Sergei Kochkin, PhD, is the executive director of the Better Hearing Institute (BHI), Alexandria, Va. He has been involved in hearing instrument market research for over 15 years and is the author of the MarkeTrak publication series, which has been funded by Knowles Electronics Inc.
HR In your view, what is the take-home message from this study for dispensing professionals and consumers?
Kochkin The take-home message is that we now know that significant hearing lossfrom mild to profoundwill almost certainly have an impact on a persons job performance and income. Because most jobs require sophisticated communication between the employee, coworkers, supervisors, and customers, those workers who are less able to communicate would be expected to underperform on the job.
What this study emphatically states is that, on average, your income will decline if you have a hearing loss, and particularly if you choose not to seek treatment for your hearing loss. The positive news is that, if your hearing loss is treated, you can mitigate or lessen the impact of hearing loss on your income by roughly a factor of 50%. And this statement applies straight across the board, whether you have a high amount or a low amount of hearing deficit. In fact, one very interesting thing about this study is that we didnt find a 100% difference in income mitigation for the most serious or profound hearing losses versus a 40% for moderate and a 20% for mild hearing losses. Instead, what we found was that, for any decline in income you might have incurred due to your hearing loss, that income loss is cut in half if you get hearing helpwhich in most cases means obtaining a hearing aid.
Hearing care and medical practitioners, as well as consumers, should look at this study and compare it to the quality of life findings from the National Council on the Aging (NCOA) [January 2000 HR, downloadable at: www.hearingreview.com/ncoa_study]. They should view this study as only one issue impacting untreated hearing loss among an entire list of 15-20 aspects related to the psychological, emotional, and social impact of hearing loss. From the scientific literature, we are finding that hearing loss has the ability to impact nearly every dimension of the human experience. So, professionals and consumers need to see this new study in that context. Its yet another studyalbeit one with a large sample size of 40,000 householdsthat supports what the literature is saying: Nearly every aspect of a persons life is impacted by hearing loss.
HR The studys main results are very linear [see Figures 1 & 2]. Did this surprise you?
Kochkin I have to say that this is one of the most beautifully linear studies Ive ever seen. Bridget Shields literature review for Hear-It, as well as work by Fred Bess and colleagues, pointed to the hypothesis that there may be a fairly clean relationship between hearing loss, income, and many different quality of life parameters. The results of this study certainly verify that hypothesis.
Intuitively, one would think that mild hearing loss has little real impact on most aspects of an individuals life. However, when you go back to the NCOA study, people with mild, moderate, or profound hearing losses were all negatively impacted to some extent on virtually every dimension of the human experience. That includes psychological, emotional, and physical health; absence of pain; quality of inter-relationships, etc. Could this really be true? A person is inclined to think, OK, Ive got a 20% hearing loss, but thats not going impact my life in any meaningful way. Well, the data in this study states that a mild hearing loss is going to impact your life in meaningful ways, albeit not as seriously if you had a profound hearing loss.
What is being confirmed between this study, the NCOA study, and articles like the literature review by Dr. Shield is this: Hearing loss per se impacts life in totally unexpected areas. And the greater your hearing loss is, the greater the effect it will have. Similarly, the extent to which you alleviate your hearing loss, the more you will succeed in mitigating its negative effects.
One of the unfortunate aspects that the study points out is that treatment for hearing loss will never quite bring you back to normal hearing [when looking at the entire population, on average]. So, we cannot state that, if we were to treat everyone who has a hearing loss, we would be able to restore them to the same levels as the normal-hearing population. But we will significantly improve the quality of their lives on many, many scales.
HR So, hearing loss can initiate a chain of negative events. Arent you also saying that, if a person has a higher income because theyve received help for their hearing loss, that higher income might then, in turn, give them access to quality-of-life enhancements like better health care, etcor even more advanced hearing aids?
Kochkin Thats correct. Hearing loss can initiate a vicious cycle. In particular, its helpful to envision younger people who have significant hearing loss. If this younger person has a solvable hearing lossby solvable I mean he or she can derive significant benefit from hearing instrumentsbut chooses not to do anything about it, the study shows that hearing loss will probably influence their job performance. Over the course of his/her lifetime, it could lead to radically negative results in their livesfar beyond the thousands of dollars lost in income.
