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30 January 2017
Joint Standing Committee on the National Disability Insurance Scheme
PO Box 6100
Parliament House
Canberra ACT 2600
Dear Committee Chairperson,
Submission to the Joint Standing Committee inquiry into the provision of hearing services under the National Disability Insurance Scheme.
Our submission makes nine (9) recommendations to the Committee, as follows:
Recommendation 1: To develop, in conjunction with all stakeholders, clear eligibility criteria for hearing services under the NDIS.
Recommendation 2: A “service needs framework” for hearing impaired and deaf individuals is developed to ensure consistency in service delivery, with flexibility to enable individual goals.
Recommendation 3: Central auditory disorders are included in the eligibility criteria for NDIS funded programs. The services provided under NDIS are far more than a device and need to include a multitude of therapies to enable appropriate outcomes for these children, such as Speech Therapy, Psychology, and Occupational Therapy.
Recommendation 4: Ensure that the eligibility criteria are inclusive of those with hearing impairments, who are at risk of not accessing services, to continue to manage their hearing loss due to financial constraints.
Recommendation 5: Accreditation of paediatric hearing service providers is mandatory to ensure quality outcomes for infants and their families.
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Recommendation 6: A mechanism or system is in place as a central depositary of data to manage and monitor outcomes, and also to continue to advance our collective understanding of best practice. This role would be best served by an independent research authority, such as the National Acoustic Laboratories (NAL).
Recommendation 7: An online portal for application and routine approval processes is introduced to ensure efficient and effective service delivery to NDIS clients.
Recommendation 8: The “service needs framework”, suggested in recommendation 2, is expanded to a “matrix” to include appropriate funding levels. Consultation should occur with a range of service providers.
Recommendation 9: That this Joint Committee, and the House of Representatives Committee undertaking an enquiry into Hearing Health and Wellbeing in Australia, work collectively and collaboratively to produce consistent and complementary outcomes and recommendations.
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About Neurosensory
Neurosensory has been a leading provider of comprehensive hearing and balance services in Australia for over 35 years. Neurosensory is owned by 61 of Australia’s leading Ear, Nose and Throat surgeons who are committed to the highest standards of clinical outcomes.
This dedication to the highest standards of clinical outcomes is reflected in Neurosensory’s refusal to link our clinicians’ salaries to the number of devices sold. We strongly believe that this pervasive approach, adopted by the vast majority of the industry, fails to acknowledge that outcomes of a hearing rehabilitation program are more a result of the clinician providing the service than the device sold.
The Company has 22 clinics in Queensland, New South Wales and Victoria, providing an extensive scope of audiological assessment and rehabilitation services. Our services include:
Hearing assessments for babies, children and adults. Balance assessments. Auditory processing assessments. Electrophysiological assessments. Hearing aid rehabilitation programs. Hearing implant rehabilitation programs. Tinnitus management programs. Assistive listening devices. Hearing protection. Vestibular physiotherapy. Psychological counselling services.
Neurosensory believes that undertaking preventative measures, wherever possible, to diagnose early-stage diseases and disorders, and provide the most appropriate, clinically-validated intervention, is the key to ensuring all Australians have the best chances of ageing healthily and continuing to contribute to the community well into their later lives.
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Term of Reference 1: Eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS.
Currently, there are no published eligibility criteria for who can access hearing services under the NDIS. Due to the lack of established eligibility criteria, it is impossible for clinicians to determine who may be able to access hearing and other hearing related services (such as balance services).
Recommendation 1: To develop, in conjunction with all stakeholders, clear eligibility criteria for hearing services under the NDIS.
The services which are available under the NDIS for hearing impaired and deaf individuals are not formulated, and appear to be derived on a case by case basis. Such service level inconsistency is time consuming for heath professionals and their families. Furthermore, services provided may put those individuals who are not able to advocate for themselves at risk of receiving less services.
Recommendation 2: A “service needs framework” for hearing impaired and deaf individuals is developed to ensure consistency in service delivery, with flexibility to enable individual goals.
