Why Audiologists Need to Step Up For Audiology and MAASA

The US government dictates, through their regulatory bodies and payment systems, how a profession is perceived in the healthcare system.  Audiology, despite our increased education and clinical focus, has been relegated to “supplier” status, in the eyes of Medicare, for literally decades. It is this “supplier” status that leads to the dreaded the physician order requirement.  Also, our services are pigeonholed into a category known as “other diagnostic services”. It is this that limits us to Medicare coverage of diagnostic services only, despite our scopes of practice including treatment and rehabilitative services. The ONLY way to remedy this situation is to finally change our status in the Medicare system. 

The Academy of Doctors of Audiology (ADA) has been spearheading this movement since 2012, first with the Audiology Patient Choice Act (APCA) and now the Medicare Audiology Access and Services Act (MAASA).  This legislative initiative morphed, in 2019, from APCA to MAASA as the latter bill allowed for support from and partnership with the American Academy of Audiology (AAA) and the American Speech Language Hearing Association (ASHA).  MAASA allows for classification of audiologists as limited license practitioners, rather than suppliers.  It also allows for the removal of the traditional Medicare physician order requirement and coverage of medically reasonable and necessary treatment and rehabilitative services.  Passage of this piece of legislation would significantly change things for us.  It would provide us with better footing and recognition within Medicare and other healthcare systems. It would also, once treatment is covered, allow us to better show the outcomes of our services. 

This bill though is never going to pass without grassroots support and action from audiologists and audiology associations at both the state and national level.  It is not enough for national audiology associations to say they support the bill.  We need to see all of them devote resources, both human and financial, to the advancement of the legislation.  I should NEVER see an advocacy update from a national association that does not stress MAASA in its contents! I should see fly-ins and write in campaigns. I should see a FOCUS on and a plan for passage of the bills.  We need to see state associations formally endorse the legislation. Believe or not, this makes a HUGE impact when you go to meet with a legislator from a given state to be able to share the endorsement of the state association. We also need audiologists to be “all in” and support this legislation by writing their congressional leaders and/or visiting congressional offices both at home and in Washington, DC and asking them to sponsor the bill and through donating to political advocacy committees and advocacy funds (we can all donate something; we would have $1 million if 10,000 audiologists donated at least $100). None of us pay enough in association dues, to any organization, for them to be able to fund these types of initiatives without financial support. It is ALL of our jobs to make this a reality. We are a very small profession, compared to other healthcare entities, so we have to have everyone engaged and involved in order to move things forward. 

Finally, we have to get physicians and consumers and patients to understand the “why” for each of their situations.  In order to do that, we have to be honest about the bill, its limits, and its opportunities.  If a physician does not want to create an order, tell them then to demand that their national organizations stop fighting regulations and legislation that want to remove this requirement. If a patient does not like obtaining an order or paying privately for cerumen removal, canalith repositioning, or auditory rehabilitation, explain that there is legislation in Congress that would change these situations and encourage them to write to their congressional delegation and ask them to support MAASA. Patients will dog their Congress people if they do not get their mail for one day; we have to make supporting this legislation just as important to them and their daily life. Stop providing free cerumen removal and auditory rehabilitation so they see the value and cost of the care you provide. They cannot be aggravated about coverage if they have no out of pocket expense for the services. 

MAASA is not a pipe dream if every audiologist dedicates time and treasure to its passage. We need everyone to engage!  It is not someone else’s responsibility but rather ours as a collective! Let’s get this done once and for all! 

Forcing Change with a Wrecking Ball

I wrote and published a large portion of this piece exactly three years ago.  I have updated it for 2020 consumption but, mostly, it is even more applicable today than it was in 2017:

The hearing aid market is not only being flooded with over the counter and direct to consumer hearing aids, personal sound amplification products and hearables, it is also being flooded by third-party administrators (TPAs) or hearing aid referral networks who market and offer provider driven care.  I noted at least 20+ of these programs are currently operating in the United States.  Some are manufactured owned.

