Interview with Dave Fabry Ph.D., Director of Clinical Research, Phonak, Naperville, Illinois
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Topic: Verification, Unbundling and Itemization
AO/Beck: Hi Dave. Thanks for joining me once again. It's always a pleasure working with you.
Fabry: Hi Doug. Thanks, nice to work with you too.
AO/Beck: I'd like to focus this interview on the topic you presented at the ARA* meeting back in the early part of summer, 2003, which had to do with verification of hearing aid fittings and aural rehabilitation.
Fabry: Right. The talk was on verification of digital hearing instruments and implications for aural rehabilitation. I discussed current verification techniques for DSP devices. The urban myth has been that you can't verify DSP devices clinically, and that has meant that clinicians are increasingly relying on the manufacturer's ability to set target gain values on the basis of a patient's audiogram and average correction factors for venting, shell type, microphone location, and residual ear canal volume. Although many do a very good job, it is ironic to me that the tremendous digital flexibility that we see in modern hearing aids is largely unused. As a result, this session discussed several methods in current use for hearing aid verification with digital hearing aids. We began by discussing functional gain and optimal aided gain (best aided threshold, usually measured while the hearing aid is hooked up to the programming device). Although these measures provide a reasonable approach for assessing how well a hearing aid amplifies soft sounds, they provide no indication of maximum hearing aid output. Furthermore, for nonlinear (e.g. wide dynamic range compression) hearing aids, gain for typical inputs, like speech, is usually overestimated using functional gain measures. Finally, even when input level is isolated to soft sounds, the frequency resolution is much poorer than for probe-microphone measurements (typically only five to ten different frequencies are used, versus 100 Hz increments for most real-ear systems). The bottom line is that except for soft sounds, functional gain methods just don't measure up for verification of DSP hearing aids.
AO/Beck: So, in other words you're looking at a snapshot of the hearing aid's performance at one fixed point in time, rather than the full spectrum of performance ability.
Fabry: Yes, that's correct. Additionally, the transferability or portability of the data is problematic. Hearing aids are not audiometers and they're not governed by the same ANSI standards in terms of step attenuation. Although hearing aids have their own ANSI standard characteristics they're not governed by audiometric zero and audiometric attenuator linearity. So moving from functional gain and best-aided or optimal aided threshold into real ear measurements takes some doing!
AO/Beck: Tell me about the difference in verification for digital versus analog instruments please.
Fabry: Well, as stated above, the big issue is nothing more than urban legend. The myth states that you can't use real ear measurements with digital devices because digital noise reduction (DNR) circuits will attempt to attenuate the signal. Some hearing aid manufacturers also perpetuated the myth that you can't evaluate their products with functional gain or real ear measurements. While it is true that you need to be careful which test stimuli you use, particularly if the DNR is active, there are numerous options available from real-ear systems that use digital noise or real speech to fool the DNR circuit into thinking that the test stimulus is speech, rather than noise. Otherwise, some hearing aids allow you to turn off the DNR circuitry during testing; this option is less attractive, in my mind, because it doesn't indicate how the hearing aid will work in-situ, when speech and noise are both typically present. Another trick that clinicians can use if they don't want to pay for the upgrade to digital test stimuli is to use very brief test stimuli during testing. By turning the test signals on and off very quickly, they can get a measurement before DNR kicks in. My advice, however, is that clinicians working with DSP hearing aids spend the money for the upgrade to digital test signals with their real-ear test system.
AO/Beck: And the number two issue?
Fabry: Number two is really linear versus nonlinear amplification. When verifying linear hearing aids, measured functional gain and insertion gain values will be the same. Because most digital hearing aids use nonlinear amplification, this is often seen as a digital issue, but it is related more of a compression issue. As stated above, the combination of these two factors has led to a reduction in hearing aid verification in the past few years. If you look at the data David Kirkwood collected in the Hearing Journal in March, 2003, some 50-65% of audiologists rarely if ever use functional gain; about half of them rarely if ever use real ear measurements. We have all of this flexibility with digital devices, but no one's using them! Part of this stems from the fact that audiologists adopted a model previously used by hearing instrument specialists that bundles hearing instrument pricing to the patient, which minimized the importance of fitting and verification, the professional service fee, and rehabilitation. In many respects, audiologists are their own worst enemy, because we do not stress the value of our services, in the form of fitting and follow-up. Instead, the impression that many patients have is that the technology alone provides the solutions, rather than the clinician. In many ways, we perpetuated that model to our own detriment and we're precariously close to a situation where we're not going to be able to recover from it as we look at Medicare reimbursement for hearing aids becoming a reality in the future. We must look to itemization of hearing healthcare services if we are going to survive.