The effects of hearing loss can be subtle. This is borne out by the fact that most people dont realize they have a significant hearing loss until theyre well into their 60s. And, along the way, some of these people may not understand why theyre getting passed over for promotions or not getting the best assignments.
Hearing loss can influence job performance in key ways relating to communicationan essential component in most jobs. In turn, this impacts their disposable income, and that disposable income impacts things like their medical care, as well as their own personal growth and self-fulfillment. When you think of deteriorated communication skills in this context, it is common sense that quality of life can be impacted in fairly profound ways by hearing loss. Additionally, according to the NCOA study, people with untreated hearing loss are likely to be more anxious, more depressed, and have more emotional problems than the average person with normal hearing. In fact, hearing loss can initiate a vicious cycle that can actually reach a point in which some peoples discretionary income might dwindle to where they perceive that they cant afford a hearing aid!
By the time an average person with untreated hearing loss retires, their retirement pay and savings may be lower. An interesting facet of the NCOA study is that people with untreated hearing loss were more likely to work into their 70s. This was a significant finding. What it may mean is that these people didnt have enough retirement income. Although this hasnt been verified, I believe the data suggests that untreated hearing loss could make it more likely that you end up in the ranks of the working poor.
So, the take-home message is that, if you wish to maximize your chances for a higher income and a comfortable retirement, make sure that you can communicate effectively early in your career.
HR What should lawmakers and government administrators take away from this information?
Kochkin When you combine this study with Shields literature review, the NCOA study, and all the data we have on quality of life, the implication is thatif a person has a solvable hearing loss and you catch them early enoughtreatment for hearing loss will make a substantial impact on the health and well-being of the population. This includes impacting income, quality of life, family structure, and providing people with the ability to make their maximum contributions to society. This also means that they will pay their maximum taxes or, looked at the other way, reduce the chances that they will drain resources from the system via welfare, unemployment, social services, and government-sponsored medical programs. Earlier treatment for hearing loss at a younger age allows people to get involved in life before they start to experience the subtle negative impacts of communication loss.
Putting the entire picture together, treatment for hearing loss at an early age should lead to improved lifestyles, reduced reliance on government services, and increased federal and state tax revenues due to their higher incomes. Hearing loss is also a family issue. Perhaps the most important aspect (that also remains one of the most difficult to quantify) is how parents and grandparents with treated hearing loss can have a more positive impact on their familieswhich leads to entire generations of families going forward and having a positive impact on society. Dr. Mark Ross says that, when a person has a hearing loss, their whole family has a hearing problem. The fact is that we havent even scratched the surface on the impact of hearing loss on family life.
HR How confident are you about this data?
Kochkin Very confident. The main message behind Table 2 is that every demographic variable listed there [all six including hearing loss] is significant at the 1 in 10,000th level relative to the ability to predict income for this sample of people…Hearing loss by group was the smallest in terms of explaining variance, yet it was still very significant. The study presents pretty conclusive results: If I were to do 10,000 studies like this, only one of them would come up with this information by chance.
Second, if you look at Figure 1, there is an almost-perfect linear relationship between hearing loss and income. Remember: This is not just some mathematical model that results from a multiplier being applied to a statistic, yielding a relationship between a hearing loss and income; rather, these are 11 independent, unidentified groups of subjects thrown into a statistical program. The groups were not identified as the 10th [hearing loss] percentile, 20th percentile, etc. The computer program didnt know what these groups represented.
The real support for our conclusion is that, for every subject group, there is a very precise drop in income as a function of their hearing loss. This is really the big finding; those data points in Figure 1 represent 11 independent groups that are completely unidentified in the model.
HR Although the data is impressive, there appears to be one nagging question: Isn’t it just as reasonable to conclude that hearing-impaired people with higher incomes purchase hearing aids because they can afford them (ie, as opposed to the conclusion that untreated hearing loss causes people to have smaller incomes)?
Kochkin First, when looking at MarkeTrak VII data, there is relatively even user adoption rates for each level of household income, with a total range of about 20%-28%. In fact, some of the low-income households have higher adoption rates than the high-income households. So, that might be one way of explaining why hearing aid affordability is not the issue here.
