When Consumer Reports (CR) published a long and largely critical article last summer on the state of the U.S. hearing aid delivery system, hearing care providers reacted strongly. Many questioned the fairness of a key finding that two-thirds of the 48 hearing aids fitted on 12 consumers who cooperated with CR on the article were misfitted. On the other hand, many in the dispensing community felt that the article drew attention to some legitimate problems and should serve as a wake-up call.
In the 2010 Hearing Journal/Audiology Online dispenser survey, we decided to give audiologists and hearing instrument specialists the chance to comment on some of the important and controversial issues raised by CR. Questions about that article, as well as on many other topics of professional significance, were e-mailed in early February to Audiology Online's e-mail address list and to the members of the International Hearing Society. A total of 640 people responded, including 535 who dispense hearing aids (for more about the respondents, see the sidebar on page ??).
SPECIAL FOCUS ON CR ARTICLE
CR's “misfit” claim: Fair or far-fetched?
Nothing in the Consumer Reports story aroused more controversy than its report on what happened to 12 consumers it tracked as each was fitted binaurally by two different dispensers (a mix of audiologists and hearing instrument specialists in the New York metropolitan area). According to CR, which assessed the results as “mediocre,” two-thirds of the 48 instruments the consumers bought “were misfit. They amplified too little or too much.” Our survey asked, “Do you agree or disagree that the results cited by CR are representative of what hearing aid purchasers are likely to experience in general?”
As Figure 1 shows, close to half the respondents (46%) disagreed with the finding (20% strongly, 26% moderately), while 38% agreed (31% moderately, 7% strongly). The remainder were neutral or uncertain. Evidently, a substantial minority of dispensing professionals do not reject the thought that most hearing aids are misfitted in this country, though more respondents felt that the article overstated the extent of the problem.
;)
Figure 1: In a study of hard-of-hearing people, Consumer Reports (CR) found that 2/3 of them were “misfit.” Do you agree or disagree that the results cited by CR are representative of what hearing aid purchasers are likely to experience in general?”
It was especially telling to read why respondents' agreed or disagreed with CR. Many who found the high misfit rate credible pointed to the failure of most practitioners to use real-ear measurement (REM) to verify their fittings. For example, an AuD who owns a practice in Florida said, “Real-ear measures are not utilized consistently. First-fit algorithms are not sufficient to allow for ear canal volume and earmold geometry.”
Other respondents contended that many practitioners (especially hearing instrument specialists, in the view of quite a few audiologists) are either not well trained or don't follow proper protocols. For example, an AuD who manages a clinic in Minnesota wrote, “Too many unqualified hearing aid salesmen have little to no knowledge of hearing aid function. Rather, they press the ‘do it’ button supplied by the manufacturer's software.”
The owner of an audiology practice in California with 43 years' experience said, “I have worked with several dispensers and audiologists who do not fully understand what they are doing. They stick with what the manufacturer recommends and know very little about the modifications available to assist the patients.”
However, most respondents rejected the article's findings. For one thing, many said, a sample of 12 patients in one area of the country is too small to be meaningful. An HIS of 33 years who owns a practice in Florida said, “Let me point out that this study is judging the entire industry's ability to dispense hearing aids based on 12 hearing-impaired individuals.”
Many noted that CR failed to explain how it determined a patient was “misfit.” An audiologist with a master's who works in a clinic in California complained, “The article didn't define criteria at all. It would have helped if they had described which fitting formula they were using to determine if a fitting was appropriate. Even then, they should have explained that target isn't the final word.” A traditional dispenser in Colorado said, “There's a lot more to customer satisfaction than what the article targeted. I'm not sure what purchasers experience on the whole, but in our practice customer satisfaction is attainable 90% of the time.”
Others pointed out that a fitting is an ongoing process and CR's conclusion that an aid was misfitted could have been premature. An AuD/BC-HIS practice owner in Georgia said, “The article talked about fitting to real-ear targets instead of taking into consideration how the patient likes the sound. Especially on new users, you often have to start them lower than target.”
A university audiologist in California with a PhD said, “The first 30 to 90 days are critical for fine-tuning and intensive counseling. The article failed to address acclimatization issues and also did not quantify who determined ‘misfit.’” A PhD audiologist who manages a clinic in California asked, “What tool was used for analysis of ‘misfit’? Hearing aid fittings aren't black and white; there's not one special setting for the perfect fit.”
