Difficulty hearing is one of the most common symptoms experienced by individuals as they get older, affecting more than two thirds of those ages 75 and older (Lin, Thorpe, Gordon-Salant, & Ferrucci, 2011). Reported data suggest that upwards of 80% of individuals older than 80 experience hearing loss (Chou, Dana, Bougatsos, Fleming, & Beil, 2011). Hearing loss is also far from benign; data routinely support its association with a broad range of negative outcomes, including depression, isolation, functional impairment, altered relationships, and diminished cognitive function. Given the cost of cognitive impairment along with increased longevity, its potential effect on cognitive functioning is receiving increasing attention, especially with several recent reports supporting the association of hearing loss with cognitive impairment as well as incident dementia (Lin, 2011; Lin, Ferrucci, et al., 2011; Lin, Metter, et al., 2011).
Although hearing loss is a significant health care concern, it remains a silent and underappreciated problem (Bainbridge & Wallhagen, in press). Only approximately 20% of individuals who might benefit from amplification use it (Cox, Alexander, & Gray, 2005; National Institute on Deafness and Other Communication Disorders, 2010); many older adults minimize or deny they have problems or do not appreciate the extent of their loss, and few practitioners screen for hearing loss in primary care (Wallhagen & Pettingill, 2008). These barriers might be addressed by broadly disseminated educational interventions. However, individuals who seek hearing health care services discover that hearing aids and related services are not covered by Medicare or many other forms of insurance. This might not be as much of a concern for individuals except that hearing aids, as currently sold, are expensive, averaging approximately $2,000 per aid but ranging dramatically in price.
Medicare has specific requirements to provide coverage for most services, including that the benefit must fall within a defined benefit category, has to be reasonable and necessary for diagnosis or treatment, and must not be excluded from coverage by statute. Hearing aids are an example of a benefit exclusion by statute. Section 1862(a)(1) of the Social Security Act (1935) regarding Medicare payment for hearing assessments and hearing aids notes:
(a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services—(7) where such expenses are for routine physical checkups, eyeglasses (other than eyewear described in section 1861(s)(8)) or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examination) to determine the refractive state of the eyes, hearing aids or examinations therefore, or immunizations (except as otherwise allowed under section 1861(s)(10) and subparagraph (B), (F), (G), (H), or (K) of paragraph (1)).
The Three “Ps” of Policy Work
The purpose of this article is to highlight one key aspect of my experience as an Atlantic Philanthropies Health and Aging Policy Fellow in 2009–2011—the importance of stakeholder analysis. As background, the Health and Aging Policy Fellowship is designed to provide an opportunity for individuals interested in becoming knowledgeable about the legislative process and influencing policies that affect the care of older adults. An added benefit was that, as fellows, we participated in the American Political Science Association Congressional Fellowship Program (APSA), which has a long history of providing fellowships in Washington, DC. This connection not only allowed us to participate in APSA’s 3-week intensive orientation in November focusing on the legislative process and current congressional affairs, but also provided invaluable networking opportunities.
The proximate goal of my fellowship was to gain a more comprehensive understanding of the payment structure that impacts hearing health care services and how to influence Medicare payment policies in this area. My broader goal was to have this focused experience help me understand how to influence an array of policies that affect the services we, as practitioners and researchers, can provide older adults to facilitate their ability to stay actively engaged in preferred activities and minimize functional decline. I am focusing this discussion on the three “Ps” of policy work: policy, process, and politics. I was introduced to the three “Ps” during the fellowship and gained great appreciation for critically understanding the range of factors that contribute to policy development and implementation.