But, in my opinion, the main rebuttal to this question is that, if affordability were a primary factor, you would expect to see some kind of flat income differentialnot the kind of gradual linear divergence that you see in Figure 2. Think about it: If the data is the result of hearing aid affordability, then within the higher income classes, one would expect a fairly flat responsefor example, a $5000 across-the-board differential in income in the lower hearing loss deciles. Instead, there is this diverging profile, with minor differences between the treated and untreated groups in Decile 1 and continuously larger differences extending through Decile 10. Theres little doubt that the people in Deciles 1-6, for example, can afford hearing aids. Yet, we still see differences in income levels between the treated and untreated groups.
Again, these are 21 groups thrown into a modela model that has no idea who owns a hearing aid, what the subjects hearing loss is, or whether the subjects hearing is normal. In my opinion, the profile itself serves as evidence for the conclusion that hearing loss negatively impacts income. We threw all our data into what amounts to a soulless regression model that had no idea what the 21 groups represented. Its the profile that emerges that tells you something deeper than affordability of hearing aids is at work here.
Having said that, this is correlational research: The only way we could ever truly confirm our conclusion that income is affected by hearing loss is to take, for example, a demographically balanced hearing-impaired group of 2000 people identified at age 20, fit 1000 with hearing aids and let 1000 go untreated, then observe the results after 50 years. Obviously, this would be highly unethical. The bottom line is that correlational studiesparticularly those supported with other sources of evidenceare very reliable and are a foundation of scientific and medical research.
HR There are fairly wide economic disparities along racial divides in the US. Have you uncovered anything regarding race and hearing aid use in MarkeTrak?
Kochkin The National Family Opinion (NFO) poll is nationally representative based on nine socio-economically variables, but it is not balanced racially. Thus, I have never had a reliable enough sample to report differences in hearing care relative to race.
HR Is there anything, in particular, that surprised you about the study?
Kochkin Obviously, the thing that surprised me was the difference in incomes for the lower hearing loss deciles. The biggest surprise of the study, in my view, is that mild-to-moderate hearing loss has a significant impact on income. But, again, when you go back to the literature review, articles have been pointing toward this premise for some time.
This study emphatically reinforces the NCOA study results. In fact, the NCOA study is where I got the idea for analyzing the impact of hearing loss on income: I noticed a similar income differential in that study. However, at the time, I thought it was a statistical quirk. But now I believe it. People of all levels of hearing loss are impacted, especially when untreated. Period. Case closed.
If all of these solvable hearing losses were treated at a young enough age to significantly impact their life earnings, were talking about hundreds of billions of dollars. You might think of this as the price of vanity. The price of vanity is a $100 billion per year issue.
This has to have an impact on society. Just taking the 15% tax bracket, it would have an $18 billion difference in the taxes received by the government, and over the years it would certainly have an impact on things like Medicaid, social services, unemployment, and ultimately, the Gross National Product (GNP). Further, it has a large hidden impact on families, and this impact probably can never be quantified in terms of dollars.
HR Lets move onto some more general questions about the recently published MarkeTrak VII. The biggest surprise may be that customer satisfaction with new (<1 year old) hearing aids bounded upward to 77% in 2004. To what might we attribute this increase?
Kochkin My personal belief is that customer satisfaction went up for two reasons. First, and most obvious, we changed the scale on the question [adding somewhat satisfied as a possible answer for survey respondents]. Its extremely difficult for a person using hearing instruments to reach the lofty category of satisfied. In most contexts, satisfied means a complete cessation of needs. However, with hearing instruments, it is very difficult to attain that level, and its arguably impossible for some hearing loss groups. Thats why we added the somewhat satisfied response.
The second issue is the increased penetration of digital hearing aids. There is an analysis in MarkeTrak VII in which we compare people whose perception was that they owned a digital or non-digital hearing aid. When we asked people, the response was that 47% of them thought they owned digital instruments. If you look at HIA statistics over the last 5 yearsand remember that MarkeTrak looks at hearing aids less than 5 years old48% of hearing aids sold were digital. I dont think thats chance or coincidence. What MarkeTrak VII shows is that there is an 11 percentage point differential in satisfaction between those people who said their hearing aids were digital and those who said their aids were non-digital. In an older  study, we obtained about a 10 percentage point differential between advanced technology of that time [ie, analog multi-channel directional programmable] and older technology [linear omni-directional non-programmable].
