Penny-wise and pound foolish: Top considerations when purchasing hearing technology

Transcription

1 Penny-wise and pound foolish: Top considerations when purchasing hearing technology Stephanie J. Sjoblad, Au.D. Clinic Coordinator / Associate Professor UNC Division of Speech and Hearing Barbara L. Winslow Warren, Au.D. Coordinator of Clinical Education / Assistant Professor UNC Division of Speech and Hearing

2 Overview of Trends History of Hearing Healthcare Terms & Definitions Agenda American Academy of Audiology Hearing Aid Billing Practices Survey Results A Model for Unbundling Current Trends vs. Best Practice Image:

3 Audiologist Professor Clinical Coordinator Consumer Advocate Mommy, Wife, Daughter, Sister, Friend And one more Bargain hunter!

4 Show of hands who has ever. GONE TO A YARD SALE SHOPPED AT A THRIFT STORE BOUGHT SOMETHING AT A CONSIGNMENT SHOP PERUSED CRAIGSLIST EXPERIENCED THE THRILL OF WINNING AN EBAY AUCTION

5 Have you thought about saving money on hearing healthcare. ONLINE HEARING TESTS INTERNET HEARING AID PURCHASES BIG BOX/WAREHOUSE HEARING AID PURCHASES

6 30+ years of marketing the product! The price of your X hearing aid includes custom programming if you so desire. Your hearing aid is already programmed for high frequency hearing loss - the most common hearing loss curves in the hard-ofhearing population.

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8 The History of Our Profession It was an ASHA Code of Ethics violation for audiologists to dispense hearing aids. The audiologist recommended the device(s) and the patient purchased the device as a retail product from a distributor. Audiologists were paid for their services, including: diagnostic services, administering hearing aid evaluations, and hearing aid adjustments and audiologic rehab. The Supreme Court ruled that A society s canon of ethics having the effect of limiting compensation among the society s members is illegal. Handbook of Clinical Audiology, 5th Edition Katz, Burkard, Medvetsky, 2002

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10 Understanding Economies of Scale Hearing Aids Cell phones Only 2% of our population use hearing aids 10

11 Economics of volume purchases Veteran s Administration BIG BOX STORES Sole Provider

12 Hearing aids do not magically just work Hearing Aids Professional Services Maximum Communication Improvement 5/29/

13 Hearing well in a noisy world, Consumer Reports (2009) Sound-proof booth for testing Several types of hearing tests Choice of brands, styles and features Real Ear Measures to customize the fitting Rehab classes and/or therapy Flexible evaluation period with option to return hearing aid(s) Convenient hours Walk-in repairs

14 Find a licensed and certified audiologist that offers the above AND an unbundled pricing option.

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16 Bundled Billing Combining products & services into one lump sum. PATIENT S BILL Hearing Aid Hearing Aid Pre-Fitting EAA $ Pre-Fitting D-Mic 2 Years Test Fee of Real-Ear Measures Service

17 Bundled Billing Combining products & services into one lump sum. PATIENT S BILL $ 2 wk: Follow-up 4 wk: Follow-up 6 wk: Follow-up 6 mo: Tubing Change 12 mo: Annual Check 15 mo: Repair (wax) 17 mo: Tubing Change 20 mo: Repair (Moisture) 24 mo: Annual Check

18 Unbundled Billing Breaking up prices completely. PATIENT S BILL Hearing Aid Hearing Aid $ $ Pre-Fitting EAA Pre-Fitting D-Mic 2-Years Test Fee Service Real-Ear Measures $ $

19 Unbundled Billing Breaking up prices completely. PATIENT S BILL $ $ Hearing Aid $ $ Hearing Aid 2 wk: Follow-up 4 wk: Follow-up 6 wk: Follow-up 6 mo: Tubing Change 12 mo: Annual Check Pre-Fitting D-Mic Test 15 mo: Repair (wax) 17 mo: Tubing Change Real Ear Measurements 20 mo: Repair (Moisture) 24 mo: Annual Check