Finally, an HIS who runs a practice in California couldn't resist saying, “CR should stick to comparing cars. This special report is out of their field. CR gave Toyota a great rating!”
CR's choice of provider not popular
The article offered a number of recommendations to consumers on how to maximize their chances of getting a good hearing aid fitting. None of these suggestions met with stronger disagreement from survey respondents than that consumers (except those eligible to go to a VA clinic) should seek help from an ENT practice because patients would likely receive a more thorough hearing evaluation than at other types of practice.
As Figure 2 shows, 60% strongly disagreed, and only 16% agreed even somewhat. It's no surprise that respondents not employed in an ENT office should reject this advice. More surprising was that 60% of audiologists who do work for an otolaryngologist disagreed, either strongly or somewhat, that their type of practice was the consumer's best choice, and just 29% of them agreed.
Figure 2: Do you agree or disagree with CR's advice that patients (except those eligible for VA care) should go for hearing help to an ENT office with an audiologist on staff?
Survey backs some other recommendations
Hearing professionals were much more positive about the article's other advice to consumers. Nearly all of them agreed, 92% of them strongly, with CR's statement. “We strongly recommend scheduling at least one follow-up appointment.” Typical of the responses was one from an HIS in British Columbia, who said, “I can't imagine not having a follow up—and more after that!”
A solid majority of respondents also seconded the article's advice that consumers going to a professional for hearing aids should “insist on” being offered a choice of styles. As Figure 3 shows, more than 70s, more than 70% agreed at least somewhat, although almost a quarter disagreed.
Figure 3: Do you agree or disagree with CR's advice to consumers that they should “insist on” being offered a choice of hearing aid styles?
Why shouldn't patients be given a choice of style? A master's audiologist who works in a clinic in Utah contended, “The provider should make the choice based on what a patient needs. Patients can't know what is an appropriate choice unless they have training.” However, most who disagreed with CR took a nuanced position. It's not that they opposed telling patients about style options, but they felt that often because of the patient's hearing loss, limited dexterity, or other factors, only one style of instrument would be appropriate. Hence, they said, it did not make sense to leave the choice up to the patient in such cases.
For example, said an Illinois audiologist working part-time in a private practice as she earns her AuD, “Consumers should be shown the variety of style options, but only offered what is best for their hearing loss and lifestyle.” A doctor of audiology employed in a private practice balked at the article's wording, saying, “‘Insist’ is a strong word. I do feel, however, that best practice is to give the patient choices.”
Among the advocates for offering a choice was an Arizona AuD employed in a clinical setting. She wrote, “I believe the audiologist should tell the patient which style they think will work best, but if the patient won't wear that style, the fitting will fail. The patient needs options.” Perhaps a California AuD employed in private practice best explained the balance between the professional and the patient on this issue. “It's important that consumers be given options and be made part of the process. It's up to the audiologist/dispenser to inform them why a particular style is or is not appropriate for the loss. It's a partnership.”
Fewer see brand choice as important
The article also advised consumers to “insist on having a brand choice,” so it recommended going to an independent practice not tied to a single manufacturer. Respondents were fairly evenly split on this issue, with 47% agreeing (28% somewhat, 19% strongly) with CR and 42% disagreeing (25% somewhat, 17% strongly).
Interestingly, as Figure 4 illustrates, while responses to this question were affected to a degree by whether the respondent was a single- or multi-line dispenser, that factor was not necessarily determinative. For example, 30% of single-line dispensers said consumers should have a choice of brand. And, 41% of multi-line dispensers disagreed with CR that consumers should necessarily go to someone who fits multiple brands.
Figure 4: Do you agree or disagree with CR's advice to consumers that they should “insist on” being offered a choice of hearing aid brands?
An AuD who works in a medical office in Virginia explained why she didn't feel a brand choice was necessary: “The top five or so brands are about equal in performance. The choice should be whether the aid is 'entry-level, mid-level, or top-of-the-line.'” Another Virginia audiologist who works in a private practice said, “Brand is not all that important in proper fitting of hearing aids.”
However, many respondents insisted that there were significant differences among brands, so that offering a choice is important. A Wisconsin AuD employed by a private dispensing practice explained, “No one brand can correctly fit every single patient; having a choice of a few companies is necessary.” Similarly, a PhD audiologist who owns a practice in South Carolina said, “Some features are only available on some brands. You need to find out what the consumer considers important and make the best match. It takes several companies to have a good set of alternatives.” Another audiologist added, “I do use multiple brands because in my experience for some people the algorithm in one brand sounds ‘better’ and the patient is the owner of the loss!”
