Barriers to Hearing Health Care for Aging Adults: Reframing the Conversation

Abstract

Untreated age-related hearing loss (ARHL) is associated with poor health and social outcomes. Treating hearing loss can mitigate these serious issues. Although there are documented barriers to care, we can look at these barriers and potential solutions differently if we view ARHL as a gradual onset, chronic condition. This provides a framework from which to solve problems in line with how other chronic health conditions experienced by aging adults are approached. With this lens, it becomes evident that early identification and treatment of ARHL can be supported by universal senior hearing screening, appropriate Medicare coverage for devices and services, and direct access to audiological care as well as avenues for self-care are necessary ingredients to change the hearing health care landscape.

Translational Significance: Age-related hearing loss (ARHL) is a risk factor for poor health and a threat to social participation. ARHL should be reframed as a permanent chronic condition characterized by gradual onset with an expected progression over time. This effort will require substantial changes in hearing health care: (a) universal screening linked to primary care and annual Medicare wellness visits, (b) greater insurance access to audiology services to diagnose and treat ARHL, and (c) ready access to simple technologies (such as an amplifier) during health care visits. This reframing would substantially enhance late-life function and well-being.

Hearing loss is the third most common physical condition in aging adults after arthritis and heart disease (1). Two-thirds of individuals over 70 years of age are expected to have age-related hearing loss (ARHL) (2). Only 18% of aging adults obtain treatment for their hearing loss, which typically would include hearing aids and the necessary services required for optimal use, such as verification of audibility and rehabilitative hearing care (3). Untreated ARHL is associated with a variety of poor health outcomes including increased risk of falls (4,5), cognitive decline (6–8), depression (8), anxiety (9), medical adverse events (10), hospitalization (11), readmission to the hospital (12,13), dissatisfaction with health care encounters (14,15), and social isolation (16,17). Importantly, treating hearing loss in older adults is associated with positive health and social outcomes including reduced risk of falling (18), cognitive decline (19–21), hospitalization (11,12), incidence of depression (22–24), and anxiety (25). Treatment also fosters increased social participation (6). Social participation is a critical determinant of healthy aging (26–29). Consider the individual who becomes more socially engaged when their ability to hear and communicate improves through audiological treatment. This individual may join friends for daily walks thereby improving strength and decreasing risk for other chronic medical conditions. This increased engagement potentially sustains cognitive health and staves off depression. Addressing ARHL can be a catalyst for a myriad of positive health effects. Together, it is estimated that untreated hearing loss results in 3 billion dollars in excess expenditures per year (eg, increased falls, hospitalizations, cognitive decline, depression) for individuals over 65 years of age (30). This does not include the cost of decreased quality of life for individuals and their families or other indirect costs such as lost wages, lost productivity, and caregiver costs (30,31). Untreated hearing loss is a public health concern. Common barriers that are cited when discussing lack of uptake of hearing health care include denial of hearing loss, cost of treatment, and a complicated pathway to care (32). It is time to reframe this discussion in the context of ARHL as a gradual onset, chronic health condition. To address this issue, we may consider a shift from the current narrow focus on an individual person to a broader, public-health-focused approach of serving the aging community as a whole and maximizing benefits for as many as possible (33).

Denial of Hearing Loss (The Case for Hearing Screening)

Approximately 98% of newborns in the United States and associated territories (34) are screened for hearing loss while still in the hospital with a resulting 2–3 out of every 1 000 of these infants identified as having hearing loss (35). The case for infant newborn screening is clear and meets all of the requirements for screening (36), including those listed in Table 1.

Table 1.

