because of the additional cost.

One way of defining satisfaction is to divide benefit by cost. It follows that the cost of hearing aids contributes not only to the remarkably low market penetration, but also to the high return-for-credit rate. Bray5 commented that the approximate 20% return-for-credit rate in our industry accounts for nearly 30% of the initial manufacturers’ cost of hearing aids. People who choose to keep their hearing aids are absorbing the cost for those who choose to return their hearing aids.

This is not to imply that the return-for-credit option should be abolished. Rather, it is to suggest that the cost of hearing aids to patients keeping their devices could be reduced if professionals were allowed to retain a reasonable fee for their time and services. This could be accomplished either by unbundling services from products, thus limiting the number of no-charge visits included, or by employing a trial retention fee that is clearly defined in the purchase agreement.

The authors thank Idris Leppla for her assistance collecting these data.

Robert Sweetow, PhD, is director of Audiology and professor of Otolaryngology, Larrain A. Bratt, MA, is an AuD candidate and hearing aid coordinator, and Monica Miller, BA, is a research assistant at the University of California, San Francisco (UCSF). Jennifer Henderson-Sabes is a doctoral candidate at Arizona State University and a research audiologist at UCSF.

1. Federal Trade Commission. Sound Advice on Hearing Aids. Available at: Accessed December 8, 2003.
2. Song-Beverly Consumer Warranty Act (abridged); California Civil Code §1793.02. Available at: laws.htm. Accessed December 8, 2003.
3. Sweetow RW, Shelton CW. Analysis of time/cost and satisfaction factors for programmable versus conventional hearing aids. Hear Jour. 1996;49, (4), 51-57.
4. Hall M, Roth L. Dispenser programmable aids: Is skepticism holding us back? Hear Instrum. 1994;45(5);16-18.
5. Bray V, Johns M, Ghent R. Description and rationale of a digital, instant fit hearing aid. Hear Jour. 2001;54(4); 38-46

Correspondence can be addressed to HR or Robert Sweetow, PhD, University of California, San Francisco, 400 Parnassus Ave., A 705, San Francisco, CA 94143-0340; email: [email protected].