DOCUMENT 4 FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only

Are Hearing Aids Everyday Equipment?

The content of this document is OFFICIAL. Please note: The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice. The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.

Research Questions: The project does not comprise of one broad research question. Instead, it comprises of 10 specific shorter research questions. The 10 research questions are: • “What is the evidence that 1 in 6 Australians have a hearing loss?” • “Hearing loss increases as age increases. What is the percentage of Australians with a hearing loss between 26 and 65 years of age?” • “How many Australians use a hearing aid?” • “Is the use of a hearing aid as common as the use of a walking stick?” • “Have there been any AAT cases about access to the scheme and hearing loss? If so, could you please provide a summary of why someone did NOT gain access to the Scheme?” • “How many participants whose primary disability is hearing impairment are meeting the criteria and gaining access to the system?” (Instigated by the researcher for greater insight) • “Of the above, how much are their plans costing on average?” (Instigated by the researcher for greater insight) • “What percentage of hearing loss in Australia is permeant loss, i.e. Not medically treatable?” • “Is there any information regarding the incidence of hearing loss at different levels? E.g. How many people have a ‘mild’, versus ‘moderate’, versus ‘severe’ hearing loss?”

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only • “What is the definition of ‘commonly used assistive technology’, as used / referred to in the Operational Guidelines for Access 8.3.1?” Date Request Received: 29/10/2021 Date Request Commenced: 22/11/2021 Requestor: Jean s22(1)(a)(ii) - irrelevant (contact person Peta s22(1)(a)(ii) - irrelevan ) Endorsed by (EL1 or above): Melinda s22(1)(a)(ii) - irrelevant mat Cleared by: Felicity s22(1)(a)(ii) - irrelev

Contents Are Hearing Aids Everyday Equipment? ………………………………………………………………………… 1
Contents ……………………………………………………………………………………………………….. 2
Summary ………………………………………………………………………………………………………. 3 2.1 NDIS eligibility criteria where the primary disability is hearing loss ………………………. 5
Research Questions ……………………………………………………………………………………….. 5 3.1 Research Question 1 – “What is the evidence that 1 In 6 Australians have a hearing loss?” …………………………………………………………………………………………………………………. 5 3.2 Research Question 2 – “Hearing loss increases with age. What is the percentage of Australians with a hearing loss between the age of 26 and 65 Years?” ………………………… 6 3.3 Research Question 3 – “How many Australians use a hearing aid?” ……………………. 8 3.4 Research Question 4 – “Is the use of a hearing aid as common as the use of a walking stick?” …………………………………………………………………………………………………….. 9 3.5 Research Question 5 – “Have there been any AAT cases about access to the scheme and hearing loss? If so, what is the summary of why someone did not gain access to the Scheme?” ……………………………………………………………………………………… 10 3.6 Research Question 6 (Instigated by the researcher to gain greater insight) – “How many participants whose primary disability is hearing impairment are meeting the criteria and gaining access to the system?” ………………………………………………………………………. 13 3.7 Research Question 7 (Instigated by the researcher to gain greater insight) – “Of the above, how much are their plans costing on average?” ……………………………………………. 15 3.8 Research Question 8 – “What percentage of hearing loss in Australia is permanent loss, i.e. Not medically treatable?” ………………………………………………………………………… 24 3.9 Research Question 9 – “Is there any information regarding the incidence of hearing loss at different levels? E.g. How many people have a ‘mild’, versus ‘moderate’, versus ‘severe’ hearing loss?” ………………………………………………………………………………………… 25

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only 3.10 Research Question 10 – “What is the definition of ‘commonly used assistive technology’, as used / referred to in the Operational Guidelines for Access 8.3.1?” ……… 26 4. Recommendations ………………………………………………………………………………………… 27 5. References ………………………………………………………………………………………………….. 28 6. Version control ……………………………………………………………………………………………… 29

Summary This project relates to hearing impairment and more specifically ‘hearing aids’ (and associated services) and its implications for the NDIS and NDIS participants with potential eligibility rates increasing. On a wider level, concerns have been raised about ‘access eligibility’, and whether there is a trend that some participants have potentially incorrectly gained support, without qualifying based on the criteria (or whether the criteria in fact needs to be better refined, articulated and interpreted). It may pose as a financially risk to the NDIA if 1 in 6 Australians are eligible for the NDIS on the basis where the primary disability is ‘hearing impairment’ (particularly with rates expected to rise). The advisors are ultimately interested in assessing any risk to the scheme in relation to the increasing prevalence of hearing loss. Additional rationale for the research was to help ascertain whether hearing aids are to be considered ‘everyday equipment’. A literature review was not requested. The overview of the key facts derived from this study include the following: • 1 in 6.5 (15.3%) Australians were likely to have experienced hearing loss in 2020. By 2050, this will increase to 1 in 4. • In 2017, approximately 35% of Australians with a hearing loss were between the ages of 25 and 64 years. • In both 2017 and 2020 studies stated that 15.3% of the total Australian population (then of 25,499,884) lived with a hearing impairment. • In 2017, approximately 35% of Australians with hearing loss were between the ages of 25 and 64 years. • ‘Presbycusis’ (age related hearing loss) is the most common cause of acquired sensorineural hearing loss and is slowly progressive with age (Westcott, 2018). A third of Australians over the age of 50 experience a hearing impairment, and this number rises such that half of the population over 60 will experience a hearing impairment. • In 2015 on average 32% of people with hearing loss used hearing aids. Other 2018 studies only recorded that 18.4% of people with a hearing impairment in fact use a hearing aid/s (skewed by lack of those people who use one, either not being denoted as

