The word of the day is “disruption.” In every professional journal and at every professional meeting, discussion about the disruptive forces of over-the-counter (OTC) hearing aids abounds. Headlines highlight the looming threat that these devices supposedly pose and hint at the demise of independent audiology practices that will subsequently result. The very word “disruption” carries a negative connotation, meaning “to interrupt the normal course or unity of,” “to throw into disorder,” or “to break apart.”1 It is no wonder then that many audiologists approach the imminent reality of OTC hearing aids with some trepidation, if not outright fear. Numerous unofficial polls have been conducted on social media or by trade publications,2 and often the results suggest that a majority of audiologists think OTC hearing aids will have a significant impact on their practice and may even pose a threat to the profession as a whole.
CLARIFYING DISRUPTIVE INNOVATION
The term “disruptive innovation” has become increasingly overused and inaccurately applied in many settings. The introduction of OTC hearing aids, however, does seem to meet the qualifications of this misunderstood model wherein incumbents are displaced by new entrants into the market. Namely, disruptive innovations originate in one of two situations, where new entrants are able to achieve either a new market foothold or a low-end foothold.3 Disrupters are able to achieve a new market foothold, for example, when introducing technology into a space where a similar product did not exist. In the case of OTC hearing aids, the new market of self-fitting devices labeled by the FDA is an obvious product innovation.
Disruptors are able to achieve a low-end foothold, on the other hand, when incumbents in the market are overshooting or ignoring the needs of the most basic customer who is simply looking for a good enough option. Think of hearing aid manufacturers who routinely introduce new technology with increasingly advanced features. Higher-end technology represents greater opportunity for profit, thus more attention is often given to higher-end products despite research suggesting that outcomes are fairly equivalent even with more basic options.4 Because of the tendency of audiologists to bundle services with the price of the device, the perception of high-priced technology is further exacerbated. Thus, the perception of the price of hearing aid technology is that it is prohibitively high. OTC hearing aids represent technology poised to meet the expectations of entry-level consumers who are seeking a low-cost, easily accessible device. If their needs are met, the disrupters (OTC manufacturers) may realize more opportunity to begin tapping into the mainstream market of consumers with higher expectations and more complex needs.
So yes, OTC hearing aids appear to be a disruptive innovation. But is audiology poised to be the disrupted? Do OTC hearing aids put the profession of audiology in peril? Is the expansion of the device market to include self-fitting devices with limited output a threat? I contend the answer is no. Based on the preceding description, traditional hearing aids stand to be disrupted. Hearing aid manufacturers certainly recognize this threat and may be positioning themselves to succeed over competitive OTC devices. OTC hearing aids are not a direct threat to audiology, but that doesn't mean audiologists can breathe a collective sigh of relief and maintain business as usual. Rather, the introduction of OTC hearing aids and the associated change to the hearing device business model have highlighted the real threat to audiology that emerged long before OTC hearing aids were even considered. The real threat to audiology is the perception of the public that “hearing health care” and “hearing aid” are synonymous. The perception that OTC hearing aids stand to disrupt audiology exists because the term “audiology” has become interchangeable with device.
TRANSFORMING PUBLIC PERCEPTIONS
Regulatory documents leading to the passage of the OTC Hearing Aid Act5-7 presented a strong focus on improving accessibility and affordability of hearing devices. But it is an important distinction that the introduction of OTC hearing aids has done little to improve accessibility and affordability of hearing health care. OTC hearing aids introduce a business model where consumers can bypass diagnostic evaluation, hearing needs assessments, and hearing health care providers in favor of self-identifying a device. Already, the FDA has indicated that they do not intend to enforce the requirement for medical clearance for the fitting of hearing devices. Adoption of an OTC device by a consumer is expected to be based on self-perceived mild to moderate hearing loss, not measured hearing capability that directly aligns with the definition provided by ASHA and referenced in the Regulatory Recommendations for OTC HA: Safety and Effectiveness Consensus Paper from Hearing Care Associations.8 There is no intended requirement that use of an OTC device should only occur after full evaluation by an audiologist (although professional organizations including the American Academy of Audiology have advocated for this requirement).