20 Completely Unbundled Billing Advantages: Transparency More options for patients Defers much of the cost until services are rendered Patient pays only for what is used Could meet patient s needs easily Disadvantages: Patients may wish to eliminate necessary procedures (EAA, REM, etc.) Patients may not reliably return for necessary visits because they will need to pay May increase administrative time to manage Greater possibility of not collecting billables

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22 AAA Hearing Aid Billing Practices Survey Does your clinic bundle services into the price of hearing aids? No 20% No 33% Yes 80% Yes 67% A survey in 2006 reported that 87% of hearing aid dispensers are bundling. (Hearing Journal, 2006)

23 2012 AAA Hearing Aid Billing Practices Survey Does your clinic retain a non-refundable professional fee if the hearing aid(s) are returned for credit? State Laws require that all fees incurred with the provision of a hearing aid be returned 7% No 16% Yes 77% State Law requires that all fees be returned to the patient. 6% No 18% 2011 Yes 76%

24 2012 AAA Hearing Aid Billing Practices Survey Is the non-refundable fitting and professional fee 72.6% 1.8% 1.6% 11.4% 6.5% 6.1% Contingent on the services provided A flat rate regardless A flat rate based on of hearing aid the level of technology technology/style/price A percentage of the total cost of the hearing aid Cannot charge a fee as this would violate state law(s) Other

25 Professional Services are valuable DENTISTS OPTOMETRISTS HAIR STYLISTS PLUMBERS ETC

26 UNC- Hearing & Communication Center

27 11 years ago an inspiring conversation Dr. B, a retired dentist from the UNC School of Dentistry He wanted to pay for services after a one hour visit His hearing aids were over 2 years old His warranty had expired At the time, we were charging NOTHING We arbitrarily chose an hourly rate for services Began charging small amounts for services such as tubing changes, inhouse repairs, etc.

28 2005 A new beginning at UNC-HCC Mission: To make hearing care more affordable! Lowered hearing aid prices, as 2 years of services were no longer included up-front» Included a 60-day trial period Term Trial Period became Evaluation & Adjustment Period Non-refundable professional fee increased proportionately to reflect services rendered during E&A Period.» Included: Pre-fitting Electroacoustic Analysis (EAA) Real-Ear Measurements (REM) Follow-up and Adjustments for 60 days Our model was inspired by Patricia Gans. (J. Nemes, To bundle or not to bundle? That is the question. Hearing Journal, April 2004.)

29 Our [Partially] Unbundled Billing Breaking up Breaking prices completely, up prices completely, after the TRIAL period. after the EVALUATION AND ADJUSTMENT period. PATIENT S BILL Hearing Aid Hearing Aid $ $ Pre-Fitting D-Mic Test Pre-Fitting 2-Years Professional EAA Checks Fee + Service 45 Days of Follow-Up Real-Ear Measures $

30 Our [Partially] Unbundled Billing Breaking up prices completely, after the initial evaluation and adjustment period. PATIENT S BILL $ $ Hearing Aid $ Hearing Aid $1000 Professional $3000 Fee + 45 Fitting Days of Follow-Up 2-Years Fee Service 2 wk: Follow-up 4 wk: Follow-up 6 wk: Follow-up 6 mo: Tubing Change 12 mo: Annual Check 15 mo: Repair (wax) 17 mo: Tubing Change 20 mo: Repair (moisture) 24 mo: Annual Check

31 Sample Impact on HA Prices: 2 Hearing Aids (premium tier, digital) Non-refundable professional fee Service period included, following fitting TOTAL INVESTMENT 2004 BUNDLED 2005 UNBUNDLED $5000 $X,XXX per device $200 total $XXX per ear Duration of 60 days manufacturer warranty $5200 Lower upfront cost

32 Enlightening patients who purchased their hearing aids on or after July 1, 2005 or had never seen the unbundled model before. Mr. Smith, we are recommending XYZ hearing aids as a part of your treatment plan. The hearing aid cost is $X,XXX per device. We recommend 2 hearing aids, therefore the hearing aids will cost $X,XXX. The professional service fees to fit these hearing aids and for 45 days of services will be $XXX/ear. The professional service fees are non-refundable. Your total investment the day you go home with the hearing aids will be $X,XXX. Services after the 45 day evaluation and adjustment period will be fee for service. Image from:

33 Reassuring patients who purchased their hearing aids prior to July 1, (And heard that their friends bought hearing aids yesterday, for less $.) Mrs. Jones All the services you need during your 2 year manufacturer s warranty period were paid for up front. You can come see us anytime you need services for your hearing aids and you have already paid for those visits. Our current policy no longer provides these unlimited services up front, and that is why the fee is less. Image from:

34 5/29/2012

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36 UNC-HCC Treatment Plan We do not sell hearing aids. We aim to rehabilitate our patient s hearing utilizing evidence-based clinical practice. As a part of our customized process, we encourage each patient to: Participate in Better Hearing Workshops (Aural Rehabilitation) Complete Auditory Training program - Listening And Communication Enhancement, also called LACE Assess benefit and satisfaction throughout the process» Abbreviated Profile of Hearing Aid Benefit (APHAB)» Client Oriented Scale of Improvement (COSI)» Satisfaction with Amplification in Daily Life (SADL) The product is worthless if the patient cannot use it effectively. 36

37 Current Trends and Recommended Procedures What exactly is best practice in the hearing aid world?

38 Current Trends: 5/29/

39 An Evidence-based Model Hearing Evaluation Functional Communication Assessment Hearing Aid Fitting Hearing Aid Followup Individualized and Group Aural Rehab 5/29/

40 Current Trend: Online Hearing Tests

41 Comprehensive Evaluation (92557)» Diagnosing the type and degree of hearing loss: Extensive case history Visual inspection / Otoscopy Speech testing Pure tone threshold search» Air conduction and bone conduction Tympanometry (92567) Acoustic reflexes (92550) Hearing Evaluation 5/29/

42 Current Trend: Online Hearing Aid (HA) Purchases 63 options

43 Hearing Aid Selection

44 Hearing Aid Evaluation (92590/1) UNC HCC Functional Communication Assessment Characteristics of Amplification Tool (COAT) Quick SIN (Speech in Noise) Loudness Discomfort Measures (LDL) Acceptable Noise Level (ANL) as needed Cochlear dead region testing (TEN-HL) as needed Lifestyle Assessment Client Oriented Scale of Improvement HA selection Earmold Impressions 5/29/ (R. Sweetow, Instead of a hearing aid evaluation, let s assess functional communication ability. Hearing Journal, 2007.)

45 Hearing Aid Selection Process Look for a clinic that offers an objective Hearing Aid Selection Process (92590, or V5010) Functional Communication Assessment (FCA) Lifestyle Assessment Self-Assessment Questionnaires (APHAB, COSI, COAT) Loudness Discomfort Levels (LDL) Test Quick Speech In Noise (QuickSIN) Test Acceptable Noise Level (ANL) Test Earmold Impressions Sweetow, R. (2007) Instead of a hearing aid evaluation, let s assess functional communication ability. Hearing Journal, 60(9),

46 Current Trend: Wholesale/Online Hearing Aid Purchases Audiology Clinic Wholesale Store Ebay

47 Hearing Aid Fitting Procedures When the HAs are Received from the Manufacturer» Quality Assurance (V5011) EAA, DM, HAC The day of the Fitting» Conformity Evaluation (V5020) Probe Microphone Measures» Hearing Aid Programming (V5014)» Orientation (V5011) Care, maintenance, use» Dispensing Fee binaural (V5160)» Hearing Aid digital BTE binaural (V5261) Hearing aid fitting follow-up» Appointments included for 45 days 5/29/2012 Recommend: 2 week and 4 week (six week as needed) 47

48 HA Quality Assurance Procedures Behind the scenes (before patient arrives):» Electroacoustic Analysis (EAA)» Directional Microphone (DM) test» Distortion test» Hearing aid check Visual inspection and listening check 5/29/

