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Thursday, March 11, 2021

Viewpoint: Audiologists Need to be Reimbursed for Tinnitus Counseling

By Richard S. Tyler, PhD; Najlla O. Burle; and Patricia C. Mancini, PhD

               Patients with tinnitus often seek help from audiologists when it disrupts their thoughts and emotions, sleep, concentration and/or hearing. This can have dramatic effects on their quality of life.1 Some of the patients can be very distressed, and there are no pills or surgery for sensorineural tinnitus.  Unfortunately, many healthcare professionals choose not to help them.  Audiologists are qualified to provide counseling, but reimbursement is difficult. The evidence is sufficient for reimbursement for counseling— period. Counseling can also be performed by a wide variety of other health care professionals, including physicians, nurse practitioners, and psychologists.

WE ARE QUALIFIED

​Tinnitus patients usually have hearing difficulties, caused by a hearing loss or their tinnitus.  We can provide counseling as our training in aural rehabilitation includes the understanding of the psychological consequences of hearing loss, tinnitus, and other such auditory conditions. If emotional consequences become severe, we can and should refer to other professionals.  Sometimes we receive referrals from psychiatrists and psychologists who need our help with their tinnitus patients. While these professionals can help with the emotional aspects, they are not trained regarding tinnitus and hearing loss and their consequences. Thus, many refer their patients for an audiologist's help.

Audiologists can help patients understand their tinnitus—how it affects their hearing, thoughts and emotions, sleep and concentration, and how they react to it. We suggest ways they might change their behavior to help manage challenges. In fact, several counseling and sound therapy treatments were designed by and taught by audiologists.2-7

REIMBURSEMENT ISSUES

As most of these patients have hearing loss, we can be reimbursed for diagnosing and measuring their hearing loss, and provide hearing aids 8.  This is an important contribution.  Which services get reimbursed and the reimbursement rate is influenced by many factors, including lobbying by organizations. Audiology services are valuable and should be reimbursed appropriately. However, because of the limited reimbursement, many cannot justify helping tinnitus patients.

EVIDENCE-BASED JUSTIFICATION

The effectiveness of any counseling largely depends on the individual interactions between the patient and the clinician. Systematic strategies can help, but the outcome is strongly influenced by the individual clinician. Even following the same counseling protocol, some patients will see relief of symptoms, but not others. Recently, a study challenged the effectiveness of cognitive behavior therapy (CBT)9 generally, and this has been applied to CBT for tinnitus 10.  The study concluded that the individual clinician is the main factor in the outcome of the CBT. Each patient with tinnitus experiences different symptoms, and research should focus on individuals, not groups. 11 Unfortunately, this rarely occurs in research studies.

               Many argue in favor of the need for “evidence-based" research studies to support treatments. With respect to tinnitus, CBT is promoted as a strategy to treat patients.12 Interestingly, for smoking cessation and weight management, evidence (and reimbursement) is available for counseling, but it does not have to be CBT counseling for weight management; it is just “counseling for weight management."

               While some tinnitus patients benefit from reading online information or those from patient handouts, others may not find these resources helpful and need personalized.4,6 Millions of dollars can be spent on each study documenting each variation of counseling for tinnitus patients. The government should direct money for counseling.

               While some patients may choose to independently seek out health care information on tinnitus, many ask for individualized, patient-centered care. Unfortunately, the current health care reimbursement landscape is a barrier to audiologists performing this type of patient-centered care.

               In the evolution of Tinnitus Activities Treatment (TAT), we saw the benefit of (and included) Progressive Muscle Relaxation and Guided Imagery.6 Audiologists ask patients to focus, at the moment, without judging. Our TAT includes helping patients to “accept," “own" their tinnitus. 