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only having a disability and / or not captured by data analysis). Noted also is that some individuals who have a hearing aid, do not necessarily always use it. • On a global basis, according to the World Health Organization (WHO 2021), they estimate that there will be over 700 million people with a hearing impairment by 2050, equating to one in every ten people. The likely increase in those living with hearing loss is predicted to more than double to approximately 7.8 million people by 2060 (DAE, 2017). • Although the data suggests that the use of a hearing aid is more prevalent than those who use other aids such as a walking stick, this information is most likely skewed as those using walking sticks and other such aids are not necessarily denoted as having a permanent disability nor are true usage figures recorded as statistic data (so any comparisons drawn cannot be validated as truly reflective and nor conclusive). • It was noted by the CEO of the NDIS (in week commencing 22nd November, 2021) stated that “75% of NDIS costs related to support work hours”, and not the cost of capital equipment per say”. This highlights the importance of a closer evaluation of the ‘auxiliary’ services denoted in columns [2] in the state / territorial annual budgetary provisions under 3.7 Research Question 7. • Only one AAT case where the participant’s primary disability was ‘hearing impairment’ ruled in favour of the Agency (details below under 3.5 Research Question 5). There have only been a total of two ‘hearing impairment’ cases that have been heard where a final ruling was delivered (others were either settled beforehand or withdrawn etc.). • No specific data was found on the percentage of permanent and not medically treatable hearing loss in Australia. However, some data does indicate that substantially less than 37% of hearing loss is treatable. • As of 2017, 2,817,164 people had mild hearing loss, 1,181,472 had moderate hearing loss, and 740,532 people had severe hearing loss. • The NDIA does not have a publicly available definition of ‘commonly used assistive technology’ but the examples our resources provide do give some indication (refer to 3.10 Research question 10). • The total number of NDIS participants (aged 25 – 64) years, encompassing all ranges of disabilities is 183,440 • The total number of NDIS participants (aged between 25 – 64 years) whose primary disability is ‘hearing impairment’ is 9,347, comprising of only 5.1% • Total costs to the NDIS, as at 30th June, 2021, encompassing all participants aged between 25 – 64 years whose primary disability is ‘hearing impairment’, totals

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only $167,730,000, however includes ‘auxiliary’ costs (refer 3.7 Research Question 7) (NDIS, 2021). • Of the total $167,730,000, $33,327,000 comprised of ‘capital’ costs (19.9%) (refer 3.7 Research Question 7) [added to version VO1.1]. • Of the total $167,730,000, $134,403,000 comprised of ‘auxiliary’ costs (80.1%) (refer 3.7 Research Question 7) [added to version VO1.1].

2.1 NDIS eligibility criteria where the primary disability is hearing loss Hearing impairments may result in reduced functional capacity to undertake communication, social interaction, learning and self-management activities.

Generally, the NDIA will be satisfied that hearing impairments of ≥ 65 decibels in the better ear (pure tone average of 500Hz, 1000Hz, 2000Hz and 4000Hz) may result in substantially reduced functional capacity to perform one or more activities. This audiometric criterion reflects the lower limit of what is likely to constitute a substantially reduced functional capacity to undertake relevant activities.

Hearing impairments < 65dB decibels in the better ear (pure tone average of 500Hz, 1000Hz, 2000Hz and 4000Hz) in conjunction with other permanent impairments (for example vision or cognitive impairments), or where there is evidence of significantly poorer than expected speech detection and discrimination outcomes, may also be considered to result in substantially reduced functional capacity to undertake relevant activities. (NDIS, Access to the NDIS - The disability requirements | NDIS). 3. Research Questions The latest information on hearing loss in Australia has been derived from two reports both commissioned by the Hearing Care Industry Association (HCIA): Social and Economic Cost of Hearing Loss in Australia (Deloitte Access Economics (DAE) 2017) and Hearing for Life: The Value of Hearing Services for Vulnerable Australians (DAE, 2020). Information was also derived directly from ABS data.

3.1 Research Question 1 – “What is the evidence that 1 In 6 Australians have a hearing loss?” In DAE 2017, hearing loss is defined as 25 decibels or worse in the better ear. As per this definition, an estimated 3.6 million Australians experienced hearing loss in 2017. Based on the report’s projections, this number would grow to 3.88 million in 2020 (DAE, 2017, p.25). This means that approximately 1 in 6.5 (15.3%) Australians are likely to have experienced hearing loss in 2020. By 2050, this will increase to 1 in 4 (World Health Organisation, 2020).

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only DAE 2020 (p.12) also supports these above statistics, stating that approximately 15.3% of the total Australian population (then of 25,499,884) lived with a hearing impairment. Both reports support the same statistical conclusion, indicating no shift in trends between 2017 and 2020. Therefore, the above evidence that 1 in 6 Australians have a hearing loss is correct and founded, supporting the two cited resources mentioned in the original research request, being the ‘Roadmap for Hearing Health’, and the ‘Parliamentary Report, Chapter 3’. (As these are not cited in this report, they are not reflected in the reference list).

3.2 Research Question 2 – “Hearing loss increases with age. What is the percentage of Australians with a hearing loss between the age of 26 and 65 Years?” It was not possible to extract exact information about the prevalence of hearing loss in Australians between 26 and 65 years of age due to how the data is arranged in DAE 2017. Based on approximations contained in the reported figures, there were roughly 1.3 million Australians with hearing loss between the ages of 25 and 64 years in 2017 (refer to Figure 1; DAE, 2017,p.19).