It should be remembered that, over the entire hearing aid user population, we still have a lot of older technology hearing aids. The recent MarkeTrak shows that, when you combine multi-channel and directional with digital technology, you get about a 17% improvement in customer satisfaction over older technology.
HR Isnt the market already dominated by digital directional aids?
Kochkin Not really. Ive measured how many of these people have directional instruments, and I dont think were anywhere near a saturation level. Only 25% of consumers indicated that their hearing instruments are directional or have multiple microphones. Thats only 1 in 4. What is going to happen is, when we finally reach some critical percentage of people who own second- or third-generation digital aidslets just say 75% for the sake of argumentI believe that we will start seeing larger increases in customer satisfaction.
If we get digital, programmable, directional, telecoil-equipped, later-generation products into more ears, Im convinced we will see higher rates of customer satisfaction. In fact, thats always been my point, even when analog programmable instruments were the best technological option: Get the best technology in consumers ears, and customer satisfaction will drift upwards with time.
HR What impact have CICs had on the market since their introduction about 10 years ago?
Kochkin Obviously, the big impact of CICs has been on visibility. MarkeTrak V showed that customer satisfaction with CIC visibility is extremely goodapproaching 90%. However, the availability of CICs has reduced the attractiveness of ITEs and BTEs, thus reducing customer satisfaction with these larger aids.
Vanity isnt dead. A dispensing professional rightly pointed out to me that It isnt my fault that patients are concerned about the visibility of their hearing aids. The task of the hearing care professional is to offer patients a solution to their hearing problems, and this solution needs to entail many factors, including how a person might feel about him/herself when using a hearing aid. When the consumer initially comes in, they are admitting to having a hearing loss but their initial reaction is: I need to hide it.
What many professionals say is that, when they initially fit people with CICs, it might not always be the optimum solution. However, its better than having the patient reject the hearing aid. Over time, as the consumer gets used to better hearing and the idea of hearing aids, they often upgrade to other hearing aid styles with more power, more features, directionality, telecoils, etc. In the end analysis, CICs may be at their greatest utility when helping people adjust to the idea of amplification. Its even possible that this is one of the reasons why BTE market share is now growing.
HR The new-user rate also increased to 39% in 2004 from 32% in 2003 which is good news. What happened?
Kochkin Well, were back to 39%, but thats still nowhere close to new-user rates of 53% in 1989. I think its encouraging that new-user rates are migrating upward, but weve got a long way to go. With the size of our market and the number of potential users, we should be approaching a level of 50% or higher relative to purchases by new users.
HR Why did we lose so much ground from the late-80s to present?
Kochkin One thing we need to ask is what was going on in 1989 when we had that many new users? We know what happened in 1994 when it declined by almost 30% [due to FDA involvement in the hearing industry]. My opinion is that, in the late 80s, we were doing a better job at promoting hearing health care and awareness. There was a lot of advertising done by some of the larger retailers, as well as excellent celebrity endorsements in these advertisements and BHI public service announcements. In particular, Miracle Ear and Beltone were very aggressive in their advertising at that time, and I think this had a ripple effect for all dispensing professionals.
HR The HR survey indicates that prices for most DSP classes (ie, premium, mid-level, and economy aids in most styles) are decreasing. What does MarkeTrak VII suggest relative to the role that price plays in terms of satisfaction, value, and benefit? What might lower prices mean for consumers and dispensers?
Kochkin We devoted an entire article, On the Issue of Value, in the MarkeTrak VI series to this topic [see February 2003 HR]. The five-word summary of what we found across 16,000 consumers in MarkeTrak VI: Our customers are rational consumers. This means they want the largest amount of benefit for the lowest price. And that relationship is tied inextricably to customer satisfaction.
So, the equation becomes: How much should a consumer pay for every percentage point of positive change in their hearing handicap? If they pay a lot of money for a little benefit, theyre not going to be very satisfied. If they pay a modest amount of money for a tremendous benefit, theyre going to experience product bliss. The value equation is simple.