AO/Beck: Can you talk about the difference between bundling and itemizing?
Fabry: Yes, gladly! There's an important distinction between unbundling and itemization. In fact, that's become my new mantra because people are resistant to the notion of unbundling . Professionals get freaked out about unbundling because they say it's bad for business and is doomed to fail. I think the opposite is probably true. As long as we bundle everything together in the cost of the hearing aid, such as the product, the tests, the office visits, the verification, aural rehabilitation etc., the patient and arguably the insurance providers, don't attach value to the professional services provided.
When we talk about unbundling, people think of an a-la-carte system where someone says, okay, the hearing aids cost X dollars, the fitting is Y, and follow-up cost is Z dollars, and the total is the amount that we bundle altogether . Of course, the professionals have to consider that the patient may say, I just want the hearing aids, I don't want Y or Z, and that's a real concern. Many fear that it can be used as an unfair advantage by their competitors, especially if the competition is willing to provide free-for-service to your patients, in the hopes of getting their repeat business later on.
With itemization you have a package plan. You say this package includes items X, Y and Z. And, they cannot be purchased separately; it comes as a complete package. If you take one item, you have to take them all. I hate making comparisons to the automotive industry, but it is sort of like when you buy a new car, you have to buy the whole package; you can't just buy the chassis and the motor and the transmission. It comes with the seats and the tires and the warranty.
AO/Beck: So itemization is when you're listing different components of the total bill, such as hearing aids, ear molds, ear mold fee and professional service fee. And bundling is when you give a total price, which is essentially the same total as the itemized bill, but the component parts of the bill have not been detailed, nor have they been appreciated!
Fabry: Exactly. And not only is it important in and of itself, I think it helps set the stage ultimately for Relative Value Units (RVUs), which is how the AMA determines the value of services for a physician. If we're all reporting a value attached to our fitting and follow-up services, we have a much better chance of going to Medicare and Medicaid and saying this is what this these services are worth.
AO/Beck: Okay, got it. But to further explore the car analogy you mentioned, if I bring my car in for service and I tell them I just need an oil change, I just want oil and filter...they'll do that. But you can bet that on the bill they will bill for oil, for the filter, and for service and a disposal fee. So that's itemization, but the component parts are not available separately. If you want the oil and the filter, you must pay for the service and the disposal, and maybe a shop fee too.
Fabry: Right. They are itemizing it and they're showing you that each component has a value, and then in the future, you understand that there is more to an oil change than oil and a filter! The mechanic or the technician has a value too.
AO/Beck: And that gets back to verification and knowing that we, as professionals matter, and there is a value to the work we do.
Fabry: That's correct, and that's another thing that troubles me about the current situation. Specifically, those of us who are involved with aural rehabilitation are true believers that we're making a difference, but we don't have the data to back it up and that's an enormous problem! There are really only two studies that verify our role in the process. The VA hearing aid study from a year or two ago, which indicated the benefits of amplification, and the article that was published in JAMA in April, 2003, where they're looked at the impact of screening hearing loss. Unfortunately, neither really showed the impact of the audiologist, but rather the technology or that someone screened for hearing loss.
And so this is an issue that can't be addressed solely by technology. Unfortunately, it's a professional, political and a technological issue. Technologically, if verification measures using probe measurements are too complicated then we need to look at how to make that more efficient. Time is money, and these measures need to be clinically efficacious.
AO/Beck: The other thing, going back to itemization, is that if we itemize it helps assure we have rehab programs, and I think that's an important point.
Fabry: I agree. We cannot continue along the same old route we're been going with regard to aural rehabilitation, we need to formalize and itemize it on the bill, much like your oil change example. We're just letting you know the cost of goods and the cost of services. I think this is a critically important point for the profession and I hope we adopt this very quickly. I'll even argue that we're providing the services and I believe very strongly that the audiologists who are providing those services are doing a great job. Their patients love them; they're making a huge difference. But collectively, we absolutely have to show the services and the dollar value of the services, or no one else is going to place a value on them either!
AO/Beck: I think a large part of the problem is that we can't charge for aural rehab.
