Editor's Message: PCAST Recommendations: Existential Threat or Golden Opportunity?

Author: Brian Taylor, Au.D.

By now most audiologists are familiar with the non-binding recommendations of the President’s Council of Advisors on Science and Technology (PCAST) and the qualified support of them from ADA. To recap, PCAST is essentially calling for a re-regulation of the industry in order to create more accessibility for our rapidly graying population. Given the aging population and long-standing static market penetration of hearing aids in the face of remarkable technological innovations, audiologists must find ways to address the unmet need of the marketplace, while continuing to create sustainable streams of revenue. Here are three fundamental questions that, I think, at the core of the evolving marketplace. All of them are worthy of deliberation and debate by everyone associated with our industry. The way we collectively address each of these questions may even determine our fate as a profession.

1. How do we contend with a rapidly aging population that often wants a fundamentally different relationship with their healthcare provider?

According to Professor Laura Carstensen at Stanford University, an American born today has a projected average lifespan 20 full years longer than one born in 1925. And, for the first time in U.S. history, the number of people over the age of 60 exceeds those under age 15. Dig deeper and you’ll find that the Graying of America is being led by the Baby-boomers. Dr. David Zapala of Mayo Clinic presented the data shown on Figure 1 at an Institute of Medicine (IOM) meeting in mid-September. It’s a picture worth more than a thousand words because it shows the “silver tsunami” in action. It’s literally an age wave. As this glut of people born within 15 years of the WW II age, their sheer size changes healthcare markets dramatically – just ask the vision industry when this group turned 45 and needed reading glasses! In addition to their size, Baby-boomers approach the market differently for services. They have an almost maniacal drive to live to be well over a 100, but maintain the vitality of a 40-something year old. Combine the size and scale of the Baby-boomer market with the fact there is a growing shortage of audiologists and hearing instrument specialists and you soon realize there is a potential bottleneck, if the bulk of these Baby-boomers decide to enter the marketplace for hearing care. New approaches to triaging – quickly & accurately determining who is at risk for ear disease and debilitating hearing loss —are needed, as Dr. Zapala highlighted in his presentation of the Consumer Ear Disease Risk Assessment (CEDRA).This approach uses simple questions about health status and ear disease symptoms to quantify ear disease risk. Audiologists need to take an active role in the testing and implementation of such triaging tools with a goal of maintaining the accurate identification of ear disease, while increasing access to hearing care treatment & management options for a growing aging population. Churning out routine audios in 20-30 minute increments is probably not going to accomplish this task. We need proven methods of sorting out hearing loss more complex in nature from hearing loss that is “normal for your age.” The former is likely to require multiple visits to the audiologist and some amount of medical oversight, while the latter entails enhancing the dayto- day function of a healthy ager. Audiologists must recognize that these two populations require a different set of skills to deliver high quality care: Individuals with complex loss are likely to benefit from a relationship-based transaction. And, those with purely age-related hearing loss may desire more of an arms-length transaction. We need to be poised to effectively do both.

Figure 1. Data presented by Dr. David Zapala at IOM meeting September, 2015.

2. How do we leverage the science, which continues to provide evidence of the impact of ARHL on all facets of life, including death to grow the demand for hearing care services?

Age-related hearing loss has been shown in several welldesigned, peer reviewed studies to be associated with myriad negative consequences, including social isolation, depressive symptoms, poor quality of life, reduced independence, lower career earnings and increased risk of mortality. Age-related hearing loss has even been associated with increases in cost of care and hospitalization (Genther , et al, 2013). These negative consequences associated with ARHL don’t occur in a vacuum. Given the increased healthcare costs associated with growing older, everyone must find ways to make the delivery of healthcare more efficient. Figure 2 shows the dramatic surge in costs associated with taking care of elderly patients. A relatively high percentage of this high risk, costly population also has ARHL, which likely affects their ability to communicate. We need to understand the greater cost reductions in healthcare associated with earlier identification and remediation of hearing loss in older adults. For example, the ability to hear and comprehend the physician’s directives during an appointment is important, but we really don’t know how much of an impact hearing loss has on the overall cost of care. It is possible that interventional strategies like making hearables available to patients during a routine visit with their physician could drive down some of the high costs of care. Given that elderly patients with co-morbid conditions, many of which are related to a higher risk of having hearing loss, comprise more than 50% of the total costs per Figure 2, audiologists may play a larger role in overall cost reduction than we realize.

The relationship between ARHL and other medical conditions requires audiologists to take an active role in the emerging integrated, accountable care organizations around the country. Because the nature age-related hearing loss is progressive and gradual (and likely less expensive to ameliorate when identified earlier) in the vast majority of adults, audiologists must intervene sooner when patients are younger and have milder hearing loss.

Figure 2.

Another issue worthy of discussion is related to the known downstream consequences of untreated age-related hearing loss. If research indicates that untreated, adventitious hearing loss in adults is related to an increased likelihood of depression, cognitive function, social isolation and overall health, audiologists must measure and share with referring physicians and the public the impact their treatment has on these conditions. Currently, very few audiologists use self-reports of outcome that evaluates how much our treatments impact the many downstream consequences of ARHL. More work is needed in this area.

3. How do we bridge the gap between access and innovation?

As evidence mounts that early identification and treatment stave off many of the ill-effects of ARHL, it’s a reasonable assumption all patients with the condition need access to affordable and effective hearing aid technology. Today, due to a combination of high costs, stigma and a lack of guaranteed success with hearing aids, uptake remains low, especially for younger individuals with milder hearing loss. Concurrently, technological innovations continue to increase. We are seeing the rise of hearables, which are a morphing of conventional hearing aid technology and consumer electronic devices, as shown in Figure 3. For consumers hearables may offer an appealing option, but current FDA regulations largely preclude their use for individuals with hearing loss.

Figure 3. Some of the key attributes of hearing aids and consumer electronics morph to create a new product category called hearables.

Hearing aid manufacturers who enjoy large profit margins in a market 25% to 40% penetrated are unlikely to risk the cannibalization of their existing business by introducing less expensive technology into the marketplace, even in the face of evidence suggesting lower cost technology provides essentially the same performance as technology at a premium price point. Audiologists must act as change agents for their patients, rather than defend the status quo, we must look for ways to grow the demand for hearing care by offering alternative and complementary products to a rapidly aging population. This starts by recognizing there are two separate and distinct markets for hearing care services. One market is comprised of the approximate 25% of individuals with moderate to severe, more complex, hearing loss requiring a customizable, higher tech solution. And, the second market consisting of the vast majority of hearing impaired individuals with mild to high frequency moderate losses, who are often younger and perhaps more amenable to “one-size-fits all” gadgetry . Taken further, there is emerging evidence from Timmer et al (2015) and Tremblay, et al (2015) that a relatively high percentage of individuals with normal audiograms (and mild hearing loss) have an inability to communicate in common, everyday listening situations. It’s reasonable to surmise these groups would benefit from technology at a lower price point, as milder communication problems warrant a less costly solution.

It all starts with our ability to ask good questions about the direction of our profession in light of the changing demands of the marketplace. Let the discussions and debates begin.    
Genther, D. et al (2013) Association of hearing L=loss with hospitalization and burden of disease in older adults. JAMA. 309, 22, 2322-2324.

Timmer, B.H.B, Hickson, L. & Launer, S. (2015) Adults with mild hearing impairment: Are we meeting the challenge?. International Journal of Audiology, 54(11), 786-795.

Tremblay,K. et al (2015). Self-reported hearing difficulties among adults with normal audiograms: The Beaver Dam Offspring study. Ear & Hearing, 36(6), e290-299.