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Modernizing Medicare

Proposed Legislation Addresses Audiology Access Gaps

Nalley, Catlin

doi: 10.1097/01.HJ.0000612552.05254.8d
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Ms. Nalley is a freelance writer and editor with a focus on health care. She was one of 14 journalists selected for the 2016 National Cancer Reporting Fellowship. She has a bachelor's degree in journalism from the Philip Merrill College of Journalism at the University of Maryland, College Park.

Current Medicare standards make it challenging for patients to access vital audiology services and for clinicians to perform to the full extent of their scope of practice.

Today, a Medicare beneficiary seeking hearing or balance services cannot simply pick up the phone and schedule an appointment with an audiologist. They must first see their physician to receive a referral. With an aging population who may face mobility and transportation challenges, this extra step can be detrimental to their ability to access appropriate care.

Recognizing these gaps, the Academy of Doctors of Audiology (ADA), American Speech-Language Hearing Association (ASHA), and American Academy of Audiology (AAA) joined forces on a legislative initiative that will ensure Medicare patients have better access to audiologists. Additionally, through appropriate classification, it will provide audiologists with the ability to work autonomously and utilize the full scope of their practice for Medicare-covered services.

“Audiologists are, rightly so, the gatekeepers of hearing and balance care. They have the education and licensure to deliver the most appropriate services to consumers,” said Ram Nileshwar, AuD, the president of ADA. “This bill will help audiology move forward, and more importantly, it will guarantee seniors have access to these critically needed services.

“In turn, we can minimize some of the negative consequences and huge costs associated with unmanaged hearing and balance disorders,” he continued. “Audiologists around the country should take ownership of this initiative, and Medicare should allow audiologists to be able to provide these services to its beneficiaries.”

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CURRENT STATE OF AFFAIRS

While Medicare already covers a range of hearing health care services that audiologists are trained and licensed to perform, it does not recognize audiologists as providers of most hearing-related services. Additionally, it will only allow reimbursement for a limited set of diagnostic tests and only after a patient obtains a physician order.

Hearing and balance assessment services are generally covered as “other diagnostic tests” under section 1861(s)(3) of the Social Security Act and payable under the physician fee schedule, according to the Centers for Medicare and Medicaid Services. There is no provision to pay audiologists for therapeutic services.

All settings require orders for any audiology services provided. Coverage and reimbursement of diagnostic tests are based on the reason the tests were performed and not by the diagnosis or the patient's condition.

“The current state of Medicare benefits for audiology is limited and unnecessarily so,” noted Jeffrey P. Regan, MA, the director of government affairs and public policy at ASHA. “As it stands, Medicare beneficiaries cannot go directly to an audiologist to be diagnosed for hearing or balance disorders and it's important to note that this is unique in the health care delivery system. Outside of Medicare, anyone who wishes to either pay out of pocket or someone who is covered by a private insurance plan can generally go directly to an audiologist to be diagnosed.

“Beyond that, audiologists are not, and have not been, recognized by Medicare as treatment professionals. They are only recognized as diagnostic professionals,” he continued. “Therefore, a whole range of hearing health services that are included in an audiologist's scope of practice are not covered, such as aural rehabilitation and vestibular treatment.”

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A COLLABORATIVE EFFORT

There has been longstanding interest within the audiology community to make improvements under Medicare, and multiple organizations have attempted to address these challenges. This most recent effort, however, is different. Three major professional organizations and many leaders in the field are working together to initiate change.

“ASHA, ADA, and AAA were able to sit down together and draft legislation that accomplishes all of the goals that each group had set out to achieve independently,” noted Stephanie Czuhajewski, MPH, CAE, the executive director of ADA. “The audiology community as a whole has wanted these issues to be addressed. It was just a matter of coming together around the most effective strategy, and we're so happy to be able to say that we are all unified on that.”

