Generally, when legislation affecting hearing healthcare is proposed, people with hearing loss and the entire industry either oppose it or stand behind it – as was the case with the hearing aid tax credit, for example. However, in the case of the Medicare Hearing Health Care Enhancement Act of 2007 (H.R. 1665/S.2352), there is both support and opposition among hearing healthcare professionals. In the Fall 2007 issue, Hearing Health ran a brief article entitled, “Common Sense Legislation.” The article, like all our content, was not intended as an endorsement by the Deafness Research Foundation or Hearing Health magazine, but rather as information for people with hearing loss about issues that affect them. We were soon made aware of the opposition to the bill, and have decided that in fairness to people with hearing loss, we will revisit the topic of H.R. 1665/S.2352 with representation from both sides of the issue.
-The Editors
Medicare Hearing Health care Enhancement Act of 2007-
H.R. 1665/S. 2352: Two perspectives
By David R. Nielsen, M.D., FACS, Executive Vice President, CEO, American Academy of Otolaryngology—Head and Neck Surgery
The article “Common Sense Legislation” from the Fall 2007 issue of Hearing Health called H.R. 1665/S. 2352, the Medicare Hearing Health Care Enhancement Act of 2007, “hearing-friendly legislation,” citing findings presented by the bills’ advocates in the House of Representatives. However, another significant contingency – ear, nose and throat specialists and head and neck surgeons – holds a different view.
The American Academy of Otolaryngology—Head and Neck Surgery is strongly opposed to the Medicare Hearing Healthcare Enhancement Act. This unwise legislation would permit audiologists direct access to Medicare beneficiaries without a physician’s referral, thereby removing the physician from the initial medical evaluation and diagnosis of the patient. Because many causes of hearing loss may be the result of, or related to, an underlying medical problem, the patient is best served by having a full clinical evaluation prior to receiving professional audiology care. Those who introduced this legislation claim its goal is to expand access to care. However, if enacted, Medicare patients would be equally likely to suffer delays from misdiagnoses, inappropriate treatment, unnecessary testing and possibly be denied access to recent advances in the medical treatment of hearing loss.
“Common Sense Legislation” noted that the Department of Veterans Affairs and the Office of Personnel Management allow veterans and federal employees direct access to audiologists; however, Medicare cannot be so compared to the Veterans’ Health Administration (VHA) and Federal Employees Health Benefit (FEHB) plans. In a recent report to Congress, the Centers for Medicare & Medicaid Services (CMS) stated that Medicare is “distinctly different” from the VHA and FEHB plans because the benefit package is pre-set, healthcare providers are paid on a per-service basis, and hearing aids are not covered by the Medicare program. In contrast to Medicare, the VHA employs its own healthcare professionals and does not pay on a per-service basis. Further, the FEHB plans consist of an assortment of individual private health plans that have the flexibility to design benefit packages, so not all FEHB plans allow direct access to audiologists.
According to the recent report by CMS, in order to ensure that Medicare pays for what is reasonable and necessary, all diagnostic tests must be ordered by the patient’s physician. CMS emphasized that the physician referral requirement is “the key means by which the Medicare program ensures that beneficiaries are receiving medically necessary services, and avoids potential payment for asymptomatic screening tests that are not covered by Medicare.” In fact, CMS has stated that direct access to audiologists under the Medicare program “could have significant adverse legal, regulatory and budgetary consequences.”
While audiologists are valued health professionals, many of whom work in concert with otolaryngologists on a daily basis, they do not possess the medical training and expertise necessary to perform the same duties as physicians. The American Academy of Otolaryngology—Head and Neck Surgery has taken an active stance against H.R. 1665/S. 2352 and believes that the legislation would be harmful to Medicare patients if enacted.
By Alison M. Grimes, Au.D., President, American Academy of Audiology
We applaud “Common Sense Legislation” published in the Fall 2007 issue of Hearing Health referring to the “common sense” Medicare Hearing Health Care Enhancement Act of 2007 (H.R.1665/S. 2352) introduced in the United States House of Representatives and subsequently in the Senate. It is the patient’s perspective that is the centerpiece of this legislation, which allows an additional avenue for Medicare beneficiaries to obtain hearing healthcare. That is why the legislation is supported by leading deaf and hearing loss consumer organizations including the Hearing Loss Association of America, the National Association of the Deaf, the American Tinnitus Association and the American Association of People with Disabilities.
Thirty one million Americans experience some degree of hearing loss and that number is expected to increase to 78 million by 2030. Hearing loss is one of the most common conditions affecting older adults, with approximately 33 percent of Americans aged 60 and older and 40 to 50 percent of those aged 75 and older with hearing loss. Currently, Medicare requires beneficiaries with hearing loss or balance problems to obtain a physician referral before undergoing a diagnostic hearing evaluation by an audiologist. Hearing loss among the Medicare population is under-diagnosed and under-treated. If Medicare beneficiaries could go directly to an audiologist, more individuals with hearing loss would obtain the tests they need and the treatment to help them maintain independent lifestyles and continue to function in society. Untreated, hearing loss can also lead to depression, isolation and in come cases, dementia in senior citizens. This bipartisan legislation would improve Medicare beneficiaries’ access without expanding the list of services covered by Medicare or broadening the scope of practice of audiologists. Moreover, Medicare currently allows beneficiaries direct access to a range of non-physician practitioners including optometrists and clinical psychologists.
Opponents of this legislation have made statements implying that Medicare beneficiaries may not receive proper treatment for medical conditions by going directly to an audiologist without first seeing a physician. This is simply not true. In the beneficiary’s initial visit, the audiologist will take a case history, perform an otoscopic examination of the ear and conduct a hearing evaluation. If the history, otoscopic examination or hearing evaluation reveals a condition requiring medical attention, the audiologist will refer the beneficiary to a physician. Medical “red flag” conditions (such as active drainage, pain or discomfort in the ear, sudden hearing loss, etc.) are well known to audiologists. Based on their training and practice guidelines, audiologists will refer the appropriate patients for a medical evaluation. This will allow the beneficiary improved access to safe, appropriate hearing healthcare without the unnecessary burden and expense to the patient of an initial physician visit and the additional cost to the Medicare program to obtain a hearing test.
After more than 10 years of experience with direct access to audiologists, the Department of Veterans Affairs has concluded that this policy provides “high-quality, cost-effective and successful hearing healthcare to veterans.” Members of Congress, in addition to all federal employees, have direct access to audiologists without referral through the Federal Employee Health Benefits Plan. Under the Medicare program, seniors do not have this same benefit. Shouldn’t the most vulnerable of our society in the Medicare program with the highest incidence of hearing loss have the same choice to access audiology services? The bottom line is that this “common sense” legislation would establish parity between Medicare and other fedearal and private sector health plans and improve Medicare beneficiaries' access to much needed hearing health care services.
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