Tel: 1800 432 748 PERMANENT SITES
Fax: 03 5022 7416 194 Ontario Ave., MILDURA VIC 3500
Email: admin@chcare.com.au 21 High Street, SWAN HILL VIC 3585
www.chcare.com.au 83A Nish Street, ECHUCA VIC 3564
ABN 37 103 577 493
Committee Secretariat,
Joint Standing Committee on the National Disability Insurance Scheme,
PO Box 6100,
Parliament House,
Canberra ACT 2600 29th January, 2017
Dear Committee Secretariat,
Re: Senate Inquiry – Hearing: The provision of hearing services under the National Disability
Insurance Scheme (NDIS)
Thank you for the opportunity to submit comment regarding the terms of reference determined by the Joint Standing Committee on the National Disability Insurance Scheme into the provision of hearing services under the NDIS.
Country Hearing Care is a small family-owned private, independent practice, situated in a relatively remote rural location in northern Victoria. We have three clinics located in Mildura, Swan Hill and Echuca and we provide visiting services to eleven other locations; Balranald (NSW), Berri (SA), Broken Hill (NSW) Cohuna (VIC), Merbein (VIC), Ouyen (VIC), Red Cliffs (VIC), Renmark (SA), Robinvale (VIC), Rochester (VIC) and Wentworth (NSW). Our main clinic is situated in Mildura and the NDIS is due to roll-out to our “Mallee” area on 1st January, 2019; and is due to roll out in the areas of our visiting clinics in the “Far West NSW” region (Balranald, Broken Hill and Wentworth) on 1st July, 2017.
We employ four audiologists and three audiometrists. We currently provide the following hearing services to our local rural communities: Diagnostic paediatric audiology, under contract to Mildura Base Hospital, including diagnostic testing of newborn patients referred by the Victorian Infant Hearing Screening Program. (VIHSP) We are a contracted service provider, as part of the Office of Hearing Services (OHS) scheme, providing hearing assessment and auditory rehabilitation, including the fitting of hearing devices, to eligible pensioners and veterans. Our audiologists and audiometrists are registered providers under Victorian WorkSafe and NSW WorkCover schemes. Our audiologists are registered with Medicare to provide Medicare-funded audiological assessments to patients referred by an Ear, Nose and Throat surgeon, or a Neurologist, and to Aboriginal and Torres Strait Islander (ATSI) patients who have the relevant medical referral. We assess paediatric and adult private patients and fit hearing devices to private adult patients, who pay for these services and who sometimes have private health insurance which will partially cover the cost of their hearing aids. One of our audiometrists is also a qualified physiotherapist and he provides vestibular rehabilitation to patients with dizziness and balance disorders. One of our audiologists provides specialised tinnitus counselling for patients with debilitating tinnitus. We provide diagnostic audiology to ATSI patients, under contract to Mallee District Aboriginal Services.
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We are in the process of setting up a vestibular assessment service, to provide the diagnostic assessment of patients with debilitating dizziness, referred by an ENT surgeon. The equipment required to facilitate this will cost us in the region of $100,000.00
We value contributing to the hearing health of our local communities, where often health services are limited due to our geographical isolation. Many employers, including Australian Hearing (AH), pay commissions on device sales and set targets for the sale of hearing devices. From the ABC Radio National programme (Ref 1), Hagar Cohen is quoted: “Gina Mavrias is the Operations Manager of the government agency Australian Hearing. Audiologists there receive a 5% commission on the price of the device they sell. So, for example, they will receive $600 for the sale a $12,000 device. This is not disclosed to the patients… Australian Hearing clinics also have sales targets for the number of top-ups they sell. In fact, across the organisation, 20% of the sales are supposed to be top-ups; that is, the more expensive devices that require additional payments.” (‘Top up’ occurs when an OHS client elects to pay extra above the government contribution for devices with additional features).
Professor Paul Komesaroff, a specialist doctor, medical researcher and ethicist who is director of the Centre for Ethics in Medicine and Society at Monash University, was also quoted in the ABC Radio National programme: “In the medical profession, if a doctor prescribed a drug in a setting where he or she gained a commission or where a surgeon utilised a device in a setting where he or she gained a personal benefit from the sale of that device, that would be regarded as corruption, as a corrupt practice. In the case of audiology, it’s become, at least to some extent, embedded systematically in the operation of the profession…It clearly documents the existence of an incentive system and a system of influence whereby audiologists are subjected to pressure to sell more of their products or sell more expensive products for their own benefit rather than primarily for the benefit of their patients…It represents a dangerous duality of interest that I believe, in many cases, does actually constitute a direct conflict of interest. I feel that it is, in general, wrong and inappropriate for a clinical practitioner to obtain material gain from a clinical recommendation that he or she may make regarding a particular therapy, whether it be a pharmaceutical drug or whether it be a device.”