The three Ps focus attention on the fact that, although we might be able to recommend, develop, or plan implementation of what seems to be a great policy, it would be difficult to bring any policy to fruition without considering politics. Politics is generally considered the art and science of governing but is also noted to be about the processes involved in “resolving—or at least attenuating—conflicts about resources, rights, and values” (Marmor, 2013, p. 407). Thus, as Gilson et al. (2012) emphasize, both the technical and political dimensions of any issue have to be considered when thinking about health system reform. This includes the necessity of taking into account the perceptions of all stakeholders regarding the policy problems and options and evolving a strategy to gain the support needed to implement the changes desired. Vance (2012) calls this the “influence game,” which “is all about knowing how to make the person you’re trying to influence feel like your idea is his or her idea” (p. 83). Put another way, it’s evolving an approach that is able to overcome any resistance by being able to address concerns raised by all those involved (Airoldi, 2013).
To adequately identify the full range of stakeholders who are interested in hearing loss policy, it was first necessary to understand how the decision to cover a given benefit occurred, as this also affects who might be the most influential in facilitating a change in policy. Although Medicare falls within the auspices of the Centers for Medicare & Medicaid Services (CMS) under the U.S. Department of Health and Human Services (USDHHS), national coverage of Medicare benefits is determined in a process that is influenced by a broad range of groups including the U.S. Congress and units within CMS. Influential groups include, for example, the Medicare Evidence Development and Coverage Advisory Committee, which is administered by the CMS and is advisory to the executive branch, and evaluates effectiveness of interventions and assesses new technologies; the Agency for Health Care Research and Quality advises the federal government on the safety and effectiveness of interventions; and the Medicare Payment Advisory Committee, an agency of the legislative branch that was established in 1997 and provides reports to the U.S. Congress. As an agency within the USDHHS—part of the executive branch of government—CMS can only address issues or implement policy that are part of Medicare law under the Social Security Act. Thus, for hearing aids or devices that are excluded from coverage by statute, CMS does not implement or address policy directly related to hearing aids. The agency does, however, have an interest in fostering quality services for Medicare beneficiaries and may influence policy through processes of inquiry or engaging with stakeholders in fact finding. To allow for Medicare coverage of hearing health care services, federal legislation has to be developed and passed by the U.S. Congress. Thus, the focus on obtaining coverage for hearing aids rests with congressional action.
Becoming aware of the stakeholders who might be affected by or interested in any policies that influence hearing health care services was an important component of my fellowship; there were more than I thought and they often held views that I had not fully anticipated. With this in mind, I first asked, “Who are the stakeholders? Who cares about the legislative efforts that might be taken to change the law?” Gilson et al. (2012) emphasize three steps underpinning stakeholder analysis: (a) the identification of the stakeholder groups, (b) the delineation of their specific views about the issue, and (c) determining the relative power that each stakeholder has over the issue. Attempting to obtain these data consumed a fair amount of my efforts during the initial year of the fellowship, as I talked with individuals across a spectrum of perspectives. The following presents a synopsis of some of these groups and where they tend to fall on the support-versus-oppose spectrum of changing Medicare policy.
One key group of stakeholders includes consumers, those individuals affected by payment policies either directly (e.g., those with hearing loss) or indirectly (e.g., family members, friends, employers) and the associations representing the consumer. These stakeholders could benefit if legislation was passed to include hearing aids and related hearing health care coverage within Medicare. If mobilized, consumers can have a powerful influence on Congress through their individual elected representatives (Pullman, Zarzeczny, & Picard, 2013). A significant impediment to garnering support at the consumer level is the hidden nature of hearing loss. Many older adults are not aware of their hearing loss, do not acknowledge it, or do not attempt to obtain treatment. Families and friends may also accommodate hearing loss and not advocate for evaluations. Although associations composed of consumers, such as the Hearing Loss Association of America, inform and attempt to mobilize their membership base, their influence often remains modest within the context of other groups with a larger presence and more lobbyists in Washington, DC.