Currently, the Commonwealth Government CSO program does not provide the funding for assessment or rehabilitation of Central Auditory Processing Disorders (CAPD) in children and young adults. It is estimated that between 2-5% of Australian children have some form of CAPD.1 Such disorders may lead to language delays, reduced academic performance, and a higher likelihood of behavioral, emotional and social difficulties.2
Recommendation 3: Central auditory disorders are included in the eligibility criteria for NDIS funded programs. The services provided under NDIS are far more than a device and need to include a multitude of therapies to enable appropriate outcomes for these children, such as Speech Therapy, Psychology, and Occupational Therapy.
Currently, when a hearing impaired child turns 27, they are no longer eligible for assistance under the OHS CSO program. Concurrently, they are rarely eligible for the voucher program, as they are not on a pensioner concession card. This cohort is at significant risk of being left behind, as they are required to self-fund their hearing services and care. From a societal perspective, maintaining the employability and health of this cohort is an important priority.
Recommendation 4: Ensure that the eligibility criteria are inclusive of those with hearing impairments, who are at risk of not accessing services, to continue to manage their hearing loss due to financial constraints.
1 National Acoustic Laboratories Website, 2017. 2 Central Auditory Processing Disorders, American Speech-Language and Hearing Association (ASHA), 2005.
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Term of Reference 2: Delays in receiving services, with particular emphasis on early intervention services.
There are a multitude of entry points into a hearing services program in Australia. This submission will focus on congenital hearing loss, and practical entry issues, as follows:
Congenital hearing loss
Australia has an excellent universal neonatal hearing screening program. The screening, diagnostic and referral pathways are well established with private groups, such as Neurosensory, State Government health departments, Federal Government agencies, such as Australian Hearing, and early intervention agencies. These parties work well together to deliver services to congenitally hearing impaired Australian infants.
A potential benefit of transitioning to a fully contestable market for these infants may lead to less agencies being involved, and therefore has the opportunity of making a family’s journey more seamless and less stressful. The challenge of this transition is to ensure the quality of service is consistent and not compromised; and data collection and monitoring of quality assurance is robust and effective.
Furthermore, as there is only one service provider to this cohort at present, Australian Hearing, the breadth and value of the data collected has led to world leading rehabilitation research. It is essential in transitioning to a multi-provider, client- choice model, that the data and subsequent research function is preserved.
Recommendation 5: Accreditation of paediatric hearing service providers is mandatory to ensure quality outcomes for infants and their families.
Recommendation 6: A mechanism or system is in place as a central depositary of data to manage and monitor outcomes, and also to continue to advance our collective understanding of best practice. This role would be best served by an independent research authority, such as the National Acoustic Laboratories (NAL).
Practical entry issues
The practical issue for all eligible participants of NDIS is how an individual applies and communicates with the NDIA. This practical issue can be overcome with an online portal, which is a real-time, on line eligibility and approval process, expediting access to services. Such a portal exists for the voucher clients in the OHS program. The introduction of the OHS portal reduced the application processing time from 4-6 weeks to less than 1 minute.
Recommendation 7: An online portal for application and routine approval processes is introduced to ensure efficient and effective service delivery to NDIS clients.
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Term of Reference 3: The adequacy of funding for hearing services under the NDIS.
The level of funding will be linked to eligibility and services delivered under the program. The current programs, such as the CSO and voucher programs, have service items and funding associated with them, which are adequate for the older population. In providing funding for the NDIS population, the following issues should be considered:
Sufficient flexibility for individual care plans. Appropriate funding to ensure appropriate and professional levels of care. Funding models which reflect the differing complexity of services, i.e. more complex services attract more funding than less complex services. Funding models which reflect the cost of providing services in rural and remote locations.
Recommendation 8: The “service needs framework”, suggested in recommendation 2, is expanded to a “matrix” to include appropriate funding levels. Consultation should occur with a range of service providers.