The other take-away point from the On the Issue of Value publication is that its impossible to have a happy customer even if they have a free hearing aidif the hearing aid provides them with very little benefit. Its the benefit and the reduction of hearing handicap in many different listening environments that are important.
HR It was interesting to note in MarkeTrak VII that non-audiologists make up a very large portion of the current units dispensed. Why is this?
Kochkin The data suggests that, at least in the consumers perception, there has been a shift in dispensing in favor of more hearing instrument specialists. But, my best guess is this is only the consumers perception, and it may not necessarily reflect the reality of the situation. What I believe is thattaken across the very wide variability of services encountered throughout the US in all the various office and practice settingsthe consumer may not be perceiving a large enough difference for it to register in the survey.
Other possible factors include the recent changes in distribution, with higher market growth in the larger retail chain segment. And some of these larger chains have committed substantial amounts of time, money, and resources to standardizing their office procedures and quality control, further blurring distinctions.
HR What does MarkeTrak suggest relative to hearing aids sold over the Internet? In your view, is this something we should watch closely?
Kochkin MarkeTrak VI and MarkeTrak VII both show that the two fastest-growing segments in the hearing industry are the VA and direct mailwhich are free and discounted hearing aids. That is the reality. We have no idea how large these two areas will get; the Internet and mail order is still relatively small at about 5% of the market, while the VA constitutes about 15%. Mail order since 1984 has nearly tripled, so its certainly something to watch. In the same time frame, VA dispensing activity has grown by a factor of seven.
HR Youve done a tremendous amount of research on what influences customer satisfaction. In your view, what features of hearing aids are most positively correlated to customer satisfaction?
Kochkin In all my experience in conducting market research in the hearing health care industry, Ive never come across a factor as strongly correlated with customer satisfaction as the directional feature in hearing instruments. Why? Because its probably the only universally agreed-upon solution that improves hearing in noise.
When you combine advanced digitalwhich can be taken to mean better hearing comfort in noisewith a quality directional systemwhich means better hearing in noiseyou arrive at a pretty good solution for hearing loss. Outside of the stigma issue, I cant understand why any reasonably active person interested in purchasing a hearing aid wouldnt be looking to obtain digital directional technology.
HR What dispensing office services and general practices are most positively correlated to customer satisfaction?
Kochkin Of the very few of these factors that Ive measured, I am absolutely convinced that counseling time and outcome measurements are two keys in enhancing customer satisfaction. If you spend a little more than the modal half-hour of counseling time, and then pair this with some form of an outcome measurement [ie, a customer survey], it will yield about 10-20% more in terms of customer satisfaction. If you spend about 2 hours of counseling of any formand this could include a CD-ROM or video, group AR, using a consumer-oriented book, personal instruction, having a trained staff member do the instruction, etcit will result in a sizable increase in customer satisfaction.
Im absolutely convinced that, with just a minor amount of change, we could increase this industrys customer satisfaction rates by 15-20%. Our surveys suggest that, within dispensing offices/practices, we need better counseling, aural rehab, creation of expectations, benefit testing in quiet and in noise, as well as measurements of customer satisfaction so we can understand those potential sources for dissatisfaction in various patient populations.
Unfortunately, because we live in a busy world, the average customerespecially first-time users of hearing aidsget much less counseling than they need. As a result, weve never really optimized the total hearing health care experience.
Similarly, if we dont do outcome measures, how can we possibly optimize the consumers experience? This survey doesnt have to be extensive. And, as Mead Killion has demonstrated, its possible to do a 3-minute QuickSIN. We need some measure of hearing in noise, as well as some other short subjective survey of customer satisfaction. Ask yourself this: If the place where I get my car oil changeda service that costs me $40asks me to complete a customer opinion survey after every visit, why cant we do this in an industry where the consumer is often spending $5000?
HR In your February 2003 HR article about value and hearing aids, you made a call for action for the hearing care field to standardize its dispensing activities and develop a "best practices" protocol. Do you still advocate this?
Kochkin Yes. I think we need to analyze what is the best, most efficient protocol that results in the highest possible levels of customer satisfaction across dispensing practices. In practical terms, the culmination of this analysis would be something like a List of 100 Activities that the best dispensing professionals do, or dont do.