Figure 1 – Number of Australians with hearing loss in 2017 by age and sex

There were 716,313 Australians with hearing loss between the ages of 30 and 59 in 2017. There were 1,903,974 Australians with hearing loss between the ages of 20 and 69 in 2017 (refer to Figure 2; DAE, 2017, p.25). In 2017 approximately 35% of Australians with hearing loss were between the ages of 25 and 64 years. This may have increased somewhat by 2021, though projections are difficult to calculate for the age cohort specified as this was not a cohort specified by either DAE report. Slightly lower percentages were noted in DAE 2020, where extrapolated statistics denoted that in 2020 approximately 30.79% of Australians with hearing loss were between the ages of 20 V0.1.1 6-12-2021 Are hearing aids everyday equipment? Page 6 of 29 OFFICIAL Page 75 of 113

FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only and 69 years. Neither report categorises the cohorts into the ages of 26 and 65 years precisely, but their aligned age categories provide some relevant data. As stated above in answering the first research question, DAE 2020 confirms the statistics stated in DAE 2017, with no significant variation. The issue of projected numbers of Australians expected to present with a hearing impairment in the future is worthy of discussion. On a global perspective, according to the World Health Organization (WHO 2021), they estimate that there will be over 700 million people with a hearing impairment by 2050, equating to one in every ten people. The likely increase in those living with hearing loss is predicted to more than double to approximately 7.8 million people by 2060 (DAE, 2017). Projections are also based on the assumption of an ageing Australian population so the increase in prevalence will be felt mostly at the higher age brackets. The report also estimates that approximately one third of instances of hearing loss are preventable. ‘Presbycusis’ refers to age related hearing loss and ‘is the most common cause of acquired sensorineural hearing loss and slowly progresses with age (Westcott, 2018). Projections do not account for any actions taken to reduce the rate of preventable hearing loss. According to DAE 2020, while it was noted that the majority of hearing loss is a result of genetics or the aging population, a third of those with a hearing impairment acquire that loss in hearing as a result of a preventable cause. Also highlighted was that a third of Australians over the age of 50 experience a hearing impairment, and this number rises such that half of the population over 60 will experience a hearing impairment. The final pertinent statistic noted was that approximately 50% of the Australian population with a hearing impairment or loss, are in fact younger than 65 years of age. The issue of noise induced hearing related loss has been well researched. A recent paper assessed a sample of 1923 individuals over the age of 50 years and concluded that excessive noise in the workplace attributes to a far greater risk of hearing loss prevalence, during the 10- year period during and / or post exposure to the noisy workplace. Statistically, hearing loss was 35.5% versus 29.1% in those who had no workplace noise exposure (Gopinath et al. 2021). Although this wider problem is beyond the scope of this study, it is worthy of consideration, and who should bear the cost of hearing loss support, if the cause can be directly attributed to workplace Occupational Health and Safety noise level potential breaches.

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Figure 2 – Number of Australians with hearing loss in 2017 by age, sex and severity of hearing loss

3.3 Research Question 3 – “How many Australians use a hearing aid?” According to the Australian Institute of Health and Welfare in 2012 1 in 7 people wore hearing aids (Australian Institute of Health and Welfare (AIHW), 2016, p.118). However, this figure is hard to comprehend considering the more recent Australian Bureau of Statistics (ABS) survey of Disability, Ageing and Carers (SDAC 2015 & 2018) and the DAE reports. While the DAE 2017 does not state precise use of hearing aids among people with hearing loss in Australia, it does provide resources to estimate the prevalence (refer to Figure 3; DAE, 2017, p.66). In 2015 on average 32% of people with hearing loss used hearing aids. More recent studies confirmed that 1 in 6.5 Australians were likely to have experienced hearing loss. Interestingly, only one in five Australians who could benefit from a hearing aid, actually use one (Hearing Care Australia, 2021). Also worth noting is that up to 40% of people who have a hearing aid, either choose not to wear it, or do not use it to its optimal capacity (Barker et al. 2016). Also worth noting in the context of NDIS financial sustainability, some war returning veterans may be eligible for the Hearing Services program, so therefore would not require NDIS funded

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only hearing aids. Many such individuals, however, return with a myriad of other physical and psychological disorders, where hearing impairment may not be the primary disability (Swan et al. 2017). Figure 3 – Percentage of people with hearing loss who use hearing aids by age and sex

3.4 Research Question 4 – “Is the use of a hearing aid as common as the use of a walking stick?” SDAC (ABS, 2015 & 2018) provides data on prevalence of hearing aid use among people with a disability (refer to Figure 4). In 2018 18.4% of people with disabilities reported using hearing aids, up from 16.4% in 2015. In 2018, 6.2% of people with a disability used a walking stick, down from 6.5% in 2015. This means that at least 802,500 Australians used hearing aids in 2018 and at least 272,300 Australians used walking sticks in 2018. It is important to emphasise that these numbers reflect the minimum estimated use of these aids in the Australian population. The use of both hearing aids and walking sticks could be much greater if people who do not identify as having a disability also make use of them. Note, that the 2018 ABS estimate is significantly under the HCIA estimate even though HCIA used 2015 SDAC data as a base. This may be explained by the fact that the SDAC is a self- reported measure and so includes data for people who identify as having hearing loss rather than people who do have hearing loss. There is often a discrepancy between self-reporting hearing loss and audiometry results (DAE, 2017, p.13). The discrepancy may also be explained by HCIA report having access to more complete raw data from the SDAC than is publicly available. This conclusion has been drawn on what data is available, with the added proviso that complete records of users of walking sticks are not available. Walking sticks may be

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Research- paper

OFFICIAL For Internal Use Only

purchased off-the-shelf for short term use and so will be difficult to track. Although the data below suggests that the use of a hearing aid is more prevalent than those who use aids such as a walking stick, this information is most likely skewed as those using walking sticks and other such aids may not identify as having a permanent disability.

