As young clinicians, we are taught the importance of accuracy when documenting clinical encounters. Yet I have observed that inaccuracy is creeping into the vernacular of cochlear implant (CI) documentation. Consider the following scenario: A 70-year-old man with progressive moderate-to-profound sensorineural hearing loss (SNHL) undergoes CI evaluation. His aided speech recognition scores meet the U.S. FDA, but not Medicare, criteria. The scenario is not uncommon; Medicare is universally recognized to have the most restrictive criteria, requiring significantly worse aided speech recognition ability than indicated in the FDA labeling. Consider another scenario: a 32-year-old woman with a history of sudden unilateral severe SNHL two years ago and 20 percent aided word recognition. Although an excellent candidate for CI, her score exceeds the labeled FDA criteria. Even FDA labeling, which is commonly referenced by commercial payers, is often overly stringent relative to best clinical practice, thereby creating a substantial, ever-widening gap between coverage and potential clinical benefit. The chart note for such encounters often states: “Patient is not a candidate for cochlear implantation” or “Patient does not meet FDA criteria.” On the contrary, each of these patients is an excellent CI candidate. Rather, in these cases, insurance may not pay for a CI because the patient doesn't meet its coverage guidelines.
Why does it matter whether our notes indicate “CI candidate” or “not a CI candidate” if the result is the same? It matters because it is our responsibility to accurately represent the facts of the case. It matters because inaccuracy in our wording may leave patients with the mistaken perception that they wouldn't benefit from life-changing technology. It matters because it leaves payers unaccountable for policies and foregoes an opportunity to drive change in our industry.
In recent years, clinical determination of CI candidacy has evolved tremendously—we use different test measures, have realized that ear-specific determination is essential and residual hearing isn't a reason to wait, and routinely observe better outcomes. Yet if clinicians choose to write “not a CI candidate” or “exceeds FDA criteria” when a patient doesn't meet insurance criteria even when he or she would be a good candidate for CI, it obscures the real issue—that payer policies are outdated and restrictive, and that although beneficiaries may benefit from the technology, their access is limited by their coverage.
Spalding, Koslov, and Carpenter considered the importance of wording in written clinical recommendations on their ultimate implementation (Int J Aging Human Dev, 85: 123-30). The authors concluded that recommendations that were conditional, ambiguous, or tentative, even though perhaps more diplomatic, were significantly less likely to be implemented. Most importantly, they highlight the importance of using confident command statements that are clear about what the provider is suggesting. The authors noted: “Effective communication unifies providers under a common understanding of what might be most helpful to a patient, while poor communication can compromise the quality of care, or at the very least fail to [represent the potential] benefits.”
Similarly, it is incumbent upon audiologists to directly and accurately describe the factors involved in determining a patient's CI candidacy, not only for that patient but also for patients yet to come who deserve improved CI access. We must clearly delineate the two factors that determine whether an individual can proceed with a CI: (1) clinical candidacy and (2) insurance coverage. If you think your patient will benefit from a CI, state that clearly, regardless of potential insurance coverage. We would never say that a patient is not a candidate for hearing aids just because Medicare doesn't pay for them. Why do we do so for CI? It is our responsibility to inform patients about option(s) that will most likely offer benefits. Although coverage determination will ultimately supersede clinical candidacy in terms of the patient's ability to proceed to surgery, it should not replace clinical determination and documentation of potential benefit for the patient. In some cases, this direct wording may encourage off-label coverage by commercial payers. In others, it will simply allow us to quantify the barriers that lack of coverage creates with the hope of improving access to CI in the future. In the words of William Raspberry, a Pulitzer Prize-winning columnist for The Washington Post, “Yes, words matter. They may reflect reality, but they also have the power to change reality.”
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