49 : New Hearing Aids 12% Passed inspection/eaa 88% Failed inspection/eaa New Orders Failing QA Inspection by Manufacturer Manufacturer A 7.60% Manufacturer B 20% Manufacturer C 25% (S. Sjoblad, B. Warren )

50 : Repaired Hearing Aids 18% 82% Passed inspection/eaa Failed inspection/eaa Percentage of Repaired HAs Failing QA Measures Manufacturer A Manufacturer B Manufacturer C Manufacturer D Manufacturer E Manufacturer F 0% 9.70% 18.90% 20.50% 20% 41.20% (S. Sjoblad, B. Warren )

51 Hearing Aid Fitting Day of Fitting» Conformity Evaluation (V5020) Probe Microphone Measures/Real Ear Measures» Hearing Aid Programming (V5014)» Orientation (V5011) Care, maintenance, use 5/29/

52 Real Ear Verification 5/29/

53 A Case for Real-Ear Measurements Pt s Loudness Discomfort Levels Hearing Aid MPO 65 db Speech 55 db Speech Patient s Hearing Thresholds (dbspl)

54 A Case for Real-Ear Measurements Pt s Loudness Discomfort Levels Hearing Aid MPO 65 db Speech 55 db Speech Patient s Hearing Thresholds (dbspl)

55 Hearing Aid Fitting Procedures When the HAs are Received from the Manufacturer» Quality Assurance (V5011) EAA, DM, HAC The day of the Fitting» Conformity Evaluation (V5020) Probe Microphone Measures» Hearing Aid Programming (V5014)» Orientation (V5011) Care, maintenance, use» Dispensing Fee binaural (V5160)» Hearing Aid digital BTE binaural (V5261) Hearing aid fitting follow-up» Appointments included for 45 days 5/29/2012 Recommend: 2 week and 4 week (six week as needed) 55

56 Balancing the Investment 5/29/

57 Current Trend: Ignoring the importance of HA follow up

58 Six Months: 5/29/2012 Visual and listening inspection Hearing Aid Check: HEARING AID PROCEDURES, EARMOLDS, AND ACCESSORIES (and related professional services) CPT / HCPCS mod. DESCRIPTION FEE HCPCS mod. DESCRIPTION FEE HCPCS mod. DESCRIPTION FEE V5299» Office Office Visit visit (V5299) V5257 Digital BTE, monaural Education & Training, individual HA Check, monaural (visual & listening inspections) V5256 Digital ITE, monaural Education & Training, 2-4 persons HA Check, binaural (visual & listening inspections) V5255 Digital ITC, monaural Education & Training,5-8 persons» HAC (92592/3) Electroacoustic Analysis, monaural V5254 Digital CIC, monaural V7212 Encounter for hearing conservation & Tx Electroacoustic Analysis, binaural V5262 Disposable Aid, monaural Shipping and Handling V5014 HA Repair by Visual Mfctr., 6 mo. Warranty and listening V5261 inspection Digital BTE, binaural V5299 Loss and Damage Deductible, per device V5014 HA Repair by Mfctr., 12 mo. Warranty V5260 Digital ITE, binaural V5299 HA Extended Warranty V5014 x2» HA Hearing Repair, in-house per small aid parts replaced repair, V5259 in house Digital ITC, binaural (V5014) Cerumen Removal [IMPACTED] V5014 HA Repair no charge V5259 Digital CIC, binaural Cerumen Removal [not impacted] V5267 HA Supplies/Accessories per ear (see reverse) small parts V5263 replacement Disposable Aid, binaural Telephone Assessment HA Evaluation, monaural (Func. Comm. Assess.) V5241 Dispensing Fee, monaural Online Assessment HA Evaluation, binaural (Func. Comm. Assess.) V5160 Dispensing Fee, binaural V5266 Battery (6 batteries/pk) V5275 Earmold Impression (each) V5110 Dispensing Fee, bilateral V5266 Battery Club Membership (8pk of 6) V5264 Earmold Custom (each) V5090 Dispensing Fee, unspecified aid (FM) V5268 ALD, Telephone V5265 Annual: Earmold, Disposable (each) V5200 Dispensing Fee, CROS V5269 ALD, Alerting V5011 Fitting and Orientation of Hearing Aid(s) V5240 Dispensing Fee, BICROS V5270 ALD,TV Amplifier V5011» Fitting Office and Orientation visit of FM (V5299) V5298 Hearing Aid, miscellaneous V5274 ALD, miscellaneous (ex. FM, wireless) V5020 Conformity Evaluation (Real-Ear Measures) V5298 Lyric Subscription V5299 Hearing Service Miscellaneous (Home visit) V5014 Hearing Aid Reprogramming Audiological Rehabilitation [pre-lingual]» HAC (92592/3) V5267 Musician's Earplugs Filters (each) Audiological Rehabilitation [post-lingual]» Hearing aid repair, in house (V5014) per ear small parts replacement EAA at one year and as needed» EAA and Directional Microphone testing (92594/5) 58