Figure 4 — Use of aids and equipment among people with a disability

% PWD 2015 Est. 2015 % PWD 2018 Est. 2018

Cane 1.4 61,800 1.7 74,000 Walking stick 6.5 277,700 6.2 272,300 Crutches 0.7 28,000 1.0 43,300 Walking frame 7.0 301,700 76 330,800 Scooter 1.0 43,400 1.2 54,000 Hearing aid 16.4 701,600 18.4 802,500 Cochlear 0.2 10,200 0.4 17,400 Implant Handgrab rails 8.2 337,800 8.1 338,600

3.5 Research Question 5 — “Have there been any AAT cases about access to the scheme and hearing loss? If so, what is the summary of why someone did not gain access to the Scheme?”

Regular and ongoing contact has been made with NDIS internal departments who deal with AAT cases, seeking answers and clarification in an attempt to answer the above research question. The specific departments who have been asked to provide input / data relating to this research question include; Access and the TAB AAT, the AAT Case Management Branch and the Chief Council Division / Legal Reporting for data / statistical input. Mr William Neely, the Assistant Director, from the AAT Case Management Branch, has been instrumental in providing both AAT case information and assisting in interpretation of the data used in answer both research question 3.5 and research question 3.6.

Of the 5 recent noted cases raised by Peta Monley (NDIS SME audiologist) only one was heard at the AAT, which involved Gheorghe Timofticiuc — ‘Timofticiuc and National Disability Insurance Agency [2021] AATA 3015 (23 August 2021). The 4 other cases were either withdrawn, waiting for the tribunal to hand down their finding or resolved with consent and did not proceed to a hearing.

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REFS

FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only Interestingly the case pertaining to Gheorghe Timofticiuc (right-sided sensorineural hearing loss) handed down a decision whereby the AAT affirmed the internal review decision that the Applicant did not meet the access criteria and ruled in the Agency’s favour, formally stated as ‘The Tribunal affirms the decision under review pursuant to paragraph 43(1)(a) of the Administrative Appeals Tribunal Act 1975 (Cth)’ (Administrative Appeals Tribunal’ (AAT). The case name was: ‘Timofticiuc and National Disability Insurance Agency [2021] AATA 3015 (23 August 2021). Rationale in summary as to the decision included the following factors (determined by Member Buxton): The respondent’s contentions included (AAT, 2021): • ‘The Respondent submitted that the decision under review ought to be affirmed as the disability and early intervention requirements had not been met in this case’. • ‘The Respondent submitted that the Applicant met the requirements of paragraph 24(1)(a) of the Act, as they accept that the Applicant has impairments attributable to the following disabilities: sensorineural hearing loss in the right ear, tinnitus, tonic tensor tympani syndrome (TTTS) and adjustment disorder with depressed mood’. • ‘As to paragraph 24(1)(b) of the Act, the Respondent accepted that the hearing loss and related adjustment disorder were permanent but did not accept that the tinnitus or TTTS met the requirements for permanence. A substantial focus both during the hearing and in the Respondent’s written submissions was the issue of whether the tinnitus episodes could be remedied by further treatment’ (AAT, 2021).

Other pertinent extracts from the hearing’s findings included: • ‘The Respondent submitted that, accordingly, if there are known, available and appropriate treatment available, that a prospective participant should generally undergo the medical treatment or review before making a determination on permanency, and identified two further processes that should first be exhausted by the Applicant in respect of his tinnitus before that condition could be regarded as permanent: ‘Undertake online consultations with Dr P Selvaratnam, Musculo-skeletal physiotherapist, who is uniquely experienced in treating the symptoms of tinnitus

related TTTS and’

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only ‘Undertake some cochlear implant testing recommended by Dr Brent McMonagle, ENT Surgeon, specialising in cochlear implants, in February 2019. This was again recommended by Dr O’Neill, ENT Surgeon in November 2020’. • ‘It was submitted by the Respondent that the bases upon which the Applicant has rejected cochlear implants was not reasonable. The Applicant has stated that he did not wish to undergo cochlear implant surgery because he would be unable to have an MRI after implantation, the rehabilitation would be challenging and the effect on his tinnitus would be unknown. The Respondent submitted that the Applicant effectively wants a “guarantee” that the tinnitus will be fixed before undergoing the procedure, which his treating doctors will not give. The Respondent submitted, with reference to an article in the Lancet Journal that was relied upon in a report prepared by Ms Myriam Westcott, that cochlear implantation has been shown to improve or eliminate tinnitus in up to 86% of patients with tinnitus. It was contended by the Respondent that the Applicant should, at least, undergo the testing for suitability for cochlear implants’. • ‘The Respondent submitted that, in respect of the impairments that it has accepted were permanent (and, with respect to the other impairments if the Tribunal found those to be permanent) that they did not lead to a substantial reduction in the Applicant’s functional capacity in order to meet paragraph 24(1)(c) of the Act.[36] Under paragraph 24(1)(c) of the Act, the Tribunal must be satisfied that the “impairment” results in a substantially reduced functional capacity to undertake, or psychosocial functioning in undertaking, one or more of the activities of communication, social interaction, learning, mobility, self-care or self-management’. • ‘The Respondent submitted that the Participant Rules provide further criteria on establishing paragraph 24(1)(c) of the Act. The Participant Rules have been held to be “deeming” provisions, in that the Participant Rules have the effect of mandatorily including some people in the category of persons with substantially reduced functional capacity’ (AAT, 2021).

