When asked to write the ‘PRO” column favoring integrating hearing services into an ophthalmology practice, I knew that it would receive pushback; most shifts in major medical paradigms do. This occurred when ophthalmologists integrated optical retail services into their practices; when optometrists were welcomed into ophthalmic practices, and when ophthalmologists were amongst the first to market and advertise their services. There was tremendous argument on both sides of these issues which now are commonplace and in standard practice around the country. Much of the resistance comes from lack of understanding and fear that these changes will adversely affect quality of patient care, the profitability of the other physicians or both. An in-depth conversation with a highly respected, now retired, ENT physician in Kansas City revealed that he was one of the first to incorporate hearing/audiology services in his ENT practice. For this he received considerable criticism. Now these practices are routinely provided by most ethical ENT practices.
Nationally, there are currently 140 ophthalmic practices that have integrated hearing services, with two to three new practices each month adding to this total. The state licensing of the hearing specialists/audiologists employed and the quality of the equipment used to perform hearing tests are exactly the same as those in ENT offices, or audiologists who own their own practices, or are employed by large retail chains. Under Obama’s Affordable Care Act, primary care is now required to at a minimum review vision and hearing.
And ophthalmologists are not alone. There are many primary care physicians around the country that have set up a hearing testing facility within their practices. In these instances neither the primary care physician nor ophthalmologist are acting as a pseudo-ENT. Most do not get involved in the evaluation or diagnosis at all. Our patients are initially informed that we are not ‘ear doctors’ and we will refer them to trusted ENT colleagues if the results of their testing warrants. Before building a hearing center, we rarely referred patients to an ENT physician. Last year, we referred 40 patients, and 10 patients in the first quarter of 2013. Most tested patients require no further evaluation, nor do they need hearing aids. Most of the patients we test would not self-refer to an ENT, audiologist nor be referred by their primary care physicians. Our center represents an entry point for a largely neglected or over-looked cohort of patients.
The result of our testing might disclose:
Tested No Hearing Loss. Upon completion it is noted that that patient has hearing levels acceptable for their age and there is no further action.
ENT Referral: The licensed hearing professional is trained and certified under state guidelines to determine the need for an ENT referral. When a patient answers key questions consistent with a need for a medical referral, they are immediately referred.
Treatable Loss: When a patient would benefit from the latest advancements in hearing instrumentation the licensed hearing professional provides those options.
At no time is the Ophthalmologist looking in ears or treating any form of hearing loss. Patients who do not address concurrent diminished vision and hearing health can suffer from withdrawal, depression and in some instances, a higher mortality rate. As physicians, we often recognize conditions outside our area of expertise and make timely and appropriate referrals. Ophthalmologists are in an ideal position to find other health problems, such has hearing disorders, because older adults visit eye care practices three times more per year than any other healthcare provider. It is this opportunity to find otherwise undetected hearing loss or ENT pathology that was the premise for adding hearing services to our ophthalmic practice.
Is there a revenue opportunity that supports the added clinical care and no cost screening/diagnostic work up? Yes, there is. It is modest by any standard. It was the suggestion and request of a number of our patients that led to the integration of hearing services into our practice. As I learned more of the overlap of conditions (macular degeneration, glaucoma, and diabetes) that we as ophthalmologists treat which includes a high proportion of patients with hearing deficits, this integration made even more sense. I would welcome ENT colleagues performing on their patients simple eye screening such as visual acuity or tonopen intraocular pressures to identify potential undiagnosed ophthalmic pathology.
We must not be afraid of ethically incorporating ancillary services into our respective practices which will benefit our patients; nor should we be embarrassed about modestly profiting from them.