Third-party administrators are middle-men between the provider and the insurer, employer, or membership group who negotiate discounts, coverage, and benefits for the group and administers the discount or benefit offerings.  Hearing aid referral networks are typically online entities who market, via the internet and social media, significantly reduced, inclusive discount pricing to consumers, have the consumers purchase such devices directly from them, and then refer those consumers to registered, in-network providers for fitting and service. Some of these referral entities do not even seem to require an evaluation, which is funny given the same manufacturer’s aversion to over the counter devices and alleged support of provider driven care. What the third-party administrators and hearing aid referral networks have in common is this: they insinuate themselves within the delivery model, sometimes undercutting a provider’s previously existing arrangements and then dictate both care and reimbursement. They do this and then ask providers to join and provide the care to the consumer that they cannot.  The saddest fact though is that audiologists and hearing instruments specialists are joining these programs in droves without ever evaluating the financial or operational viability of the program for their practice. 

Audiologists bear some responsibility for the shear existence of these programs. We did not listen to consumers or respond to their needs and desires. We vehemently refused to itemize or offer any form of price transparency.  We failed to offer value based or affordable solutions to consumers. We provided free evaluations and failed to routinely provide evidence based care.  And finally, and this fact is important, many of us ignored our managed care agreements and played a dangerous insurance game where every hearing aid patient was forced to pay for an upgrade, where we billed for hearing aids we had not fit and would not fit them until we received payment, where we had the patient pay in full upfront, even though they had a benefit, and where we charged the payer differently than we charged our general population.  Insurers, employers, worker’s compensation plans, and, most importantly, consumers got tired of the game and got tired of losing and pushed for a lower cost and defined delivery system.  Now the primary losers in the current game are the providers themselves.  

I am not saying all of these entities are evil and that providers should not enroll.  Some actually can and do offer a win-win-win proposition, especially compared to the system and reimbursement many providers faced when dealing with the insurer directly through their own managed care agreements. Some also offer audiologists access to a managed care network in which might not otherwise be able to participate.  Still others offer no charge marketing and access to a large swath of new customers. Unfortunately, though that is not what leads most to join. Many of us just react when a program becomes available or enters our market and sign up randomly, without every fully evaluating the programs and its costs versus benefits, to both the provider and the patient. Rest assured that there are programs out there now where the only winner is the middleman. There are others that are questionably ethical or legal in both their marketing and their operations. In other words, all TPAs are not created equal and should not all be painted with the same brush. 

I want this piece to be a wakeup call to providers to truly evaluate each program before they agree to participate or, if they are already enrolled, take the time to evaluate the merits of such participation or lack thereof.  These programs will not change and will continue to exist, thrive and multiply as long as they have providers and consumers willing to accept their products, terms and payments as is. When we participate in programs which are not good for us and our patients then we become, yet again, our own worst enemy.  We become complicit. 

Also, when you see consumers being misled or lied to by insurers, insurance brokers, or third-party networks or administrators, please encourage and help patients to file complaints with Medicare and the parent insurer, if it is a Medicare Part C (Advantage) plan, the associated union and parent insurer (if an employee or retiree plan), and, always, the state department of insurance and the state attorney general’s office.  This is especially important if your state has a mandate and the third-party plan conflicts with the legislative language. State audiology associations and audiologists also need to get involved and advocate for their patients when they have evidence of patient harm. 

To evaluate a plan, everyone needs to know what their breakeven rate is and the type and amount of care they typically provide to their average patient in the hearing aid evaluation and delivery process. Everyone needs to educate themselves about these programs and ask questions, in writing, when they do not understand a program or its implementation. Complaining alone accomplishes little and, when we do it to patients, we look self-serving and small. It is time to evolve rather than merely react!

There are ways to compete against these entities. I teach audiologists to do this all of the time.  There are also ways to legitimately thrive in managed care.  It just takes education, processes and a change in mindset. Success moving forward will also require providers to evolve and accept some certain truths: providers will have to itemize, as most of these entities provide itemized care, they will have to be able to justify to the patient the value and costs of the care provided and they will have to accept less than their upfront, full fee, bundled usual and customary rate. But, on the flipside, providers who participate, because it is financially and operationally viable, receive compensation for their services, at their rates, for the items or services they actually provided.  Providers may just not be pre-paid for care they may or may not actually render. 