Fabry: It's a self-sustaining, vicious cycle. When you look at reimbursement rates for audiograms and you look at why it's so poor, part of it is when they go out and look at assigning Relative Value Units, they look at people who give away the audiogram or minimize the fee to get the hearing aid money, as well as those clinics who charge a fair market value for their work. When you average the two together, you obviously devalue the importance and reimbursement for the audiogram. So looking at one possible Ghost of Christmas Future , I see Medicare paring down our diagnostic fees so we get paid almost nothing, because some are giving away diagnostic services to get at the hearing aid patients. Then, when hearing aids are reimbursed by the government, one future view says that we'll get paid very little for the technology, and next to nothing for the service, and no one will be able to affords to dispense hearing aids.
AO/Beck: And frankly, we know the work matters. I think we can say with certainty based on the Walter Reed stuff from 50 or 60 years ago that aural rehab programs were significant contributors to successful hearing aid use. In fact, we know the technology was very poor at that time, but the aural rehabilitation training the veterans went through was significant and efficacious, and the impact was greater than just hearing. It goes to emotional, cognitive, and psychological impact to, in other words, it's a quality of life issue.
Fabry: Right. We know that when you're providing an audible signal to that person with hearing loss that it makes a difference. However, we can't argue effectively that it meets the letter of the law for double-blind controlled, big scale studies that the government and other insurers want to see. But what we can say is that if you're insuring audibility at some level that is going to make a difference. Stuart Gatehouse collected data for the Hearing Aid Modernization Act in the UK, where they compared analog to digital technology, and also the impact of an old and new service delivery model, that varied in the amount of aural rehabilitation provided. Gatehouse's data indicated that as they evolved from analog to new technology, there was a big difference in performance across four metrics that they measured: hearing aid use, benefit, satisfaction, and residual disabaility. Surprisingly, however, when Gatehouse looked at providing the old technology with new services (more aural rehabilitation), the results also showed considerable improvements. So, it's not just technology; it's the technology and the service component together. Audiologists just have to have the guts to charge for our services and for our professional services. That's my message.
AO/Beck: Thanks David. I think it's a reasonable message and I think it helps protect all of us, patients and professionals, for the long term.
Fabry: Thanks Doug.
*ARA = The Academy of Rehabilitative Audiology was founded in 1966 to promote excellence in hearing care through the provision of comprehensive rehabilitative and habilitative services. Each year the ARA hosts the ARA Summer Institute which provides a forum for discussion on the latest developments in auditory rehabilitation research and therapy. ARA membership is open to anyone conducting research or providing services in the area of audiologic rehabilitation. For more information visit www.audrehab.org or call the national office at 952-920-0484.
Click here to visit the Phonak website.
Fabry: Hi Doug. Thanks, nice to work with you too.
AO/Beck: I'd like to focus this interview on the topic you presented at the ARA* meeting back in the early part of summer, 2003, which had to do with verification of hearing aid fittings and aural rehabilitation.
Fabry: Right. The talk was on verification of digital hearing instruments and implications for aural rehabilitation. I discussed current verification techniques for DSP devices. The urban myth has been that you can't verify DSP devices clinically, and that has meant that clinicians are increasingly relying on the manufacturer's ability to set target gain values on the basis of a patient's audiogram and average correction factors for venting, shell type, microphone location, and residual ear canal volume. Although many do a very good job, it is ironic to me that the tremendous digital flexibility that we see in modern hearing aids is largely unused. As a result, this session discussed several methods in current use for hearing aid verification with digital hearing aids. We began by discussing functional gain and optimal aided gain (best aided threshold, usually measured while the hearing aid is hooked up to the programming device). Although these measures provide a reasonable approach for assessing how well a hearing aid amplifies soft sounds, they provide no indication of maximum hearing aid output. Furthermore, for nonlinear (e.g. wide dynamic range compression) hearing aids, gain for typical inputs, like speech, is usually overestimated using functional gain measures. Finally, even when input level is isolated to soft sounds, the frequency resolution is much poorer than for probe-microphone measurements (typically only five to ten different frequencies are used, versus 100 Hz increments for most real-ear systems). The bottom line is that except for soft sounds, functional gain methods just don't measure up for verification of DSP hearing aids.
AO/Beck: So, in other words you're looking at a snapshot of the hearing aid's performance at one fixed point in time, rather than the full spectrum of performance ability.
Fabry: Yes, that's correct. Additionally, the transferability or portability of the data is problematic. Hearing aids are not audiometers and they're not governed by the same ANSI standards in terms of step attenuation. Although hearing aids have their own ANSI standard characteristics they're not governed by audiometric zero and audiometric attenuator linearity. So moving from functional gain and best-aided or optimal aided threshold into real ear measurements takes some doing!
AO/Beck: Tell me about the difference in verification for digital versus analog instruments please.
