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Breaking News: Direct Access Bill Has Wide Support, Save Two

Scheck, Anne

doi: 10.1097/01.HJ.0000411240.84154.91


HR 2140, more commonly known as the direct access bill, is giving audiology an opportunity to live up to a frequent criticism: That it can be a house divided. Legislation that would give Medicare recipients direct access to audiologists — erasing the need for a physician referral — is solidly crafted, widely supported, and long overdue, according to its advocates. But it also faces stiff opposition inside the profession.

The proposed legislation has among its proponents the Academy of Doctors of Audiology (ADA) and the American Academy of Audiology (AAA), as well as 46 co-sponsors. The American Speech-Language-Hearing Association (ASHA) is not among them, however. ASHA is for direct access by the Medicare-insured but not the bill itself. “We do not support the current legislation as it locks audiology into a diagnostic category,” said Vic Gladstone, PhD, the chief staff officer of audiology for ASHA. “We believe that a more comprehensive audiologic benefit is better for the patient and for the profession.”

While ASHA mulls over its own proposal, the ADA is solidly behind the Medicare Hearing Health Care Enhancement Act of 2011. It is fine as currently written, said Stephanie Czuhajewski, the executive director of the ADA.

The possibility of two different bills doesn't seem problematic to the Hearing Loss Association of America (HLAA). “It now seems clear that the direct care (bill) and the bill ASHA is considering introducing are quite different, so we see no conflict there,” said Lise Hamlin, the director of public policy for HLAA. “We see no problem with HLAA supporting more than one piece of legislation regarding how consumers get access to hearing health care.”

Meanwhile, the International Hearing Society (IHS) is opposing HR 2140 for the very reason the ADA and the AAA support it: If it becomes law, it will enable Medicare beneficiaries to bypass the physician in the delivery of hearing health care. “We are supportive of the physician-led team approach as we believe physicians, otolaryngologists specifically, are the only providers equipped to render medical diagnoses related to hearing loss,” said Alissa Parady, the government affairs manager of IHS. “And we are concerned that this will lead to unnecessary (auditory) testing and, as a result, increase Medicare costs.”

To some, this clash over the bill, which was introduced this past June by U.S. Rep Mike Ross (D-AR), is just one more sign that audiology organizations cannot seem to adopt a united front, and it provides more evidence that the various groups need to learn how to reach consensus.

“I think one of the things that needs to happen is that ASHA, ADA, and AAA need to learn how to play together in the same sandbox,” said Robert Fifer, PhD, the director of audiology and speech language pathology at the Mailman Center for Child Development at the University of Miami. “It really poses some risks if they don't. What will serve the profession best in the future is to work together.”

The crux of the dispute among these organizations appears to be what some are calling the “one-shot” scenario, a reference to the potential that there will only be a single chance to pass legislation allowing direct access for audiologists, and that whatever the resulting law does — or doesn't do — will seal off future possibilities for legislation.

Though the bill in its present form would eliminate the requisite physician referral for Medicare patients, it does nothing to broaden the scope of practice to include treatment monitoring or rehabilitative care, such as therapy following cochlear implant, Dr. Fifer said. “The bill is intended to put us on equal footing” with other health professionals, he said. “But I am not in favor of it; it leaves us as diagnosticians only.”

Dr. Fifer noted that podiatry and optometry “are fields that are in a (Medicare) benefit category other than simply diagnostic” as well as one that allows direct access. This expansion, and assured coverage of it, is what audiology needs, too, he said.

HR 2140 also leaves open the possibility that regulations formulated after passage of the bill could actually make practice limits more restrictive, depending on the final language. “I think we will only get one shot at this, and for that reason, it cannot be a step-wise process,” he said.

Melissa Sinden, the senior director of government relations for AAA, asserted that passage of the measure means changes that will do more than ease access to audiologists for Medicare recipients. Professional autonomy would increase, and that's essential, she said. More than 80 percent of members responding to a recent academy survey ranked direct access as the most important initiative AAA should be pursuing, she said.

A majority of insurance companies permit direct access to audiologists, such as the Veterans Health Administration, which has allowed it for the past two decades. With the aging baby-boom cohort, however, Medicare represents the likeliest single largest insurer of the future.

Five years ago, the Centers for Medicare & Medicaid Services looked at the issue and in a summary report concluded that under current governing statutes direct access to licensed audiologists could have “significant adverse, legal, regulatory, and budgetary consequences.” A new law is seen as a remedy for that, though scores of physician groups are fighting the bill, with more than 50 signing a letter of objection that was sent to leaders of the House of Representatives.

Health care reform, or more specifically, how the establishment of a “medical home” will affect audiology may pose another barrier. Under the present fee-for-service system, compensation has been tied to specific procedures. This fall, a diagnosis-oriented system of reimbursement will begin to provide the basis for payment by Medicare, a new approach for determining how health care providers are to be paid. “Goodbye, factory-type medicine,” Dr. Fifer said. “How will it affect our profession? We will have to see how it will play out.”

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• Read the full text of HR 2140 at

• Track the progress of HR 2140 as it moves through Congress at

• The ADA has a sample letter to send to Congress and talking points about the bill at

• AAA has a variety of HR 2140 resources, including a patient advocacy poster, at

• Read ASHA's position on the direct access bill at

• HLAA states its position on HR 2140 at

• Comments about this article? Write to HJ at

• Follow us on Twitter at

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