Methods for Prescribing Gain for hi HealthInnovations’ Hearing Devices: Reliability and Accuracy

Dear Editor: Regarding the January 2012 Hearing Review article, “Methods for Prescribing Gain for hi HealthInnovations’ Hearing Devices: Reliability and Accuracy,” by Dianne J. Van Tasell, PhD, the National Centre for Audiology at The University of Western Ontario provided a subset of the validation data mentioned in this report.

Specifically, we collected hearing threshold estimates from 500 to 6000 Hz using a calibrated audiometer and insert earphones and compared them to those collected with a rigorously calibrated iPad and insert earphones. A registered audiologist also collected threshold measurements from normal hearing participants from 500 to 6000 Hz using a calibrated audiometer and insert earphones and one type of ear occluding headphones. All data (audiometric and iPad) were collected under highly controlled conditions in a sound booth. A registered audiologist confirmed that the ear canal was clear via otoscopy, and that the participant was free of cognitive issues that would have impaired his or her ability to complete the self-administered hearing test. Participants had previously received a full audiometric battery and were known to be free of middle ear, retrocochlear, or other ear pathologies that would require medical assessment.

We cannot endorse the accuracy of self-assessment systems under non-controlled conditions, with uncalibrated transducers, or by users who have not received otologic or medical clearance. We certainly do not endorse the application of self-assessment systems for the prescription and fitting of hearing aids and, in the interest in public safety, recommend that anyone concerned they have hearing loss speak to their family physician or a registered audiologist.

— Paula Folkeard, AuD, Susan Scollie, PhD, and Prudence Allen, PhD,
National Centre for Audiology, The University of Western Ontario

Cost-effective Pricing for Hearing Aids and Related Audiological Services

Dear Editor: I am writing regarding the November 2011 edition of the Hearing Review article, “Cost-effective Pricing for Hearing Aids and Related Audiological Services,” by Ron Leavitt, AuD, et al that contained several statements that caused me grave concern.

First, the authors are tying diagnostic audiologic testing to the purchase of the hearing aid. They mention “all of the cost-containment plans known to the authors have a streamlined evaluation procedure. Specifically, none require in-depth diagnostic testing for outer or middle ear pathology, retrocochlear disorders, central auditory processing deficit, balance disorders, or hair cell function.” I completely disagree with several aspects of this statement. It is always our ethical and legal obligation to assess a patient’s hearing and balance function, irrespective of their potential need for and purchase of amplification. These are separate audiologic procedures that are diagnostic—not rehabilitative—in nature. There are other cost containment options involving unbundling that enhance, rather than sacrifice, the appropriate audiologic assessment of the patient and fitting of amplification.

Second, I am concerned about the validity of the following: “Physicians and accountants representing the Centers for Medicare and Medicaid Services (CMS) have worked for years with scientific/professional audiology organizations to establish a list of tests, services, and fees that are considered necessary to protect patient health. Any attempt to sell hearing aids at a price that is lower than the fees for the hearing aid plus diagnostic and validation tests necessary to confirm appropriate hearing health care and hearing aid performance is contrary to this agreement.”

CPT and/or HCPCS codes are established to represent many but not all of the diagnostic and rehabilitative items and services within the scope of practice of an audiologist. While CPT codes are currently valued by the American Medical Association (AMA) and CMS, the HCPCS codes that represent the vast majority of hearing aid services we provide are not. Fees are not established through the Centers for Medicare and Medicaid Services (CMS) for the HCPCS codes that cover hearing aids. Individual state Medicaid programs value these codes for use within their own state programs. These Medicaid valuations carry little to no weight in the remainder of the hearing aid marketplace.

I am also concerned by the contents of Table 1. The table is titled “Medicare fees as provided by the American Speech-Language-Hearing Association (ASHA) Web site for hearing and balance-related diagnostic testing.” There is no place in the ASHA document that the article references where prices for hearing aid related services, such as hearing aid programming and electroacoustic evaluation, are listed or discussed. ASHA cannot and would never provide such data, as it does not exist. Medicare does not have cost information related to hearing aid services as hearing aids and their related services are non-covered by Medicare. The author has inappropriately assigned hearing aid related service fee data to ASHA but provides no guidance as to the source of these costs. The article goes on to state, “Anything below this amount [$706] ignores the agreement reached by an independent third-party review board and the major US audiology organizations.”

As a sitting member of the audiology coalition committee that addresses the professional issues surrounding audiology coding and reimbursement, I can report that we do not, have not, and cannot enter into any agreements with any third-party review board that would regulate the price of hearing aids in the United States in the manner Dr Leavitt has described. That type of action could be construed as a violation of federal collusion and anti-trust laws and is strictly prohibited by our individual organizations.

In my opinion, this statement leads the reader to believe that the audiology organizations have significant influence over the fees assigned to diagnostic and hearing aid services. This is absolutely not the case. As an audiologist who has spent the majority of her career educating audiologists on matters such as these, I believe this type of misinformation can lead audiologists down unfortunate paths.

— Kim Cavitt, AuD, Audiology Resources Inc, Chicago

Digital Wireless or Looping?

Dear Editor: Kudos to the authors of recent articles in the February HR and in previous editions of HR and HRP on new developments in wireless technologies that increase signal-to-noise ratio. In particular, I agree that “intuitive and easy-to-use” supports widespread use, lest ITE and BTE hearing aids become ITD (in-the-drawer) hearing aids.

One reason for the joint Hearing Loss Association of America/American Academy of Audiology “Get in the Hearing Loop” initiative, and for the accelerating support for hearing loops among both hearing consumers and hearing care professionals, is indeed their simplicity of use. This one simple technology—using an inexpensive telecoil receptor—enables me to hear clear office phone conversation through both aids, listen to my TV (which broadcasts through my in-the-ear loudspeakers), hear my preacher, listen to lectures on my campus, and even understand boarding announcements at my airport.