Manufacturers of hearing aids and other assistive listening devices and all the various hearing health care providers who provide services could be considerable potential advocates for policy change. These practitioners include: (a) hearing aid dispensers or hearing instrument specialists, who are licensed and regulated by each state to sell or dispense hearing aids; (b) audiologists with a doctorate of audiology, now the entry into practice degree; (c) audiologists with PhDs; and (d) physician otolaryngologists. One might expect these providers to support a change in Medicare payments for hearing aids because this would increase their client base, but this is not the case. Many hearing health care providers are concerned about potential constraints or restrictions on payment for services by Medicare. Many are especially concerned about having hearing aids specifically covered because of the payment model commonly used to cover services. Currently, the cost of a hearing aid is often “bundled”; that is, when an individual purchases a hearing aid he or she is not just purchasing the aid but also the surrounding services—testing, fitting, adjustments, and followup care and monitoring. Individuals are often not aware of this and assume the cost is for the hearing aid itself. Although there are efforts to promote unbundling, which could increase the transparency of the cost, unbundling is viewed as risky by some in the hearing health care field because they are concerned that individuals will only get the hearing aid and not return or purchase the other components of care and follow up. In addition, the various providers differ among themselves regarding what changes are needed to support and sustain their professions long term. Most audiologists would like to remove the requirement for a referral from a physician to provide services (i.e., getting direct access approved [Zapala et al., 2010]), but this is not universal; the physician otolaryngologists support the need for maintaining this restriction. Each professional association has its own lobbyists, but their different perspectives and differing legislative efforts can limit their overall effect.
Other stakeholders include CMS, congressional representatives, and those of us in the general (i.e., nonspecialty) health care field who care for individuals with hearing loss. Conversations with individuals connected with or knowledgeable about CMS supported the fact that CMS is concerned about any policy that affects health care costs and believe, whether true or not, that there would be an outpouring of demand if hearing aids were covered by Medicare. Legislators are concerned about the views of their constituencies but also the cost of health care and who is most able to present their perspectives in the most pervasive way. Starting in 1977 with the efforts of Claude Pepper, various bills have been introduced to allow Medicare coverage of hearing health care services, but most of these have never made it out of Committee in Congress, which is the second of many steps involved in getting a law passed. Health care providers who care for individuals with hearing loss, such as physicians and nurses, have an interest in providing care to their clients that supports their positive health, but most practitioners have minimal understanding of the impact of hearing loss and do not address it or pay attention to it in daily practice. Mobilizing this stakeholder group might take significant effort, as it does not currently view hearing loss and its treatment as a significant concern, but it may be possible if consumer groups are actively involved. Complicating any effort to mobilize health care professionals is lack of adequate data to support the value of screening. This was recently highlighted by the U.S. Preventive Services Task Force (Moyer & USPSTF, 2012) after their recent review to update their recommendations about screening for hearing loss. Although they acknowledged that there were no data suggesting harms, they also noted that there were not enough data to assess the benefits of hearing loss in asymptomatic adults ages 50 or older (Moyer & USPSTF, 2012). Such statements by this group can have a significant effect on clinical practice and is a change from earlier recommendations. Countering this view may be difficult, given the focus on time, efficiency, and other complex chronic conditions that practitioners manage on a daily basis. This may be especially true given the impact of the media.
The media is an often overlooked participant in this debate. Generally, the view of hearing aids and hearing loss in the media, especially as presented by advertisements for hearing services, is that it should be kept confidential. Advertisements promote the size of the hearing aid that an individual could obtain, emphasizing that it is virtually “invisible” and that no one would know, as if hearing loss is something to hide rather than acknowledge and address so as to be able to remain engaged in conversations.
Moving the Agenda
Having gained insights to the range of perspectives, especially ones that are diverse and often at odds, the question arises: What’s next? Can a framework for policy change be evolved that can address the concerns of the varying stakeholder groups? Airoldi (2013) emphasizes the importance of creating a climate where all stakeholders experience a part of the decision-making process and can come to a common understanding of the opportunity costs of various budgetary models. This may be viewed in terms of trade-offs; what is possible, what can individuals accept? If coverage for hearing aids themselves is viewed as problematic, could enough support be generated by supporting coverage for the surrounding services, thus minimizing the need to bundle costs? This approach may also be more acceptable to Medicare if the cost is perceived as manageable and definable—a specific health care benefit. Furthermore, hearing aids are only one component of a comprehensive hearing health care package; hence, a broad public health–focused educational campaign should be initiated to provide consumers and other health care professionals with information about other forms of assistive listening devices and communication strategies.