If audiology had built its brand well, the public would be fully committed to pursuing OTC options only at the recommendation of their audiologist, after a thorough diagnostic assessment. The fear that a device that could be obtained without input from a qualified professional would be obtained after bypassing audiology's input would be unlikely if the public valued audiology's role in hearing health care. Herein lies the root of the fear audiologists have ascribed to OTC hearing aids.
Consider OTC eyeglasses. Most audiologists realize that comparing glasses to hearing devices clinically is a flawed analogy. But comparing their business models makes sense. Similar to OTC vision options, OTC hearing options are intended for more mild losses where consumers can easily perceive improvement. Yet despite the seemingly low cost and easy accessibility of OTC glasses, they accounted for only 0.2 percent of the vision care market in 2017. The majority of vision care (>65%) was attributed to lenses and frames. Most importantly, 23 percent of the market was examinations.9 What do these data suggest? That vision care consumers recognize the value of their optometrist or ophthalmologist in the management process. Think about how the public discusses hearing health care. It is very telling that the dialogue for vision care tends to be “I need to get my eyes checked” and for hearing care tends to be “I need to get a hearing aid.”
OTC hearing aids should represent one end of a spectrum of services (Fig. 1) supported at all levels by diagnostic evaluation and counseling regarding recommendations for management. It may be that fearful audiologists heard the term “over-the-counter” and envisioned a distant counter, perhaps situated in a drugstore or big-box store. In reality, the intended counter can just as easily be a counter in an audiologist's practice. In fact, OTC hearing aids introduce the potential for a business model that not only meets the needs of the cost-savvy and access-hungry public, but also could generate welcome revenue for those providers willing to serve the spectrum of hearing health care from diagnostics, to prevention, to implants. But the key to this model is the message that before deciding on any option, it is essential to have your hearing checked by an audiologist. It is not enough for audiologists to convey this messaging. Audiologists must gain buy-in and commitment to this process from key stakeholders such as physician and allied health referral sources, regulators, legislators, and payers.
Thus, OTC devices in and of themselves do not pose a threat to audiologists. But, if the public does not place value on the services and expertise of audiologists such that they embrace a business model that allows for the bypassing of the audiologist entirely, then that is where the true disruption and threat exists. To date, most of the arguments for or against OTC hearing aids have centered on the devices themselves, displacing the more significant conversation that must be held: What is audiology's value to the public and how can audiology capitalize on it?
ACTUAL THREAT #1: COMMODITIZATION OF HEARING CARE
Audiology has allowed itself to be defined by a device, thus the introduction of OTC devices that bypass professional input feels threatening. Furthermore, that device is viewed as a commodity, which is defined as a product or service for which the public perceives no differentiating factor except price. When differentiating among options, an individual omits from consideration those factors that are not understood and those factors that are assumed to be equal. The remaining factors are the determinant attributes, or those factors considered by a consumer when deciding which product to use or which service to employ. Factors such as aesthetic appeal, ability to improve hearing, and even experience of the provider are assumed to be equal and therefore often left unconsidered. Factors such as underlying medical cause of hearing loss, negative consequences of untreated hearing loss, and appropriateness of the circuitry or fitting are not understood by the average consumer so are often discounted. Unfortunately, the importance of comprehensive assessment also falls in this latter category. Thus, the primary differentiating factor consumers are left with is price and perhaps convenience or quality of the experience. This leaves hearing devices, and by association, audiology a perceived commodity. Audiologists must move many of the factors that are not understood or assumed to be equal back into the equation of differentiation by making the invisible visible and valued.
