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Cover Story: Unlocking Direct Audiology Access with Limited-License Status

Shaw, Gina

doi: 10.1097/01.HJ.0000430569.65497.4f
Cover Story


At Salus University in Elkins Park, PA, two healthcare professional education programs stand side by side: the Pennsylvania College of Optometry and the George S. Osborne College of Audiology. Both training programs are similar in composition and structure, with a biomedical foundation, preclinical training labs, and clerkships on campus and in local and national practice settings. Both graduate their students with four-year degrees: the Doctor of Optometry (OD) and the Doctor of Audiology (AuD).

There the resemblances end.

Figure. Vic

Figure. Vic

“When they complete their degrees, doctors of optometry are limited-license physicians, able to open a practice and have patients come to see them for vision care without going through a physician first,” said Victor Bray, PhD, dean of the Osborne College of Audiology. “The insurance companies recognize them as a primary care provider for vision diagnosis and treatment.”

But the freshly minted AuDs leaving the College of Audiology—and any of the other 70 or so AuD programs currently enrolling students in the United States—don't have the same privileges as their optometry colleagues—or, for that matter, as podiatrists and chiropractors, who also are limited-license practitioners under Medicare, treated as physicians when they provide specific services.

About 20 years after the establishment of the AuD degree, the Academy of Doctors of Audiology (ADA) is putting on a full-court press to change that situation with the “18 x 18 initiative,” aimed at achieving limited-license physician status for audiologists. To do that, Title XVIII of the Social Security Act would need to be amended, something the ADA hopes to achieve by 2018—hence the “18 x 18” moniker.

Figure. E

Figure. E

“Now that audiology has transformed into a doctoral-level profession, it needs to align with similar doctoral-level professions,” said Eric Hagberg, AuD, the ADA's immediate past president and chair of the 18 x 18 steering committee. “Our board discussed this in early October, and then at our annual meeting in November in Phoenix, our members overwhelmingly gave their support for this idea, both philosophically and also with their pocketbooks.” Just under $200,000 was pledged to the effort by ADA members in October and November alone.

“They absolutely want our PAC [political action committee] money to go to this effort because they believe this is right for the patient and the profession, as well as offers the best outcomes for the Medicare system,” Dr. Hagberg said.

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The Academy of Doctors of Audiology has been reaching out to audiology organizations and has received official support for the 18 x 18 initiative from the state academies of audiology in Illinois, Georgia, South Carolina, and Kentucky, as well as the Audiological Resource Association. Larger national organizations such as the American Speech–Language–Hearing Association and the American Academy of Audiology (AAA) had not yet taken an official position at press time.

In March, the ADA announced that it had retained the government relations firm Prime Policy Group to help push the legislation forward. As of mid-April, actual legislation had not been introduced, and the ADA had not publicly identified potential congressional sponsors and cosponsors. It is aiming for a bipartisan group.

Dr. Hagberg indicated that the legislation would go beyond direct-access bills proposed by the AAA in several previous congressional sessions and will be written to achieve three primary goals:

  • Allow audiologists the autonomy to make clinical recommendations and practice the full scope of audiology and vestibular care as allowed by their state license and as dictated by their educational requirements and competencies.
  • Eliminate the need for a physician order for a Medicare beneficiary to receive coverage of medically necessary, covered audiology and vestibular services.
  • Allow for Medicare coverage of medically necessary services such as vestibular rehabilitation, cerumen removal, and aural rehabilitation provided by audiologists practicing within their state-defined scope of practice.

“In the past, there have been strict direct-access legislative proposals, but we believe it makes more sense to pursue these three goals together,” said Robert M. Gippin, Esq., the ADA's lead counsel.



“When you propose direct access to audiologists, then the question naturally comes up as to where audiologists stand in the scheme of provider professionals under Medicare's structure. That question ought not to be just left hanging, which means limited-license-physician status.

“And if you pursue extended Medicare benefits for services such as vestibular rehabilitation, it immediately leads to the question of who is providing those benefits. It makes sense that they could be provided by an audiologist without the need for a physician to have to provide services first that are going to cost additional money.”

The recognition of audiologists as independent, entry-level hearing and balance care providers is nothing new and is, in fact, the standard practice of other payers.

“The Medicare system is the sole third-party payer in the U.S. to require a physician referral for patients to seek audiological services, even though the vast majority of hearing loss is not medically or surgically treatable,” pointed out the AAA's response to the American Medical Association (AMA) scope-of-practice data series (see FastLinks).