We agree that setting sales targets and paying commission is unethical We take pride in delivering ethical service; we do not impose sales targets on hearing aid fittings, and on hearing aid ‘top-up’ and we do not pay our clinicians commission. We believe the provision of hearing devices should be based solely on a patient’s hearing needs and should not be affected by financial benefits to the dispenser.
a) the eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS;
The OHS funding model has been used as an interim model for the NDIS. This model has a 23dB 3-frequency average hearing loss (3FAHL) minimum level for determining client eligibility for device fitting and outside of this level does not look additionally at the functional ability of a patient. Two clients with the same 3FAHL can experience very different hearing problems and therefore have very different hearing needs. The OHS model is primarily aimed at assessing and fitting hearing aids to a mostly-elderly population. We would expect the service needs of patients less than 65 years of age, especially the paediatric group, to be very different to this OHS cohort.
Much of the marketing and promotion about hearing loss is targeted at selling hearing aids and is aggressive. There is little public education and promotion about realistic benefits and expectations of hearing aid outcomes and other hearing rehabilitation outside the purchase and fitting of hearing devices. Hearing loss is more than just about hearing aids as hearing loss impacts communication and functional ability and it affects a person’s physical and mental health, independence and ability to work. Untreated hearing loss has been linked to increased cognitive decline and depression.
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There has been a significant amount of confusion regarding the patient eligibility criteria for determining access to services. We have received conflicting information during NDIS presentations, including that presented at the National Audiology Australia Conference in Melbourne in May 2016. I note from the Department of Health submission (Submission 1) to this senate inquiry that “The Office of Hearing Services, as the administering body of the program, has been working with NDIA as it determines the eligibility criteria in terms of hearing loss threshold for NDIS participants. The NDIA are expected to confirm and publish their eligibility criteria shortly.” This confusion, along with rumours and speculation about possible subsequent changes to OHS, including the revision of OHS fees, has made us, as small business owners, feel financially vulnerable, insecure and concerned as we try to plan ahead in an uncertain business landscape.
b) delays in receiving services, with particular emphasis on early intervention services; We hope that there will be safeguards should Australian Hearing be privatised, to ensure an acceptable level of appropriate, ethical and timely delivery of hearing services to paediatric patients. There is an additional consideration in the hearing needs and timely delivery of service to paediatric patients whose support needs are long-term, affecting speech acquisition, education outcome, quality of life and employment.
c) the adequacy of funding for hearing services under the NDIS; Audiology has become a highly competitive business, following the Access Economics report “Listen Hear”, published in 2006, which highlighted the potential for profit in hearing aid sales. (Ref
- There are approximately 300 businesses which provide hearing services to OHS-eligible patients, yet only six of these companies dominate 86% of the market, with the government-owned Australian Hearing being the largest. These large companies have immense buying power of devices and have large marketing departments, devising marketing strategies and business models, making competition for the smaller independent companies significantly challenging and difficult. The profitability for these larger chains can be seen by the annual profit before tax noted in the AH annual reports, which for 2012/13 was $4.2M, for 2013/14 was $12M and for 2014/15 was $25M with no significant increase in staff wages which in 2013/14 was $71.76M and in 2014/15 was $73.89M. (Ref 3) Competing in this marketplace, as a small business owner, can be intimidating. Competition for smaller businesses will be more challenging when legislation is changed in 2017-2018 to allow AH access to the private market. (Ref 4)
Within the audiology profession, there is significant uncertainty regarding the future rollout of the NDIS and given this, we have grave concerns about its long-term financial sustainability. There have not been clear guidelines from the NDIA regarding eligibility criteria or exactly how hearing services are to be provided. The OHS funding model used in the interim covers only the assessment of hearing and the provision of hearing devices. There are many audiological services, including tinnitus counselling, vestibular assessment and rehabilitation and central auditory processing assessment, which fall outside this limited remit.
At our clinic, we have OHS clients who are seen multiple times as part of their fitting procedure to enable desired and appropriate outcomes, and others who need be seen only a couple of times, yet the same fitting fee applies to both groups. These extra visits to provide counselling and therapy and other audiology services would be best served under NDIS by allocating an hourly rate (as is done by the $170/hr NDIS rates for Occupational Therapists- up to 10 hours) to cover the time necessary for providing the aforementioned services. Audiological service provision under NDIS for hearing should extend beyond dispensing hearing devices. There should be clear guidelines to cover the level of technology approved and rules for replacement when devices are lost or damaged.
