Challenges of Getting Otology Care in Socioeconomically Impacted Areas

For people living in socioeconomically depressed or rural locations, obtaining specialty healthcare like otology can be difficult for a variety of reasons.

The main challenge is lack of resources, including human resources, healthcare infrastructure, and health services, because otology services are mainly concentrated in metropolitan areas, said Ana H. Kim, MD, director of the Cochlear Implant Program and associate director of the residency program and an associate professor of otolaryngology–head and neck surgery at Columbia University Medical Center in New York City. Socioeconomically challenged patients may lack an understanding of ear diseases or may not know to see a specialist for certain ear issues. They may also have different cultural or religious beliefs, social support, and language barriers that may prevent them from gaining access to appropriate medical care.

Some otology care, such as a cochlear implant program, is available only at academic institutions due to the high cost of establishing and sustaining such services, said Dr. Kim. This requires a multidisciplinary team approach. For instance, a child with hearing loss, whether fitted with a hearing aid or undergoing cochlear implantation, requires continued access to service providers such as a speech therapist, educator, and social worker.

In addition, people living in isolated areas are more likely to lack the transportation that would allow them to access otology care and give them the ability to go to multiple or ongoing appointments. They might also lack the resources and internet access that would enable telehealth visits, said Matthew L. Bush, MD, PhD, MBA, chair of rural health policy, vice chair for research, and associate professor in the department of otolaryngology–head and neck surgery at the University of Kentucky Medical Center in Lexington.

Catherine Palmer, PhD, director of audiology and hearing aids in the department of otolaryngology and department of communication science and disorders at the University of Pittsburgh (UP) and the UP Medical Center, pointed out that amplification devices require regular maintenance and periodic repair. This can be burdensome for someone who doesn’t live close to a clinic. Some regions may have audiologists and otologists who travel there on a monthly or quarterly schedule, but that’s still problematic if a device has stopped working and the next visit isn’t for several months.

Challenges Mount

In addition to access issues, people in socioeconomically depressed and rural communities face other challenges in getting otology care. With a high percentage of unemployment, low incomes, and disability, these community members are more likely to rely on public insurance options. Unfortunately, studies have shown that public health insurance recipients, specifically those on Medicaid, have a higher risk of not scheduling or completing follow-up recommendations (Am J Audiol. 2009;18:24-33). This may occur due to the cost of having multiple appointments, as well as confusion regarding decision making around hearing loss, said Allison McGrath, AuD, CCC-A, clinical audiologist and assistant of otolaryngology, division of audiology, department of otolaryngology–head and neck surgery at Johns Hopkins Medicine in Baltimore.

Overall, 28 million Americans have hearing loss. Based on those numbers, some people aren’t getting diagnostic testing and likely aren’t getting treated. —Matthew L. Bush, MD, PhD, MBA

Patient education is an important part of getting help for hearing loss. A lack of education about identifying hearing loss and appropriate treatment options (e.g., otologic intervention, devices covered by insurance, devices available online or in ads, and over-the-counter devices) can result in patient dissatisfaction and poor adherence to recommendations (J Am Board Fam Med. 2016;29:394-403; JAMA Otolaryngol Head Neck Surg. 2020;146:13-19). “Direct-to-consumer interventions, such as those online and in advertisements, promise a false hope of a quick fix for hearing loss,” Dr. McGrath said. “When such readily available interventions fall short of patient expectations, they’re often deterred from seeking further options that may be more appropriate and managed by a trained medical professional.”

Furthermore, Medicaid and Medicare recipients are required to have a primary care physician (PCP) referral to see medical specialists like audiologists. “This is yet another obstacle keeping this population from accessing hearing healthcare,” Dr. McGrath said.

Along these lines, Chelsea Conrad, AuD, an audiologist in the division of audiology at Henry Ford Health System in Detroit, said that low-income individuals are more likely to be uninsured or be Medicaid recipients, and will seek healthcare less often. Patients frequently don’t seek care until it’s emergent, and although adults eligible for Medicaid may have hearing aid benefits, provider participation in this service provision remains low due to the administrative burden of preauthorization and low reimbursement. Some state and charitable organizations offer programs specific to hearing loss, but navigating these services for enrollment, care coordination, and follow-up is challenging for many patients. This difficulty can be amplified for individuals who have no internet access and who have low literacy levels.

Another challenge stems from the fact that if adults with chronic ear pathology aren’t treated promptly, erosion of ossicles may result, Dr. Kim said. This can cause conductive hearing loss, and in some cases irreversible sensorineural hearing loss, labyrinthine fistula resulting in balance dysfunction, cerebral spinal fluid leak, facial nerve paralysis, and meningitis, just to cite few examples.

At some point, severe to profound hearing loss may no longer be helped with conventional hearing aids. Even if hearing loss is treatable, most insurance provides nominal coverage for hearing aids at best, Dr. Kim said.