59 Current Trend: Fear of Being Billed for Services HEARING AID PROCEDURES, EARMOLDS, AND ACCESSORIES (and related professional services) CPT / HCPCS mod. DESCRIPTION FEE HCPCS mod. DESCRIPTION FEE HCPCS mod. DESCRIPTION FEE V5299 Office Visit V5257 Digital BTE, monaural Education & Training, individual HA Check, monaural (visual & listening inspections) V5256 Digital ITE, monaural Education & Training, 2-4 persons HA Check, binaural (visual & listening inspections) V5255 Digital ITC, Education & Training,5-8 persons Insert Electroacoustic graphics Analysis, monaural and V5254info Digital CIC, monauralonline HE V7212 Encounter for hearing conservation & Tx Electroacoustic Analysis, binaural V5262 Disposable Aid, monaural Shipping and Handling V5014 HA Repair by Mfctr., 6 mo. Warranty V5261 Digital BTE, binaural V5299 Loss and Damage Deductible, per device V5014 HA Repair by Mfctr., 12 mo. Warranty V5260 Digital ITE, binaural V5299 HA Extended Warranty V5014 x2 HA Repair, in-house per ear small parts replaced V5259 Digital ITC, binaural Cerumen Removal [IMPACTED] V5014 HA Repair no charge V5259 Digital CIC, binaural Cerumen Removal [not impacted] V5267 HA Supplies/Accessories (see reverse) V5263 Disposable Aid, binaural Telephone Assessment HA Evaluation, monaural (Func. Comm. Assess.) V5241 Dispensing Fee, monaural Online Assessment HA Evaluation, binaural (Func. Comm. Assess.) V5160 Dispensing Fee, binaural V5266 Battery (6 batteries/pk) V5275 Earmold Impression (each) V5110 Dispensing Fee, bilateral V5266 Battery Club Membership (8pk of 6) V5264 Earmold Custom (each) V5090 Dispensing Fee, unspecified aid (FM) V5268 ALD, Telephone V5265 Earmold, Disposable (each) V5200 Dispensing Fee, CROS V5269 ALD, Alerting V5011 Fitting and Orientation of Hearing Aid(s) V5240 Dispensing Fee, BICROS V5270 ALD,TV Amplifier V5011 Fitting and Orientation of FM V5298 Hearing Aid, miscellaneous V5274 ALD, miscellaneous (ex. FM, wireless) V5020 Conformity Evaluation (Real-Ear Measures) V5298 Lyric Subscription V5299 Hearing Service Miscellaneous (Home visit) V5014 Hearing Aid Reprogramming Audiological Rehabilitation [pre-lingual] V5267 Musician's Earplugs Filters (each) Audiological Rehabilitation [post-lingual]

60 2011 Hearing Aid Billing Practices Survey How many visits does the average patient have during the manufacturer s warranty period? Greater than 6 times annually 1.7% 5-6 times annually 4.4% 3-4 times annually 39.5% 1-2 times annually 54.3% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

