Billed as a benefit designed to promote health through risk-modifying screenings and assessments, the Medicare Annual Wellness Visit (AWV) was introduced in 2011 by the Centers for Medicare and Medicaid with the overarching goal to shift the focus from acute medical problems to early identification and shared management of clinical problems.1,2 Introduced as part of the Medicare Part B expansion under the Affordable Care Act, the AWV is for older adults who have Medicare Part B3 and starts the year following the “Welcome to Medicare” preventive visit, which takes place within the first 12 months of enrolling in Part B of Medicare. Thereafter, those enrolled are eligible for a wellness visit once every 12 months to develop an individualized prevention plan,3 the basis of which is a Health Risk Assessment questionnaire (selected sections shown in Box 1).
In addition to routine biometric assessments, the physician has the option to use screening questionnaires to assess mood, falls risk, cognitive status, and hearing status. Data are all gathered via in-person interviews that may or may not be compromised by failure to use strategies to compensate for hearing and communication deficits. Screenings, such as for glaucoma, diabetes, and diabetes management education, are recommended as part of the AWV. These are generally covered by Medicare.1 However, implementing the AWV has been a challenge with only few beneficiaries and health care practices participating. Despite the increasing national attention being given to the risks posed by unidentified and untreated hearing loss, stakeholders—including primary care physicians, caregivers, and patients—have yet to make any significant progress in improving earlier recognition of hearing loss. Since the AWV is focused on preventive care, health screenings and wellness planning, hearing care professionals need to be proactive in educating primary care physicians about the importance of hearing screenings.
INFLUENCING HEARING SCREENING IN PRIMARY CARE
While hearing screening is often included by physicians in the AWV, a gap remains in the identification of hearing loss. The reasons, I suspect, are complex—ranging from the belief that hearing loss is a normal part of aging to the perception that hearing interventions are costly and services inaccessible.
Another variable may be the 2011 conclusion by U.S. Preventive Services Task Force (USPSTF) that evidence was insufficient to assess the balance of benefits and harms of hearing loss screenings for asymptomatic adults aged 50 years or older.4 However, the task force cautioned that its recommendation did not apply to those with perceived hearing problems or cognitive or affective symptoms that may be related to hearing loss. The task force did recommend that people with hearing difficulties be assessed for objective hearing impairment and treated when indicated.4
The USPSTF recently revisited this issue—a cause for optimism and action in the audiology community—and published a research plan to guide a systematic review of current evidence in preparation for a new recommendation statement on this topic.5 The key questions to be systematically reviewed are listed in Box 2, while Box 3 shows contextual questions that, while not systematically reviewed, will inform the researchers as they prepare the systematic review. The contextual questions, in my view, should be addressed by audiologists as part of their clinical work. Measuring health outcomes of patients is imperative, and indicating those associated with hearing interventions, including (1) quality of life, (2) function, (3) depression, (4) cognitive status, (5) falls history, and (6) social isolation must be included in the Task Force's final research plan. Since primary care is the ground zero for most people with age-related hearing loss (ARHL) who may take action to remedy some of the social/emotional effects of hearing loss, hearing care professionals must communicate to referring physicians the value added of audiological interventions.
A USEFUL TOOLKIT MODEL
Considering our evolving health care system, audiologists have a responsibility to promote physician awareness about the consequences of untreated hearing loss, the contribution of hearing/communication to overall well-being and brain health, and to importance of viewing hearing/communication as central to patient-centered care and healthy aging.
Following a model recently adopted by the Gerontological Society of America (GSA)6 to engage primary care physicians in the evaluation and care of patients with dementia, hearing care professionals can develop and disseminate a simple four-step toolkit for primary care physicians that include: (1) Tips for initiating conversations about hearing health in asymptomatic or symptomatic patients, (2) Tips for identifying patients who have hearing/speech understanding difficulties, (3) Strategies to screen for hearing loss/difficulties and make appropriate referrals, and (4) Tips physicians should offer to patients on coping with hearing loss.7 More suggestions about this toolkit, including a customized newsletter for private practices to help spread the word about the health consequences of hearing loss and the benefits of hearing assistance, will be discussed in my next column. Increasing engagement and collaboration with physicians may just be the key to boosting the utilization of AWV benefits, ultimately improving an opportunity to identify hearing loss.
1. Gorin, S & Resnick, B. (2019). Introduction to the Annual Wellness Visit for the Older Adult. Public Policy & Aging Report
. 29: 1-4.
2. Resnick, B. (2019). Description of the Annual Wellness Visit. Public Policy & Aging Report
. 29: 8-12.
3. Centers for Medicare and Medicaid (2018), The Medicare Learning Network. Retrieved from https://go.cms.gov/2WfZgZa
4. Chou, R., Dana,T., Bougatsos, C., et al., (2011). Screening Adults Aged 50 Years or Older for Hearing Loss: A Review of the Evidence for the U.S. Preventive Services Task Force. Annals of internal medicine
5. U.S. Preventive Services Task Force. February 2019.Final Research Plan: Hearing Loss in Older Adults: Screening. https://bit.ly/2ukQM7f
6. KAER Toolkit Gerontological Society of America. https://bit.ly/2FnEKPy
7. NIH. Hearing Loss: A Common Problem for Older Adults. 2018. http://bit.ly/2JzT8cH