Pediatric hearing loss in socioeconomically depressed areas is even more challenging, especially for prelingual hearing loss. These children may present with concomitant behavioral or developmental issues due to late presentation. “Children from these areas are less likely to get the medical and social support necessary to achieve adequate hearing during a critical time of speech and language development,” Dr. Kim said. This may result in communication difficulties, learning impediments, dropping out of school, isolation, and employment challenges.

Hearing Testing Falls Short

A lack of hearing testing can also be problematic. Although the majority of babies born in hospitals are screened for hearing loss at birth, parents in socioeconomically depressed areas may be less likely to obtain follow-up testing for infants who failed screening, Dr. Palmer said. This can be due to transportation, time, or financial challenges preventing access to pediatric audiological care. If diagnostic testing reveals a significant hearing loss, ongoing appointments will be required to fully assess a baby’s hearing as they mature, as well as fittings and reprograming hearing aids or cochlear implants as they grow, in addition to medical management provided by a pediatric otologist.

The majority of adults aren’t screened for hearing loss regardless of their socioeconomic status. According to HealthyPeople.gov, 20% of adults under age 70 have had a hearing test in last five years. For adults older than 70, about 40% have had a hearing test in the last five years. An objective of the government’s Healthy People 2020 initiative is to increase that percentage by over 10% over the next decade.

A hearing screening is meant to be included in an initial Medicare visit, but oftentimes this isn’t accomplished, Dr. Palmer said. Although hearing loss is expected in older adults, it isn’t without consequence; data indicate that less than 50% of adults accurately identify that they have hearing loss when asked (Gerontol Nurs. 2020;46(6):34-42). This finding suggests that a screening would be necessary to identify individuals who need treatment.

Furthermore, many insurance carriers and Medicare won’t reimburse for screening adults for hearing loss because it isn’t a national standard for PCPs to do so, Dr. Bush said. In children, even though hearing evaluation is often a part of school entry or pediatrician visits, this kind of evaluation may be given inconsistently for children living in rural settings.

Community leaders should encourage the public to participate in hearing assessment and address particular community needs. —Ana H. Kim, MD

Although there is evidence that hearing loss is more prevalent among adults living in rural communities compared with those living in urban settings (J Rural Health. 2002;18:521-535; Am J Epidemiol. 1998;148:879-886), there aren’t any national data on hearing loss specific to rural or remote areas. Dr. Bush estimates that about half of the number of adults in socioeconomically depressed or rural areas have their hearing tested compared to the general population. That would amount to about 10% of adults under the age of 70 and only 20% of adults older than the age of 70 who have had a hearing test in the last five years.

“That’s significant, because, overall, 28 million Americans have hearing loss,” Dr. Bush said. “Based on those numbers, some people aren’t getting diagnostic testing and likely aren’t getting treated.”

The American Speech-Language-Hearing Association recommends adults be screened at least every decade through age 50 and at three-year intervals thereafter. Additional governing bodies such as the U.S. Preventive Services Task Force, the American Academy of Family Physicians, and the American Academy of Audiology lack specific hearing screening recommendations for adults, Dr. McGrath said (JAMA. 2021;325:1196-1201).

A 2008 study found that up to 86% of general physicians don’t routinely screen their patients’ hearing (Am J Epidemiol. 1998;148:879-886). This lack of identification is a contributing reason to the fact that fewer than 20% of adults with confirmed hearing loss obtain intervention. Unfortunately, the small percentage of patients who do seek intervention have an even lower likelihood of adoption of and adherence to treatment recommendations, especially if they’re from socioeconomically depressed areas, Dr. McGrath said (J Health Care Poor Underserved. 2016;27:1812-1818).

In another study, only about 15% of the total U.S. population reported having a hearing screening during their last physical exam (The Hearing Review. 2009;16:12-31). This is consistent with another study of the National Health and Nutritional Examination Surveys (NHANES), which found that 40% of respondents had a hearing test in the past four years (J Aging Health. 2016;28:68-94), said Jennifer Alyono, MD, MS, clinical assistant professor, otolaryngology–head and neck surgery at Stanford University. While the NHANES study did not find that income level correlated with the rate of hearing testing, researchers did find that Black individuals were less likely to use hearing aids, even though they were more likely to report recent hearing testing than White individuals (J Aging Health. 2016;28:68-94).

Based on nationally representative data, Carrie Nieman, MD, MPH, assistant professor of otolaryngology–head and neck surgery at Johns Hopkins University School of Medicine in Baltimore, has seen higher reports of recent hearing testing among minority older adults. Specifically, she said that approximately 43% of Black older adults report recent hearing screening versus 39% of White older adults.

“The reason for this difference is unclear,” Dr. Nieman said. “One possibility is that Medicare generally covers hearing testing and can serve to attenuate disparities in care among older adults. The difference may also be due to differences in geographic access, stigma, or referral rates between groups. Among Black older adults, recent hearing testing was associated with increased healthcare use and may reflect greater access and/or use of healthcare in general (J Aging Health. 2016;28:68-94).