Term of Reference 4: The accessibility of hearing services, including in rural and remote areas.
The issue of accessibility is an important one. In order to ensure appropriate delivery of care to rural and remote communities, suitable funding will be required to ensure delivery of these services. Please refer to recommendations 7 and 8.
Term of Reference 5: The principle of choice of hearing service provider.
Neurosensory supports a fully contestable market. It is challenging for Neurosensory to progress our plans to position for the NDIS due to the lack of knowledge surrounding eligibility, services providers and associated funding. Consequently, this information is critical in ensuring that a fully contestable market will operate.
Term of Reference 6: The liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages.
There is yet to be any consultation with hearing service providers, however, Neurosensory welcomes the opportunity to participate.
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Term of Reference 7: Investment in research and innovation in hearing services.
Australia’s contribution to hearing research is world-leading. The Australian Government’s commitment to hearing research has been unwavering and pioneering over the past 70 years. Neurosensory fully supports ongoing hearing research funding. Please refer to recommendation 6.
Term of Reference 8: Any other related matters.
Neurosensory notes that the House of Representatives is currently undertaking an Inquiry into Hearing Health and Wellbeing in Australia, to which Neurosensory has provided a comprehensive submission (see appendix A). It is requested that this Joint Committee and the House of Representative Committee inform each other and collectively and collaboratively provide recommendations and outcomes which are consistent and complementary.
Recommendation 9: That this Joint Committee, and the House of Representatives Committee undertaking an enquiry into Hearing Health and Wellbeing in Australia, work collectively and collaboratively to produce consistent and complementary outcomes and recommendations.
Neurosensory welcomes the opportunity to be involved in the consultation process for developing hearing services under the NDIS.
Yours sincerely,
Nina Quinn
Chief Executive Officer
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APPENDIX A
23 December 2016
The Standing Committee on Health, Aged Care and Sport
PO Box 6021
Parliament House
Canberra ACT 2600
Dear Committee Chairperson,
Submission to the Inquiry into the Hearing Health and Wellbeing of Australia
Our submission, made in two parts, makes four (4) recommendations to the Committee.
Section 1 - The current state of balance disorders in Australia
Recommendation 1: That the Government fund research to fully understand the economic impact of balance disorders, including dizziness, disequilibrium and vertigo, on the Australian economy.
Recommendation 2: Given the known increases in balance disorders amongst older Australians, and the efficacy of vestibular rehabilitation, Government should include allied health treatment services for persons at risk of falls and balance disorders through the current Chronic Disease Management Plan arrangements.
Section 2 - The paradox of funding for pensioner hearing services
Recommendation 3: That the Office of Hearing Services program be extended to include services for recipients of implantable hearing devices.
Recommendation 4: That the Office of Hearing Services program be extended to include the replacement or upgrade of implantable hearing device processors.
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About Neurosensory
Neurosensory has been a leading provider of comprehensive hearing and balance services in Australia for over 35 years. Neurosensory is owned by 61 of Australia’s leading Ear, Nose and Throat surgeons who are committed to the highest standards of clinical outcomes.
This dedication to the highest standards of clinical outcomes is reflected in Neurosensory’s refusal to link our clinicians’ salaries to the number of devices sold. We strongly believe that this pervasive approach, adopted by the vast majority of the industry, fails to acknowledge that outcomes of a hearing rehabilitation program are more a result of the clinician providing the service than the device sold.
The Company has 22 clinics in Queensland, New South Wales and Victoria, providing an extensive scope of audiological assessment and rehabilitation services. Our services include:
Hearing assessments for babies, children and adults. Balance assessments. Auditory processing assessments. Electrophysiological assessments. Hearing aid rehabilitation programs. Hearing implant rehabilitation programs. Tinnitus management programs. Assistive listening devices. Hearing protection. Vestibular physiotherapy. Psychological counselling services.
