Although hearing loss can affect people of any age, it is especially prevalent in the older population. CDC data indicate that it is the third most common chronic health problem,(www.cdc.gov) after hypertension and arthritis, in older adults. Hearing loss affects not only the ability to communicate and function effectively, but also can lead to decreased quality of life and increased risk of depression.
Yet despite its prevalence, research also shows(www.nidcd.nih.gov) that only 10 percent to 20 percent of older adults with documented hearing loss use a hearing aid.
Several factors are thought to explain this gap. Results of a recent study(academic.oup.com) in The Gerontologist pinpoint the role these factors plays in determining whether a person owns or uses hearing aids.
Led by Michael McKee, M.D., M.P.H., assistant professor in the Department of Family Medicine at the University of Michigan Medical School in Ann Arbor, researchers analyzed the records of more than 35,000 participants in the Health and Retirement Study, a nationally representative longitudinal study of older Americans. All participants were 55 or older and reported some degree of hearing loss. To clarify their findings, the researchers also interviewed 21 older adults with hearing loss who lived in the surrounding community.
- A recent study published in The Gerontologist examined the socioeconomic factors that determine whether people with hearing loss own or use hearing aids.
- Insurance coverage, cost, personal wealth and veteran status were among the factors that influenced a person's interest in and ability to obtain a hearing aid.
- Legislation enacted in 2017 has created a new category of OTC hearing aids that is intended to make these devices more affordable.
The study authors found that multiple factors influenced patients' interest in and likelihood of obtaining a hearing aid. Many of these factors were linked to one another:
- Insurance coverage. Most health insurance programs (including Medicare) do not cover hearing aids. Medicaid coverage for hearing aids and related services varies from state to state,(www.hearingloss.org) and private insurance plans may or may not cover hearing aids. As a result, patients typically must pay for these devices out-of-pocket.
- Cost. A single hearing aid can cost more than $2,000(www.hearingreview.com) depending on the technology. Most patients with hearing loss need hearing aids for each ear, along with batteries and other accessories.
- Personal wealth. Individuals whose annual household incomes were in the top 25 percent of the study group were almost twice as likely to use hearing aids as those whose incomes in the bottom 25 percent.
- Veteran status. Military veterans ages 55 to 64 who had hearing loss were more than twice as likely as age-matched non-veterans to use a hearing aid. A likely reason is because veterans who qualify for health care benefits administered by the Department of Veterans Affairs often receive full coverage for hearing aids and accessories.(www.va.gov)
- Personal stigma. Black patients reported the lowest hearing aid use of any subpopulation in the study (18.5 percent). Interviews with black participants indicated a "palpable" stigma associated with hearing loss.
- Vanity. Some female participants expressed concerns about personal appearance as a barrier to hearing aid use. Male patients were more likely to minimize their hearing loss or state that they could function without a hearing aid.
- Relationship with significant others. Family members were considered "important drivers" of whether an individual was tested for hearing loss or obtained a hearing aid. Friends and peers with hearing loss were deemed particularly good resources for understanding how to get tested and obtain some degree of coverage.
The authors provided several recommendations to increase the number of hearing aid users. First, they suggested that policymakers such as CMS consider covering hearing aids for recipients. Second, they suggested additional training for primary care health professionals on the importance of addressing hearing loss, along with enhanced patient education to reduce stigma associated with the condition. Finally, they recommended implementing tailored public service campaigns to improve overall patient acceptance of hearing aids.
Legislation Creates New Category of Hearing Aids
Barriers to hearing aid access have drawn congressional scrutiny in recent years. Most recently, the FDA Reauthorization Act of 2017(www.congress.gov) included a provision that directs the FDA to establish a new category of OTC hearing aids to be used by adults with mild to moderate hearing loss. Specifically, the legislation
- defined what constitutes an OTC hearing aid;
- subjected these products to FDA regulation;
- required the FDA to issue regulations regarding the safety, effectiveness and appropriate labeling of OTC hearing aids within the next three years; and
- mandated that the FDA update and finalize a November 2013 draft guidance document(www.fda.gov) on hearing aid devices and personal sound amplification products (PSAPs).