The process began in early 2019 with the three groups developing a framework for the legislation. “We sought to draft legislation that would have the most impact for patient access,” explained Czuhajewski. “Additionally, we focused on making the necessary improvements to modernize Medicare so that audiology is appropriately recognized, and audiologists can be better deployed to help the patients who need them.”

After an extensive development process, the Medicare Audiologist Access and Services Act (H.R. 4056) was first introduced on July 25 by Reps. Tom Rice (R-SC), Matt Cartwright (D-PA), Mark Meadows (R-NC), Ralph Norman (R-SC), Mike Kelly (R-PA), Jan Shakowsky (D-IL), Brad Schneider (D-IL), Ann Kuster (D-NH), Gus Bilirakis (R-FL), and Lisa Blunt-Rochester (D-DE).

An identical companion bill was introduced in the Senate (S. 2446) on Sept. 9 by Sens. Elizabeth Warren (D-MA), Rand Paul (R-KY), Sherrod Brown (D-OH), and Roger F. Wicker (R-MS).

This bipartisan effort is endorsed by AAA, ASHA, ADA, and the Hearing Loss Association of America. “As leaders in the profession come together and all agree on key points of legislation, I hope it will help the rest of the audiology community come together and support this initiative,” said Lisa Christensen, AuD, the president of AAA. “We have to make some big moves ahead and this is one of them.”

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INS & OUTS OF H.R. 4056/S. 2446

What exactly will the passage of this legislation accomplish? It will ensure that Medicare beneficiaries have access to hearing and balance services and that audiologists are able to efficiently provide the necessary care.

The legislation includes three key components:

  • Amends the definition of “audiology services” to encompass all services already covered by Medicare that are also within an audiologist's scope of practice.
  • Changes the Medicare definition of “practitioner” to include audiologists. This would improve beneficiary access to audiologic and vestibular care, and is consistent with Medicare's classification of similar health care providers.
  • Adjusts the classification of audiology services in the Medicare system as “other diagnostic tests” to eliminate the pretreatment order requirement.

“This legislation allows Medicare beneficiaries direct access to audiology services and audiologists without requiring an order from a medical doctor,” Nileshwar said, emphasizing that this would not increase expenses, but rather help streamline care and avoid unnecessary costs. “It would eliminate the duplication of services and increase efficiency while preserving safe and effective care. The passage of this bill would be a huge step forward toward professional autonomy.”

The reclassification of audiologists as practitioners would be beneficial to both the profession and the patients for whom they care. “That designation would enable audiologists to provide services via telehealth, which would make it possible to expand care to many older adults struggling with transportation and mobility issues,” noted Christensen.

“As the country's population continues to age, the number of Americans with hearing disorders is going to continue to increase. Therefore, it makes sense to have, especially for Medicare, a system in place whereby someone who may have a hearing disorder can easily access a trained health care professional to evaluate, diagnose, and treat that disorder effectively,” Regan emphasized. “And so the biggest benefit to this bill is eliminating some unnecessary and outdated barriers, allowing access to be facilitated more robustly.”

This legislation seeks to create impactful change for the audiology community and its patients, but it is also important to clarify what it doesn't aim to do. “We are not asking for an expansion of scope of practice as outlined in any state audiology licensure law,” noted Nileshwar. “The legislation will not allow for prescriptive rights or place audiology services under a therapy cap. Additionally, it will not include a provision for a hearing aid coverage under Medicare. That's a completely different issue and not the focus of this legislation.”

“No new services are being asked for under this legislation,” Czuhajewski reiterated. “We are focused on services that Medicare already covers and that the audiologist is already licensed to provide in all 50 states, Washington, DC, and U.S. territories. The legislation is about modernizing Medicare so that it's consistent with evidence-based practice.”

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WHAT'S NEXT?

The introduction of this legislation in the House and Senate is only the first step toward making these important changes a reality.

“Now the work really begins,” noted Czuhajewski. “Getting a bill introduced in Congress is a very small part of what actually has to happen in order to have it enacted. Now we are focused on increasing awareness for the legislation and building on the momentum we have already gained.”