All this is possible with a mere button push, and without the fuss of checking out or charging and pairing extra equipment. Moreover, an additional M/T setting allows me to hear others or the home doorbell while watching TV. Voilà!—with their doubled functionality, I love the hearing aids I once barely tolerated in challenging situations.

Will an alternative future technology eventually replace hearing loops (which have spread across the UK and Scandinavia, and are now spreading in the USA)? I, for one, welcome any new alternative future technology, providing it can be similarly:

  • Simple;
  • Affordable;
  • Available with most hearing instruments, as telecoils are;
  • Demand no significant battery power;
  • Enable simultaneous microphone use—via hearing aid mic + telecoil (MT) settings;
  • Cover both small and large areas—from discrete places (New York City’s 488 newly looped subway booths) to the huge (12,200 fixed seats of Michigan State University’s looped basketball arena); and
  • Receive a universal signal—and thus serve everyone, no matter their hearing aid brand.

For now, telecoils and hearing loops are the technology that meets these aims, which explains why so many of us are working to get our communities “in the hearing loop.”

— David G. Myers, PhD, professor of psychology,
Hope College,

…And One More Thing About Looping

Dear Editor: Remember the days before fuel injection engines? Back when you had to start a cold engine by closing the choke? In some cars, pumping the gas pedal was required to get the engine to start on a cold day. Once the engine warmed up, you had to remember to open the choke to avoid excessive fuel use. Starting a warm engine with the choke closed ran the risk of flooding it. Then along came modern fuel injection that delivered fuel in just the right amount allowing one to “simply turn the key” and go.

Enter hearing aids with RF and Bluetooth wireless technology, devices that require a more sophisticated and involved dispenser, as well as user. These users have to know when to pair the streamer or intermediary device, how to pair, what device to turn off, in what order to turn them back on in order to link with the desired device, and, at times, re-pair a connection when it is lost. The user also has to keep track of the devices, keep them properly charged, and, since they will not stream signals for more than 3-5 hours, plug them in directly while watching TV at night.

Does this remind you of the old carbureted engine days? Sometimes, I did not know when to pull the choke out or push it back in and was often accused of “flooding the engine.”

No wonder many hearing aid users are not buying, or when they have, end up not using these wireless devices as much as they thought they would. Some are confused as to what type of technology to buy: RF or Bluetooth? They ask me, should I wait until something better comes along?

Several audiologists and dispensers have told me privately they do not feel equipped to handle all this technology. When the manufacturer’s representative is in the office and during the demo, it all works well. Yet, all too often there are issues that the clinician in his/her office cannot resolve: The user doesn’t own a Bluetooth cell phone; the home telephone has Bluetooth but they don’t know how to use it; the user doesn’t own a TV set with a separate RCA audio out; the hearing aid user owns a TV set that has a headphone jack only; and now the client’s spouse can no longer hear the TV when the wireless TV device is plugged in, etc.

Other potential snags: Some TV sets now come with an optical-out and require a special digital-to-analog convertor, and some clients use cable and DVD players so the sound from the TV can be heard but not when the DVDs are played. Some want to link the streamer to their iPad to listen to books on CD, or use their Mac to Skype, and the iPhone to talk. Some TV transmitters stop working in the home, necessitating the clinician to spend a significant amount of time to troubleshoot the problem: Is it the hearing aid, the streamer, the transmitter, or did the client accidentally pull the transmitter out of the TV?

Just because something is new doesn’t mean that it always is an improvement. (How many of you own salad-shooters? Come on, admit it.) We have to face reality. This new technology is cumbersome, takes up a lot of valuable time, and in the end it just doesn’t offer our clients the uncomplicated access to sound we had hoped it would provide.

Now fast-forward to the current day hearing loop technology: Sound from a PA system goes wirelessly and directly into the hearing aids at the touch of a button and, because the telecoil is powered by the inductive magnetic field from the loop, it essentially consumes zero battery power. Just like fuel injection was around a long time before it was made available and affordable to the consumer, the hearing loop technology installed to the IEC standard 60118-4:2006 coupled with improved t-coils, voice prompts to alert the user to a program selection, digital programmability in the fitting software and multiple t-coil listening programs, is not the same hearing loop technology that was poorly installed 30 years ago.

Hearing loops and t-coils give the user uncomplicated, seamless, and integrated access to sound at the touch of a button. I know the day is coming when pairing, linking, and multiple devices will all work seamlessly with a universal wireless signal that a united hearing industry will agree to provide in each and every hearing instrument at low cost. And this new connectivity will then be easy to use, will not require much power, and will be used worldwide—but we have been told by experts in the field this won’t occur for another 10 years or possibly never.

Until that day, hearing loops provide easy-to-use direct sound injection (DSI) for those with hearing loss the world over. DSI (aka hearing loop technology) offers our clients easy access to sound, and gives them phenomenal hearing and understanding— something that has been known to choke them up. I am not an advocate for this DSI or induction hearing loop technology as much as I am an advocate for the absolute best present-day technology for assistive listening at concerts, theater venues, places of worship, and meeting rooms. The best present-day technology—and this will hold for at least the next 5 to 10 years—is hearing loops.

Will better technology come along, either by improving loops via digital processing, or by developing an entirely new technology? Of course! And then, I will advocate just as passionately for that technology.

Helping my clients hear better (the reason I became an audiologist) with easy uncomplicated technology—now this is news that I can get, uh…well, you know…choked up about.

—Juliette Sterkens, AuD, Oshkosh, Wis