In addition to defining what this new OTC category of hearing aids should be, the legislation sought to clarify what these devices should not be by emphasizing that PSAPs currently on the market are not included in the new category. (The FDA now has followed suit by recently issuing a letter(www.fda.gov) to hearing aid manufacturers to clarify the status of these products.) This is an important distinction that patients, and even some health care professionals, may not be aware of. Hearing aids are customized to a patient's specific needs and programmed specifically to amplify only the sounds a user cannot hear well, which factors into their cost. PSAPs, on the other hand, are designed to amplify all sounds, which may actually cause more damage(www.connecthearing.com) and further impair hearing in patients who use them.
Study Author Shares Personal Experience
McKee not only is the recent study's lead author, he also has first-hand experience with hearing loss. In an interview with AAFP News, he took time to answer additional questions about the study, the recent legislation, and the difficulties patients face in procuring hearing aids.
Q: How does your personal experience with hearing loss and using hearing aids shape the discussions you have with patients about these issues?
A: I have a congenital hearing loss in both ears as a result of a recessive, nonsyndromic deafness gene. I was fitted with hearing aids when I was a young child, but I later received a cochlear implant on my right ear during my medical residency. The experience growing up with a hearing loss shaped much of who I am as an individual and also generated my passion in helping our patients who struggle from hearing loss, other types of disabilities, or even health conditions. Patients struggling with these issues appear to appreciate having a provider who is empathetic to their needs. They feel more comfortable opening up and even asking personal questions. Some of these questions can be instrumental in helping them move forward with a decision to seek further care for their health issues.
Q: A lot of evidence suggests that hearing loss can affect one's physical and psychological well-being. What else can hearing loss contribute to?
A: Cognitive health is a major concern. Fortunately, there are studies underway to investigate this further. We do believe that by addressing hearing loss we can slow or stop this associated cognitive decline, but this needs to be confirmed. Also, hearing loss is a major contributor to unemployment and underemployment, resulting in significant economic hardships. Lastly, hearing loss can isolate individuals from incidental information, including helpful health information.
Q: What are your thoughts on the provision in the FDA Reauthorization Act that creates a new category of OTC hearing aids?
A: The jury is still out on this. I am hopeful that the act will prompt a lot of disruptive technology to not only make hearing aids cheaper but also more consumer-oriented. We have seen this level of disruptive technology with our smartphones and a variety of apps. … What remains to be seen, though, is whether individuals with hearing loss will have adequate guidance on what over-the-counter types of hearing aids they should acquire.
Currently, consumers purchase hearing aids from audiologists who often provide helpful guidance on the hearing aids they should use. Furthermore, many older individuals need training on how to correctly use their hearing aids, including basic troubleshooting when they don't work. (As the FDA legislation is implemented), there will be a need for consumer guides to help individuals with hearing loss select appropriate hearing aids or assistive devices. Given the speed of technology enhancements, this will need to be updated frequently.
Q: What should family physicians be aware of with regard to PSAPs?
A: I think we will see more of these devices in our clinics and hospitals. For example, devices such as pocket talkers can help make communication a bit easier between clinicians and patients who have milder forms of hearing loss. I don't think they are the answer to everything but could be another strategy to further minimize the communication and health care gaps we currently see among individuals with hearing loss.
Q: If a patient came to you and showed signs of hearing loss, what would your first step be?
A: We encourage all of our clinicians to inquire if their patients above 50 have a hearing loss. This simple question can be quite useful in identifying hearing loss among our patients. Many patients with a hearing loss may not be easily recognized by clinicians. … Once I see someone who does have hearing loss, I recommend them to get a full audiogram. While we do have audiometers, I do not think they are effective screening or diagnostic tools in our clinic. The audiogram from the audiologists can help establish a baseline hearing (level) even if (a patient does) not obtain a hearing aid. It also can help get them more aware of their hearing loss and how they should prepare going forward.
Q: If a patient cannot afford hearing aids, what other options are available?
A: This depends on where you reside. There are charitable organizations who may assist with hearing aid acquisition. Audiologists often will know if there are discounts or financial assistance with hearing aid companies, as well. Vocational rehabilitation can sometimes help too. Unfortunately, in most cases, people struggle due to (hearing aid) costs.
Related AAFP News Coverage
CDC Vital Signs Report
Family Physicians Can Help Patients Limit Hearing Loss
More from AAFP
American Family Physician: Geriatric Assessment: An Office-Based Approach
FDA: Status on Over the Counter (OTC) Hearing Aids(www.fda.gov)