ACTUAL THREAT #2: LACK OF A STRONG BRAND AND UNDERMINING KEY CAPABILITIES
In the absence of other differentiating factors, the public turns to branding to guide their decision-making process. Audiologists feel threatened by big box stores because they have been successful in building their brand as economical. National pharmacy chains have built a brand of trusted, easily accessible health care. Many likely OTC manufacturers have well-known brands rooted in high-fidelity sound with names consumers will recognize. Conversely, audiology has failed to ingrain a professional brand into the psyches of consumers. Audiologists have allowed two components of practice, devices and technical assessment of hearing loss (not even interpretation), to be perceived as the profession's great capabilities. Audiologists’ significance has been curtailed and confined as a result of invisible and unvalued great capabilities. “Great capabilities—those few things that allow you to be better than your competition at what matters to your customers—typically outlast markets. Without them, you are at the will of others to redefine your space; with them, you have tremendous abilities to shape your own future.”10 Audiology is at risk of sacrificing ownership of the great capabilities that distinguish the profession. In fact, much of audiology's marketing serves to reinforce public perceptions by obscuring the services and associated value provided (Table 1).
ACTUAL THREAT #3: POOR RECOGNITION, REIMBURSEMENT FOR SERVICES
The public's perception of audiology's great capabilities is made apparent through reimbursement that is not commensurate with audiologists’ expertise or level of training and that doesn't include time spent counseling or offering rehabilitative services. Should audiologists’ fear be focused on OTC hearing aids? Absolutely not. Audiologists should be terrified that our greatest capabilities are not always sought after by the public or recognized by regulatory agencies and commercial or government payers. As a result, the majority of practices must focus on dispensing devices. The efforts of the profession should be focused not on a device, but rather on educating the public such that they recognize audiologists’ value and demand access to it. Audiologists should be pooling resources to support efforts that would directly improve reimbursement for our services, including counseling and interpretation of diagnostic evaluations. Perception of hearing care and its providers and reimbursement for our services should be of paramount concern.
Audiology cannot maintain business as usual. Disruptive innovation doesn't happen overnight or without warning; it emerges over years.11 Most often it is not the disruptive innovation itself that tumbles large organizations. It is a failure to recognize the impending change and respond accordingly. Kodak is a classic example of downfall due to a lack of awareness. Although Kodak actually invented digital photography technology, they failed to recognize that they had to evolve to stay relevant and never capitalized on this great asset. Similar stories abound in the business world. Blockbuster's demise at the hands of Netflix. Amazon's overpowering of… well, nearly everyone. In all of these cases, what began as a seemingly small change to the business model rapidly grew unchecked and changed the way we all function on a daily basis because the significance was overlooked or underappreciated.
Audiology stands on a similar precipice. There is a window of opportunity to change the perception of the public and thus the future of the profession. A positive aspect of the introduction of OTC hearing aids is the unbelievable uptick in the presence of stories on hearing loss in the media. Regulators and payers are increasingly interested in issues related to hearing care. What an opportunity! Hearing is at the forefront of the conversation. How can audiologists direct that conversation? Take every opportunity to reinforce the value audiologists provide. Emphasize the importance of a hearing evaluation before deciding to use any hearing device. Help the public understand that inappropriate hearing devices can be as detrimental as no hearing device. Support advocacy efforts that will improve accessibility to quality hearing care and will directly impact audiologists’ reimbursement. Contribute to the professional organizations that represent your interests on a national level. Incorporate best practices. Bill for every service provided and itemize. Make the invisible visible. Most importantly, build an army who will drive demand for your services, from your patients to your referral sources. Be the disrupter, not the disrupted.
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2. OTC Readership Survey Results: Audiologists Seek Opportunity Amid Uncertainty. Hearing Journal.
2018;71(9):26. doi: 10.1097/01.HJ.0000546259.46692.c8.
3. Christensen CM, Raynor ME, McDonald R What is disruptive innovation? Harvard Business Review,
4. Cox RM, Johnson JA, Xu J Impact of advanced hearing aid technology on speech understanding for older listeners with mild to moderate, adult-onset, sensorineural hearing loss. Gerontology,