In the context of Australia’s aging population, Neurosensory believes that undertaking preventative measures, wherever possible, to diagnose early-stage diseases and disorders, and provide the most appropriate, clinically-validated intervention, is the key to ensuring all Australians have the best chances of ageing healthily and continuing to contribute to the community well into their later lives.
Section 1 - The current state of balance disorders in Australia
This section addresses items 1 and 6 from the terms of reference.
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The current causes and costs of hearing loss, and ear or balance disorder to the Australian health care system should existing arrangements remain in place.
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Access, availability and cost of required drugs, treatments and support for chronic ear and balance disorders sufferers.
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Causes of balance disorders
At its simplest, our balance system uses inputs from our eyes, inner ears, muscles and skeletons, which are processed by the central nervous system, in turn providing output to our muscles and skeletons to keep us upright; and to our eyes to keep our visual field stable. Dysfunction in any of these pathways is enough to disturb our sense of balance, which leads to poorer physical stability, and secondary implications such as higher risks of falls and associated injuries.
Following a fall, or a close call, a person with balance dysfunction often will significantly reduce their social and workforce participation, at which point they are at increased risk of developing psychological disorders, such as depression and anxiety, as well as physical disorders such as weakness and obesity.
It is logical to infer that a person with a balance disorder who has become heavier and weaker is going to be less able to correct their posture when they are slightly off balance, and therefore are at an ever-increasing risk of falls. This is the unfortunate, debilitating cycle of patients with chronic imbalance, vertigo or dizziness.
Most common amongst the causes of balance problems are disorders of the inner ear, such as Benign Paroxysmal Positional Vertigo (BPPV), Meniere’s disease and vestibular neuritis, which account for approximately half of all balance problems (Bronstein et, al. 2010).
Costs of balance disorders
The 2006 Listen Hear! report by Access Economics calculated a real financial cost of hearing loss to the Australian Economy in 2005 of $11.75 billion, or 1.4% of GDP. Less widely reported upon, however, is the cost of balance disorders to the Australian health care system. While there has been some work in this area, the full economic impact has not been fully investigated, nor addressed.
International studies underscore the substantial economic burden caused by fall related injuries, across a variety of medical care systems, with fall injuries reported to be amongst the 20 most expensive medical conditions (Carroll et al, 2005). In the United Kingdom, in 1999 the cost of emergency department and fall related injuries, among people aged over 60 years, was almost £1 billion (Stevens et al, 2006). In the United States, the Centre for Disease Control and Prevention report the cost of falls in 2015, to the Medicare system alone, to have been US$31 billion (Burns et al, 2016).
In 2004, a Western Australian study (Hendrie et al, 2004) estimated that the cost to the Australian healthcare system of emergency department treated and hospitalized fall injuries alone, was $86.4
million. The Incidence and Cost of Falls Injury Among Older People in New South Wales 2006/07
report (Watson et al,2010) commissioned by New South Wales Health, found that:
It is clear that, in terms of economic cost alone, falls injury is responsible for a significant burden to the NSW community equivalent to five per cent of the NSW health budget. In order to reduce the impact of fall-related injury among older
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people, significant investment is required to promote evidence-based falls prevention programs at the local level across the state.
International incidence data indicates that balance disturbance accounts for as many as 4.9% of all GP visits (Neuhauser, H. 2007), with incidence in the USA reported as being 22% in the 65 to 69 years of age group, increasing to 40% in the 80 to 84 years of age group (Cutson, 1994). Dewane (1995) reports that dizziness and falls are two of the most common health complaints in the elderly population.
In Australia, the estimated number of serious injuries due to falls in people aged 65 and older in 2010/11 was 92,150. The patient days for hospital care for people aged 65 and older, directly attributable to fall-related injury, doubled, from 0.7 million patient days in 1999/2000 to 1.4 million patient days in 2010/11. One in every 10 days spent in hospital by a person aged 65 and older in 2010/11 was directly attributable to an injurious fall (Bradley, 2013).