A request was made to the Chief Council Division / Legal Reporting to obtain more extensive data on past AAT cases, where the primary disability was ‘hearing impairment’, in an attempt

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only to identify any trends over recent years. More specifically the purpose was to assess how many hearing outcomes ruled in favour of the Agency. The summary is as follows: • Only one case that has gone to AAT where the ruling was in favour of the agency (as above (‘Timofticiuc and National Disability Insurance Agency [2021] AATA 3015 (23 August 2021)’. • Only one case that has gone to the AAT where the ruling was in favour of the participant (‘Evans and National Disability Insurance Agency [2019] AATA 754 (24 April 2019)’. See Hearing loss and substantially reduced functional capacity - Evans and NDIA [2019] AATA 754 (ndiscases.blogspot.com) // Evans and National Disability Insurance Agency [2019] AATA 754 (24 April 2019) (austlii.edu.au). In summary, The Tribunal sets aside the decision under review and in substitution decides that the Applicant satisfies the access criteria, pursuant to s 24 of the Act, to become a participant of the National Disability Insurance Scheme. • There have been a total of 36 cases planned to go to the AAT where the primary disability was ‘hearing impairment’, but 34 of outcomes were neither clearly either ‘in favour of the agency’ or in ‘favour of the participant’, and were instead concluded with a status of either; ‘dismissed’, ‘hearing decision set aside’, ‘no jurisdiction’, ‘resolved by consent’ or ‘withdrawn’. The remaining two are listed / named above.

3.6 Research Question 6 (Instigated by the researcher to gain greater insight) – “How many participants whose primary disability is hearing impairment are meeting the criteria and gaining access to the system?” A broader data search was undertaken to address the two additional research questions responded to in 3.6 Research Question 6 and 3.7 Research Question 7 (instigated by the researcher to gain more insight into financial costs and sustainability). Derived from the Explore data | NDIS database (as at 30th June, 2021), the following data below was extrapolated pertaining to participant’s plans who are aged between 25 – 64 years (which was the categorisation of ages from this data source) whose primary disability is ‘hearing impairment’. A summary of numbers divided between all Australian states and territories is depicted below (NDIS, 2021):

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State / Territory Participant Numbers

ACT 188

NSW 3093

NT 78

QLD 2039

SA 731

TAS 200

VIC 2321

WA 697

Total = 9347

Summary of pertinent facts: • The total number of NDIS participants is 468,177, encompassing all ranges of disabilities • The total number of NDIS participants (aged 25 – 64) years, encompassing all ranges of disabilities is 183,440 (*), as evidenced by, “There are 183,440 participants in state(s) of ACT, NSW, NT, OT, QLD, SA, TAS, VIC, WA and All Service Districts, disability group(s) of ABI, Autism, Cerebral Palsy, Developmental delay, Global developmental delay, Hearing Impairment, Intellectual Disability, Multiple Sclerosis, Other, Other Neurological, Other Physical, Other Sensory/Speech, Psychosocial disability, Spinal Cord Injury, Stroke, Visual Impairment and age band(s) of 25 to 34, 35 to 44, 45 to 54, 55 to 64” (NDIS, 2021). • The total number of NDIS participants (aged between 25 – 64 years) whose primary disability is ‘hearing impairment’ is 9,347, comprising of only 5.1% of that above mentioned population group (data reflected above), as evidenced by, “There are 9,347 participants in state(s) of ACT, NSW, NT, OT, QLD, SA, TAS, VIC, WA and All Service Districts, disability

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only group(s) of Global developmental delay, Hearing Impairment and age band(s) of 25 to 34, 35 to 44, 45 to 54, 55 to 64” (NDIS, 2021).

3.7 Research Question 7 (Instigated by the researcher to gain greater insight) – “Of the above, how much are their plans costing on average?” Also sourced from the Explore data | NDIS database (as at 30th June, 2021), the data below was extrapolated to indicate what the average Annual Budgets were for participants plans whose primary disability is ‘hearing loss’, indicating where the ‘capital’ expenditure was spent (presumably on the hearing aid/s devices) and ‘other / auxiliary services within the participant’s plans (where the specifics and nature of such services were not explicitly indicated). The data is also categorised into age brackets and all the individual Australian states and territories (NDIS, 2021). ACT

Age Average Average Average Total Categories Budget Budget Capital Budget Average component (Auxiliary Budget x (Number of [1] + [2] (presumably hearing support No. of participants (per the cost of the services Participants below) participant hearing aid/s) component) [2] [No. of plan) [1] participants x Average Budget [1[]

[2] = [3]

25 – 34 years $11,000 $3000 $8000 $539,000 (49 participants)

35 – 44 years $10,000 $0 $10,000 $340,000 (34 participants)

45 – 54 years $16,000 $3000 $13,000 $640,000 (40 participants)

55 – 64 years $10,000 $3000 $7000 $650,000

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only (65 participants)

Total = Sub-Total = Sub-Total = Total cost $47,000 $9000 $38,000 to the NDIS

$2,169,000

NSW

Age Categories Average Average Average Total Budget Budget Capital Budget Average (Number of component (Auxiliary Budget x participants [1] + [2] (presumably hearing support No. of below) (per the cost of the services Participants participant hearing aid/s) component) [2] [No. of plan) [1] participants x Average Budget [1[]

[2] = [3]

25 – 34 years $12,000 $3000 $9000 $8,748,000 (729 participants)

35 – 44 years $17,000 $3000 $14,000 $9,979,000 (587 participants)

45 – 54 years $17,000 $3000 $14,000 $12,988,000 (764 participants)

55 – 64 years $16,000 $3000 $13,000 $16,208,000 (1013 participants)

Total = Sub-Total = Sub-Total = Total cost $62,000 $12,000 $50,000 to the NDIS

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$47,923,000

NT

Age Categories Average Average Average Total Budget Budget Capital Budget Average (Number of component (Auxiliary Budget x participants [1] + [2] (presumably hearing support No. of below) (per the cost of the services Participants participant hearing aid/s) component) [2] [No. of plan) [1] participants (**) x Average Budget [1[]

