Testimony of Angela Loavenbruck to ASHA Legislative Council

My name is Angela Loavenbruck. I am an audiologist in private practice in New City, New York. I have been a member of ASHA since 1965 and I am an ASHA Fellow. I served on ASHA's Standards Council, Ethical Practice Board and Legislative Council, as well as numerous task forces and committees. I am here to ask the Legislative Council to express its support for HR 1068, the Medicaid Audiology Act, and to direct ASHA to stop the negative, misleading
and exceptionally damaging lobbying it has been carrying out on Capitol Hill
against this bill. ASHA lobbyists have told members of congress that ASHA
represents audiologists, that audiologists do not support this bill, that this bill will permit unqualified individuals to practice audiology and that our licensure laws are just inches away from being repealed at all times.
None of this is true. ASHA has joined the American Academy of Otolaryngology in opposing this bill. The American Academy of Otolaryngology opposes this bill because they rightly see it as legislation that advances the audiology profession - as they see it, the bill expands our scope of practice and this ENT group opposes anything that will do that. While it is easy to understand
why the American Academy of Otolaryngology would oppose the Medicaid Audiology Act, it is difficult to understand why ASHA, which claims to
represent audiologists, would do so.

In 1994, Congress passed a law which amended the Medicare statute to define the terms ''qualified audiologist'' and ''audiologic services'', as well as the terms ''speech-language pathologist'' and ''speech-language pathology services.'' ASHA initiated this legislation and lobbied for its passage. They claimed credit for this success in any number of ASHA publications. And indeed ASHA had done a good thing. Prior to this ASHA effort, audiologists were not mentioned in the Medicare law at all (remember, we hardly existed as a profession in 1965 and if you wanted to find audiologists in any listing, you generally had to look under the letter ''s'' for speech pathology at that
time). The earlier Medicare regulations did mention audiologists, however, because we were recognized as providers of ''Other Diagnostic Services''. In the initial Medicare regulations, ''qualified audiologist'' was defined as an individual holding the ASHA certificate. When the 1994 definition change was published in the federal register, Congress and HCFA noted that the earlier definition of audiologist (and SLP) were written at a time (the 1960's) when no statutory definition of the two professions existed. They stated that it was inappropriate to continue to use a private voluntary certificate since
licensure laws now provided statutory definitions of audiology and speech
pathology in virtually all states. In fact, in state after state, ASHA
assisted local audiologists and SLP's in getting licensure by testifying to
the necessity of strong licensure laws, not certificates purchased from a private organization, as the best consumer protection mechanism for both professions.

In 1998, the American Academy of Audiology wrote to Nancy Ann Min de Parle, the Adminisrator of HCFA and asked her, in light of the change in the Medicare statute, to make similar changes to the definition of ''qualified
audiologist'' in the Medicaid program so that the two would be consistent.
Ms. De Parle said that HCFA did not have the authority to do this, and that a change in the Medicaid statute required legislative action. The Academy of Audiology then initiated the Medicaid Audiology Act, and began to look for legislative sponsors. The Academy wrote to ASHA, asking for support in these efforts. ASHA's response was that the Medicaid Audiology Act was a direct attack by the American Academy of Audiology on its certificate, and they not only refused support, but also began actively lobbying against the bill.

Here is why it is important to audiologists to have the Medicare language repeated in the Medicaid statute:

1. Audiologists, like other health professionals, should be defined by their licensure, just as all other health professionals are. A certificate does not define physicians, dentists, chiropractors, podiatrists, optometrists, clinical psychologists, clinical social workers, nurses, etc. - they are defined by licensure. No matter what certificate programs are developed by professional organizations, these are voluntary programs; they have no statutory standing, and they are not required (nor should they be) as a prerequisite to practicing a profession. An interesting question is whether the federal government, as a pre-requisite for professional participation in tax funded health programs, can require purchase of a voluntary certificate when legal definitions of our profession exist. Under these circumstances, the certificate is no longer a ''voluntary'' purchase.

