Ramachandran, Virginia AuD; Stach, Brad A. PhD; Becker, Erika
Mild-to-moderate hearing loss is a common problem in older adults and may cause communication disorders for many. Although hearing aid amplification is an obvious solution for improving communication in those with mild-to-moderate hearing loss, the disparity between the number of adults with such hearing loss and the number who pursue hearing aid solutions is substantial.
Estimates suggest that as many as 75-80% of adults with hearing sensitivity loss do not acquire hearing aids.1 When degree of hearing loss is factored in, the disparity in acquisition of hearing aids becomes more apparent. Most people with a hearing impairment have a mild-to-moderate loss and over 90% of those individuals do not acquire hearing aids.
Recent trends and discussions about changing models of hearing healthcare delivery (such as Internet sales, over-the-counter hearing aids, self-fitting devices) are focused on lowering the cost of hearing aids in an effort to reach this mild-to-moderate hearing loss majority. There are two underlying assumptions of this effort. One assumption is that individuals with mild-to-moderate hearing loss want hearing aids; the other is that cost is a significant barrier to hearing aid acquisition.
The factors contributing to the lack of hearing aid adoption are thought to be numerous and complex.2 Many people who do not use hearing aids consider their hearing loss and related communication disorder to be too inconsequential to use hearing aids, others have negative attitudes toward hearing aids and the stigma of hearing loss, and still others are confused about how to access hearing healthcare.
Indeed, the cost of hearing care may play a role in the lack of hearing aid adoption. In the United States, with the exception of the Veteran's Administration (VA) system, hearing aid care is generally not covered by government or private insurance programs. Kochkin found that, excluding VA fittings, third-party payment for hearing aids accounted for only approximately 30% of hearing aid purchases.1 Even with recent increases in third-party payment for hearing aids, for most individuals with hearing loss, hearing healthcare is an out-of-pocket expense that competes with other discretionary expenses for priority.
It is not unreasonable to assume that cost may be a prohibitive factor in accessing care; financial reasons are cited as a definite factor in non-adoption of hearing aids for 46% of the hearing loss population.2 However, the extent that cost contributes to non-adoption of hearing aids is unclear. In the same survey, 79% and 62% of those sampled reported “hearing loss” and “need,” respectively, as definite reasons for non-adoption of hearing aids. Furthermore, MarkeTrak surveys suggest that those from the most affluent households are least likely to obtain hearing aid amplification.1,3 Clearly, cost is not the only factor involved in hearing aid acquisition.
The National Institute on Deafness and Other Communication Disorders (NIDCD) sponsored a working group in 2009 to examine means for increasing accessibility and affordability of hearing aids for individuals with mild-to-moderate hearing loss.4 Part of the motivation for this initiative was a U.S. Senate report that “recommends that the NIDCD support research to develop, improve, and lower the cost of hearing aids...”
The working group developed an array of research recommendations to explore various barriers and solutions to hearing healthcare access. However, the extent to which cost of hearing aids and hearing healthcare was a focus of the recommendations clearly highlighted the assumption that cost is a significant barrier to hearing aid acquisition in the mild-to-moderate hearing loss population, and that low-cost alternatives would impact penetration of this market.
But to what extent is cost a factor? And will reducing cost be sufficiently motivating to entice those with mild-to-moderate hearing loss to access hearing healthcare? Certainly the MarkeTrak data suggest that cost is an important reason for non-adoption of hearing aids. However other cited reasons, such as insufficient perceived hearing loss and insufficient need, outweighed cost. In addition, these data are based on self-report rather than patient behavior.
Clinical experience dispensing hearing aids in various payment models made us curious about the relationship between hearing aid cost and hearing aid acquisition. In the state of Michigan, there is an unusually high portion of patients who have private insurance coverage for hearing aids and who have varying levels of coverage for their hearing healthcare. This situation gave us the opportunity to examine the behaviors of patients who acquire hearing aids with different levels of hearing aid coverage. In the current study, we sought to address the question of hearing aid cost and its influence on the degree of hearing loss at the time of hearing aid acquisition.
At our institution, the Henry Ford Health System, the largest private insurance provider has two categories of insurance coverage for hearing aids, allowing us to examine acquisition behaviors for three groups of patients (Table 1). In the first category, the full-coverage group, patients are eligible for bilateral Level 1 amplification. This accounts for approximately 50% of our hearing aid patients.
In the partial-coverage group, patients have a fixed sum of money ($400) to use toward the cost of hearing aids and they pay the remaining cost out of pocket. This category has been offered by the insurer in some years, and not in others. In the years that partial coverage was available, it accounted for about 15% of hearing aid patients.