Despite the higher prevalence of dizziness and balance disorders amongst older members of the community, perhaps the most severe impacts, in terms of social and economic costs, occur amongst those of working age. Bronstein et al (2010) found that 27% of patients with dizziness or balance disorders had to change jobs because of their balance problems, and a further 21% gave up work entirely. 57% of these patients also reported disruptions to their social lives, due to an inability to take part in outdoor activities and travel.
The economic impacts of these disorders in Australia are not fully understood. However, based on international incidence and economic impact studies, and the demographics of Australia’s aging population, the local economic impacts are likely to, at a minimum, run into the many hundreds of millions of dollars.
Recommendation 1: That the Government funds research to fully understand the economic impact of balance disorders, including dizziness, disequilibrium and vertigo, on the Australian economy.
Treatments for balance disorders
Amongst the current treatment approaches for balance disorders, there is limited research to support the efficacy of many commonly prescribed medications for dizziness. Despite this, most patients presenting for balance assessments have taken a course of either Serc or Stemitil, with some being completely reliant on daily administration of these medications. While these drugs may suppress the symptoms in some patients, the underlying disorder is not treated
More targeted approaches to resolving chronic balance problems generally aim to destroy the inner ear balance organs on the affected side, either through the administration of vestibulo-toxic agents to the inner ear or, less commonly, by drilling out the inner ear balance system.
While generally effective in treating the cause of the patient’s dizziness or imbalance, these patients are left completely reliant upon the remaining inner ear balance system in the other ear. Should something impact upon the function of that remaining ear, the patient is at risk of developing a
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bilateral vestibulopathy, leaving them chronically unstable, and with a visual field that distorts with even the slightest head movements.
An alternative approach to treating the symptoms of balance disorders, which has a growing base of efficacy, is the use of vestibular rehabilitation (VR) exercises, conducted by a qualified physiotherapist or audiologist. Indeed, VR has been shown to be an effective treatment for patients with dysfunction of one inner ear balance system (Herdman, 2013), though the efficacy is largely based upon the skill of the practitioner (Tjernstrom, Zur and Jahn, 2016). Recent Australian research has also shown VR to be effective in cases of vestibular migraine, a condition which does not involve the inner ear balance system (Vitkovic et al, 2013).
Despite the growing evidence regarding the efficacy of VR, one limitation to the uptake of these allied health services is funding. Currently, while there are some public hospital programs providing these services, waiting times can be significant, and given the debilitating nature of these disorders, such delays between symptom onset and the eventual treatment potentially result in the development of the abovementioned physical and psychological secondary conditions. Private services exist and are partially funded through private health insurance, but for many, the out-of pocket expense of accessing these services creates barriers to access.
Recommendation 2: Given the known increases in balance disorders amongst older Australians, and the efficacy of vestibular rehabilitation, Government should include allied health treatment services for persons at risk of falls and balance disorders through the current Chronic Disease Management Plan arrangements.
Section 2 - The paradox of funding for pensioner hearing services
This section addresses item 3 from the terms of reference.
- Access to, and cost of services, which include hearing assessments, treatment and support, Auslan language services, and new hearing aid technology.
Australia leads the world in some areas of hearing care. Our neonatal hearing screening programs, and subsequent rehabilitation services for infants diagnosed with hearing loss, have significantly improved outcomes for these children, and ultimately this investment has positively impacted upon their quality of life, and that of their families. The Office of Hearing Services (OHS) program also provides an excellent service for most hearing impaired pensioners. Unfortunately, however, a significant gap in this service exists.
Pensioners are able to access fully subsidised hearing aids through the OHS program, from the point of developing a mild hearing loss, all the way down to when their hearing loss reaches the severe to profound range. It is in the severe to profound range that this paradox of funding occurs.
As hearing loss progresses, the inner ear distorts the incoming sound more and more, reducing the benefit obtained from hearing aids. The hearing aids provide volume but not clarity. It is at this point
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that a person requires a cochlear implant. Currently, there is some state government funding for public cochlear implants in Australia, however, the majority of implants are funded privately through the patients’ health insurance.
