January 31, 2016

What Did You Say?

We have a Model 88 radio on our kitchen table that we must have had for 20 years. It’s one of those devices where you adjust the volume by pressing the “up” button or the “down” button. My mother, who turned 90 last month, customarily set the volume to 50 and I set it to 35. I don’t know how those numbers translate into decibels, but 50 is louder than 35. Considerably louder. I took this quantitative observation as definitive evidence that my mother’s hearing was impaired, as is true for just about everyone who’s made it to their tenth decade, but she wasn’t persuaded. After a year of nagging—I confess, I nagged—my mother responded to an offer of “free hearing screenings” at the local senior center. When the screening was cancelled because of a blizzard, I figured that was it—I’d lost my chance. But the audiologist was persistent and he managed to reschedule the test.

My mother didn’t pass the exam. She was frankly quite surprised and assured me that all her friends complained that their children “mumbled” and were hard to understand, but they—octogenarians all—had no problem hearing each other. I suggested that was because they were all hard of hearing so when they got together they sat around yelling. She didn’t appreciate my comment, but she humored me and actually got fitted for hearing aids. She disappointed the fellow who did the initial screening and found a different audiologist, a lovely woman whose office is nearby and who treated my mother with both patience and respect. Nearly two years after I started nagging, and a year after the blizzard of 2015, my mother has two remarkable, virtually unnoticeable, in-the-ear hearing aids—and a $6000 hole in her bank account.

I can’t say that the hearing aids have transformed her life. But we don’t have nearly as many of those awkward dinner conversations in which I say something and a minute later, my mother says the same thing because she didn’t hear what I’d just said. The television in her room no longer blasts away in the evenings. The hearing aids haven’t solved all her problems, but they help. Just because it may not be possible to cure disease or restore function, doesn't mean there's no point improving a few crucial domains such as hearing and balance. Those modest adjustments can make all the difference.

My mother is not unique in her skepticism about hearing aids. Although 80 percent of people over age 80 have hearing loss, only 20 percent use hearing aids. For people with mild hearing loss, the rate is dramatically lower—more like 2 to 3 percent. A recent report by the President’s Council of Advisors on Science and Technology (PCAST), whose findings in the realm of hearing were summarized by Christine Cassel of the National Quality Forum and colleagues in a recent issue of the Journal of the American Medical Association makes some important policy suggestions that could radically change the status quo. 

PCAST identifies two critical barriers to change: primary care doctors, who tend to ignore hearing loss, feeding into their patients’ denial; and Medicare regulations, that exclude insurance coverage for audiology assessments and for hearing aids. The report doesn’t have much to say about how to modify physician behavior other than to assert forcefully that “it is time for the health care system to make hearing a priority.” It does have some concrete suggestions about paying for hearing aids, pointing out that the Veterans Administration does cover this technology and negotiates prices from major manufacturers, with the resulting cost averaging $400 rather than $2400 per device. Other western countries such as England, Denmark, and Switzerland include hearing aids as part of basic health care coverage. After all, the rationale for excluding them from the original Medicare legislation in 1965 wasn’t that they failed to meet the "reasonable and necessary" standard, but rather that they were presumed to be low cost, something consumers should pay for themselves. PCAST also suggests that the FDA could allow certain types of hearing aids to be sold over the counter, much as some reading glasses are available over the counter. The hope is that by making the process of getting hearing aids more “user friendly,” usage would increase.

Hearing loss has major consequences: it is associated with a marked increase in the risk of both falls and dementia. It leads to social isolation, poor quality of life, and greater dependence. And we can actually do something about it. The cost of making a difference is far less than the cost of treating all the hip fractures that older people will have because they don’t hear a warning or the services they need because they have become frail and dependent. Why can’t Congress (which would have to amend the Medicare legislation to pay for hearing aid technology and to amend the FDA’s rules for device regulation) see that this is a win-win situation?

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