Fabry: Well, as stated above, the big issue is nothing more than urban legend. The myth states that you can't use real ear measurements with digital devices because digital noise reduction (DNR) circuits will attempt to attenuate the signal. Some hearing aid manufacturers also perpetuated the myth that you can't evaluate their products with functional gain or real ear measurements. While it is true that you need to be careful which test stimuli you use, particularly if the DNR is active, there are numerous options available from real-ear systems that use digital noise or real speech to fool the DNR circuit into thinking that the test stimulus is speech, rather than noise. Otherwise, some hearing aids allow you to turn off the DNR circuitry during testing; this option is less attractive, in my mind, because it doesn't indicate how the hearing aid will work in-situ, when speech and noise are both typically present. Another trick that clinicians can use if they don't want to pay for the upgrade to digital test stimuli is to use very brief test stimuli during testing. By turning the test signals on and off very quickly, they can get a measurement before DNR kicks in. My advice, however, is that clinicians working with DSP hearing aids spend the money for the upgrade to digital test signals with their real-ear test system.
AO/Beck: And the number two issue?
Fabry: Number two is really linear versus nonlinear amplification. When verifying linear hearing aids, measured functional gain and insertion gain values will be the same. Because most digital hearing aids use nonlinear amplification, this is often seen as a digital issue, but it is related more of a compression issue. As stated above, the combination of these two factors has led to a reduction in hearing aid verification in the past few years. If you look at the data David Kirkwood collected in the Hearing Journal in March, 2003, some 50-65% of audiologists rarely if ever use functional gain; about half of them rarely if ever use real ear measurements. We have all of this flexibility with digital devices, but no one's using them! Part of this stems from the fact that audiologists adopted a model previously used by hearing instrument specialists that bundles hearing instrument pricing to the patient, which minimized the importance of fitting and verification, the professional service fee, and rehabilitation. In many respects, audiologists are their own worst enemy, because we do not stress the value of our services, in the form of fitting and follow-up. Instead, the impression that many patients have is that the technology alone provides the solutions, rather than the clinician. In many ways, we perpetuated that model to our own detriment and we're precariously close to a situation where we're not going to be able to recover from it as we look at Medicare reimbursement for hearing aids becoming a reality in the future. We must look to itemization of hearing healthcare services if we are going to survive.
AO/Beck: Can you talk about the difference between bundling and itemizing?
Fabry: Yes, gladly! There's an important distinction between unbundling and itemization. In fact, that's become my new mantra because people are resistant to the notion of unbundling . Professionals get freaked out about unbundling because they say it's bad for business and is doomed to fail. I think the opposite is probably true. As long as we bundle everything together in the cost of the hearing aid, such as the product, the tests, the office visits, the verification, aural rehabilitation etc., the patient and arguably the insurance providers, don't attach value to the professional services provided.
When we talk about unbundling, people think of an a-la-carte system where someone says, okay, the hearing aids cost X dollars, the fitting is Y, and follow-up cost is Z dollars, and the total is the amount that we bundle altogether . Of course, the professionals have to consider that the patient may say, I just want the hearing aids, I don't want Y or Z, and that's a real concern. Many fear that it can be used as an unfair advantage by their competitors, especially if the competition is willing to provide free-for-service to your patients, in the hopes of getting their repeat business later on.
With itemization you have a package plan. You say this package includes items X, Y and Z. And, they cannot be purchased separately; it comes as a complete package. If you take one item, you have to take them all. I hate making comparisons to the automotive industry, but it is sort of like when you buy a new car, you have to buy the whole package; you can't just buy the chassis and the motor and the transmission. It comes with the seats and the tires and the warranty.
AO/Beck: So itemization is when you're listing different components of the total bill, such as hearing aids, ear molds, ear mold fee and professional service fee. And bundling is when you give a total price, which is essentially the same total as the itemized bill, but the component parts of the bill have not been detailed, nor have they been appreciated!
Fabry: Exactly. And not only is it important in and of itself, I think it helps set the stage ultimately for Relative Value Units (RVUs), which is how the AMA determines the value of services for a physician. If we're all reporting a value attached to our fitting and follow-up services, we have a much better chance of going to Medicare and Medicaid and saying this is what this these services are worth.
AO/Beck: Okay, got it. But to further explore the car analogy you mentioned, if I bring my car in for service and I tell them I just need an oil change, I just want oil and filter...they'll do that. But you can bet that on the bill they will bill for oil, for the filter, and for service and a disposal fee. So that's itemization, but the component parts are not available separately. If you want the oil and the filter, you must pay for the service and the disposal, and maybe a shop fee too.