61 Why are there fees for repairs? Out of Warranty repair Patient pays the manufacturer s repair invoice, plus a fee for our services. In Warranty Repair Patient still pays a fee for our services. SERVICES may include: Hearing Aid Check , Attempt to repair the hearing aid in house - V5014 EAA 92594/5 Directional Mic Test 92594/5 Hearing Aid Programming V5014 Feedback Test, as needed V5014 Synchronization, as needed V5014 Shipping and Handling 99002

62 Service Plan Examples: Minimal Care Patient pays for services following trial/adjustment period Standard Care Includes most necessary services, standard accessories, semi-annual checkups, annual evaluation, etc. Premium Care Worry Free Option includes everything with VIP treatment for the life of the device. Coverstone, J. (2011) Fee for service models in audiology practices. Audiology Today, 24(5),

63 What our patients are saying? PATIENT: R.P. I am more than happy to come in for any appointment that will improve my ability to hear and I am happy to pay for it. PATIENT: S.M. When it came time to fit my hearing aids, I really think your use of this thing [patient points to real ear measurement system] made all the difference. Yeah, [your billing method] did surprise me a little bit. But I think the main thing was that I was seeing everything that you guys do here, versus what I had been getting before. PATIENT: S.H. You are not charging me enough for all that you do. PATIENT: S.O. My experience with your clinic and these hearing aids is like nothing I have ever experienced before, I am so sorry I did not find you sooner.

64 Summary of Objectives Describe the considerations consumers should identify when embarking in the search for a hearing healthcare provider and new hearing technology. Understand various billing models and fee structures one may encounter during the hearing aid selection and evaluation process. Discuss the importance of evidence-based practice in successful hearing aid fitting and audiologic rehabilitation outcomes 5/29/

65 Finding the best hearing care checklist Find a Board Certified Audiologist who follows AAA Guidelines for Management of Hearing Loss Inquire if the practice offers itemized/unbundled billing options before you make an appointment Review the practice website and verify the use of objective hearing aid selection procedures and Real Ear Probe Microphone Measures Recognize that hearing aids will not cure hearing loss. Enroll in Audiologic Rehab classes and consider Auditory Training.

66 Beyond Monday Morning Be prepared that hearing loss treatment is an on-going process. Routinely attend your local HLAA Chapter meetings for ongoing support from others with hearing loss. Continue to educate yourself! 5/29/

67 Don t be fooled by the mad world of hearing aid advertising. Image from: Men Advertising That Would Change America.aspx Proceed as a wise consumer!

68 References Bonta, R., (2004) Communicating true value. Advance for Audiologists, 6(5), Cavitt, K., (2010) Personal communication. Foltner, K., (2009) What s my time worth? Part 3: Breakeven analysis. Advance for Audiologists, 11(3), 44. Gitles, T., (1999), Re-inventing the profession: A new model of hearing care delivery (First of two parts). Hearing Journal, 52(9), Gitles, T., (1999) Re-inventing the profession: A new model of hearing care delivery (Second of two parts). Hearing Journal, 52(10), /29/

69 References (con t) Nemes, J., (2004) To bundle or not to bundle? That is the question. Hearing Journal, 57(4), Stone, C., (2005) Real talk on unbundling. Advance for Audiologists, 7(6), 59-60, 76. Sjoblad, S., Warren, B., (2009) Get real: Can QA checks and REM improve the bottom-line? Presented at AudiologyNow 2009, Dallas, Texas Sweetow, R. (2007) Instead of a hearing aid evaluation, let s assess functional communication ability. Hearing Journal, 60(9), Sweetow, R. (2009) Hearing aid delivery models: Part 1 of 2. Audiology Today, 21(5), /29/

70 References (con t) Sweetow, R. (2009) Hearing aid delivery models: Part 2 of 2. Audiology Today, 21(6), Van Vliet, D. (2003) In praise of unbundling. Hearing Journal, 56(4), 36. 5/29/

71 CONTACT INFORMATION: Stephanie Sjoblad: Barbara Winslow Warren: SPECIAL THANKS TO: AAA Debbie Abel, Au.D. Annette Burton, Au.D. Kim Cavitt, Au.D. Katherine Cresante Melissa Uhlman, Au.D 5/29/