In the third category, the private-pay group, patients pay the full cost of hearing aids themselves. In the years that partial coverage was available, as mentioned above, private-pay payments by patients accounted for about 15% of the hearing aid caseload. In years when partial coverage was not available, the private-pay group was about 25% of the total. The remainder of hearing aid acquisitions was funded through a variety of other third-party payors.
In a retrospective analysis, we examined the hearing aid acquisition behaviors of patients who had full coverage or partial coverage, or who paid for hearing aids themselves. Specifically, we sought to determine the average age and hearing loss at which patients obtained hearing aids as a function of insurance coverage. We also wanted to know what role insurance coverage played in acquisition of unilateral versus bilateral amplification and how it impacted the hearing aid technology level that was purchased.
The medical record numbers of all patients who obtained hearing aids from 2007 to 2010 were collected from the TrakAid Hearing Aid Data Management System at the Henry Ford Health System. Records were sorted according to payment method.
Three groups of payment methods were chosen for this study. The private-pay group consisted of patients who paid the entire cost of their hearing aids and related services themselves. The full-coverage group consisted of patients who had full coverage for binaural hearing aids and related services. Essentially, Level 1 hearing aids and all services were free to these patients. Patients in this group were able to upgrade to higher levels of hearing aid technology by paying the difference between the covered cost and the upgraded cost.
The partial-coverage group consisted of patients who had a fixed incentive per year to apply toward the cost of hearing aids and related services. The incentive was equal to the average cost of a Level 1 hearing aid device and represented a savings of approximately 40% of the bundled cost of a single device.
Patients below the age of 51 were removed from the data sets. From the remaining pool, 1,200 patients (400 audiograms per group) were randomly selected for inclusion in the study.
Information collected from the hearing aid database included insurance coverage, gender, age, level of hearing aid technology, and number of aids purchased. The audiometric thresholds from each patient were collected from the electronic medical record system.
Within our Health System, hearing aid technology is grouped into one of four categories of bundled costs. Nearly all styles of hearing aids are available at each cost level and we offer hearing aids from a number of different manufacturers. The pricing levels tend to follow the four-tier system that is currently commonly used by the majority of these manufacturers. Audiologists in our Health System do not receive commission on hearing aid sales.
Data were analyzed using descriptive statistics to characterize the average age and audiometric thresholds of patients, the hearing aid technology levels, and the number of hearing aids purchased, all as a function of insurance coverage. T-tests were used to determine statistical significance for age and audiometric thresholds. Approval from the Institutional Review Board of Henry Ford Health System was obtained prior to data collection.
Degree of hearing loss and age at hearing aid acquisition
The degree of hearing loss at the time of hearing aid acquisition was the same for patients in the private-pay (PTA=49) and partial-coverage groups (49), but significantly better in the full-coverage group (44) (Table 2).
Results of the distribution of the private-pay and partial-coverage groups are shown in Figure 1A and results of the full-coverage group are superimposed in Figure 1B. The average age of patients at the time of hearing aid acquisition was highest for patients in the partial-coverage group (79 years), followed by the private-pay group (78 years) and the full-coverage group (71 years). Group differences were significant at the 0.05% level. Data are displayed in Table 3.
The role of insurance coverage on age and degree of loss at time of hearing aid acquisition
Does insurance coverage decrease the age and degree of hearing loss at which patients obtain hearing aids? Yes and no. Full insurance coverage for hearing aids and services lead to a significant decrease in both the age and degree of hearing loss present at the time of hearing aid acquisition compared with patients in the partial-coverage and private-pay groups. This supports the notion that elimination of cost of hearing aids does lead to earlier acquisition of hearing aids by patients with mild-to-moderate hearing loss. However, partial-insurance coverage had no impact on the degree of hearing loss at the time of acquisition relative to the private-pay group.
Why did full coverage for hearing aids lead to earlier access while partial coverage did not? The reduction in cost for hearing aids was not inconsequential in the partial-coverage group. Hearing aid costs were reduced by 20% for bilateral or 40% for unilateral amplification. The cost of the reduction was approximately equivalent to the clinic's cost for Level 1 hearing aid technology. Stated another way, in the partial-coverage group, a hearing aid device was provided to the patients for free, with the patients paying only for the cost of the associated audiologic professional services. These results suggest that for patients with mild-to-moderate hearing loss, simple reduction in the cost of hearing aids may not be sufficient to cause them to access hearing healthcare.