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d) the accessibility of hearing services, including in rural and remote areas; We have endeavoured to ensure, with our eleven visiting sites, that hearing services in our relatively remote rural areas are accessible. This has a financial cost to our business, with extra travel and accommodation costs to cover our clinicians travelling to these sites and extra freight costs. There is no extra payment to us for providing such services under the OHS funding.
e) the principle of choice of hearing service provider; NDIS and OHS have as a key underpinning principle the importance of a patient’s choice of provider. Despite this, we are aware of a business arrangement, operating as a Memorandum of Understanding (MOU) between some hearing clinics, including the government-owned AH, and participating General Practitioner practices, which we believe significantly, undermines and diminishes OHS client choice of hearing services provider. We have evidence that at many medical practices the way the MOU is run results in administrative staff at the GP clinic contacting patients who are eligible for government-subsidised hearing services through OHS to invite them in for a “free” hearing test at the GP clinic, which is bulk-billed. The patient’s referral to enable them to access OHS-funded services is then given directly to the hearing services provider with whom the medical practice has the MOU, not to the patient. This does not provide the patient with a choice of provider. This MOU is promoted to GPs via the AH website. (Ref 5)
The audiology profession is self-regulated and, unlike other Allied Health professions, is not regulated under the Australian Health Practitioner Regulation Agency (AHPRA). This means that audiological professional practitioner bodies have no power to police unethical business practices and can only monitor the practices of individual audiologist members, even with the recently revised Code of Conduct. This was noted by Dr Tony Coles, the CEO of Audiology Australia, in his letter of reply to us regarding this MOU, dated 19th August, 2015: “As you are aware our Code of Ethics and Code of Conduct are structured to provide guidance to audiologists who are members, and not to the employer of audiologists.” The current President of Audiology Australia wrote an article in Audiology Now, highlighting five breaches and a further three possible breaches of Codes of Conduct and Codes of Ethics resulting from the administration of this MOU. (Ref 6)
We would hope that the NDIS can safeguard against such business arrangements to ensure and protect a patient’s right of choice of provider and to provide a level playing field to all hearing service providers, including small independent businesses such as ours which do not have the same degree of financial benefit as AH, the vertically-integrated (manufacturer-owned) and national chains, such as volume discounts, sales targets and preferred supplier agreements.
f) the liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages;
Personally, we have found the process of attempting to register as an NDIS hearing services provider to be confusing and time-consuming, with conflicting information available. The NDIS website has provided a toolkit and some extra written information to help with this process, and this runs to 998 pages.
g) investment in research and innovation in hearing services; Investment in research is fundamental to the improvement of hearing testing techniques, diagnostic equipment and hearing device technology. The results of this research and development are available to all hearing professionals via textbook and online publications, journals, conferences and seminars. We are concerned that the research available via the National
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Acoustics Laboratory (NAL) is being used to the commercial advantage of AH in their marketing of their GP continuing professional development program (Ref 7) which states “We are uniquely supported in Australia by our research division, the world-renowned National Acoustic Laboratories
(NAL).”
We would be willing to discuss any of this material further with the Committee.
Yours sincerely,
Jane MacDonald
Audiologist/Clinical Team Leader
BSc, DipAud, MAudAus, CCP
Don MacDonald
Director
BA(Hons), MACAud, MHAASA, CCP
References:
1: “Have I Got a Hearing Aid For You? ABC Radio National
http://www.abc.net.au/radionational/programs/backgroundbriefing/2014-11-30/5920176
2: “Listen Hear” Access Economics, 2006. https://audiology.asn.au/public/1/files/Publications/ListenHearFinal.pdf
3: Australian Hearing Annual Reports: www.hearing.com.au
4: Hearing Services Program, NDIS Transition Plan http://www.hearingservices.gov.au
5: Australian Hearing, Partnering with Australian Hearing, 2015, cited 2017: https://www.hearing.com.au/general-practitioners-partnering-australian-hearing/
6: ‘The Ethics of Marketing in Audiology”, Audiology Now Issue 60, Autumn 2015
7: Australian Hearing. Have you heard? General Practitioners (GPs) can now obtain 40 CPD points with Australia’s first hearing-based Plan, Do, Study, Act (PDSA) program: Identifying and managing hearing loss in adults. 2017 cited 2017; Available from: https://www.hearing.com.au/general-practitioners-refer-patients-australian-hearing/
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