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The provision of hearing services under the National
Disability Insurance Scheme
(NDIS)
Joint Standing Committee on the NDIS – Hearing Services
Terms of Reference
Submission by EARtrak
This submission focuses on the delivery of hearing services through the NDIS, in relation to item 1.e the principle of choice of hearing service provider,
and
the relationship between the current Office of Hearing Services (OHS)-administered Hearing Services Program (“the Program”) and the developing NDIS-funded hearing services.
The current Program is supported by a thicket of regulatory instruments which endeavour to guide the performance of contractors (big and small, Government and private). Additions to and modifications of this regulatory and advisory environment are planned later in 2017.
There is no evidence that increasing these requirements has led to any better outcomes from the Program because no outcomes are currently measured. This means that clients are not able to access information which allows them to make an informed choice of provider.
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What is EARtrak?
The EARtrak project developed as a means of measuring treatment effectiveness of hearing care. The data are collected from surveys sent to clients six months after hearing aids have been fitted, It is a proven tool for implementation of Continuous Quality Improvement (CQI) processes, and yields a substantial database of real world performance data to inform clinical decision-making.
Three significant factors contribute to its power:
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Client surveys are returned to a third party, not to the provider or funder, so unbiased opinions are more reliably obtained. * 1,2
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The level of detail asked of clients enables identification of positive and negative outcomes across a range of hearing aid and service features.
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Each individual clinic receives a confidential report, comparing their performance against benchmark data (the average for the entire group of participating practices).
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EARtrak provides a clinic rating of treatment effectiveness which is of highest importance to clients in choosing a provider.
The EARtrak company was established to manage the process, including independent data analysis and reporting. This has also enabled the service to be extended outside the original group of private clinics (Ear Associates) and outside Australia (Germany, New Zealand, USA).
EARtrak has marketed the benefits of independent performance monitoring and benchmarking to the hearing care industry through various methods, including conference exhibitions, professional workshops, and articles in scientific journals and trade magazines. Unfortunately, most professionals do not see the need to examine their own performance. Even fewer are prepared to compare their outcomes with that of their peers. This is a common amongst health professions. In the hearing care industry, the fact that people with poor outcomes rarely complain has led to complacency about effectiveness of treatment on the part of most hearing care providers and funders.
The operation of EARtrak generates a large body of information about clinical effectiveness and how hearing aids work in the real world. Analysis of the database with respect to outcomes from hearing aids funded by Government (OHS) informs our submission.
*“The successful provision of hearing health care ultimately comes down to each individual patient’s personal satisfaction with his or her hearing aid outcome.”
Professor Jerry Northern, The Hearing Journal, 2000
“It could be reasonably asserted that the patient’s perspective is the gold standard for hearing aid effectiveness.” Professor Robyn Cox et al, Ear & Hearing, 2016
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The Hearing Care Environment
It is commonly accepted that Government-funded hearing aids constitute about 80% of the market in Australia. Within the EARtrak group, 71.1% are funded by OHS, but this group does not include Australian Hearing, which has almost 100% OHS funding under the Program. Government funding may be total (“free to client”) or partial (“top-up”), but in either case the influence of the Program dominates the industry.
OHS has the capacity to collect and report information about clinical outcomes of the Program. This monitoring was done in the early stages of the Program, but no outcomes data have been collected/reported for many years. For example, OHS counts how many hearing aids are fitted, but cannot answer the simple question “What percentage of hearing aids are actually worn?” In 2016, in a survey of its members, Audiology Australia, found that 44% of respondents had their remuneration linked to sales of devices rather than outcomes.
Some earlier OHS data showed that the dominant factor in choice of provider was proximity of the clinic to the client. This might have changed with the implementation of more proactive marketing methods in recent years. For instance, many larger provider companies (including Australian Hearing) offer free hearing screenings in convenient locations to enroll potential clients. Call-centre “cold calling” by many companies also generates clients’ enrolment in the Program. How many of us choose services based on proximity or advertising, rather than proven quality of service, particularly in health care?
