Time to spice things up a little bit with another Q&A to start this post! Question: What is “Direct Access” in audiology?
a) The ability to obtain hearing aids directly from an audiologist.
b) Something that is inappropriate to discuss on this blog.
c) A bill that, if passed, would allow Medicare beneficiaries to receive an audiologic examination without first obtaining a physician referral.
d) This actually doesn’t exist, and I’m just wasting your time with these stupid multiple-guess answers.
If you answered “a” – valiant effort, but this is not the definition of Direct Access. Actually, you already can obtain hearing aids directly from an audiologist (provided that they are licensed in the state in which they practice, and/or have a hearing aid dispensing license in that state, if applicable). If you answered “b” – perhaps another blog is better suited for you to read. If you answered “d” – well, same thing. Or maybe blog-reading isn’t for you. If you answered “c” – congratulations! You win. If I could, I’d give you a cookie. Probably one of these, made by my former roommate (they are still the best cookies I have ever had, to this day… and that’s saying something, because she makes some extremely yummy treats).
So, what exactly does this mean? Here’s a scenario for you:
You are an avid Hear to Here blog reader. You are also a Medicare recipient. After reading the last post about audiograms, you realized perhaps you are having difficulty hearing and would like to have your hearing evaluated. Under the current Social Security Act, you would first have to see a physician to obtain a referral to see your audiologist. Once that physician writes you a referral, you can see an audiologist and have those diagnostic evaluations covered (at least in part) by Medicare. If you fail to obtain a physician referral, Medicare will not cover the expense of any of these services provided by an audiologist.
Yes, it is quite a lengthy (and dare I say, bureaucratic) process. Which is one of the many reasons why audiologists are currently working towards eliminating the need for a patient to first obtain a physician referral before seeing us to receive services. This is where the Medicare Hearing Health Care Enhancement Act of 2007 (otherwise known as the “Direct Access” bill), introduced by Representative Mike Ross (D-AR), comes into play. If passed, this bipartisan bill would allow Medicare beneficiaries to seek services directly from a qualified audiologist.
So why is it the current standard for Medicare beneficiaries to first obtain a physician referral, you ask? I suppose the answer you receive will depend on whom you ask. Before answering that question, I would like to list some of the reasons to support Direct Access:
- There are many people who are able to directly receive services from audiologists. These individuals include:
- Veterans – The Department of Veterans Affairs (VA) has allowed veterans to directly access audiologists since 1992, and reports that this policy provides “high-quality, efficient, and cost-effective healthcare.”¹
- Federal employees, including Members of Congress – these employees are able to directly access audiologic services through the Federal Employees Health Benefit Plan.¹
- Beneficiaries of other insurances – There are many insurance companies that allow their beneficiaries to directly access audiologic services.
- Medicare beneficiaries currently have “direct access” to a multitude of non-MD/DO providers, including:
- Nurse practitioners
- Physician assistants
- Clinical psychologists
- Clinical nurse specialists
- Clinical social workers¹
- As of 2004, an estimated 31.5 million individuals in the U.S. had some degree of hearing difficulty; this incidence of reported hearing loss is expected to grow to over 40 million individuals by the year 2050.² That amounts to A LOT of physician referrals. In the current model, a patient typically visits his/her primary care physician, who then refers to an ENT, who then refers to an audiologist. It is estimated that PCPs were paid approximately $84 million from Medicare for these referrals, and ENTs were paid an additional $84 million from Medicare. By eliminating these referral steps, Medicare would save approximately $168 million per year.³ (That is approximately 16,800,000 Chipotle dinners consisting of a burrito bowl + chips & guac). And yet we sit and wonder why our current healthcare system is in the state of financial crisis that it is…
- Speaking outside of monetary terms, eliminating the need for referrals also saves a patient’s time. Simply put, it is much easier to be treated by one healthcare professional (when you really only need to see one), rather than by multiple healthcare professionals. When you think about the average patient for audiologists (the elderly), this really comes into play. For many of these patients, it is extremely difficult (not to mention costly) to go to multiple appointments.
- Audiologists are licensed, masters- or doctoral-level professionals that have graduated from accredited institutions. We are trained in the diagnosis and treatment of hearing loss and vestibular disorders. In fact, audiologists often teach medical students, ENT residents, and physicians about hearing loss and diagnostic audiometric evaluations. In other words, audiologists are perfectly capable of being the first line of care for the management of hearing and balance disorders in patients.