2. The Medicare definition of audiologist and audiologic services uses the same language as is used to describe the privileges given to physicians and limited license practitioners under the law. Saying that audiologic services are those provided by qualified audiologists within their legally defined scope of practice and as would be covered ''if provided by a physician'' is critical terminology in the audiologists' efforts to gain recognition as entry level practitioners in hearing health care. Those of you familiar with ''any qualified provider'' language, which is found in insurance reimbursement laws in some states, will recognize the importance of that phrase for reimbursement directly to audiologists for the services they provide.

3. As of 1995, Medicaid, which is funded by a combination of state and
federal tax dollars, covered 18.7 million children, 7.6 million adults, 4.4 million elderly people and 5.9 million disabled individuals. Approximately 1/3 of all the children in this country are covered by some health program funded by Medicaid. The Medicaid statute covers the early and periodic screening programs for children, as well as a number of other programs vital to the health of infants and children. It is likely that Medicaid funds will cover some parts of the infant hearing screening programs now being mandated and developed in many states. Individuals covered by Medicaid will be seen in the practices of audiologists in virtually every practice setting. It is critical that these patients have access to all qualified audiologists, not just those who choose to buy the ASHA certificate. It is critical that the language used to describe us in any federal law accurately portrays who we
are and speaks to our autonomy in hearing health care.

4. Medicaid covers audiologic services not currently covered by Medicare.
Medicare defines audiologic services only as diagnostic audiologic and
vestibular services. The American Academy of Audiology is currently
petitioning HCFA to broaden the Medicare definition of audiologic services to include vestibular and aural rehabilitation treatment services. Having the same terminology as is used in the Medicare definition of audiologic services used by Medicaid, which covers both diagnostic and treatment services provided by audiologists, will help us in our lobbying efforts in this area.

5. Finally, this essentially technical bill, which should certainly not have
been controversial, would have provided an excellent opportunity for audiologists to interact positively with legislators and to educate them
about our work. The American Academy of Audiology asked for and expected
that ASHA would gladly work together with it and the Academy of Dispensing
Audiologists in this worthwhile effort on behalf of the audiology profession.
Instead, ASHA has engaged in divisive and demeaning lobbying which portrays the profession in a destructive way.

Why has ASHA done this - what could possibly be the motivation? I believe
that ASHA has done this purely because of the way it markets its entry-level
certificate and because of fears that people will finally start to examine
why they are paying for this certificate year after year. I believe that ASHA has also done this because it fears it will lose ground among its public school SLP constituents, particularly with respect to Medicaid payments for SLP services provided in the schools. These services must now be provided by (or supervised by) someone with the CCC's in SLP. Since the schools are generally exempt from licensure laws, these Medicaid requirements have provided a way for ASHA to make some headway in requiring appropriate entry level standards for school based SLP's. I think, however, that terminology used in the Medicare law for SLP's would strengthen, not weaken efforts to have higher standards for SLP's in the schools - they might not have to buy the CCC's, but they would have to meet higher standards - and that is what we should all be battling for.

For years, we have all been bullied into paying over and over for a
certificate that signifies that we met entry level standards at some point in
our career. The term ''current CCC'' is an oxymoron. It is fraudulent to
present the CCC's as anything more than what they are and it is unconscionable for a professional organization to call 2/3rds of its budget certification renewal fees. ASHA has long confused the development and promotion of high standards, which should be the mission of every professional organization, with the sale of a product it created to document that the standards had been met, and it has used the certificate like a hammer - branding individuals who choose not to purchase this certificate, but who are in every possible way compliant with the very highest standards of the profession, as ''unethical.'' ASHA needs to rethink its approach to the sale of this product. ASHA needs to rethink its standards program, and its certification and accreditation programs. These activities are best carried out by independent organizations not owned by any one professional organization, but supported by all.

ASHA needs to begin supporting HR 1068 now, and if it cannot, ASHA needs to examine whether it can effectively represent both audiologists and
speech-language pathologists. We are after all two separate and distinct
professions. While our work with patients sometimes overlaps, our
professional needs and realities are very different. Who will ASHA represent if what audiologists need to further their profession conflicts with what SLP's might need to further theirs? It is a question that both audiologists and speech-language pathologists need to ask.