What Makes a Screening Exam “Good?” Adapted from Herman, 2006 (36)

	Criteria
The disease in question should:	Constitute a significant public health problem, meaning that it is a common condition with significant morbidity and mortality
	Have a readily available treatment, potential for treatment, or an effective management strategy that increases with early detection
The test for the disease must:	Be capable of detecting a high proportion of disease in its preclinical state
	Be safe to administer
	Be reasonable in cost
	Lead to demonstrated improved health outcomes
	Be widely available, as must the interventions that follow a positive result

In 2021, the U.S. Preventive Services Task Force reviewed the evidence for adult hearing screening and found that the evidence was insufficient to warrant a recommendation for screening at this time (37). This was not a negative recommendation related to screening, but rather a call for the needed studies that evaluate the impact of screening on access to intervention. The same rigorous work that was done to develop the case for universal newborn hearing screening is needed in this arena.

Approximately 23% of adults had their hearing screened at their last physical despite the Center for Medicare and Medicaid Services (CMS) adding hearing screening to the “Welcome to Medicare” guidelines that should be followed during the routine visit when an individual turns 65 years of age (38). By contrast, 74% of adults have their eyes examined every 2 years and 63% of adults visit the dentist annually. This could be interpreted as a lack of urgency related to identifying untreated hearing loss, although there are other factors that may impact the completion rate of the Medicare Initial Preventive Physical Exam (IPPE) hearing screening. This exam is included for beneficiaries of Medicare Part A and Part B (39) (ie, Medicare Part C beneficiaries do not receive this examination, so not all Medicare beneficiaries are eligible for it). Additionally, although the IPPE does include a component related to functional ability and safety level that warrants an evaluation of their hearing, there are no specific instructions related to how that evaluation may be completed (40). Ultimately, examiners are expected to use questions or questionnaires that are recognized by a national medical professional organization and complete a referral for further evaluation if it is warranted (41). In many cases, health care providers expect individuals to self-identify if they have hearing loss.

Mormer et al. provided some of the first data that specifically examined whether aging individuals could accurately self-identify hearing loss (42). Rather than denying hearing loss, it was evident that 40% of these individuals did not realize they had hearing loss, which is consistent with a gradual, chronic health condition that does not cause pain or outward physical symptoms. Interestingly, in this sample, only 50% of healthcare providers accurately identified when a patient they were interacting with had hearing loss. In a large-scale survey, Edwards further identified groups who recognized they had hearing loss with some taking action and some choosing not to take action (potentially denying the problem) as well as a group that did not recognize they had hearing loss (43). The data reported by Edwards reveal that the vast majority of individuals with ARHL fall into the group who do not realize they have hearing loss.

Considering available data related to the consequences of untreated hearing loss and the inability of the majority of individuals and/or healthcare providers to accurately identify hearing loss within a physical examination, universal senior hearing screening is indicated. ARHL meets the criteria for screening (36), but the current challenge is innovating simple, affordable, scalable mechanisms for hearing screening and implementing this practice in primary care settings. An important by-product of hearing screening in healthcare settings is that management strategies (eg, use of amplifier and/or effective communication methods during episodes of care) can be applied in real-time and can positively impact the healthcare interaction as well as provide a pathway to timely identification and referral for treatment.

Cost of Hearing Health Care

Most media interviews related to access to hearing health care lead with “Why are hearing aids so expensive?” The interviewer provides the most recent average price of hearing aids, which is approximately $4 500 (44–47). The interviewee starts by explaining that the price associated with hearing aids typically represents a bundled price that includes the cost of the 2 devices along with all of the associated care to select, fit, and maintain the devices and support appropriate adaptation and use over a 2- to 3-year period. Given that hearing loss is a chronic condition, hearing aids have a life expectancy of 5–7 years, and hearing aids are excluded from Medicare coverage, hearing aids will be the third largest expense over most individuals’ lifetimes following the cost of a home and automobiles (47). When we place ARHL in the proper context of a chronic health condition, it is clear that the lifetime cost of ongoing treatment is low compared to other chronic conditions such as diabetes, hypertension, and arthritis (48–50). The difference is that the treatment for these conditions is covered by Medicare and not borne by the individual. A private expense of $4 500 every 5 years is expensive and out of reach for the majority of individuals—but not for Medicare. This becomes especially true when one reviews the positive impact of treatment on falls, cognitive decline, depression, etc. where medical cost savings can be expected (51). Audiologists provide Medicare-covered services under the auspices of “other diagnostic tests” as defined in the Social Security Act. Audiologists designated as diagnosticians results in Medicare’s stance of “no provision for payment to audiologists for rehabilitative aspects of hearing health care, including rehabilitative services and hearing aid devices” (52). Thus, audiologist participation in the Medicare program is limited to services that are diagnostic in nature, not rehabilitative. The Centers for Medicare and Medicaid Services would have to amend their Medicare Benefit Policy Manual to add these services and devices to their coverage policies.

