Audiology: Audiology: A Profession in TransitionA Profession in Transition

Wayne A. Foster, PhD, CCC-SLP/AChair, Audiology Advisory Council

ASHA Board of Directors

The Field of Audiology

• Heritage of Audiology

• What Makes Audiologists Unique?

• Expansion of Scope of Practice

• Doctor of Audiology

• A Bit on ASHA

• The Future of Audiology

Pre WWII

Physicians, Otologists & Commercial

Dealers

Post WWIIMilitary Aural

Rehab Centers

Heritage of Audiology: Evolution

� Harvey Fletcher

� Hallowell Davis

� Raymond Carhart

� Norton Canfield

� The Ewings (Alexander & Ethel)

� André Djourno

� Georg von Békésy

� Peter Dallos

� James Jerger

Heritage of Audiology: Foundational Figures

Heritage of Audiology: Technology Can you remember?

1st cochlear implant

ABR technology

OAEs were identified

1st BTE introduced

Middle ear function was measured

Heritage of Audiology: Breakthroughs

• These three advances were critical:

� Assess Middle Ear Function (Tympanometry)

� Assess Cochlear Function (Otoacoustic Emissions - OAE)

� Assess Retro Cochlear Function (Auditory Brainstem Response - ABR)

What Makes Audiologists Unique?

• Scope of practice

� Evidence-based research

� Doctoral degree required

� Clinical care

• Life-changing profession

Practice areas that overlap other disciplines•Intraoperative Monitoring•Vestibular Assessment/Rehab•Cerumen Management

Speech-

LanguagePathology

Audiology

Scope of Practice

Human Communication

• Expanded curriculum to cover increased scope of clinical practice

• Incorporated clinical work throughout the course of study

• Value of doctoral education is learning how to problem solve(must be adaptive)

Must evaluate program of study and clinical experience

related to long-term career path.

Audiology Doctoral Career

• More than 150,000 members

• World’s largest association of audiologists(Over 14,000)

• Dedicated to advancing audiologyas a profession

� Advocating for the professional

� Public education

� Credentialing

� Audiology Resources

A Bit on ASHA A Bit on ASHA: Advocacy

• The audiology/SLP seat at the table with the Center for Medicare and Medicaid Services (CMS).

• Since 2003, 11 codes approved for audiology

• Medicare Audiologic Rehabilitation Act (2003)

• Medicare Hearing Health Care Enhancement Act (2007)

• Funding – for industry research and policy initiatives

• Spearheading collaborative efforts

• “Better Hearing and Speech Month”

• “Listen to Your Buds”

• Americans with Disabilities Act (ADA)

• Individuals with Disabilities Education Act (IDEA)

• Universal Newborn Hearing Screening (UNHS), and Early Hearing Detection and Intervention (EHDI)

• Classroom Acoustics

• Healthy People 2020

• Consumer Helpline

A Bit on ASHA: Public Awareness

• Technical Assistance• Publications and Web Site (www.asha.org):

� 4 scholarly journals, including American Journal of Audiology

� Audiology Connects and Access Audiology

� The ASHA Leader

� Articles and practice policy documents

• Special Interest Divisions• Career & Business Development:

� EdFind

� Career Mover CD

� Online Career Center

� ProSearch

Audiology Resources

• Governance: Audiologists have equal voice� Same number of profession-specific positions on the

Board of Directors

� Audiology Advisory Council

• Professional Development� Research

� Annual Convention & Conferences

� Continuing Education

• ASHA Foundation, Travel AwardProgram & Scholarships

• Member Discounts

ASHA Offers

• What if…� Hair cell replacement supplanted hearing aids?

� Medicare benefits expanded to include diagnostic services?

� Genetic breakthroughs prevented hearing loss or restored hearing?

� Telepractice by audiologists became widespread?

� Medicare paid for hearing aids?

• What would this mean for the field?

The Future of Audiology

Basic Board StructureBasic Board Structure

National Office

President Vice Presidents Advisory Council

NSSLHA

CEO President Science & Research Chair: Audiology National Advisor

Past President Planning Chair: SLP

President Elect Standards & Practice: Aud

Standards & Practice: SLP

Academic Affairs: Aud

Academic Affairs: SLP

SLP Practice

Aud Practice

Finance

Government Relations & Public Policy

Committee/Boards/CouncilsCommittee/Boards/Councils

Board of Directors

National Office

Advisory Council Chairs

Vice Presidents

CBC CBC CBC CBC CBC

Advisory Councils

Governance Restructure in 2008

� Eliminated the Legislative Council (LC)

• Voting body

• State representatives

• Number of representatives determined by number of ASHA members in the state

� Advisory Councils

• One SLP and one Audiology member per state

• Not “representing” the state

• Reflection of broad array of work sites and areas of expertise (Note: 25% are private practice/dispensing audiologists)

• Provides advice to the Board of Directors

SLPAC and AAC: 2012

March AC Meeting: Face-to-Face

ASHA Collaboration Site: Monthly Interactions

Provides input to BOD and responds to targeted questions.

Specific Issues Facing Audiologists

What is Direct Access?The ability to see a patient without a referral from a

physician or other health care provider.

