Friday, February 21, 2020

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! 

Thursday, January 23, 2020

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.