[2] = [3]

25 – 34 years $34,000 $0 $34,000 $510,000 (15 participants)

35 – 44 years $52,000 $0 $52,000 $1,040,000 (20 participants)

45 – 54 years $49,000 $0 $49,000 $1,078,000 (22 participants)

55 – 64 years $36,000 $0 $36,000 $756,000 (21 participants)

Total = Sub-Total = $0 Sub-Total = Total cost $171,000 $171,000 to the NDIS = $3,384,000

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only QLD

Age Categories Average Average Average Total Budget Budget Capital Budget Average (Number of component (Auxiliary Budget x participants [1] + [2] (presumably hearing support No. of below) (per the cost of the services Participants participant hearing aid/s) component) [2] [No. of plan) [1] participants x Average Budget [1[]

[2] = [3]

25 – 34 years $17,000 $4000 $13,000 $6,766,000 (398 participants)

35 – 44 years $22,000 $4000 $18,000 $7,436,000 (338 participants)

45 – 54 years $20,000 $4000 $16,000 $11,160,000 (558 participants)

55 – 64 years $19,000 $4000 $15,000 $14,155,000 (745 participants)

Total = Sub-Total = Sub-Total = Total cost $78,000 $16,000 $62,000 to the NDIS

$39,517,000

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only SA

Age Categories Average Average Average Total Budget Budget Capital Budget Average (Number of component (Auxiliary Budget x participants [1] + [2] (presumably hearing support No. of below) (per the cost of the services Participants participant hearing aid/s) component) [2] [No. of plan) [1] participants x Average Budget [1[]

[2] = [3]

25 – 34 years $14,000 $2000 $12,000 $1,988,000 (142 participants)

35 – 44 years $17,000 $3000 $14,000 $2,023,000 (119 participants)

45 – 54 years $20,000 $3000 $17,000 $4,000,000 (200 participants)

55 – 64 years $20,000 $5000 $15,000 $5,400,000 (270 participants)

Total = Sub-Total = Sub-Total = Total cost $71,000 $13,000 $58,000 to the NDIS

$13,411,000

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only TAS

Age Categories Average Average Average Total Budget Budget Capital Budget Average (Number of component (Auxiliary Budget x participants [1] + [2] (presumably hearing support No. of below) (per the cost of the services Participants participant hearing aid/s) component) [2] [No. of plan) [1] participants x Average Budget [1[]

[2] = [3]

25 – 34 years $13,000 $4000 $9000 $572,000 (44 participants)

35 – 44 years $18,000 $4000 $14,000 $684,000 (38 participants)

45 – 54 years $19,000 $5000 $14,000 $1,045,000 (55 participants)

55 – 64 years $17,000 $4000 $13,000 $1,071,000 (63 participants)

Total = Sub-Total = Sub-Total = Total cost $17,000 $50,000 to the NDIS = $3,372,000

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only VIC

Age Categories Average Average Average Total Budget Budget Capital Budget Average (Number of component (Auxiliary Budget x participants [1] + [2] (presumably hearing support No. of below) (per the cost of the services Participants participant hearing aid/s) component) [2] [No. of plan) [1] participants x Average Budget [1[]

[2] = [3]

25 – 34 years $16,000 $3000 $13,000 $9,776,000 (611 participants)

35 – 44 years $18,000 $4000 $14,000 $7,776,000 (432 participants)

45 – 54 years $20,000 $4000 $16,000 $11,880,000 (594 participants)

55 – 64 years $20,000 $4000 $16,000 $13,680,000 (684 participants)

Total = Sub-Total = Sub-Total = Total cost $74,000 $15,000 $59,000 to the NDIS

$43,112,000

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only WA

Age Categories Average Average Average Total Budget Budget Capital Budget Average (Number of component (Auxiliary Budget x participants [1] + [2] (presumably hearing support No. of below) (per the cost of the services Participants participant hearing aid/s) component) [2] [No. of plan) [1] participants x Average Budget [1[]

[2] = [3]

25 – 34 years $17,000 $5000 $12,000 $2,720,000 (160 participants)

35 – 44 years $23,000 $7000 $16,000 $2,783,000 (121 participants)

45 – 54 years $24,000 $4000 $20,000 $4,824,000 (201 participants)

55 – 64 years $21,000 $4000 $17,000 $4,515,000 (215 participants)

Total = Sub-Total = Sub-Total = Total cost $85,000 $20,000 $65,000 to the NDIS

$14,842,000

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only SUMMARY OF TOTAL COST ACROSS ALL 8 STATES / TERRITORIES

STATE / TERRITORY TOTAL AVERAGE BUDGETED COSTS x ALL PARTICPANTS (derived (Participant numbers below) from column [3] above)

ACT $2,169,000 (188)

NSW $47,923,000 (3093)

NT $3,384,000 (78)

QLD $39,517,000 (2039)

SA $13,411,000 (731)

TAS $3,372,000 (200)

VIC $43,112,000 (2321)

WA $14,842,000 (697)

TOTAL COST TO THE NDIS = $167,730,000 (as at 30th June, 2021)

Summary of pertinent fact impacting financial sustainability of the provision of ‘hearing impaired’ participant plans (with caveat that these figures include ‘auxiliary’ costs):: • Total costs to the NDIS, as at 30th June, 2021, encompassing all participants aged between 25 – 64 years whose primary disability is ‘hearing impairment’, totals $167,730,000 (NDIS, 2021). V0.1.1 6-12-2021 Are hearing aids everyday equipment? Page 23 of 29 OFFICIAL Page 92 of 113

FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only • Of the total $167,730,000, $33,327,000 comprised of ‘capital’ costs (19.9%) (NDIS, 2021). • Of the total $167,730,000, $134,403,000 comprised of ‘auxiliary’ costs (80.1%) (NDIS, 2021).