Regardless of the marketing effort, about two-thirds of people with significant hearing loss do not seek treatment. Results of several research studies (in Australia and overseas) have found that non-seekers cite negative perceptions (e.g. “Hearing aids don’t work” / “Hearing aids are a hassle” / “Hearing aids whistle”) related to performance/benefit of hearing aids as the reason for avoiding hearing care 3,4,5.
This non-use rate has persisted despite great advances in hearing aid technology and professional training. This is of great concern, given the “burden of disease” of non-treated hearing loss (Access Economics, 2006)6. The predicted increase in the incidence of hearing loss (from 1:6 to 1:4 by 2050) also highlights the importance of addressing the problem sooner rather than later.
Despite the presence of the Hearing Services Program, Australia’s situation is similar to most first-world countries where there is government funding for hearing care/hearing aids (including Denmark, UK Germany, Norway, France). Many of these countries have recognized their systems are failing to deliver consistent quality of care and are now taking steps to address these problems (BEAR project in Denmark, Autorité de la Concurrence, France ).
French Competition Authority launches a vast survey on the hearing aids sector “However, of the 4.4 million people who could use hearing aids, only 1.5 million have these devices, a fitting rate of just 32%…” “The authority will examine measures that could help to improve information to consumers and reduce asymmetry of information with the professional.”
Audiology World News 12 Feb 2016
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Quality Variation in Hearing Care
It might be assumed that hearing care providers working within standard Government contracts requiring tightly scripted processes/inputs would deliver consistent treatment outcomes. Data from across 53 clinics using EARtrak to monitor performance shows this assumption is incorrect.
The following graph (Figure 1) plots the scores for these 53 clinics. Each clinic’s score is the average percentage of communication situations where the clinic has delivered satisfactory outcomes for their clients. The bell curve (distribution of scores around the average) illustrates the fact that there is significant variation, with almost 40% difference between the best and poorest clinic outcomes.
0.070000
0.060000
0.050000
0.040000
0.030000
0.020000
0.010000
0.000000 %
0 20 40 60 80 100
Figure 1: Distribution of clinic scores (53 clinics) Each score is the average percentage of communication situations that the clinic has delivered satisfactory outcomes for their clients.
This data is derived from the EARtrak group of clinics, a self-selected group of businesses using the EARtrak process to monitor their performance. The range of performance is large enough to cast doubt on any claims that the hearing care industry as a whole is a quality industry, where the definition of quality is consistent standard of outcomes. It clearly shows that choice of provider makes a difference to a client’s chance of a successful outcome.
The second graph (Figure 2) compares one key aspect* of the performance of the Hearing Services Program against the performance of HSP clients seen by clinics using EARtrak. The study by Professor Harvey Dillon, and reported in 2006 7 is now 10 years old, but is the most recent published data to look at outcomes for clients of the Program.
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Daily hearing aid usage - OHS clients
40 35 35
30
25 21 19 % 20 15 13 10 10
5
0
0 hr <1 hr 1-4 hrs 5-8 hrs 8+ hrs
Hearing aid use – Hours/day
Figure 2: Hearing aid usage data for clients fitted with hearing aids funded by OHS, Dillon 2006.
Dillon concluded from his data that approximately one-third of treatment was ineffective (21% hearing aids never worn, and 10% used less than one hour/day). Only 13% of clients used their hearing aids more than 8 hours/day. At the time, OHS explained these results by factors such as the reduced communication needs of older people, and their difficulty managing hearing aids.
EARtrak data for the same period showed a different picture (Figure 3). The non-use rate was more than halved, and the percentage of clients using their hearing aids more than 8 hours/day was more than tripled. Same demographic profile, same levels of technology, same funding between the two groups – but completely different outcomes. Clearly, the clinic is the key to delivering a successful outcome.