Australian Hearing’s Community Service Obligation Funding covers the cost of parts and repairs for pensioners with cochlear implants, however, there is no funding for the fitting and fine tuning of these pensioners’ cochlear implant processors. If these pensioners were to be fitted with hearing aids, then the fitting and fine tuning of their hearing aids would be funded through OHS.
Unfortunately, we have seen many cases in our clinics where, due to this lack of funding, pensioners, for whom a cochlear implant would be the most appropriate intervention, are fitted with hearing aids which provide limited benefits.
Recommendation 3: That the Office of Hearing Services program be extended to include services for recipients of implantable hearing devices.
Cochlear implant processor replacements or upgrades are necessary to maintain communication and quality of life. In recognition of this, the Government funds these services for Australian citizens up to the age of 26 years. However pensioners must self-fund these devices at a cost of $6,800 to $9,000 (ex GST). Those pensioners who hold private health insurance may be able to access a replacement or upgrade through that channel, however, for many pensioners, private health premiums are unaffordable. The consequence of these costs can be that some implant recipients may become non-users, while others are reliant on second-hand devices loaned by their implant clinics.
Recommendation 4: That the Office of Hearing Services program be extended to fund processor upgrades for eligible pensioners.
Concluding remarks
Hearing and balance services in Australia are amongst the best in the world. Despite this, there are still massive economic and social impacts that result from gaps in the current clinical knowledge, a lack of community awareness, and constrained funding programs. While these factors will never be fully resolved, we believe that through well-planned, targeted programs, the Government can significantly reduce the burden of these health care issues on the community.
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References
Access Economics (2006) Listen Hear! The Economic impact and cost of hearing loss in Australia. Canberra.
Bradley, C. (2013) Trends in hospitalisations due to falls by older people, Australia 1999-00 to 2010
- Injury research and statistics series 84. Cat. no. INJCAT 160. Canberra: AIHW. Bronstein, A. M., Golding, J. F., Gresty, M. A., Mandala, M., Nuti, D., Shetye, A. and Silove, Y. (2010) The Social Impact of Dizziness in London and Siena. Journal of Neurology. 257: 183-190.
Burns, E.B., Stevens, J.A., and Lee, R.L.(2016) The direct costs of fatal and non-fatal falls among older adults—United States. Journal Safety Research. 2016:58.
Carroll, N. V., Slattum, P. W., & Cox, F. M. (2005). The cost of falls among the community-dwelling elderly. Journal of Managed Care Pharmacy, 11(4), 307-16.
Cutson, T. M. (1994) Falls in the elderly. American Family Physician. 49:149-156.
Dewane, J.A. (1995) Dealing with dizziness and disequilibrium in older patient: a clinical approach. Topics in Geriatric Rehabilitation. 11:30-38.
Hendrie, D., Hall, S. E., Arena, G. et al (2004) Health system costs of falls of older adults in Western Australia. Australian Health Review 28:363–373.
Herdman, S. J. (2013) Vestibular rehabilitation. Current Opinions in Neurology. 26:96-101.
Neuhauser, H. (2007) Epidemiology of vertigo. Current opinions in Neurology. 20:40-46.
Stevens, J.A., Corso, P.S., Finkelstein, E. A., Miller, T.R. (2006) The costs of fatal and non‐fatal falls among older adults Injury Prevention. 12(5): 290–295.
Tjernstron, F., Zur, O. and Jahn, K. (2016) Current concepts and future approaches to vestibular rehabilitation. Journal of Neurology. 263:565-570.
Vitkovic, J., Winoto, A., Rance, G., Dowell, R. and Paine, M. (2013) Vestibular Rehabilitation outcomes in patients with and without vestibular migraine. Journal of Neurology. 260:3039-3048.
Watson W, Clapperton A, Mitchell R. (2010) The incidence and cost of falls injury among older people in New South Wales 2006/07. Sydney: NSW Department of Health.
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