The distinction between elimination of cost and reduction of cost is not trivial. The trends of elimination (full coverage) versus reduction (partial coverage) of hearing aid cost may be of importance when considering the policy questions frequently asked regarding third-party reimbursement for hearing aids, general issues of hearing aid cost, and policy issues such as tax credits for hearing aid purchases. Our data suggest that simply reducing the device cost of hearing aids will not lead to greater acquisition by individuals with mild-to-moderate hearing loss. Further reductions, or possibly elimination, of the cost of professional services to the patient would need to be made as well.
A “TIPPING POINT” FOR HEARING AID ACQUISITON?
The striking overlap between the private-pay and partial-coverage distributions (Figure 1A) suggests that there may be a “tipping point” of hearing sensitivity at which patients determine that hearing aids are a necessity and where cost becomes much less of a determinate for hearing aid acquisition. Only when hearing aids are provided to patients completely free does the distribution begin to be skewed toward a lesser degree of hearing loss sensitivity. The difference between these distributions might be the difference between hearing loss becoming noticeable to patients and hearing loss becoming problematic for them.
INSURANCE COVERAGE AND PRICING AS FACTORS
It may also be the case that reduction and elimination in costs via health insurance coverage, per se, may result in distinct acquisition behaviors. For individuals whose cost has been eliminated, an attitude of entitlement may promote different hearing aid acquisition behaviors. For example, patients who would otherwise not obtain hearing aids could conceivably do so, not out of need or desire, but because they are entitled to the benefit. We do not know what role insurance coverage in and of itself plays in choosing to access hearing care.
Another possibility is that patient perception of hearing aid pricing may influence acquisition behaviors. For example, patients may view lower-cost hearing aids differently than those that are partially covered by insurance and may behave differently accordingly, despite no actual difference in the bottom-line cost of the aids to the patient. Furthermore, it is unknown whether reactions differ when there is a reduction in cost via insurance coverage when there is an “unadvertised” true reduction in cost, or when there is an advertised reduction in cost that the patient perceives to be “a deal.” Perceptions related to bundled versus unbundled hearing aid costs may contribute to willingness-to-pay attitudes as well.
CHANGES IN ACQUISITION
Another question that remains unanswered is how many patients who have more severe degrees of hearing loss gain access when the cost of aids is reduced. We do not know how many patients would not have otherwise obtained hearing aids if it were not for the cost reduction provided by partial-insurance coverage.
To begin to understand this question, we performed a post-hoc analysis of changes in hearing aid acquisition patterns in years when the partial-insurance coverage incentive had been discontinued by the insurance carrier. In the years 2006, 2008, and 2009, the insurance carrier provided the partial-coverage benefit for patients. In the years 2007 and 2010, this benefit was unavailable to patients. These data are displayed in Table 5.
Full coverage of hearing aids was relatively stable across 2006-2010, ranging from 49% to 55%. For the years where the partial-coverage benefit was unavailable, 23-24% of hearing aid sales came from the private-pay category. For the years when partial coverage was available, the private-pay category percentage decreased by nearly the same percentage that the partial-coverage category increased.
There are numerous possible factors that can account for the fluctuations over the course of these years, but one reasonable interpretation is that in the years where partial coverage was not an offered benefit, the body of patients who would have obtained the aids with the partial coverage simply paid for the entire cost of hearing aids themselves. What remains still completely unanswered by these data is how many patients would be unable to afford hearing aids even with partial insurance coverage.
The notion of affordability of hearing aids remains a challenging concept. While healthy hearing care is an important contribution to quality of life, it is nevertheless a quality-of-life concern rather than a life-sustaining concern. As such, people are bound to rank treatment for hearing loss within the framework of other factors that also contribute to quality-of-life.
NUMBER OF HEARING AIDS AND LEVEL OF HEARING AID TECHNOLOGY
We were also curious about the impact of insurance coverage on the number of aids purchased and the level of hearing aid technology chosen. The number of hearing aids purchased did indeed differ as a function of insurance coverage. Patients from the full-coverage and private-pay groups obtained bilateral amplification in 92% and 83% of cases, respectively. Patients who had partial coverage for hearing aids obtained bilateral amplification in 65% of cases. Data are shown in Figure 2 and Table 4.