Back to the original question – why does this law currently exist, or why would anyone oppose Direct Access to audiologists? Well, here’s where things get tricky. In short, what some argue is that some patients would be improperly managed. It is true that there are patients with certain types of hearing loss and balance disorders that require medical management. For example, this would be the case if a patient presented with symptoms of a retrocochlear pathology (e.g. acoustic neuroma), a conductive hearing loss, additional/other otologic symptoms (dizziness, tinnitus, active drainage), etc. However, there are current standards of care and guidelines that require referral from an audiologist back to a physician (typically an ENT) if this is the case. As I mentioned before, audiologists are higher-level professionals that are able to make these referrals appropriately if necessary. Further, we already do make these referrals back to physicians (when necessary and appropriate).
The opposition to Direct Access comes mainly from the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS). As stated by the current president of the American Academy of Audiology, Dr. Therese Walden, AuD: “The leadership of the AAO-HNS contends that by allowing patients the option of going directly to an audiologist for hearing and balance problems, that somehow the safety and efficacy of the patient’s care would be compromised by not seeing a physician first. In fact, there is significant data and research that supports audiologists as an entry point into the healthcare arena for these problems.”¹
One of the studies to which Dr. Walden refers is one completed by Dr. Dave Zapala. Dr. Zapala and his colleagues “…examined more than 1,500 charts from Medicare-eligible recipients (in the year 2007) at the Mayo Clinic. They evaluated the differences between assessment and treatment plans from ENT docs and audiology docs, as judged by a panel of two ENTs and two audiologists. The bottom line is that there were no discrepancies in treatment plans for over 95 percent of the patients.”¹ The article reads: “The jury of four judges found no audiology discrepant plans in over 95 percent of cases…[and]…in no case where a judge identified a discrepancy in treatment plans did the audiologist’s plan risk missing conditions associated with significant mortality or morbidity that were subsequently identified by the otolaryngologist.”4 In fact, the otolaryngologists in this study reported that for 78% of patient cases reviewed, audiologic services were the only services needed.
I know I am biased, but to me, these are considerable numbers. This is particularly true when we think about the aging baby boomer population. I don’t have numbers off of the top of my head, but I’m sure you can imagine that the dollar signs (spent simply on appointments for a physician referral to an audiologist) will really start to stack up. And let’s not forget the inefficiency in care and the inconvenience for so many patients. In fact, audiologists do not receive any monetary benefit from passing the Direct Access bill – it is really about efficiency and quality of healthcare services.
All of this being said, your next question is probably along the lines of – well, what can we do about it? Glad you asked! What we need is support from the general population for this bill. If Members of Congress begin to recognize that more of their constituents are interested in and passionate about a particular bill, they start to pay attention. Fortunately or not, audiology is a (relatively) small profession. Our membership numbers and dollars raised are very small when compared to larger organizations such as the AAO-HNS. We need all of the support we can get from audiologists and non-audiologists alike.
That’s where you come in! There are many easy ways to support Direct Access. By clicking here, you can send an email and/or letter to your representative(s) in support of Direct Access in literally a matter of minutes. If you’re feeling particularly civic-minded, you could even organize a meeting with your respective representative(s) to discuss Direct Access and what it means to you.
If you’re looking for more information about Direct Access is, here are several very helpful/informative links:
As always, questions, comments, etc. are much appreciated!
1. Beck, D. (Interviewer) & Walden, T. (Interviewee). (2011). Direct Access: Interview with Therese C. Walden, AuD, President of the American Academy of Audiology (Interview transcript). Retrieved from the American Academy of Audiology Web site: http://www.audiology.org/news/Pages/20110719.aspx
2. Kochkin, S. (2005). MarkeTrak VII: Hearing loss population tops 31 million people. Hearing Review, 12(7), 16-29.
3. Freeman, B.A. & Lichtman, B.S. (2005). Audiology Direct Access: A cost savings analysis. Audiology Today, 17(5), 13-14.
4. Zapala, D.A., Stamper, G.C., Shelfer, J.S., Walker, D.A., Karatayli-Ozgursoy, S., Ozgursoy, O.B., Hawkins, D.B. (2010). Safety of audiology Direct Access for Medicare patients complaining of impaired hearing. Journal of the American Academy of Audiology, 21(6), 365-379.