We know there are differences in hearing aid use by race, ethnicity, and income among older adults with hearing loss, with a lower prevalence of hearing aid use among minority older adults. —Carrie Nieman, MD, MPH

“But these numbers do not translate to hearing aid use,” Dr. Nieman cautioned. “We know there are differences in hearing aid use by race, ethnicity, and income among older adults with hearing loss, with a lower prevalence of hearing aid use among minority older adults (J Aging Health. 2016;28:68-94) as well as low-income older adults (J Health Care Poor Underserved. 2016;27:1812–1818).”

The Impact of Undiagnosed and Untreated Hearing Loss

Hearing loss can affect both children and adults in profound ways. Undiagnosed and untreated hearing loss can negatively impact communication and social development in children and occupational opportunities and success in adults, Dr. Bush said. Emotional health and wellbeing are impacted by hearing loss, as is the ability to interact with people on a daily basis and feel a sense of community. Adults with hearing loss may become isolated and limit their social exposure and interactions due to fear or embarrassment of missing something in a conversation.

Dr. McGrath said that underdetection and undertreatment of hearing loss in people across a lifespan is disheartening in light of repeated evidence that hearing loss management improves quality of life and public health enterprises. Children with unmanaged hearing loss are at a higher risk for decreased academic success, resulting in a higher likelihood of low educational attainment, unemployment, and low-income status (Otol Neurotol. 2015;36:545-550). According to the CDC, the lifetime medical, educational, and occupational costs resulting from children in the United States who are born with hearing loss are estimated at $2.1 billion (MMWR Morb Mortal Wkly Rep. 2004;53:57-59).

On the other end of the age spectrum, adults with untreated hearing loss have a greater lifetime history of hospitalization, reduced productivity in society, a higher risk of disability, and a higher mortality rate, Dr. McGrath said. Studies have shown that these adult populations with hearing loss have higher incidences of comorbid medical conditions and exposure to adverse environmental conditions associated with hearing loss (Vital Health Stat. 1997;10(194)). The total economic costs associated with adult-onset hearing loss are estimated to be between $1.8 and $194 billion, including the estimated $12.8 billion associated with excess medical costs (JAMA. 2017;143:1040-1048). The economic costs related to adult-onset hearing loss can be inferred to be on the higher end of the range in economically suppressed areas.

Individuals with untreated hearing loss also accrue higher healthcare use, costing more than $20,000 more than those without hearing loss over a 10-year period (JAMA Otolaryngol Head Neck Surg. 2019;145:27-34). On an individual level, hearing loss has been linked to increased rates of social isolation, mental health difficulties, dementia, and cognitive decline, Dr. Alyono said.

Increasing Access to Otology Care

Improving otology care in socioeconomically depressed areas is particularly challenging and should be addressed at several different levels, said Dr. Kim. At the national and state levels, hearing loss should be made a priority by governmental agencies allotting sufficient funding to support hearing loss-related campaigns, activities, and research.

Early intervention only covers services up to age three. Prevention of hearing loss through vaccination (e.g., measles, rubella), screening (e.g., cytomegalovirus, HIV, syphilis), and early screening of hearing loss through education (e.g., congenital, genetic, maternal factors associated with hearing loss) should all be prioritized, Dr. Kim said. Importantly, otological services should be made more accessible, available, and affordable.

At the hospital level, outreach services are needed to assist communities in need. “Community leaders should encourage the public to participate in hearing assessment and address particular community needs,” Dr. Kim says. At the school level, administrators, counselors, teachers, and students should be educated regarding the impact of hearing loss and hearing protection.

Dr. McGrath said patient-centered information and education regarding services and interventions needs to be improved. “Providing such information to primary healthcare providers doesn’t ensure that the information reaches the patient and leaves room for continued patient confusion in medical decision making,” she said. Direct-to-patient information would provide support to help patients understand their options, access services, and realize the potential benefits intervention can have on their overall quality of life.

Hearing screenings also need to be more readily available to patients, especially adult patients, where this is lacking (JAMA. 2021;325:1196-1201; Am J Audiol. 2008;17:3-13). This could include educating PCPs on the association of hearing loss with compounding medical issues that a provider may find more pertinent, such as dementia, diabetes, and depression, Dr. McGrath said. Expanding provider education on the association of hearing loss and its impact could raise the importance of discussing hearing healthcare at primary care visits and facilitating more regular screenings and specialist referrals.

Improving direct access for patients with public insurance to audiology would improve cost-effectiveness, time efficiency, and quality of care for patients, Dr. McGrath continued. Currently, public insurance allows direct access to social workers, psychologists, chiropractors, and optometrists, none of whom have an MD or DO degree. Allowing patients with hearing concerns direct access to an audiologist without first seeing a physician for a referral could significantly reduce the time between noticed hearing concerns and hearing loss management.

The bottom line is that although people in socioeconomically depressed areas are at a disadvantage for obtaining otology care, there are ways to improve access and availability.

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Karen Appold is a medical writer in Pennsylvania.