Hearing Tests in Ophthalmology Offices? I Don’t Like the Sound of That!

It Use To Be: Eyes-Ears-Nose & Throat (EENT)

The fields of otolaryngology and ophthalmology have a long and illustrious history together. In 1896, Dr. Hal Foster organized a meeting in Kansas City, Missouri, for practicing ophthalmologists and otolaryngologists. This two-day meeting led to the formation of the Western Ophthalmological, Otological, Laryngological, and Rhinological Society which soon thereafter would become the more familiar American Academy of Ophthalmology and Otolaryngology. This society would pioneer the establishment of the first two American specialty boards: the American Board of Ophthalmology in 1917 and the American Board of Otolaryngology in 1924.

The Academies remained unified until 1977, when it was determined that the growing and diverse needs of Ophthalmology and Otolaryngology would be better served by separate Academies. The American Academy of Ophthalmology and the American Academy of Otolaryngology-Head and Neck Surgery have since been separate.^1,2 Otolaryngologists undergo at least five years of residency training, a significant portion of which is devoted to examination and care of the ear.

Missouri Law on Hearing Testing

In Missouri, hearing aids are sold by physicians’ offices, independent audiologists and hearing aid dispensers in free-standing clinics (see Figure 1). In Missouri, “only a Missouri Hearing Instrument Specialist licensee is allowed to recommend a particular device or assist with the selection of a hearing instrument for a patient,” as set forth by the Board of Examiners for Hearing Instrument Specialists of the Missouri Division of Professional Registration.³ As of January 1^st, 2013 to obtain a Missouri Hearing Instrument license in the state of Missouri, one will be required to have associate degree or higher in hearing instrument science or a masters or doctoral degree in audiology.⁴

Figure 1.

Physicians are exempt from this regulation, and therefore any physician, irrespective of training, is permitted to fit and dispense hearing aids in the state of Missouri without licensure.³ Physician offices which sell hearing aids in Missouri are predominantly otolaryngology practices, in conjunction with licensed Hearing Instrument Specialists. A study by Consumer Reports in 2009 examined and evaluated multiple models of identifying, evaluating and treating hearing loss and determined that the best value for patients from a cost and quality standpoint was provided by a combined practice of an audiologist and an Otolaryngologist.⁵

Marketing of Hearing Services to Ophthalmologists & Primary Care

Recently, medical specialties other than otolaryngology (mainly ophthalmology and secondarily primary care practices) have begun performing audiometric testing and fitting hearing aids.^6,7,8 Several such ophthalmology practices are currently advertising the sale of hearing aids.^6,7,8,9 To facilitate the sale of hearing instruments by practices that have previously not offered hearing services, corporations such as Physician Hearing Services, Inc., have become more prominent.^7,8,10 This corporation offers a “turnkey” hearing services program designed to take advantage of an alternative revenue stream that is not dependent on third party insurance.^8,10

Why are practitioners willing to sell hearing aids given the significant potential for medicolegal risk and extended patient follow up? The answer is simple: hearing aids can be a lucrative source of income.⁷ Unlike most advanced economies, private insurance and Medicare do not provide hearing aid benefits. Therefore, in the United States hearing aids are generally a cash business. Because the pricing rates for hearing aids are outside of the regulation by private insurance and Medicare, they can be subject to significant markups.

This development has garnered the attention of both the American Academy of Ophthalmology and the American Academy of Otolaryngology in recent years. Dr. Zacks, Chair of the American Academy of Ophthalmology’s Ethics Committee in 2009, stated that, “Ophthalmologists, by reason of their education, training and experience, are best qualified to treat diseases of the eye and the ocular adnexa. We can’t have ophthalmologists representing that the medical services they provide are identical to those of someone who, by training and experience, practices otolaryngology.”⁶

David Nielsen, MD, Executive Vice President and CEO of the American Academy of Otolaryngology-Head and Neck Surgery, raised the question of optimal quality of care for patients during an interview when he offered that “Selling hearing aids as a revenue generator, without the clinical experience, training and equipment to examine the ear, hearing and balance function, and oversee the medical aspects of diagnosing hearing loss, is less than optimal care.”⁶

When hearing aids are sold and dispensed in conjunction with an otolaryngology practice, the patient first receives audiometric evaluation followed by otologic evaluation. Most otolaryngologists have a microscope in the clinic which greatly facilitates cerumenectomy and thorough ear examination. Many cholesteatomas are quite difficult to see with the hand held otocscope, making diagnosis by non-otolaryngologists difficult. Audiometric evaluation allows the office to determine the type and severity of hearing loss, while the otologic evaluation, in conjunction with the data obtained from audiometry, allows the otolaryngologist to determine if the patient is an appropriate candidate for a hearing aid.

This initial otologic exam serves to exclude more serious underlying pathologies, such as cholesteatoma, vestibular schwannoma or cerebrovascular disease, as the causes of hearing loss. Missing any of these serious diagnoses can not only put the patient at medical risk, but may also place the hearing aid dispenser at medicolegal risk. These are major risks as failure to diagnose an acoustic neuroma in a timely fashion can limit a patient’s treatments options and cause undue morbidity. Such a case of delayed diagnosis, Ebin v. Kimmelman returned a verdict of $2 million for the plaintiff in 2002. A Google search with key words “ophthalmology hearing aid” returns with a link for a personal injury firm as the first search result. Missouri non-otolaryngologist dispensers may be a particular target of interest for trial attorneys with the lifting of the $350,000 non-economic damages cap by the Missouri Supreme Court in August of 2012.

When hearing aids are dispensed in the office of an otolaryngologist, device selection, hearing aid fitting and follow up are performed by the hearing aid dispenser or audiologist only after this initial otologic assessment. Unlike most eye glasses, hearing aid devices require a substantial amount of follow up. At first, follow-up appointments primarily focus on mechanical and physical alterations to the hearing aid device itself. However, prolonged care is also required. Patients who wear hearing aids experience cerumen impaction and otitis externa at a significantly higher rate than the general public due to stimulation of the cerumen glands and mechanical obstruction by the hearing aid.^11,12 Cerumen removal is easily accomplished in the otolaryngology office under binocular microscopy.¹¹ Cerumen itself can greatly reduce the effectiveness of the hearing aid. Cerumen impaction can limit hearing aid performance by up to 40 dB.¹² Hearing aid manufacturers indicate that 60–70% of hearing aids sent for maintenance are done so because of the effects of cerumen.¹¹ The requirement for initial and maintenance otologic care are not adequately satisfied by those specialties outside of otolaryngology.

Conclusion: Not in the Patient’s Best Interests

While dispensing of hearing aids by a physician other than an ENT in Missouri is legal; we have demonstrated that such practice is not in the best interest of the patient nor of the untrained physician dispenser.

Biography

Martin E. Anderson, Jr. MD, (left) and Anthony A. Mikulec, MD, MBA, (right) are in the Department of Otolaryngology at Saint Louis University School of Medicine.

Contact: mander71@slu.edu