A Connecticut HIS who owns his practice gave a different reason for offering consumers a choice. “With today's technology the computer chip performs basically the same from product to product with some minor differences. It boils down to who knows the computer well enough to provide after-fit adjustments.” But, he continued, “A choice of brands is a comfort to potential users. It indicates that the dispensing professional has their best interest at heart by offering a choice.”
The importance of real-ear
The CR article emphasized the importance of having hearing aid fittings verified by real-ear measurement. Although the leading professional organizations in audiology consider REM a best practice, CR stated that fewer than a quarter of hearing aid providers use it regularly. Therefore, the article urged consumers to make sure before they buy hearing aids that the practitioner agrees to verify the fitting with REM.
The last of the survey questions about the issues raised by CR asked respondents if they agreed that real-ear measurement should be considered a must-do procedure. There was a clear consensus in favor. Among all respondents, 39% strongly agreed and another 23% somewhat agreed, while 26% disagreed, 10% strongly.
When the data were divided by dispenser groups, differences emerged, as seen in Figure 5. For example, 66% of audiologists agreed compared with 52% of HISs. Audiologists' views differed considerably depending on where they worked. Close to 80% of those employed in clinics and hospitals said yes to routine REM and 67% of those in private practice did. Interestingly, only 47% of audiologists employed in ENT offices, CR's recommended place to go for hearing aids, considered REM a must.
Figure 5: Do you agree or disagree with CR's advice that before being fitted with hearing aids consumers should insist that the dispenser agree to verify the fitting with real-ear measurements?
Advocates tended to see the case for the measurement as open and shut. “Without real-ear measurements, you are fitting somewhat blindly,” said an AuD from California who works in a medical office, while a master's degree audiologist in North Dakota said, “There is no other way to verify objectively what has been accomplished.” An AuD who manages a private practice in Pennsylvania described the benefits thus: “It is a must-have. Not doing it is underserving the patient, and satisfaction and audibility and performance are often lower. It helps avoid problems and reduce returns.”
A number of those who don't see the procedure as essential said it depended upon the case. A hearing instrument specialist in a practice in North Carolina said, “Real ear is a trouble-shooting procedure for problem fittings, needed in about 20% of patients.” Others, like an AuD in clinical practice in Alabama, cited practical issues. She said, “It is a great practice, but not always feasible in busy facilities, from a time and a space perspective.”
Some respondents didn't see the benefit. For example, an AuD at a clinic in Texas said, “Most of the benefit is self-perceived. No matter what a piece of equipment tells the patient, they know what sounds good to them and how much real-world benefit they are getting.” However, a master's audiologist employed in a private practice in British Columbia strongly disagreed. She said, “Without this measure, you are just guessing and you present yourself as nothing more than a salesperson charging top dollar for no actual professional fitting services. This is a failure of the profession, a failure for our clients, and a failure in achieving the ultimate goal—better hearing for our clients.”
QUESTIONS ABOUT PRACTICES
Use of real-ear measurement
Along with giving their views on the statements made by Consumer Reports, survey respondents answered many questions about their own practices.
Since the CR article placed so much importance on doing real-ear measurement, we decided to find out how often dispensers used it. Although more than 60% of respondents agreed with CR that REM should be standard procedure, fewer than half (48%) said they did it most of the time with adult patients and 30% said they did it rarely or never (see Figure 6). Even among the 89% of respondents who had access to the equipment, only 55% said they did REM most of the time and 20% did it rarely or never.
Figure 6: How often do you conduct real-ear measure ments to verify and adjust the gain/output of the hearing aid on the day of the fitting?
On the other hand, the 48% of respondents who said they did REM most of the time was much greater than the under-25% figure that CR cited. It also was substantially higher than the 34% of respondents to our 2005 survey who reported usually doing REM.
Ironically, audiologists who work in ENT offices—the same group that CR recommended to consumers—were much less likely to do REM than other audiologists or than hearing instrument specialists. About 30% of them reported doing it usually or always, while nearly 60% of audiologists in clinics and hospitals said they did. Also, more than 40% of HISs said they conducted the measure on most hearing aid patients. It's not surprising that the audiologists employed by MDs were the respondents most likely to reject CR's contention that REM is a must.