Fabry: Right. They are itemizing it and they're showing you that each component has a value, and then in the future, you understand that there is more to an oil change than oil and a filter! The mechanic or the technician has a value too.
AO/Beck: And that gets back to verification and knowing that we, as professionals matter, and there is a value to the work we do.
Fabry: That's correct, and that's another thing that troubles me about the current situation. Specifically, those of us who are involved with aural rehabilitation are true believers that we're making a difference, but we don't have the data to back it up and that's an enormous problem! There are really only two studies that verify our role in the process. The VA hearing aid study from a year or two ago, which indicated the benefits of amplification, and the article that was published in JAMA in April, 2003, where they're looked at the impact of screening hearing loss. Unfortunately, neither really showed the impact of the audiologist, but rather the technology or that someone screened for hearing loss.
And so this is an issue that can't be addressed solely by technology. Unfortunately, it's a professional, political and a technological issue. Technologically, if verification measures using probe measurements are too complicated then we need to look at how to make that more efficient. Time is money, and these measures need to be clinically efficacious.
AO/Beck: The other thing, going back to itemization, is that if we itemize it helps assure we have rehab programs, and I think that's an important point.
Fabry: I agree. We cannot continue along the same old route we're been going with regard to aural rehabilitation, we need to formalize and itemize it on the bill, much like your oil change example. We're just letting you know the cost of goods and the cost of services. I think this is a critically important point for the profession and I hope we adopt this very quickly. I'll even argue that we're providing the services and I believe very strongly that the audiologists who are providing those services are doing a great job. Their patients love them; they're making a huge difference. But collectively, we absolutely have to show the services and the dollar value of the services, or no one else is going to place a value on them either!
AO/Beck: I think a large part of the problem is that we can't charge for aural rehab.
Fabry: It's a self-sustaining, vicious cycle. When you look at reimbursement rates for audiograms and you look at why it's so poor, part of it is when they go out and look at assigning Relative Value Units, they look at people who give away the audiogram or minimize the fee to get the hearing aid money, as well as those clinics who charge a fair market value for their work. When you average the two together, you obviously devalue the importance and reimbursement for the audiogram. So looking at one possible Ghost of Christmas Future , I see Medicare paring down our diagnostic fees so we get paid almost nothing, because some are giving away diagnostic services to get at the hearing aid patients. Then, when hearing aids are reimbursed by the government, one future view says that we'll get paid very little for the technology, and next to nothing for the service, and no one will be able to affords to dispense hearing aids.
AO/Beck: And frankly, we know the work matters. I think we can say with certainty based on the Walter Reed stuff from 50 or 60 years ago that aural rehab programs were significant contributors to successful hearing aid use. In fact, we know the technology was very poor at that time, but the aural rehabilitation training the veterans went through was significant and efficacious, and the impact was greater than just hearing. It goes to emotional, cognitive, and psychological impact to, in other words, it's a quality of life issue.
Fabry: Right. We know that when you're providing an audible signal to that person with hearing loss that it makes a difference. However, we can't argue effectively that it meets the letter of the law for double-blind controlled, big scale studies that the government and other insurers want to see. But what we can say is that if you're insuring audibility at some level that is going to make a difference. Stuart Gatehouse collected data for the Hearing Aid Modernization Act in the UK, where they compared analog to digital technology, and also the impact of an old and new service delivery model, that varied in the amount of aural rehabilitation provided. Gatehouse's data indicated that as they evolved from analog to new technology, there was a big difference in performance across four metrics that they measured: hearing aid use, benefit, satisfaction, and residual disabaility. Surprisingly, however, when Gatehouse looked at providing the old technology with new services (more aural rehabilitation), the results also showed considerable improvements. So, it's not just technology; it's the technology and the service component together. Audiologists just have to have the guts to charge for our services and for our professional services. That's my message.
AO/Beck: Thanks David. I think it's a reasonable message and I think it helps protect all of us, patients and professionals, for the long term.
Fabry: Thanks Doug.
*ARA = The Academy of Rehabilitative Audiology was founded in 1966 to promote excellence in hearing care through the provision of comprehensive rehabilitative and habilitative services. Each year the ARA hosts the ARA Summer Institute which provides a forum for discussion on the latest developments in auditory rehabilitation research and therapy. ARA membership is open to anyone conducting research or providing services in the area of audiologic rehabilitation. For more information visit www.audrehab.org or call the national office at 952-920-0484.
Click here to visit the Phonak website.