There are several things that the ADA legislation is not designed to do, such as provide for hearing aid coverage under Medicare or prevent audiologists from opting out of the program entirely, Dr. Hagberg stressed (see FastLinks).

“It does not give prescription rights or ordering rights,” he said. “And it does not change or expand the scope of practice at the state level, where those things are defined. The audiologist would still be held to his or her state scope of practice.”

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The Association of American Medical Colleges projects a shortage of about 90,000 physicians by 2020, a gap that will grow to about 130,000 by 2025.

“We already have 10,000 audiologists prepared to step onto the front lines and work alongside primary care physicians and ENT physicians to provide point-of-entry primary care for hearing and balance disorder patients,” Dr. Bray said.

“What happens when we get 30 million new people coming into the healthcare system under the Affordable Care Act [ACA]? The country can't afford not to think about having audiologists on the front line to help identify and treat these people.”

Mr. Gippin also mentioned the ACA and how that legislation relates to the discussion at hand (see FastLinks).

“I think there's a much broader understanding in Congress and the administration that nonphysician providers of a wide range of services are at least as competent as physicians to render those and sometimes better qualified because they specialize in those aspects of care,” he noted.

“You see that in the Affordable Care Act. Many of the assumptions that underlie the ACA's cost savings presume that many services will increasingly be provided by nonphysician providers at lower cost.”

In an overview document on this year's federal legislative priorities, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) referenced audiologists' efforts to achieve limited-license physician status (see FastLinks).

“Members of Congress are urged to oppose ‘direct access' to audiologists without a physician referral and proposed Title XVIII expansions to ensure patient safety is preserved,” the Academy said in the document.

The AAO-HNS declined requests for interviews, issuing the following statement:

“Due to significant safety concerns, the AAO-HNS has opposed previous attempts by members of the audiology community to remove physician referral requirements and ‘thereby' achieve direct access to Medicare patients. While audiologists play a critical role in providing quality hearing healthcare, their desire to independently diagnose hearing and balance medical disorders transcends their level of training and expertise.

“The AAO-HNS strongly believes a physician-led hearing healthcare team with coordination of services is the best, and most cost-effective, approach for providing the highest quality care to patients.

“In addition, efforts by members of the audiology community to seek autonomy and/or increased independence at the same time the overall healthcare delivery system moves toward greater collaboration and team-based care seems misguided and anachronistic.”

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ENTs who spoke with The Hearing Journal declined to take a public position on the legislation but discussed the importance of a close relationship between audiology and otolaryngology, stressing that, whatever the outcome of the 18 x 18 initiative, this relationship must stay strong.

Figure. C

Figure. C

“It's essential for our fields to collaborate professionally and responsibly,” said Charles Limb, MD, associate professor of otolaryngology–head & neck surgery at the Johns Hopkins University School of Medicine.

“Here at Johns Hopkins, we have a very collaborative approach. For example, our cochlear team consists of several surgeons and several audiologists. There is no overlap in what we do, no overlap in our skill set and our training, and our level of respect for one another remains unparalleled. It's a fantastic model, and I'd say that most of the team agrees. The audiologists here are comfortable with the roles they have and don't have, and likewise the surgeons.”



Karen Rizzo, MD, vice president of the Pennsylvania Medical Society and a member of the State Board of Examiners in Speech–Language and Hearing, has had an audiologist in her Lancaster, PA, practice since she first opened it. She noted, with caution, that Medicare primarily serves senior citizens who have comorbidities and complex medical histories that can affect hearing and balance.

“The evaluation of that population can be more complex, and I think a thorough knowledge of medicine and how it can interrelate with pathology in the ear is important.”

Having an audiologist and ENT working in partnership in the same office, as her practice does, has many advantages, she said.

“If the audiologist is doing a hearing test and the patient has, say, a foreign body in the ear canal, she can walk them right down the hall to me and have it removed. It's one-stop care for the patient.

“I think most otolaryngologists feel that we can't do what audiologists do, and they can't do what we do. Together we're complementary and providing a service that optimizes care for the patient.”

Audiologists are eager to work in teams with ENTs and other physicians and healthcare professionals, and they already do so in many settings, Dr. Bray agreed.

“We train our graduates in an interprofessional model, and they learn to assess whether a patient has a hearing and balance disorder that can be cared for by an audiologist, or whether they instead need team management.

“Frankly, many do need team management because they have illnesses or syndromes that are part of a broader disease process. Team management is the future of healthcare. We just want to be on the team.”

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© 2013 Lippincott Williams & Wilkins, Inc.