Some may be concerned about the costs related to adding coverage for hearing aids and rehabilitative services to the Medicare program. However, recent data indicate that, even when the cost of hearing aids is included within the general health system (eg, in countries such as France or Germany, where 89% and 94% of survey respondents, respectively, reported that total or partial costs related to hearing devices were covered for them), the hearing aid adoption rate does not exceed 45% (52,53).

Untangling a Complicated Treatment Pathway

Currently, under most circumstances, a Medicare beneficiary must obtain a physician order for their hearing test to be covered by insurance for the purpose of diagnosing hearing loss. Hearing tests for the purpose of obtaining, fitting, and adjusting hearing aids are not covered. If the hearing test reveals that the individual is a candidate for hearing aids and related services, in most states, a physician is required to medically clear the individual. This requirement is dictated by each individual state and is not legislated at the federal level. Zapala and colleagues provide compelling evidence from the Mayo Health System supporting the safety and efficacy of an individual reporting directly to audiology for diagnostic testing and treatment (54). There were no instances when a medical referral was indicated where it was not made by the audiologists (N = 352). Other data from this study indicated that 78% of the cases reviewed only needed to be examined by an audiology provider (ie, the majority of individuals did not require medical otologic care, N = 1 198). Once again, state and federal legislative changes are required to remove these barriers to care which potentially result in 2 extra appointments and co-pays for Medicare beneficiaries.

Over-the-counter (OTC) and prescription hearing aids were differentiated through Food and Drug Administration rules in October 2022. The goal of this change in regulation was to create a new classification of hearing aids distinct from prescription hearing aids that could be obtained direct-to-consumer without the need for the involvement of a licensed professional. The OTC classification is indicated for adults 18 and older with perceived mild-to-moderate hearing loss. At the time of the writing of this article, there were over 100 companies making more than 1 000 OTC hearing aids. Currently, there is no way for a consumer to navigate through all of these choices in a manner that will lead to a manageable set of devices that should meet their needs (55). At this time, OTC hearing aids have fallen short of improving access, but this self-care pathway is new and we may see a change in uptake as innovative solutions that support consumers in navigating these choices are introduced.

Urgency to Action

The negative health and social outcomes associated with untreated hearing loss should create urgency to action in primary health care settings that support older individuals. Although ARHL is expected, it is not benign. Audiologists need to partner with primary healthcare providers to create opportunistic screening, offering a test for a disorder of which the individual is unaware at a time when a person presents to a doctor for another reason. Primary healthcare providers need to have the resources to help guide their patients to appropriate care, whether that is the individualized testing and care provided by an audiologist or self-care that can be pursued through OTC products. Ultimately, until we see changes in the policies dictating Medicare coverage and reimbursement of relevant services, improved methods for and access to universal screening programs, and ways to successfully partner with primary care physicians who can encourage their patients to pursue hearing health care, age-related hearing loss will continue to be a public health concern.

Funding

None.

Conflict of Interest

The first author is involved in the development of a simple, low-cost hearing screener/amplifier that can be used in healthcare settings.

Data Availability

This article does not report data and therefore the preregistration and data availability requirements are not applicable.