Client Physician Audiologist

Direct Access to Audiologist

Current Status for Audiology ServicesImpact on Clients and Clinicians

� Limits beneficiary choice of providers

� Increases costs to Medicare program

� Increases wait time to see an Audiologist

� Inefficient use of physician resources

� Administrative burden on audiologists to track down referral if patient comes in without one

Current Medicare Policies

Audiometric Testing

� Audiology services are recognized for Medicare purposes as a diagnostic test under the Social Security Act (Sec. 1861 (s)(3))

� Regulations require that diagnostic tests be ordered by a treating physician for the purpose of using the results of the test in the management of the beneficiaries’specific medical problem. (42 CFR 410.32)

� What is an audiologist in the current CMS service provider paradigm?

� EVERYONE recognizes this as a problem!

Current Medicare Coverage

Audiology Services

� Testing must be for:

� obtaining additional information necessary to make a diagnosis

� evaluation of the need for the appropriate type of medical or surgical treatment of a hearing deficit or other medical problem.

� Audiology services are not covered when the diagnostic services are furnished only to determine the need for a hearing aid.

� Rehabilitative services are NOT covered.

Medicare Direct AccessWhat it would mean for Audiologists

� Beneficiaries could go directly to an audiologist.

� Audiology will remain a diagnostic benefit.

� Medicare will not pay for services deemed not medically necessary or can be perceived as a screen.

� Need to develop additional education of patients on Medicare coverage policies and exclusion of audiology

services related to hearing aids.

Direct Access to AudiologistsLegislation

H.R. 3024 “Medicare Hearing Health Care Enhancement Act of

2009”• Section 3: Allows Medicare beneficiaries direct access to an

audiologist• Section 4: Defines audiology services as a diagnostic benefit

• Section 5: Nothing in the act will expand scope of audiology services for which payment can be made under Medicare

Prior to 2009 ASHA backed the Direct Access approach. (Members of the

GRPP Board presented at the ASHA Convention on this issue.)

Direct AccessCMS Report

� In the 2010 Medicare Physician Fee Schedule final rule, CMS stated that it will not reimburse any audiology service that can be construed to have an evaluation and management or therapeutic component.

� Impacts tinnitus code, auditory rehabilitation and cochlear implant codes.

� CMS made this ruling based on the fact that audiology

services are covered as part of the diagnostic benefit.

Comprehensive Audiology BenefitCost/Fiscal Impact on the Medicare Trust Fund

� CMS had indicated concerns with increased cost

� Historically Congressional Budget Office (CBO) factors

in woodworking effect*.

� No concrete data on cost of direct access or comprehensive benefit

� High cost requires an off-set in the Medicare program

* Woodworking Effect: If benefit is available –more

providers will enroll and beneficiaries will access.

Direct AccessPotential Solution to CMS Concerns

Comprehensive Audiology Benefit� Work with Congress to define in statute a

comprehensive audiology benefit that would include both diagnostic and therapeutic intervention.

� Comprehensive benefit would include direct access to audiology services.

� Not include coverage of hearing aids.

ADA’s 18 X 18 Initiative

� Title XVIII of the Social Security Act amend to provide for the treatment of audiologists as

physicians for the purposes of furnishing services under Medicare. It would also broaden the scope of audiology services. (Limited practice physicians)

� 2018The date by which this initiative would become law

18 X 18

� Allow for Medicare coverage of medically necessary, covered treatment services such as vestibular rehabilitation, cerumenremoval, and aural rehabilitation provided by an audiologist practicing within their state defined scope of practice.

� Eliminate the need for the physician order required for a Medicare beneficiary to receive coverage of medically necessary, covered audiology and vestibular services

� Allow audiologists the autonomy to make clinical recommendations and practice the full scope of audiology and vestibular care as allowed by their state license and as

dictated by their educational requirements and competencies.

ASHA Approach

� Medicare coverage of comprehensive audiology services in coordination with current billing and reimbursement standards

� Be consistent with other non-physician services covered by Medicare.

� Allow audiologists to bill for:� hearing and balance assessment services

� auditory treatment services (including auditory processing and auditory rehabilitation treatment)

� vestibular treatment

� Intra-operative neurophysiologic monitoring

� In addition, audiologists will have the option to opt-out of Medicare.

Issue: Service Provision System of Care

� A goal for the MAJORITY of the people in the U.S. with significant hearing loss -estimated >31 million: with ~24% currently being helped (Kochkin, 2005)

� Un-rehabilitated hearing loss affects individual self actualization/quality of life as well as productivity

� Hearing loss is a personal problem, a family problem, a vocational/avocational problem, a societal problem reducing the capacity of our volunteer/wage earning work force…

Service Provision

Basic Intermediate Atypical

Clinic/Practice

Audiology Technician/Telehealth Follow-up

Audiologist

What we need now……..

� Alternative service delivery models

� National outcome database that drives…..

� Standards of practice (e.g., use of real ear)

� Reimbursement systems that match “real” costs.

Healthcare Summit: 2012

Service delivery systems are being evaluated: The

national healthcare debate is driving

changes that audiologist must be in front of.

Questions or Comments

Telehealth

Practice Models

Reimbursement

Online Purchases

Technological Changes

Bio-medical

Advances

Training of AudiologistsUse of Technicians

Outcomes Based Service

Bundling or Unbundling