Why itʼs bad for audiology (2002)

When the America's Hearing Healthcare Team Initiative (AHHTI) was originally established in March 2001, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) approached The Academy in an effort to commit audiology to the initiative. At the time, discussions centered on the development of a joint statement that could be used to educate patients, legislators, healthcare providers, and insurers regarding the role of team members. The discussions broke down when The Academy and AAO-HNS were unable to agree that audiologists provide diagnostic hearing evaluations, even when accompanied by the provision that audiologists are excluded from medical or surgical treatment of hearing loss. Additionally, The Academy was concerned about the overlapping roles of audiologists and commercial hearing aid dispensers on the AHHTI, and ultimately we elected not to participate. This decision was made after significant member input through Member Concerns phone calls, The Academy web site, a Presidential Message published in Audiology Today, and discussions with related professional organizations, including the Academy of Dispensing Audiologists (ADA) and the American Speech-Language-Hearing Association (ASHA). The message was loud and clear: The AHHTI is bad for audiology, and sends the wrong message to consumers, healthcare officials, and legislators regarding the professional role of audiology. Consequently, it was with some surprise that The Academy learned in September of ASHA's decision to commit our profession to the AHHTI. In their joint statement, ASHA and AAO-HNS substituted “autonomous” for “diagnostic” (a minor difference to many consumers, but a big one in healthcare circles), and slipped the CCCs into the statement as the “nationally accepted certification standard” for audiology. From The Academy's perspective, it appeared that ASHA's participation was rather self-serving, given that member certification generates millions of dollars annually for that association. Regardless of the underlying motives for ASHA's initial decision to participate, The Academy believes that there is ample evidence to suggest that the AHHTI remains flawed, confusing, and potentially detrimental to consumers. To wit: WHAT'S WRONG WITH THE AHHTI (1) THERE IS A LACK OF CONTROL OVER DELIVERY OF THE AHHTI'S MESSAGE TO CONSUMERS In a letter to its members dated December 10, 2001, ASHA contended that the AHHTI is a “public awareness activity designed to help the public and referral groups know more about how to access the hearing healthcare system.” The same letter contained a description of an audiologist that was mutually agreed on by AAO-HNS and ASHA, and points out that audiologists are characterized as “autonomous and independent practitioners.” What the letter failed to mention, however, is that hearing aid dispensers also agreed to a joint statement with AAO-HNS that describes their role as providing “an important entry point into the hearing healthcare delivery system.” Furthermore, the document states that hearing aid dispensers “…are independent professionals and… provide direct patient care…This specialist has specific training in assessment and testing of patients who seek rehabilitation for hearing loss…The nationally accepted standard for Hearing Aid Specialists is certification by the National Board for Certification in Hearing Instrument Sciences, which awards the Board Certified in Hearing Instrument Sciences (BC-HIS) designation.” More recently, in a special AAO-HNS six-page supplement of USA Today (March 8, 2002) devoted to ear, nose, and throat issues, the word “audiologist” is never used. So much for the “public awareness” efforts of the AHHTI! Despite the AHHTI, otolaryngologists in numerous states are actively opposing legislation (e.g., Iowa House Study Bill 697) that promotes audiology as an alternative point-of-entry to hearing healthcare. This is in direct conflict with the expressed goals of the AHHTI. The Academy is in favor of collaboration, but we will not endorse a team that relegates audiologists to “second string.” The difference of opinion between ASHA and The Academy remains over whether it is possible to resolve this issue by “working from within.” So far, it does not appear to be working. (2) CONFUSION OVER TEAM ROSTERS AND THEIR ROLES Admittedly, commercial hearing aid dispensers are licensed by states to sell hearing aids. This is largely because audiologists were prohibited from dispensing hearing aids by ASHA's code of ethics until 1978. When audiologists began dispensing hearing aids, in large measure we adopted the business practices of a sales industry, and this practice continues to evolve today. One reason that hearing aid market penetration remains so poor may be the public perception that hearing instrument dispensing is a retail operation. The AHHTI only serves to confuse this issue further, and this perception cannot be changed as long as commercial hearing aid dispensers are involved in an equivalent role to audiology. If anyone doubts that commercial hearing aid dispensers will use their role on AHHTI to expand their scope of practice, one need look no further than the October-November 2001 issue of The Hearing Professional, the official bulletin of the International Hearing Society. That issue contains an article entitled “Preferred Practice Guidelines for Tinnitus and Vertigo,” written by a commercial hearing aid dispenser, which provides a glimpse at their intentions. Finally, if the underlying goal of the AHHTI is to be inclusive and to educate consumers regarding all of the team players, then why are nurse practitioners and physician's assistants conspicuously absent? Could it be that they represent a threat to otolaryngologists because they may provide medical treatment for some types of hearing loss more economically than physicians? (3) MANDATORY, ENTRY-LEVEL CERTIFICATION IS AN OUTDATED METRIC TO DETERMINE COMPETENCE In their joint statement, AAO-HNS and ASHA claim, “The nationally accepted certification standard for audiologists is the ASHA Certificate of Clinical Competence (CCC-A).” In the past, the CCC-A ensured that minimum standards were met across the dozens of programs granting graduate degrees in audiology. However, as our profession evolves to the AuD, audiologists should be evaluated the way that other healthcare professionals (including physicians) are: by their degree, a national entry-level examination, state licensure, and with continuing education requirements. Requiring audiologists to repurchase their CCC-A annually, and creating the impression that this renewal ensures additional expertise, is misleading to consumers. The message should be simple: The AuD and licensure replace the need for the CCC-A. Greater emphasis needs to be placed on maintaining appropriate accreditation standards for doctoral programs in audiology to ensure that the educational requirements meet the scope of practice. Certification and accreditation should be independent of any single professional organization so as to eliminate the potential for a professional conflict of interest, which may impact quality of patient care. CONCLUSION In summary, the ideal of a professional collaboration that is altruistically devoted to the patient's best interest certainly makes sense. In addition, the reality is that only 20% of those with measurable hearing loss wear hearing aids, so there should be plenty of work to go around. The problem, from the American Academy of Audiology's view, is that the AHHTI subjugates the profession of audiology to physicians, restricts the role of the audiologist in the hearing healthcare system, and jeopardizes our goal of obtaining limited license practitioner status with the Centers for Medicare and Medicaid Services (formerly HCFA) and third-party payers. All of these factors restrict access, add cost, and compromise quality of care. Some issues require compromise, but some require resolve and commitment to our ideals. The Academy requests that ASHA re-evaluate its position on the AHHTI and withdraw its commitment of our profession to this “semi-pro” team.