I say two things all of the time.  One is a quote from Dr. Phil: you cannot change what you do not acknowledge.  Audiologists have got to stop the pity party and start being proactive in taking steps to respond to this changing landscape.  The second is my own quote: I could care less what each audiologist decides to do in the end.  All I care about is that they make an informed decision and not one based upon fear or bullying. Audiology alone cannot will these programs away.  Educate yourselves.  Read the proceedings of what is happening in the industry and the latest research.  Truly listen to what consumers are saying. Do not respond based upon fear but rather fact.  Do not be bullied. Re-evaluate the situation at least once a year for every plan. And, most importantly, do what is best for YOU and YOUR practice. 

I promise providers that if they do these things their chance of long-term success multiplies tenfold. 

Evidence Matters

There has been a great deal of buzz recently about evidence based practice: who creates it, who can police it, and why its important. Here is my two cents: Audiology would not exist, as a discipline or as a profession, without research and the evidence it produces.  To date, no national association, credentialing or accrediting body has held audiologists accountable or required the attestation of evidence based care.  Evidence yields professional and clinical standards and guidelines. It creates new procedure.  It also provides the foundational support for new CPT and HCPCS codes as well as increased coverage of certain items and procedures. Research and evidence make a profession viable and, in turn, keeps it relevant. 

Some of our current professional challenges can be correlated to our lack of consistent focus on evidence based practice.  It is evidence based, patient centered practice that can differentiate an audiologist from disruptive delivery channels. This is the evaluation and care that cannot be delivered OTC or by the majority of other provider types. 

The hallmarks of ethical practice are also evidence based.  Most of our licensure laws hold each of us accountable to these types of ethical standards of practice. Every patient deserves to have the best possible care delivered to them at every visit. We should treat our patients as we would expect our healthcare providers to treat us.  Do we want our physicians, dentist, optometrist, chiropractor, physical therapist, or nurse practitioner to cut corners because of time, resources, or lack of knowledge? Do we want our healthcare providers to stay on top of the latest research and clinical techniques? I know I do.  I also know that the most successful practices, both professionally and financially, are those who put the patient at the forefront of her decision and action. 

Audiologists cannot use research and evidence as a marketing tool (i.e. cognition, falls, depression, dementia, and co-morbidities) and then ignore the evidence in other aspects of daily practice. Its disingenuous and misleading.  For example, I would assume that, if you discuss cognition in your marketing, that your practice screens for cognition, fits amplification with cognitive status in mind, and provides auditory rehabilitation to provide compensatory strategies for the cognitive limitations.  Just like in tinnitus, amplification is only PART of the answer.  Research supports a much larger evaluative and rehabilitative approach. 

For example, there is significant evidence surrounding the value of the use of speech in noise testing, handicap and hearing aid inventories, real-ear measurement and auditory rehabilitation to patient performance, satisfaction and outcomes. There is also evidence surrounding using a Hallpike as the primary means of diagnosing BPPV and using recorded speech materials instead of monitored live voice. There is research supporting the value of entry level hearing aid technology, OTCS and PSAPS. We have a great of basic and translational research available to us that can greatly influence our day to day practice and, in turn, provide better patient outcomes, performance, and satisfaction.  THIS is how we retain patients and grow our professional footprint in healthcare. We just have ask, acquire, appraise, apply, and ACT! 

Let’s have 2020 be the year of increased adherence to clinical practice standards and guidelines, to consistently devoting time to reading the literature, to supporting state and national meetings and research symposiums through attendance, and through, every day, providing the highest degree of evidence based, patient centered care possible. This is how we win and outperform the competition! I promise it will be worth it! 

The Unholy Alliance Between Academia, Preceptors, AuD Students and the Profession

The current AuD education model is one where the academic training program trains the student, both theoretically and clinically, on campus for the first one to three years.  The student’s clinical education is then relegated, almost completely, to off-campus, volunteer preceptors, who have their own clinical responsibilities outside of student education.  The final year of clinical training, the externship, is again relegated to off-campus, often out of state, volunteer educators,  who we are asking to take on full time clinical and professional education. All the while, academia is the one reaping any and all financial benefit. 