For more on how, why, and when REM is used, see the article by Mueller and Picou in this issue.
Other procedures
Table 1 summarizes the frequency with which respondents use several other procedures. A large majority (84%) said they routinely use a standard prescriptive fitting procedure on the day of the fitting, 66% always or nearly always and 17% usually. Most (59%) said they routinely conducted aided loudness judgments. However, fewer than half routinely used any of the other procedures asked about.
Table 1: How often do you do each of these procedures on the day of the hearing aid fitting?
Despite frequent recommendations that practitioners give their hearing aid patients self-assessment inventories, only 34% of those surveyed said they usually do so. Two standard inventories were most often used: the COSI (by 47%) and the APHAB (by 14%), followed by the IOI-HA and the HHIE, each 7%. Eleven percent said they did their own survey.
LOWER SALES, BUT HIGHER HOPES
Although manufacturers sold 8.5% more hearing aids last year than in 2008, survey respondents reported selling fewer hearing aids per month per person in 2009 (see Figure 7). The 13.7 per month figure was down from 15 per month reported in our previous survey.
Figure 7: How many hearing aids per month on average did you dispense in 2009? Note: The results show the number of hearing aids dispensed per person, not per practice. The number in parentheses in each column is the mean figure reported by respondents to last year's survey.
The discrepancy between manufacturer and dispenser results is not inherently illogical, since manufacturers are reporting on the total market and dispensers are reporting per-person volume. So, if more people are dispensing, sales per person could decline even if the market grows.
Most of the gain reported by manufacturers was fueled by the 28% increase in VA purchases. It's known that the VA has substantially increased its roster of audiologists, so growth in that sector is being divided among more dispensers. That may also be true in the private sector, where sales grew by 4.9% in 2009. However, there is no reliable information on whether the number of people dispensing has risen, fallen, or stayed the same.
As Figure 7 shows, some sectors of the dispensing market reported higher sales in 2009, including HISs, whose per HISs, whose per-person sales increased from 17 to 19 hearing aids a month. Overall, 35% of respondents said they dispensed more instruments in 2009 than in 2008, while 26% reported a downturn.
Respondent were far more sanguine about 2010 than last year's survey participants were about 2009. In January 2009, only 43% expected their business to increase in 2009. This year, 60% predicted they would dispense more hearing aids than last, and 21% expected growth of over 10%. Only 5% predicted a decline from last year.
Mini-BTEs sales exceed 50%
The sale of behind-the-ear hearing aids, and specifically the very small, open-canal models, has grown dramatically over the past few years. Respondents reported that 55% of the instruments they dispensed last year were of the new mini-BTE style, up from 48% in our previous survey. In that group, the survey found that 54% had the receiver in the ear canal and 46% had it in the aid.
Telecoils, binaural fittings gain
The percentage of binaural fittings hit a record high of 83% in this year's survey. However, that was not significantly different from the 81% reported for 2008 or the previous high of 82% in 2004. Basically, the portion of binaural fittings seems to have hit a ceiling of a little over 80%.
Dispensers reported that 64% of their 2009 fittings on average contained a telecoil. That was something of a comeback from 2008, when 58% of fittings did and slightly more than the previous high of 62% reported for 2006 and 2007. The provision of telecoils has been on the rise during the past decade, from 37% in 2001 to close to or higher than 60% in each of the past 4 years.
MIXED DATA ON HEARING AID PRICES
The latest survey found that the reported average price for all hearing aids sold in 2009 was $1942, which was 2% less than the $1986 reported for 2007 (this figure was not calculated for 2008). There was a considerable range among dispenser groups, with audiologists working in clinics and hospitals charging 11% less than audiologists in private practice and 9% less than traditional dispensers (see Figure 8).
Figure 8: What was the overall average price that you charged per hearing aid in 2009? (This figure does not include data from dispensers who unbundle the price of the hearing aid from their professional charges or from VA and other audiologists who do not charge for hearing aids.)
However, when respondents reported the average price for 15 different combinations of hearing aid styles and technology levels (see Figure 9), there was a slight upward trend. That was most true for high-end products, where the average price charged for state-of-the art mini-BTEs hit $2957, compared to $2791 in 2008. The high-end in-the-canal prices rose by a similar amount.