The point is that we should be developing evidence-based protocols. Ultimately, you want to spend your time doing more of those things that are correlated with positive outcomes, and fewer of those things that are correlated with negative outcomes based on dozens of factors like patient satisfaction, benefit, employee morale, office profitability, market growth, etc.
What Im advocating is to study the wide variety of dispensing professionals and their practicesthose who consistently outperform on a number of positive outcome factors as well as underperformersand get their protocols into some form of a behavioral inventory. Then, across these professionals and practices, what would emerge is a Suggested Protocol that is highly correlated to positive patient and practice outcomes.
By the way, this isnt a novel concept. A similar study was conducted across Americas corporations by the Boston Consulting Study and its a feature of virtually every MBA program. Essentially, what that study demonstrates is how you can measure every conceivable thing that a company does, and yield a behavioral measures that are related to the companys growth, profitability, etc. So, what we need for dispensing offices is a list of drivers of customer satisfaction. Until we methodically itemize these behaviors, Im not convinced that we can ever get to levels that could truly be defined as maximum customer satisfaction, benefit, and value with hearing instruments.
HR What do you see as the most influential trends in the hearing care field?
Kochkin I think were coming to a point where there may be synergies in the improvements of hearing aid technology, and these will make a big difference on many levels. We have technology that has dramatically improved, but the marketplace hasnt realized it yet. So, our challenge is to educate people that the technology is truly different compared to 15 years ago. Our message should be: If you thought analog programmable aids were a step up, you should see what digital directional has to offer.
We also have to market customer satisfaction studies. You might look at this as methodical myth busting. One of the biggest myths is that hearing aids dont work. Well, we have a darn good MarkeTrak study on customer satisfaction that demonstrates that they do workand this supports the VA study on the efficacy of hearing aids [see June 2005 HR, p 16]. Almost 78% of people are satisfied with their new hearing aids. That means that new hearing aids are located in the top-third of all products and services in the United States. Can we get into the top 10%? Yes, we can, and even better technology and services will get us there.
Another myth is that dispensers of hearing instruments are not consumer-oriented. In the last MarkeTrak, hearing care professionals had an overall 93% customer satisfaction rate. Thats remarkable. Sure, there are news stories aired on 60 Minutes or published in Family Circle about negative encounters with a particular dispenser, but these are things that go wrong with one consumer out of the 1 million-plus people who purchase hearing instruments every year.
HR How do you think passage of the Hearing Aid Tax Credit Act might influence hearing aid dispensing?
Kochkin Effectively, the $500 per hearing aid tax credit would reduce the cost of hearing instruments by 20-35%. We know from an upcoming article in ASHA that the price elasticity of hearing instruments is going to be about 0.6. That means, for every 10% reduction in hearing instrument price, youll get a 6% increase in demand. So, if we have a $500 tax credit for a hearing aid, or a 25% decrease in average price, one might expect to see about a 15% increase in hearing aid use.
We need to encourage proactive programs like these that make it easier for people of all economic segments to obtain hearing aids. Tax credits are one way. Others include encouraging insurance programs to cover all or part of hearing aid costs, getting unions involved in hearing health care, and encouraging more charity among dispensing professionals and the industry. The point is that, obstacle by obstacle, we need to reduce the barriers in obtaining treatment for hearing loss.
HR What BHI activities are you most excited about as we move toward 2006?
Kochkin The Better Hearing Institute is moving into a more multi-dimensional communication model, with our target audience being Americas 31 million people who are hard of hearing. It would be beneficial if we promoted less the product invisibility and hiding ones hearing loss aspects in favor of convincing the consumer that hearing instruments can literally transform their lives, help them become more effective in their communication, and allow them to maximize their quality of life. Our goal is to leverage our knowledge of the impact of untreated hearing loss on quality of life.
By focusing on the human experiencerather than on strategies for hiding hearing lossI believe we have unlimited opportunities to educate and motivate people who have a hearing loss to seek a hearing solution. Our ultimate goal is to find unique and different ways to motivate people to positively address their hearing problem at age 40 or age 50 rather than at age 70. If we do this, we will have a tremendous positive influence on society.
Correspondence can be addressed to Karl Strom, The Hearing Review, 6100 Center Dr, Ste 1020, Los Angeles, CA 90045; email: [email protected]. Email for Sergei Kochkin, PhD