Interview with Richard Gans Ph.D., President of the American Academy of Audiology

Beck: Good Morning Dr. Gans. Thanks for speaking with me this morning.

Gans: Good Morning Dr. Beck. Thanks for your time too.

Beck: Richard, I wonder if we can start by clarifying the term of the American Academy of Audiology (AAA) presidency. I know that's changed a little over the last few years. Is it the calendar year or the fiscal year?

Gans: I became president of the AAA July 1, 2004, and my term ends June 30th, 2005. so, yes we do follow the fiscal calendar.

Beck: Thanks for clearing that up. Why don't we start with professional autonomy - Where are we as a profession, and more importantly, where are we going?

Gans: There are many different aspects to autonomy. Let me address one aspect that's very important right now, and that has to do with Medicare enrollees having direct access to audiologists. This has lots of momentum and we've had some nice support and it's growing. Currently, we have some 55 co-sponsors in the House, and some 5 or more in the Senate. Obviously the Veteran's Administration (VA) and the Federal Employee Health Benefit Program (FEHBP) and other managed care and preferred providers allow direct access, and that's the model that's advantageous and efficient for the patients and the taxpayers.

Beck: I'm glad you mentioned that because some people may not realize that our elected officials, such as the Congress and the Senate members, all currently have direct access to audiologists - isn't that correct?

Gans: Yes. That's correct, and not only do they have direct access to audiologists, but their staffs and dependent family members have direct audiology access too. And so just to be clear, I have no complaints about that at all - that's exactly what we're fighting for. If it's good enough for the elected officials, it's good enough for Medicate recipients too! Of course one argument we've heard is that the cost of direct access is prohibitive, but based on the research and experience of the groups that provide direct access, we know direct access is cost effective. We know the cost of direct access is highly beneficial for the VA and the FEHB, and even United Health Care has been allowing direct access for more than ten years now. So again, we know that it works, it's safe, and it saves steps and costs, while providing excellent care and access. You know that's the other argument I've heard ...."If we allow direct access, patient safety might be compromised"....But of course, if that were true, Senators and Congressmen would not allow their own families and loved ones to participate.

Beck: Agreed. So the two primary arguments against direct access are the safety issue and the cost issue, but neither argument has much traction?

Gans: No, they don't. The arguments against direct access are not supported by the research or the data, but they are standard arguments used, whenever turf battles are brewing, or whenever change is introduced into a system with a rich history in which things tend to be done as they have always been done. Change is rarely embraced, and it takes effort and time, so it's always an uphill battle.

Beck: OK, very good. Let's talk a little about "incident to" billing. Please tell me what that is, and what's it all about?

Gans: Doug, as you know, physicians have the ability to bill virtually any CPT codes. This effects not only audiology, but all patients and professionals in the healthcare system. Sometimes CPT codes billed by physician offices reflect a test or procedure done by a tech, or an assistant, not a licensed healthcare professional. Of course, as long as the physician has ordered the test, and it is performed, the physician can bill for it. However, this leads to unlicensed, non-certified, non-degreed people doing hearing tests, ENG tests, allergy tests, electrocardiograms, biopsies and all manner of clinical protocols, , often with little training, no licenses, and little more than an abbreviated understanding of what they're doing, or why, and what the results mean...Yet patient care is highly dependent on these in-office protocols, and they are billed and reimbursed as if the real, and arguably the "intended professionals" had performed and interpreted the tests!

Beck: As you know, in some hearing healthcare practices, extremely clever, well designed, automatic tests have been performed essentially by machines. And as best I can tell, no one is arguing that automation is bad or inappropriate, but when those tests are billed as if they were done by healthcare professionals, that must be an issue too? In other words, I guess the question comes down to...Should the third party payer pay the same fee for a machine-based, automatic test, as they do for professional time, skill and interpretation?

Gans: Exactly right....that is the issue. We're not opposed to electronics and automation for basic tasks which lend themselves to automation, but I think arguably, it should be abundantly apparent when the CPT code used is based on someone hitting the "start" and "stop" buttons, rather than a professional actually seeing, diagnosing and managing the patient. Again, automation is fine, but it seems like it was not the intent of the code or it's reimbursement level. When a machine performs a basic test, with concomitant billing which implies that a licensed professional performed the test, referred to as "incident to" the physicians visit, we're concerned that the patient, the professionals and the third party payers are not really getting what they've asked for, or paid for. So that's the issue in a nutshell. It can be argued that "incident to" billing perhaps encourages physicians and others to submit bills for work which arguably should be performed by professionals, to be done by machines and technicians with little training, little education and no licenses, and this essentially serves to compromise patient care and of course, professional integrity.