Currently, there is a great deal of finger pointing. Many believe academia does a poor job in teaching theory and evidence based practice, in nurturing and then demanding critical thinking, in weeding out those students who are ill-equipped to become true colleagues, and in providing little if no support, either personal or financial, to off-campus preceptors. Others believe a great deal of responsibility lies with these unpaid preceptors, who provide insufficient support and supervision, who do not consistently illustrate, in their own work, evidence based practice and critical thinking, who see students as nothing more than cheap labor rather than the students they truly are, and who fail to evaluate students by their true capabilities and performance, which results in some students who are enabled to slide through a profession they are ill prepared to work in independently.  Still others, blame this generation of students and see them as entitled, whiny and under prepared. Finally, many blame the profession and our professional associations and accrediting bodies for their significant failures in formalizing and operationalizing the off-campus clinical education component of AuD education, in requiring stricter academic standards and more 21^st century curriculum and educational models, and in closing or forcing consolidation of programs, who do not have the financial or human resources to provide a comprehensive theoretical or clinical education. 

Many of us, including myself, think this current clinical education delivery model is broken and that often the outcomes are not as expected by any of the participants, including the student. How do we change this paradigm and its direction? 

Our approach to change, to date, has solely been top down.  It has been led by associations and accrediting bodies and their insular group of decision makers.  There have been innumerable meetings, task forces, committees, sub-committees, forums, and conferences solely dedicate to AuD education.  I know, I have participated in them and heard about the others. These endeavors have produced, to date, more reports and more meetings but little if no actionable items.  The biggest change we have seen is that where ASHA will begin to allow for a pathway to certification post-graduation in 2020. Outside of this, no real, tangible change has been made.  They seem to lack the political will to make the tough call. Valuable human and financial resources have been continually squandered.

The majority of academia will not change until they are forced by national associations, accrediting bodies and market forces. Students and preceptors, despite their roles and responsibilities, in many situations, have little to no voice.  Most academic programs have no will nor no ability for honest self-reflection or motivation to evolve voluntarily. Their goals, in many cases, are solely self-preservation and “butts in seats”.  Quality and outcomes appear secondary. 

The change is going to have to be grassroots and going to have to come from preceptors and students. First, more audiologists, who provide evidence based practice and patient centered care, need to step up, step in and precept. AuD clinical education cannot occur without you. But, they should ONLY precept for programs that consistently (I stress this because every program, no matter how good, has outliers) produce students with strong critical thinking skills, interpersonal skills, and theoretical knowledge.  We can teach anyone to push the buttons; what is harder is teaching individuals to think and make patient centered decisions. Marginal programs will have to change, close or consolidate if audiologists refuse to precept their students. Preceptors should also grade students fairly and honestly and not push students forward who are ill prepared for the professional and interpersonal demands of audiology. Finally, preceptors need to recognize and accept that AuD students, whether in their first year or fourth, are STUDENTS! These students need you to lead by example, both clinically and personally, every day and with every patient.  They need your commitment to supervision, professional support, and honesty. They need you to let them fly, when they are ready, but to be there with a net. 

Students also have a role in all of this.  In the application and decision process, potential candidates need to ask about student outcomes, resources, course offerings, support systems, and off-campus clinical opportunities.  A lower graduation rate is GOOD thing in a clinical specialty, not a bad thing!  It means the program will not allow a classmate, who is under prepared, to earn the same degree as you! You want to know how many students pass the Praxis, present at state or national meetings, or have leadership positions? What are the depth and breadth of clinical placement opportunities? What courses are available? How many students are still in the profession in five years? Ten years? How many students are in leadership positions in five years? Ten years? 

Students also have to step up and step in.  This is not high school or their undergraduate college experience.  They are now adults in a professional, adult educational setting. Mom and dad have no role or voice here.  The student voice reigns supreme. They need to consistently respond with self-reflection, maturity, initiative, honesty, and professionalism. They need to appreciate and realize that good preceptors are volunteers, committed to audiology and them, who are attempting to build strong colleagues. Students need to demand more and speak up when concerned, but with solutions and not merely with complaints. Students need to push and demand more from the profession they are committing more in time and treasure, than any previous generation before them, to join. 

There are audiologists out there, like myself, that are willing to support change and change agents. I see my responsibility to audiology now as one where I work hard to build a stronger profession and I support those who will lead the next generation forward.  I will be successful only when audiology is successful. Audiology’s future is extraordinarily bright if we have the political and personal wills to put egos and self-interests aside, push up our collective sleeves, and dig in to make the critical and difficult decisions to move the needle! Who wants to join the Audiology Revolution? 