The level of hearing aid technology purchased also differed as a function of insurance coverage. Patients who had full coverage were most likely to obtain the lowest level (Level 1) of hearing aid technology (78%), followed by Level 2 (16%), Level 3 (4%), and Level 4 (3%). Patients in the private-pay group were the least likely to obtain Level 1 hearing aid technology (41%) and the most likely to obtain Level 2 (34%), Level 3 (17%), and Level 4 (8%) technology. Patients with partial coverage fell between these groups, with most patients obtaining Level 1 technology (69%), followed by Level 2 (22%), Level 3 (7%), and Level 4 (3%). Data are displayed in Figure 3.
Partial and full insurance coverage for hearing aids clearly played an important role in the number of hearing aids and level of hearing aid technology purchased by patients. Patients who paid completely out-of-pocket for the cost of hearing aids were highly likely to purchase two hearing aids and were also likely to pay more money for higher levels of hearing aid technology.
This trend is highly contradictory to the notion that cost is a significant motivating factor in the decisions surrounding hearing aid acquisition. Indeed, patients who spent the least amount of money on the base price of a set of hearing aids, the full-coverage group, were the least likely to spend any additional money to obtain higher levels of hearing aid technology. This trend was followed to a lesser extent by the partial-coverage group.
The acquisition of bilateral versus unilateral hearing aids is similarly disparate among groups. Those patients with full coverage for bilateral hearing aids, not unexpectedly, nearly always obtained two hearing aids. It is likely that the 8% of patients who obtained only one aid were nearly all only candidates for unilateral amplification. However, when patients had to pay the full cost of hearing aids out-of-pocket, they were also highly likely to purchase two aids. When a cost reduction through partial insurance coverage was offered, patients chose to obtain unilateral amplification much more frequently (35%).
These trends demonstrate that cost is one of, but not the only, factor motivating hearing aid acquisition decisions. It has been frequently observed by those clinicians who provide treatment for these various insurance coverage populations that patients often explicitly state that they want “whatever the insurance covers.”
It is possible that provision of insurance coverage for hearing aids could promote purchasing and acquisition behaviors that are complicated by attitudes regarding the role of insurance coverage in health care decisions, even when patients can afford hearing aid amplification.
It may even be the case that provision of insurance coverage for hearing aids could have unintended effects of creating a psychological barrier to patient decisions regarding the most appropriate hearing aid amplification option for the individual patient. The additional various psychological and attitudinal factors motivating patient behavior toward hearing aid acquisition and their relationships to hearing aid cost and the role of insurance coverage remain to be examined.
Insurance coverage for hearing aids plays a significant role in hearing aid acquisition. Full coverage for bilateral aids and related services results in a decrease in the age and hearing loss level at which patients obtain hearing aids. Patients with full coverage are highly likely to obtain bilateral amplification, but are unlikely to pay more to upgrade to higher levels of hearing aid technology.
Partial insurance coverage for hearing aids did not result in a decrease in the age or hearing loss level at which patients obtained hearing aids. In addition, patients were much more likely to obtain only one hearing aid, but were more likely to obtain higher levels of technology.
Patients who paid for hearing aids themselves were those most likely to obtain higher levels of hearing aid technology. Overall, the patients who paid most of the base cost of hearing aids were more likely to purchase increased hearing aid technology than those patients who paid less or who paid nothing at all.
These findings also suggest that the behaviors of patients with insurance coverage for hearing aids are complex and motivated by more than the cost of hearing aids, and raise a number of important issues regarding hearing aid acquisition and use in the mild-to-moderate hearing loss group:
* What is the role of health care insurance “entitlement” in hearing aid acquisition behaviors?
* What are the patterns of use, benefit, and satisfaction for those hearing aid users with mild-to-moderate hearing loss?
* How much does lowering or eliminating the cost of hearing aids impact those individuals with great hearing care needs, such as those with greater degrees of hearing loss?
* How much does lowering or eliminating the cost of hearing aids impact those individuals with low or fixed incomes?
This study also supports the notion that there may be a “tipping point” for hearing aid acquisition, at which cost no longer becomes a primary concern for patients in acquiring hearing aids. To support the needs of patients with hearing loss while balancing issues of cost, it may be necessary to better understand the difference between noticing hearing loss and being restricted by hearing loss.
While all patients with hearing loss could potentially benefit from hearing aid amplification, it is worthwhile to realize that many people, particularly those with mild-to-moderate hearing loss, may not want hearing aids at any cost.
Kochkin, in interpreting his most recent MarkeTrak data suggested that “people with mild hearing loss simply don't use, or perhaps need, amplification for their hearing loss.”1 It may be important to consider that factors other than cost may be contributing in a much more substantial way to hearing aid non-adoption, especially for patients with mild-to-moderate loss.
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