Auxiliary costs associated with training of digital hearing aid usage etc, could be reduced by the use of ‘group based’ sessions, potentially even delivered online. Group follow-ups and group visits could lower costs and reduce the economic pressure on public resources (Vlastarakos et al. 2017). ‘Auxiliary’ hearing services could also be reduced, particularly in rural areas, if local community pharmacists played an active role in providing support to improve ear healthcare and broader associated quality of life, especially for indigenous and vulnerable populations. “Globally, Indigenous populations are at a high risk of hearing loss with an estimated 6.1% of the world’s population living with hearing loss and an annual cost of unaddressed hearing loss of 750 billion USD” (Taylor et al. 2021, pg.1). The question was asked to Mr William Neely to clarify what these ‘auxiliary’ costs precisely consisted of and were they ‘hearing impaired’ related. The response was, “these auxiliary services could and in a number of participants would be related to “other” impairments the Applicant has. And the only way to ever narrow that down would be going in to each applicant and looking at their plans. Even then, in many cases it would be impossible to identify if a support is specifically linked to the hearing impairment” (Neely, 2021).

3.8 Research Question 8 – “What percentage of hearing loss in Australia is permanent loss, i.e. Not medically treatable?” Data answering this question was not readily available, though general insight can be derived from the information at hand. DAE 2017 follows the World Health Organisation report in estimating preventable childhood hearing loss at 49% and adult preventable hearing loss at 37% (p.4). Of course, while total preventable hearing loss includes hearing loss that is permanent, it also includes the subset that is reversible or treatable. One can assume then that percentage of treatable hearing loss is lower than the percentage of preventable hearing loss. Several conditions which cause hearing loss are medically treatable. According to the HCIA report: “The more common medical and surgical interventions include, in the case of an ear canal obstruction, blockages by matter such as excess cerumen, benign growths or tumours may be addressed through removal of the foreign object(s). Similarly, where hearing loss is caused by fluid build-up in the middle ear, fluid can be drained through a surgical incision, known as a myringotomy, and further fluid build-up prevented with the insertion of a tympanostomy tube, to keep the middle ear aerated. Hearing loss resulting from autoimmune disorders or conditions such as otitis media may be treated through

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only the use of appropriate medications, such as corticosteroids or antibiotics. Structural deformities in the middle ear or the outer ear may be rectified surgically” (2017, p.9). It was not possible to find a breakdown of causes of hearing loss which might have provided some indication as to percentage of hearing loss that is treatable.

3.9 Research Question 9 – “Is there any information regarding the incidence of hearing loss at different levels? E.g. How many people have a ‘mild’, versus ‘moderate’, versus ‘severe’ hearing loss?” The HCIA report provides information on prevalence of severity levels of hearing loss (refer to Figure 5). Figure 5 – Total prevalent cases of hearing loss by severity levels, age and sex

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only 3.10 Research Question 10 – “What is the definition of ‘commonly used assistive technology’, as used / referred to in the Operational Guidelines for Access 8.3.1?” NDIS Rules (Becoming a Participant) 2016 section 5.8(a) states that an impairment results in substantially reduced functional capacity if: the person is unable to participate effectively or completely in the activity, or to perform tasks or actions required to undertake or participate effectively or completely in the activity, without assistive technology, equipment (other than commonly used items such as glasses) or home modifications. This is elaborated in the Access Operation Guidelines section 8.3.1 which states: By itself, reliance on commonly used items will not result in a substantially reduced functional capacity to participate effectively or completely in an activity. Commonly used items include glasses, walking sticks, non-slip bath mats, bathroom grab rails, stair rails, age appropriate child safety locks, simple adapted kitchen utensils and dressing aids. The NDIA does not have a publicly available definition of “commonly used items” in the sense of a set of necessary and sufficient conditions by which we could determine whether something is “commonly used” or not. A definition may be drawn from the characteristics of the items listed in Access OG 8.3.1. The list suggests possible interpretations. “Commonly used” might mean:

A large portion of the Australian population use the item
Something like “commonly available” or “easy to obtain”, that is, you could probably purchase it from the chemist, supermarket or hardware store, it is likely to be low cost etc. There are difficulties with both interpretations. A difficulty with (1) is that there is no formal definition of “a large portion of Australians”. The example of glasses can be used, as this is referred to in the Rules. How much less commonly used than glasses does something have to be before it is not commonly used? A walking stick is less commonly used than glasses. How many people have to use an item for it to be commonly used? There are no existing answers to these questions. This interpretation would also not always assist in determining if something counts as commonly used when there is a dearth of data on their use. (2) Does capture low-cost off-the-shelf items such as glasses with fixed prescriptions or walking sticks. It also makes sense to assume that something available from a supermarket is commonly used. However, it might not capture commonly used but customised items such as specialty prescription glasses, which require consultation with an optometrist and a higher cost than off-the-shelf chemist prescriptions. It might also capture too much, for example, a potential participant requires a low cost off the shelf wheelchair, grab rails, stair rails, walking