Figure 9: What was the overall average price that you charged for each of these hearing aid categories in 2009? The prices above the columns are those reported in our 2009 survey about 2008 sales. (This figure does not include data from dispensers who unbundle the price of the hearing aid from their professional charges or from VA and other audiologists who do not charge for hearing aids.)
On the low end of the scale, average prices reported edged up slightly, while prices for mid-level instruments were basically unchanged from 2008.
What these data indicate is that while retail prices for specific products rose a bit (except in the mid-range) last year, dispensers sold a lower percentage of high-end models, resulting in the slight decline (from 2007) in the overall price shown in Figure 8.
ABOUT THE PURCHASERS
Finally, the survey asked dispensers a few questions about the people they fitted with hearing aids last year. Dispensers said that their average age was 64.8 years, essentially the same as the 64.6 reported in 2008.
The percentage of new users crept up slightly to 56% from the range of 52%-54% reported for the years 2004-2008.
Dispensers said that 29% of their patients had their hearing aids fully or partially paid for by a third party, and 14% of their paying patients bought their instruments on the installment basis.
Acknowledgments
My thanks to the hundreds of practitioners who took the time to respond so thoughtfully to our annual survey. I am grateful also to Gus Mueller, PhD, our contributing editor, who helped write the survey questions; Paul Dybala, PhD, and Stephanie Miller of Audiology Online, who formatted the survey and e-mailed it to prospective respondents; and to the International Hearing Society for permitting us to include its members in our survey population. Above all I am grateful to Erin M. Picou, AuD, a PhD candidate at Vanderbilt University and a research coordinator in the Dan Maddox Hearing Aid Research Laboratory, for analyzing the survey data and creating the figures for this article.
SURVEY DRAWS A LARGE AND REPRESENTATIVE CROSS SECTION OF THE DISPENSING POPULATION
The 640 professionals who responded to the lengthy (over 60 questions) document were among the most ever to take part in the annual joint survey of The Hearing Journal and Audiology Online. Of these, 535 (85%) dispense hearing aids. We drew replies from practitioners in 48 U.S. states and from 13 other countries, led by Canada, which contributed 9% of the total.
The great majority of participants were either audiologists (65%) or hearing instrument specialists (23%). The rest were people employed in the hearing industry, students, physicians, and “others,” a category that included several people who identified themselves as doctors of audiology or audioprosthologists. Overall, 67% of the respondents were women, including 77% of the audiologists. Among hearing instrument specialists (HISs), men outnumbered women 64% to 36%.
In terms of experience, respondents ran the gamut from neophytes to veterans with careers dating back to the 1970s. As seen in Figure A1, they are fairly evenly divided by seniority, except for the over 30-year group, which was smaller than the others. On average, participants reported being in practice for 17.6 years.
Figure A1: How many years have you been in practice?
Increasingly, audiologists who take part in the survey hold the AuD degree. This year, 58% of them were doctors of audiology, while 35% had a master's degree and 6% a PhD. Only 5 years ago, in 2005, 34% of the audiologists were AuDs. And, while very few states require traditional dispensers to hold a college degree to be licensed, 60% of those who replied this year had at least a 2-year degree, and more than half of these held a bachelor's or a graduate degree.
Most respondents reported holding professional credentials in addition to a college degree and state license. Most HISs (63%) were Board-Certified in Hearing Instrument Sciences (BC-HIS) and 12% had earned the American Conference of Audioprosthology (ACA) credential. The American-Speech-Language-Hearing Association's CCC-A remained the certification most commonly held by audiologists surveyed (58%), followed by the American Board of Audiology (ABA) credential (14%). Five years ago, 79% had the CCC-A and 12% the ABA.
HISs MOSTLY OWN, AUDIOLOGISTS MOSTLY DON'T
Asked about their role in their practice, a third of respondents reported being owner or part owner, while two-thirds were employees, including 10% who managed the practice. However, a majority of the traditional dispensers (57%) said they owned their own practice, while only 25% of the audiologists did.
More than 95% of the HISs worked in private practice, while the audiologists reported much more diversified work settings, including 42% in private practice, 28% in a clinic or hospital, 22% in a physician's office, 5% in a university, and 2% in a public school.
The most common type of private practice, reported by 62% of respondents, was an independently owned business that was not in a network. Fourteen percent said they worked in an independent practice that was a member of a network, 11% a private practice affiliated with a manufacturer, 11% a practice owned by a network, and 2% a practice owned by a larger store, such as Costco.
