Many elderly people — particularly those with low incomes — had trouble accessing not only hearing aids, but also hearing aid-related services such as fittings and maintenance visits, researchers found.
Dually eligible patients — those eligible to receive both Medicare and Medicaid — were 41% less like to use hearing care services, and were twice as likely to report having a lot of trouble hearing with their aids, compared to high-income Medicare beneficiaries, Amber Willink, PhD, of Johns Hopkins University in Baltimore, and colleagues, reported in a study in Health Affairs. In addition, older beneficiaries with less than a high school diploma were 30% less likely to use hearing aid services.
Medicare currently doesn’t cover either hearing aids or hearing aid services, co-author Nicholas Reed, AuD, also of Johns Hopkins University, said in an interview with MedPage Today. These services include those directly related to the hearing aid (such as customizing and verifying the output of the device and providing maintenance and repair services) and those related to the patient (such as offering communication techniques for overcoming difficult listening situations, counseling for coping with hearing loss, and managing expectations about the hearing aid), the authors explained.
“Under Medicare, when they first started thinking about hearing aids… [Medicare was] only supposed to be for disaster situations; they didn’t want older adults to end up with massive hospital bills they couldn’t pay, and thought people could take care of preventative care out of pocket,” Reed said. “And hearing care already falls on the preventive side, and was also a nascent technology at that time. I don’t think people were thinking about it as something to be used all the time.”
Now that hearing aids and their associated services are used regularly and have gotten more expensive, the researchers decided to look at whether lower-income beneficiaries were having trouble accessing the benefit. They noted that hearing loss, which affects two-thirds of adults ages >70, is independently associated with dementia, cognitive decline, and falls. “Moreover, recent literature has found that older adults with hearing loss experience substantially higher health care costs and are more likely to receive poor care, according to measures such as 30-day readmission rates,” they wrote.
The investigators examined 2013 data from the Medicare Current Beneficiary Survey Cost and Use file. The study population included Medicare beneficiaries, ages ≥65, who reported using a hearing aid in the previous 12 months, no matter how frequently or infrequently. A little more than 9,000 beneficiaries, ages ≥65, were surveyed.
In all, 11% of the beneficiaries surveyed used a hearing aid that year. The population using hearing aids was substantially different from the rest of the older Medicare population. Those using hearing aids were more likely to be older white males. They also had higher educational attainment, compared with those who did not use hearing aids, and reported having higher incomes, the researchers found. And among those who used hearing aids, about a third said they used hearing aid services in 2013.
Problems with hearing aids varied by income, the authors said. For example, “27% of older Medicare beneficiaries who were dually eligible for Medicaid reported having a lot of trouble hearing with their hearing aid, compared to 11% of those with incomes of 400% or more” of the federal poverty level (FPL).
Use of Hearing Aid Services
To look at barriers to hearing aid services use, the researchers used the Andersen-Aday behavioral model of health services use. They found that 71% of dual eligibles who used hearing aids did not receive hearing aid services in 2013, compared with 58% of beneficiaries with incomes ≥400% of the FPL. Interestingly, beneficiaries who had a helper because of limitations in performing activities of daily living increased the odds of getting hearing aid services by 29%.
Although the study couldn’t directly prove that income differences were the cause of the difference, “the only inference we can make is that people with Medicaid are less likely to use hearing care but more likely to report having a lot of trouble hearing with their hearing aids, whereas people in higher income brackets are using hearing aid services more and are less likely to say they’re having trouble with their hearing aid,” Reed said. “So we can make an inference [about that].” In their study, the researchers concluded that “further investigation is needed to shed light on the causes of poor access among high-need older adults.”
Hearing aids and related services are also expensive, with an average cost of $4,700 per set and a range of $2,200 to $7,000, depending on which services are sold with them, the investigators noted. That may change somewhat, however, with the passage in 2017 of the Over-the-Counter (OTC) Hearing Aid Act, allowing patients to buy the devices over the counter to treat mild or moderate hearing loss. This new law “promises a substantial departure from the status quo of hearing care in the U.S. by increasing market entry and competition, lowering prices, and increasing the accessibility of hearing aids,” the researchers wrote.
“Under this new arrangement, in which hearing care services are expected to be further decoupled from the purchase price of the hearing aids, policy makers should consider new service delivery models to promote the access to and use of complementary hearing care services.”
Guidelines Still to Come
With the new law, the FDA has until 2020 to decide what the guidelines are going to be for OTC hearing aids, explained Tricia Ashby-Scabis, AuD, director of audiology practices at the American Speech-Language-Hearing Association (ASHA), in Rockville, Maryland. ASHA worked with several other organizations to make some recommendations, “but there are other groups doing the same thing. Until the FDA really says ‘Here’s what we’ve decided to adopt,’ we’re all waiting to see what [these companies] can produce and what the limits are going to need to be,” she said in a phone interview.
Ashby-Scabis said she thinks a lot more companies will come into the hearing aid marketplace as a result of the law — companies like Bose and Apple who would be able to provide, for example, connectivity with phones. However, they won’t necessarily bring down prices enough to make a difference for very low-income patients. “For people for whom price is a barrier, it’s still a barrier at $500-600 per device, or $2,000 per device,” she said. “The other hard thing is trying to get people to come in and learn about hearing aids.” People can’t always find an audiologist in their area, and they often don’t come in for help until their hearing loss has gone beyond mild or moderate, she said.
Study limitations included self-reported use of hearing care services; constraints in sample size, which prevented evaluating racial differences in access beyond white and non-white; and inability to evaluate factors increasing barriers to service use, such as lack of transportation or limited provider availability.