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only stick or walker, non-slip bathmat and several other low-cost items. Together all the items might be quite costly and burdensome to the individual, but because their need is met by commonly used equipment, they may not meet 5.8(a). 4. Recommendations Wider implications to consider beyond the scope of this research task: • Statistical analysis of total number of approved versus rejected hearing-impaired applications (provision and funding of hearing aids and auxiliary support services) and whether there any trends regarding source or demographic (both from participant and approver) to assist in identifying any other reasons for the increase in support being granted. • A closer evaluation any ‘interpretation’ issues from the perspective of the assessor (one approving the request for support). Does better training need to be undertaken to ensure correct / enhanced assessment of degree of hearing impairment? Could there be misinterpretation of audiograms by the access team? • Ensuring rigour re the quality of evidence being provided as rationale for eligibility. • A closer evaluation / investigation into the discrepancy between relatively minimal ‘capital’ costs in participant’s plans, versus the comparatively high budgetary allocation of the ‘auxiliary’ component of the budgetary provision. In some of the above data, there had been a ‘$0’ allocation of capital provision in the plans, however excessive costs allocated to the ‘auxiliary’ services (a closer audit potentially recommended, particularly for WA). Is there a logical explanation as to why the ‘auxiliary’ costs far exceed the costs of the capital equipment (e.g. Presumably being the cost of the hearing aid/s)? (**

investigation is required to determine whether there are other State services which fund hearing aids in the NT). • Are the ‘auxiliary’ costs being allocated to participant’s plans in fact accurate and entirely ‘reasonable and necessary’? And is the criteria being uniformly applied across all states and territories? • A closer evaluation / investigation into the discrepancy between the budgetary allocations of participant’s plans comparing each state / territory (a closer audit potentially recommended, particularly for WA). • Is compliance for eligibility both correct and robust? • Commercialisation – are there any external forces / pressures at play which may be influencing participant numbers (e.g. Advertising, incentives etc.) // and / or unconscious bias of the assessor / planner, or ‘overestimation’ of the amount / extent of ‘auxiliary’ services required.

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FOI 24/25 - 0002 Research paper OFFICIAL For Internal Use Only • Other underlying factors impacting the increase in Australians presenting with a hearing impairment, such as increased exposure to noisy workplaces (e.g. Construction and building sites and associated OH&S compliance). • Avoidable hearing loss scenarios. According to the WHO (2021, pg. 1), “Over 1 billion young adults are at risk of permanent, avoidable hearing loss due to unsafe listening practices”. • People with undiagnosed hearing loss, who may eventually seek diagnosis and support (further recommendation to try to determine the extent of those with ‘undiagnosed’ hearing loss, to determine future predictions as to NDIS support – although may be difficult to quantify). 5. References Administrative Appeals Tribunal 2021, The case of ‘Timofticiuc and National Disability Insurance Agency [2021] AATA 3015 (23 August 2021). Australian Bureau of Statistics 2015, Survey of Disability, Ageing and Carers, Australia, Jan 2017, Cat. no. 4433.0, Australian Bureau of Statistics, Canberra, accessed 22 November 2021, https://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4430.0Main+Features1022015?OpenD ocument. Australian Institute of Health and Welfare 2016, Australia’s health 2016, Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Accessed 22 November 2021, https://www.aihw.gov.au/reports-data/australias-health/previous-releases. Barker F, Mackenzie E, Elliot L, Jones S, de Lusignan S, 2016, Interventions to improve hearing aid use in adult auditory rehabilitation (review), Cochrane Database of Systematic Reviews, Issue 8. Art No: CD010342. Deloitte Access Economics 2017, The social and economic cost of hearing loss in Australia, Report for the Hearing Care Industry Association, Canberra, Australia. Gopinath B, McMahon C, Tang D and Burlutsky G, Workplace noise exposure and the prevalence and 10-year incidence of age-related hearing loss, Plos One, Journal Pone, pg. 1- 10. Deloitte Access Economics 2020, Hearing for Life – The Value of Hearing Services For Vulnerable Australians, Report for the Hearing Care Industry Association, Canberra, Australia accessed 22 November 2021, https://www.hcia.com.au/hcia-wp/wp- content/uploads/2020/02/Hearing_for_Life.pdf. Neely W, AAT Case Management Branch, email conversation with Assistant Director – Case Manager, 2 December 2021.

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Research- paper OFFICIAL For Internal Use Only

Hearing Care Industry Association 2021, Deafness and Hearing Fact Sheet, Accessed 24 November, 2021, Deafness and hearing loss (who. int).

NDIS Access Operational Guidelines 2019, Access to the NDIS — The Disability requirements NDIS. Accessed 29 November, 2021, Access to the NDIS - The disability requirements | NDIS.

NDIS 2021, Explore data | NDIS, Accessed 29 November, 2021, https://data.ndis.gov.au/explore-data.

Swan A, Nelson J, Swiger B, Jaramillo, Cc, Eapen B, Packer M and Pugh M 2017, Prevalence of hearing loss and tinnitus in Iraq and Afghanistan Veterans: A Chronic Effects of Neurotrauma Consortium study, Hearing Research 349, pg 4-12.

Taylor S, Cairns A, Solomon S and Glass B 2021 Community pharmacist interventions in ear health: a scoping review, Primary Health Care Research & Development, Vol 22, e63.

Vlastarakos P, Cameron A and Nikolopoulos T 2017, How successful is the fitting of digital hearings aids? Implications for the allocation of resources within the national health systems, Ent Journal, Vol 96, No. 3, pg. 33-38.

Westcott, M (2018), The Role of Aids in Managing Hearing Loss, Medical Republic, Victoria, Australia.

World Health Organisation 2020, Hearing Care Industry Association, Hearing Loss Facts & Figures, Australia and Beyond, Accessed 24 November, 2021, Hearing Loss Facts & Figures, Australia + Beyond | Connect Hearing.

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Version Amended Brief Description of Change Status by 0.1 AHR908 |Draft of section related to prevalence of Draft 22-11-21 hearing loss and hearing aids 1.0 FFM634 |Final version Completed 2-12-21 1.1 FFM634 |Final version (with added statistics) Completed 6-12-21 V0.1.1 6-12-2021 Are hearing aids everyday equipment? Page 29 of 29

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