Introduction:
Provision of hearing aids through health insurance plans is a development audiologists should welcome and encourage. Provision of hearing aids must occur in an environment of comprehensive audiological services, including reimbursement for diagnostic audiologic evaluation, appropriate counseling, auditory rehabilitation, and dispensing of appropriate amplification devices.
We believe audiologists should promote insurance coverage for amplification to ensure that all individuals who need and desire amplification have affordable access to it. Currently, through health insurance, a minority of hearing impaired people are able to obtain hearing aids. We contend that all parties (the patient, the professional and the insurance provider) would benefit if this proportion were to be increased.
Should audiologists welcome the inclusion of hearing aids into insurance plans?
Many audiologists are opposed to the inclusion of hearing aids as an insurance benefit, fearing discounted prices and lower reimbursement rates for hearing aids provided through insurance contracts. Of course, "private pay" patients can be charged the "Usual and Customary" fees; while hearing aids provided through an insurance plan may have to be provided at a negotiated discount.
While a certain reduction in revenues might be required, there are insurance plans offering an allowance for hearing aids which can be spent in any way, on any product the patient desires. This model should be encouraged as it allows greater flexibility, lower cost for the patient, greater amplification options for the patient, and more appropriate reimbursement for the audiologist.
Health Insurance Packages:
Health insurance "packages" are constructed according to the priorities, needs and budgets of the payer, which is typically the employer. Employer-sponsored health benefit packages may include a number of programs, including partial or total reimbursement for dental, orthodontic, vision, and/or pharmacy expenses. The inclusion of audiological services and hearing aids as a part of the benefit package has advantages for both the insured (patient) and for the provider (audiologist). Some Senior HMO plans also have hearing aid benefit, and this development should similarly be welcomed by audiologists.
Potential Benefits Associated with Hearing Aid Coverage:
It is well known that only 20% of adults who need hearing aids obtain them. This has been a historical and chronic problem, and there are no signs this trend is changing for the better.
One could speculate that:
- Individuals with hearing loss who have hearing aid benefits in their health insurance package, might be more willing and interested in being fitted with appropriate amplification.
- The stigma associated with hearing aids might be lessened as more adults are fitted with hearing aids, making hearing aid use a more routine occurrence.
- Provision of hearing aids as part of a health benefit package helps lend legitimacy to the use of hearing aids. What kind of a message is sent to a patient when s/he discovers that eyeglasses and dental braces are deemed worthy of insurance coverage, and hearing aids are not? Might they think "If my insurance doesn't pay for it, it must not be necessary?" or worse, "If my insurance does not pay for hearing aids, they must not really work!". When hearing aids are viewed as having value and as being "medically necessary", these perceptions may change.
- When hearing aids are covered by insurance, it is likely that a greater proportion of the people who need them will seek services. The patient directly and tangibly benefits by hearing better and the audiologist benefits by seeing more patients.
The Value of Hearing Care:
As we work to document the value of hearing care (e.g., Larsen, et al,.2000), and the importance of hearing aids in improving mental and physical health (e.g., Crandell, 1998, NCOA, 1999, Mulrow, et al., 1990), we must also work to promote insurance benefit plans that value and provide hearing aids and audiologic services.
It appeared, for a time, that senior (or Medicare) HMO plans might lead the way regarding including hearing aid benefits for a large number of people. Newspaper ads touted "hearing aids" as part of the enticement to sign on with several senior HMO plans. More recently, however, many HMOs have pulled out of the senior market as increasing costs and decreasing Medicare reimbursements have made these plans no longer economically viable. Among senior HMO plans still in existence, much of the recent emphasis and money has been directed toward adding or maintaining pharmacy benefits.
Employers and health plans may hesitate to include hearing aid benefits, as there are fewer dollars to spend on new benefits and as the cost of existing benefits has dramatically increased. Employers must pick and choose which benefits to include. There is also concern among the insurance providers that hearing aid providers might "over-sell" hearing aids if they are reimbursed by a third party, driving up the total cost of the benefit package.