This begins by connecting with the appropriate committees of jurisdiction who have oversight over Medicare Part B. In the House, this includes the Ways and Means Committee as well as the Energy and Commerce Committee. On the Senate side, it is the Finance Committee.

“Finding ways to advance this legislation when those opportunities present themselves is key,” Regan said. “Now that it has been introduced in both chambers of Congress, we are working on building additional support for the legislation.

“The three groups, collectively, have had about 50 meetings over the past few months with members of Congress, especially with those who sit on the Ways and Means Committee. H.R. 4056 currently has 13 co-sponsors [as of September 2019] and that number is going to continue to increase,” he noted.

“And now that the Senate bill has been introduced, we are targeting the Senate Finance Committee, which has jurisdiction over Medicare, to build greater support for the bill and gain additional co-sponsorship.”

Following this push for support, the next step will be to find the best way for the legislation to move forward. “A likely scenario is that this legislation could be attached to a larger health care vehicle that's moving through both chambers of Congress,” Regan explained. “While we cannot predict an exact time frame for this process, right now we're focused on building support for this legislation as well as educating members of Congress about the current environment for hearing health care services under Medicare. And I'm pleased to say we've had a very positive response from Congress so far on this effort.”

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ADVOCATING FOR CHANGE

Continued momentum for the successful passage of this legislation depends, in large part, on the grassroots effort of individual audiologists.

“Medicare beneficiaries are one of our most vulnerable patient populations and their access to care right now, without this legislation, is dismal. And so, that's how we have to start. Everyone needs to reach out to their representatives and senators to express their support,” Christensen said. “It's important that you, as their constituent, use your voice because you're the one who keeps them in office.

“And if you don't have time to make a direct visit, you can send an email. Make a phone call,” she continued. “But when your legislators are back in their home office, a visit to explain what audiology is and how critical this is to our Medicare beneficiaries would definitely be a big bonus.”

ADA, ASHA, and AAA all offer resources on their websites that help individuals connect with their legislators and share their support for H.R. 4056 and S. 2446. “All three audiology organizations have links on their website that will allow individuals to write a letter to their member of Congress in a very easy and quick manner,” Czuhajewski explained. “There's a template that allows you to share your support. This is important because members of Congress and their staff keep track of the volume of requests they receive on a particular issue.”

Connecting with Congress is crucial and can be accomplished through a variety of avenues. ADA has organized a lobby day, to be held on Nov. 14, which offers support to audiologists who want to meet with their representatives and senators on Capitol Hill.

“Lobby day is open to all audiologists and anyone else who wants to advocate for the legislation,” Nileshwar said. “We schedule meetings with the legislators and offer training for participants beforehand. Additionally, all meetings are done in groups to ensure everyone is comfortable and has the necessary support.”

“We want to make sure that legislators get as much information from as many people as possible about why this is an important bill,” Czuhajewski noted. “We also want to make sure that people are able to inform legislators about the importance of treating hearing loss as soon as possible because there's a lot more data today than there was even 15 or 20 years ago about the negative implications.

“Coordinated lobby day is a fantastic opportunity, and we encourage people to participate because we do believe there's strength in numbers,” she added. “However, if it just won't work out for someone's schedule, an invitation to tour your practice and learn more about audiology is a great opportunity to connect with your legislators as well.”

Patients and anyone else impacted by hearing and balance disorders can also make a difference. “My daughter has hearing loss and we have testified to committees,” Christensen recalled. “Our legislators are not experts in hearing loss, so it is up to us to educate them.

“When they meet someone who has hearing loss and learn firsthand about the difficulties associated with access to care, it makes a difference,” she concluded. “Those personal stories from patients are very impactful to our legislators.”

Do you want to get involved? Visit these websites to voice your support for this legislation.

www.chooseaudiology.org

www.asha.org/advocacy/

www.audiology.org/advocacy

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