RECOGNIZING THE VALUE OF AUDIOLOGY SERVICES

Hearing loss is not just about hearing but also about how we use our hearing for communicating, interacting with friends, enjoying life, and planning for the future. Smoking cessation and weight management are reimbursed by government health care and insurance agencies—so why not hearing loss and tinnitus? Audiology services are valuable and should be reimbursed appropriately. Clinicians must make choices about how to spend their time and resources. Because of the limited reimbursement, many cannot justify helping tinnitus patients.

Our professional organizations need to work collaboratively with legislators and take this on as the most important focus of our profession. It is necessary to conduct solid research not only on the effectiveness of counseling but also its cost-benefit analysis compared to other reimbursable procedures. We need the help of audiology professional organizations to speak up—as well as the help of people with tinnitus, including those committees and legislatures, since they can appreciate the consequences and be helpful.

               Audiologists can provide counseling to help with the psychological consequences of hearing loss and tinnitus (and hyperacusis). A reasonable, driving force, behind our ability to help these patients depends on reimbursement for our audiological services.

ABOUT THE AUTHORS: Richard Tyler, PhD, is a professor of otolaryngology–head and neck surgery and of communication sciences and disorders at the University of Iowa. Najlla O. Burle is a speech therapist affiliated with the Post-Graduate Program in Speech Therapy Sciences at the Universidade Federal de Minas Gerais in Brazil, where Patricia C. Mancini, PhD, is an associate professor in the university's department of speech-language pathology and audiology.

REFERENCES:
1. Tyler, R., Perreau, A., Mohr, A. M., Ji, H., & Mancini, P. C. (2020). An Exploratory Step Toward Measuring the 'Meaning of Life' in Patients with Tinnitus and in Cochlear Implant Users. Journal of the American Academy of Audiology, 31(4), 277-285. doi: 10.3766/jaaa.19022.
2. Sweetow, R. W. (1984). Cognitive-behavioral modification in tinnitus management. Hearing Instruments, 35, 14-52.
3. Tyler, R. S., & Erlandsson, S.  (2003). Management of the tinnitus patient.  In L.M. Luxon, J.M. Furman, A. Martini, and D. Stephens. (Eds.), Textbook of Audiological Medicine (pp. 571-578).  London, England: Taylor & Francis Group.
4. Henry, J., & Wilson, P. (2001). The Psychological Management of Chronic Tinnitus: A Cognitive-Behavioral Approach. Needham Heights, MA: Allyn & Bacon.
5. Mohr, A. M., & Hedelund, U.  (2006). Tinnitus Person-Centered Therapy. In R.S.Tyler (Ed.), Tinnitus Treatment: Clinical Protocols (pp. 198-216).  New York: Thieme.
6. Tyler, R. S., Gehringer, A. K., Noble, W., Dunn, C. C., Witt, S. A., & Bardia, A. (2006). Tinnitus activities treatment. In R. S. Tyler (Ed.), Tinnitus treatment: Clinical protocols. (pp. 116-132). New York, NY: Thieme.
7. Tyler, R. S., Gogel, S. A., & Gehringer, A. K. (2007) Tinnitus activities treatment. Progress in Brain Research, 166, 425-434.
8. Tyler, R., Jilla, A. M., & Von Dollen, S. (2020) Coding and Reimbursement Specialty Series:  Tinnitus. Audiology Today,  March/April.
9. Johnsen, T.J., & Friborg, O. (2015) The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin, 141(4), 747-768.
10. Tyler, R. S., & Mohr, A. M. (2017). Is CBT for tinnitus overemphasized? The Hearing Journal, 70(2), 8-10.
11. Tyler, R. S., Oleson, J., Noble, W., Coelho, C., & Ji, H. (2007).  Clinical trials for tinnitus: Study populations, designs, measurement variables, and data analysis. Progress in Brain Research, 166, 499-509.
12. Tunkel, D. E., Bauer, C. A., Sun, G. H., Rosenfeld, R. M., Tyler, RS,…et al. (2014) Clinical Practice Guideline:  Tinnitus. Otolaryngology-Head and Neck Surgery, 151(2S), S1-S40.