When the network administrator (the entity responsible for the management of the network, which may be a group of practices, a multi-site hearing aid dispensary or a hearing aid company) does not realize a direct profit form the sale of hearing aids, as is the case with National Ear Care Plan, utilization is typically quite low. Indeed, although we recognize the potential fear of "over-utilization," our experience does not bear this out.
Utilization Facts and Figures:
We evaluated five years of collected claims data from three healthcare plans. The following trends were noted:
- For a "high-tech" company with younger workforce with an average hearing aid benefit ($500 per ear every 3 years), utilization averaged 0.31% per year, with a 5-year total of 1.54% of the population.
- For a slightly older blue-collar worker group with a more generous benefit ($800-1200 per ear every 3 years), utilization averaged 0.54% per year with 2.7% utilization over the 5 year period
- For a senior HMO with a lower hearing aid benefit ($150 per ear every 2 years), utilization averaged 1.34% per year, with a 5-year average utilization of 6.7%.
These averages indicate that utilization is low, even when the benefit is generous or when the population is over 65 years. These data show that access to hearing aid benefits results in modest utilization.
This information (above) may help re-assure employers they will not experience high costs and high utilization if hearing aid benefits are initiated. Employers may also be reassured that their employees who need audiological services and hearing aids will be able to obtain them at a reasonable cost to the employer.
Utilization figures might look very different if the contracted provider group profits from the sale of each hearing aid. Specifically, if the provider (such as a franchised hearing aid company or large group practice) were to market directly to the beneficiaries, this would likely increase utilization to levels greater than those shown above.
Audiologists know that every patient does not "need" the highest technology and/or most expensive digital hearing aids! When the patient and the insurer share the financial responsibility for payment, there is increased probability that more modest technology will be sought. Recent work by Bentler and Duve (2000), and Larsen, et al.(2000), demonstrated that appropriately fitted amplification, whether analog or digital technology, provides substantial patient benefit in quiet and in noisy situations.
While our preferred model for provision of audiologic evaluation and hearing aids is "X dollars toward the purchase of any hearing aids of the patient's choosing, with the patient to pay the balance", many plans require contracted providers to accept lower reimbursement.
By carefully selecting appropriate technology, it is possible to fit patients with hearing aids that will provide good benefit without necessarily choosing high-end digital products.
By including audiologic and hearing aid benefits through a network of providers, control over the level of provider and quality of service can be assured. When the benefit is written as a diagnostic audiology and rehabilitation package, to include an allowance toward the purchase of hearing aids, audiologists will benefit by the recognition that they are the appropriate provider of diagnostic and rehabilitation services.
Patients who may be unsure whom to see for diagnostic hearing evaluations, or how to purchase hearing aids, will have confidence that their insurance company has contracted with an appropriate professional provider group. Use of a professional network ensures uniform quality of services, including adherence to standards of care and minimum requirements for testing and equipment. Credentialing (state licensure/registration and/or certification) of providers ensures that audiologists meet appropriate state licensing requirements.
And finally, it is important to remember that audiologists provide comprehensive rehabilitation, of which hearing aid dispensing is only a part. Audiologists are not salespeople selling a product, rather, audiologists are professionals providing comprehensive diagnostic and rehabilitative services.
References
Bentler, R., and Duve, M. (200). Comparison of hearing aids over the 20th century. Ear & Hearing 21:625-639).
Crandell, C. (1998). Hearing aids: Their effects on functional health status. Hearing Journal, 2:22-32.
Larson, V.D, et al. (2000) Efficacy of 3 commonly used hearing aid circuits. J. American Medical Association, 284:14,1806-1813.
Mulrow, C., et al. (1990). Quality of life changes and hearing impairment. Annals Internal Medicine, 113:188-194.
National Council on the Aging (1999). The consequences of untreated hearing loss in older persons. Washington, DC.