- “Key aspect” = Hours of use/day of hearing aids. This aspect reflects the performance/benefit of the hearing aid to the client. Hearing aids that are comfortable, easily managed and that deliver significant hearing improvement are more likely to be worn for longer periods of time each day.
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50 44.1 45
40 35 35
30
% 25 21 20.3 19 18.2 20
15 13 9.8 10 10 4.9 5
0
0 hr <1 hr 1-4 hrs 5-8 hrs 8+ hrs
OHS - EARtrak Group Hearing aid use – Hours/day
OHS - General Group
Figure 3. Hearing aid usage for OHS clients – General group usage (Dillon, 2006) compared with EARtrak group data (2006).
OHS strongly assert that the requirement for contracted clinics to measure their own outcomes is sufficient to guarantee quality of hearing care. “In-house” outcomes measurement by providers is not publicly available information, does not allow valid comparisons between providers, and is therefore of no benefit to people seeking reliable independent information to help them choose a provider with proven quality outcomes.
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The Case for Meaningful Choice
The distribution of clinic scores on the first graph (Figure 1) shows the importance to clients of choosing providers with proven quality outcomes. However, this information is not available to clients of the Program.
OHS implicitly endorses all contracted providers as equal. Real-world data from EARtrak (most EARtrak users have an OHS contract) shows this to be false. Not all providers are delivering the same outcomes for their clients. Some are delivering far higher levels of treatment effectiveness than the average, and others are well below the average.
It is generally assumed that hearing care under the NDIS will be a relatively small part of hearing care in Australia (although early reports show it to be disproportionately expensive).
It is unreasonable to expect NDIA care planners to have sufficient performance history to guide NDIS clients in their choice of a hearing service provider that would lead to best outcomes. “Shopping around” for quotes for the best price for hearing aids does not necessarily mean that the best clinics will be chosen to provide the supporting hearing care to obtain the best hearing aid outcome.
Put simply, informed choice requires information, and the most important information for clients and care planners is the documented performance of service providers. Consumer and professional organisations, such as Better Hearing Australia and the Australian Society of Rehabilitation Counsellors, have long advocated for this type of information to be available.
Recommendation
That OHS institutes an on-going quality measurement system in the Hearing Services Program, and publish the results to guide Hearing Services Program clients and NDIA care planners and clients.
Logistics
EARtrak submits that OHS has the legal and administrative capacity to implement a quality measurement system almost immediately, with results being deployed to end-users within two months.
The cost should be less than 1% of the current spend on Vouchers, and has the potential to guide consumer choice, improve accountability of providers, reduce waste and control costs.
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References
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Northern, Jerry L “Patient satisfaction and hearing aid outcomes” The Hearing Journal June 2000, 53(6), pp10-16.
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Cox RM, Johnson JA & Xu J “Impact of Hearing Aid Technology on Outcomes in
Daily Life 1: The Patient’s Perspective.” Ear & Hearing, 2016, Feb 12
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Meyer C & Hickson L “What factors influence help-seeking for hearing impairment and hearing aid adoption in older adults?” Feb 2012, International Journal of Audiology 51(2):66-74.
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Kochkin S “Obstacles to adult non-user adoption of hearing aids” The Hearing Journal 2007, 60(4):27-43.
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Hougaard S, Ruf S & Egger C “EuroTrak + JapanTrak 2012: Societal and Personal
Benefits of Hearing Rehabilitation with Hearing Aids”
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Access Economics “Listen Hear! The economic impact and cost of hearing loss in Australia. February 2006.
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Dillon, H “Hearing Loss: The Silent Epidemic. Who, why, impact and what can we do about it” Libby Harricks Oration, Perth, Australia, May 2006
Contact details:
Tracey Matthies, Chief Executive Officer
Neil Clutterbuck, President
Susan Clutterbuck, Vice President, Research and Clinical Studies
EARtrak
PO Box 595
Traralgon, Vic 3844
Ph. 03 5133 6111 Mob. 0448 543 861 Email outcomes@eartrak.com