Choosing a Singular Path for Audiology

It is that time of year: the association membership renewal season. A time where every state and national association you have ever been a member of reaches out to you to ask, encourage and, sometimes, even bribe you to join or rejoin.

In 2019, I have belonged to no fewer than seven state and national associations in the audiology/otolaryngology spaces. These costs run, each year, around $1500 total in dues and memberships alone. In the past, I have joined these entities in order to support them and their cause, mission or movement. Like many of you, I joined because I thought I should.  In 2019 though I have done a bit of soul and my hope is that my journey will help my colleagues also reconsider their choices in 2020.

First, let’s start at the state level.  In my opinion, state audiology associations are the best value, and undeniably, the most important membership to have and maintain.  Why you may ask? First, a state license is the only requirement to practice audiology in the United States.  Period. ASHA and/or AAA certification, while possibly being required by a smattering of employers, is not a requirement to be an audiologist and is redundant to licensure. State audiology associations and their volunteers help seat licensure boards, create and shepherd licensure act and rules changes, and respond to legislative, regulatory, and managed care threats and opportunities.  In other words, it is these folks that help protect our day to day right to practice and landscape in which we work. Secondly, they offer affordable and easy access to continuing education opportunities. Finally, they are a wonderful place to network with your “neighbors”. Unfortunately, state audiology associations are underrepresented in almost every state.  The membership numbers just do not reflect the acknowledgment of the invaluable role they play in our practices. Audiologists want folks to protect their scope of practice but do not realize that it takes membership, convention attendance and fundraising dollars to make that happen!  A lobbyist, which is required at the state level, costs an association between $20,000  and $50,000 every year!  If there is one membership I will NEVER give up, it is my membership in my state association, which, in my case, is the Illinois Academy of Audiology.  It is the best $115 can ever spend!

Now, national audiology associations offer a tougher decision because there are so many options.  Did you know that audiology, despite is rather small size, is represented by no fewer than ten stakeholder groups and more than one “parent” group, who each purport to represent the profession? These parent groups can say they are the main representation because many of us belong to both groups. As a result, they each get to count us as one of them. This fragmentation could be part of our demise. We need to decide who we want to represent us and our profession and end the days of being part of so many groups.  I know this is hard; I too need and will be making this decision for 2020. Here are the things I am considering in making my decision:

·      Whose organizational mission, and accompanying actions, best represent my vision for the future of the profession?

·      Which organization do I trust to protect the profession of audiology over it is own association interests?

·      Which organization is honest and transparent in their dealings with members and colleagues?

·      Which organization has the human and financial resources to move the profession of audiology forward?

·      Which organization offers valuable member benefits, journals, and training opportunities?

·      Which organization responds in a timely, honest manner to member inquiries and concerns?

·      Which organization has the best vision and plan for audiology’s legislative and regulatory future?

·      Which organization has a “hill they are willing to die on” where they put the well-being of the profession ahead of the survival of the association?

·      Which organization is the most inclusive?

·      Which organization provides the best value of the member dollars I paid?

I am going to decide, in 2020, between the American Academy of Audiology (AAA) and the American Speech Language Hearing Association (ASHA) memberships once and for all in 2020. I encourage many of my colleagues to consider doing the same so both organizations cannot say they represent each of us. We need a true, singular professional leader and membership (like voting) is the only way our voices can be heard and that our message can be clear and consistent.

Despite the fact that I feel as though I should support and be represented by one of the two larger audiology associations, for me, the Academy of Doctors of Audiology is my professional home because my professional value and priorities best mesh with theirs. While I would LOVE to see it as the primary audiology association (because they have and continue to do so much for all of the profession given their limited size), I am not sure that is realistic.  Each of you may also have another professional association that is not AAA or ASHA and better serves your professional needs.  If so, great! But, again, I encourage all of us to support AAA OR ASHA as well as these other valuable associations. I, for example, will remain an ADA member and a member of ASHA or AAA. These decisions will also reduce my costs and give me dollars to donate to advocacy or awareness initiatives.