Beck: So in essence, what I'm hearing is that the AAA is not opposed to automated tests, but is opposed to having the automated test reimbursed at the same level as a test performed by a licensed healthcare professional?

Gans: That's right. We want to make sure the government and other third party payers know what they're paying for. We have never entertained or considered the thought that automated tests are equivalent to professionally performed tests. They are not the same, and they should not be treated, billed or reimbursed at the same level.

Beck: I understand, thanks for clarifying that. I recall there was an apparent misunderstanding as to the AAA's position on that, and I'm glad you clarified it. So in essence, none of the AAA executives have stated or argued that automated tests are equivalent to, or the same as, professionally acquired tests?

Gans: You're absolutely correct. I have personally spoken with the last 4 AAA presidents on this specific issue, and we have no idea where that got started. We maintain a steadfast position on this. Automated tests may be part of the future however, we believe automated tests, when billed as "incident to" a physicians visit, are likely misleading to all concerned, and that's where the issue lies. If the automated test had a specific CPT code, so it can be recognized and billed and reimbursed at an appropriate level, that may be fine. But if it appears that the automated test was done by a doctor, whether it be an audiologist or a physician, that's where we take issue, and that's where we oppose "incident to" billing protocols.

Beck: Thanks Richard. I think you've made the AAA position on that very clear. Let me shift gears here and let's address the issue of three versus four year Au.D. degree programs. Some colleges and universities are trying to push forward three year Au.D. degrees, and frankly, that seems to me, highly counterproductive to all we've learned and accomplished over the last ten years since we've had the basic 4 year Au.D. Please tell me your thoughts on that issue?

Gans: The position of the Academy is that the Au.D., is, and will remain, a four year degree, just like the majority of other doctoral level health care professions such as optometry, dentistry, osteopathy, medicine and many others. The quantity of clinical, professional, academic, lab and related experiences was not designed to fit into a three year program, and it cannot be appropriately accomplished in a three year time period. The new standards reflect a four year course of study, and that's what the new accreditation body, the Accreditation Commission on Audiology Education (ACAE) will be working towards. As you know Doug, the ACAE has been supported by the AAA and the ADA and this is a powerful alliance working towards rigorous standards for the profession. The four year model wasn't arbitrarily chosen, it was chosen based on a proven professional and recognized track record, and that's the model we support. In fact, this December, we'll be testifying in front of the US Department of Education, and we'll be advocating the four year model. I think the academic programs are clearly going to want the 4 year model to be the "gold standard" and I think professionals want that too, so I anticipate that's what we'll all settle on.

Beck: Richard, I know you're very busy, and you've been very generous with your time, but can we address one more topic before you go...Can we talk about CPT codes for aural rehabilitation?

Gans: Sure Doug. That's an area that the Academy and ASHA are working together when possible .

Beck: Thanks for mentioning that! I think ASHA and the AAA probably agree on some 80 percent of the issues, but the 20 percent they disagree on are the ones that get the press! Is that right?

Gans: Yes, it probably is correct. ASHA and the AAA do work together on the majority of issues, and that's really in everyone's best interest, and it's very productive. In fact, there are several aural rehab codes that we've been working on together, and they will hopefully be released in the near future. We need to be a little cautious here, because although we'd like to be able to treat patients via aural rehab, we want to make sure it does not confuse things, such as our SOC codes and our grouping as professionals.

Beck: And in that respect I think you're saying that we want to make sure we are allowed to treat patients via aural rehabilitative protocols, as licensed hearing healthcare professionals. Further, we ought to bill for professional time, knowledge and management, consistent with the "incident to" argument we discussed a few moments ago. However, we need to approach this with caution so as to not be confused with professions that are primarily rehabilitative - is that the idea?

Gans: Yes, that's pretty much the idea. We want to exist alongside dentists, podiatrists and optometrists and we need to make sure we're categorized as such.

Beck: Richard, it is always a joy to speak with you. I am very appreciative of your time, and I'm grateful for your leadership of the AAA.

Gans: Thanks Doug. It's always nice working with you, and thanks for allowing me and the AAA to participate on Audiology Online.

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