Finally, I have been a member of the Academy of Otolaryngology Head and Neck Surgery for at least two decades.  I find their clinical guidelines and resources to be stellar, as well as the access to a plethora of excellent journals.  In 2020, I have to decide if continuing this membership is in the best interest of me, my clients, and the profession.

Think about it, if each of us dropped association memberships that are not valuable to us, our daily practice, our patients, or our profession and moved even a portion of those monies into supporting our state audiology associations or funding political action or awareness or audiology, where we could be.  Washington DC lobbyists are $150,000+ per year. If every audiologist did not renew at least one national membership next year and spent at least one-third of those dues on joining their state association and at least one-third on a political action committee, advocacy or awareness donation, you could save approximately $100 for your family, raise approximately $5000 - $10000 for every state association and raise approximately $900,000 for the future of our profession.

Audiology has limited numbers and even more limited human and financial resources.  We have to make sure that we are using our resources wisely and that we have a singular voice representing us.  We face many professional challenges in the coming years and it is VITAL that we have an entity representing and protecting us, as well as making the hard choices need to advance our profession.

Audiology has an identity crisis. The situation is the result of a lack of consumer awareness and understanding about audiology, what it is, what it offers, and how it can positively impact a consumer and their quality of life.

The mission of Think Audiology is to stop merely talking about the need for audiology awareness and actually do something about it, through the creation of consumer and audiologist resources.

Think Audiology has two connected, yet separate, offerings and approaches to the awareness issue.  First, Think Audiology has launched a consumer website and mission to bring attention to the research based evaluation and treatment of hearing, tinnitus and balance conditions and the role audiologists play in assisting the consumer in their journey. The site offers basic information about a variety of audiologic and vestibular conditions and treatment options and provides consumers with unbiased, step by step guidance and resources on how to best address their concerns and their condition. This site is can be viewed at www.thinkaudiology.org. The site focuses on ALL conditions in our skillset, not just hearing and hearing loss. Many colleagues, including Cliff Olson, AuD and Brian Urban, AuD, have contributed to the Think Audiology materials.

Second, Think Audiology has created a set of “ads” or images that audiologists can use in their social media and print marketing campaign pieces. These professionally designed ads were created specifically to address all aspects of audiology, not just hearing and hearing aids. The goal is to create a grassroots national audiology awareness campaign and movement. We can accomplish this when audiologists all over the country use the same ads and images in their marketing communications during the same date or window of time.  Think Audiology will create images for specific awareness initiatives (such as Better Speech and Hearing Month, Healthy Aging Month, Audiology Awareness Month, etc.)  and an “Awareness” calendar.  We will then suggest the use of certain images or themes for your marketing communications during specific days, weeks or months.  We will begin our calendar on June 1, 2019.  At this time, all of these materials will be provided at no charge to audiologists and audiology practices.

Think Audiology has a few terms of use.  They include:

§  The hashtag (#thinkaudiology) or the Think Audiology logo will be on every image.  The reason for this is simple: we want to consistently expose the public to the word “audiology”. Many of our business names and marketing strategies do not include the word nor specifically address the profession.  One of the primary goals of the Think Audiology initiative is to change that, one ad, image, blog post, or interaction at a time. We, truly, want folks to Think Audiology.

§  Think Audiology owns the rights to many of these custom designed images and the Think Audiology logo and hashtag. These ads and images cannot be used by manufacturer owned practices or hearing aid dispenser practices. The movement is the promotion of audiology. Use by corporate owned entities and non-audiologists is incongruent to the primary goals of the initiative, which is to promote audiology awareness and the scope of practice of an audiologist. We believe our professional success lies in the practice of audiology, not just hearing and hearing aids.

Ascending Audiologists, who shares our audiology awareness mission, will be our partner in managing access to the Think Audiology DropBox account.  You will need to join Ascending Audiologists before you can access the Think Audiology portal. Think Audiology membership in Ascending Audiology is free of charge. You can access Ascending Audiologists and Think Audiology ads and images at https://ascendingaudiologists.com/. Please contact Think Audiology or Ascending Audiologists for more information.

For questions or to learn more or participate in the Think Audiology initiative or movement, contact Kim Cavitt at info@thinkaudiology.org.