Taking advantage of current contextual forces is also a viable and important option. Thus, although the fellowship occurred during a time of significant budgetary concern, there are now factors that might help mobilize consumers as well as policy makers and may influence hearing health care providers to look more closely at alternatives. First, there is the growing number of older adults who want to stay engaged in their communities and often wish to remain in the workforce. Being able to hear is important in achieving these goals. Second, newer data highlighting the potential links between hearing loss and cognition are receiving the attention of policy makers. Although data are still not available to make causal links or to support that treating hearing loss will decrease the incidence of cognitive decline, there is more interest in minimizing or treating hearing loss. Third, commercial forces are creating pressures on hearing care specialists. Online sales of hearing aids and improvements in hearing amplifiers are creating a situation that may significantly affect the cost of hearing aids. For example, there are now multiple applications (apps) to facilitate hearing on cell phones, cell phones with hearing aid chips, as well as lower cost approaches to sales (Stock, 2013; Zeng, 2013). Although personal sound amplification products are not meant to be sold to individuals with hearing loss, and are thus not under the same regulatory requirements (Ross, 2011), they have improved, are sometimes adjustable, and are often purchased by individuals with hearing loss. Hearing health care specialists will need to clearly articulate the benefits of their services and why the surrounding supportive interventions that they have the expertise to provide, such as aural rehabilitation that facilities the ability to relearn how to hear and that promotes effective use of a hearing aid, are worth the time and extra cost. Finally, the time may be right to move hearing loss to the public health arena. Hearing loss has never been considered a health care issue and yet it is critical to health. Individuals now appear ready to hear this appeal.
One of the most beneficial aspects of the Health and Aging Policy Fellowship for me as a researcher, practitioner, and scholar of hearing impairment in older adults was facilitation of a new and vibrant network of stakeholders in policy work. In gaining an understanding of the extent of payment policies, factors influencing the current payment structures, and the stakeholders’ views, I was able to talk with a broad range of individuals about possible approaches to achieving the goal of obtaining financial assistance for older adults dealing with hearing loss. The fellowship helped me recognize not only the importance of understanding the contextual factors influencing the views of each stakeholder but also the range of possible approaches to promoting a more effective payment structure that will promote access to hearing care. The value of a careful stakeholder analysis became much clearer and provides a framework to consider how we as nurses can approach other policy debates in ways that can most effectively support positive care environments for older adults and their families. In addition, nurses, especially those who focus on the care of older adults, can directly advocate for hearing screening and assess those with whom they work for hearing difficulty so that resources can be provided to promote enhanced communication, engagement, and quality of life.
- Airoldi, M. (2013). Disinvestments in practice: Overcoming resistance to change through a sociotechnical approach with local stakeholders. Journal of Health Politics, Policy and Law, 38, 1149–1171. doi:10.1215/03616878-2373175 [CrossRef]
- Bainbridge, K.E. & Wallhagen, M.I. (in press). The extent and effects of hearing problems, and treatment, in an aging American population. Annual Review of Public Health.
- Chou, R., Dana, T., Bougatsos, C., Fleming, C. & Beil, T. (2011). Screening adults aged 50 years or older for hearing loss: A review of the evidence for the U.S. preventive services task force. Annals of Internal Medicine, 154, 347–355. doi:10.7326/0003-4819-154-5-201103010-00009 [CrossRef]
- Cox, R.M., Alexander, G.C. & Gray, G.A. (2005). Who wants a hearing aid? Personality profiles of hearing aid seekers. Ear and Hearing, 26, 12–26. doi:10.1097/00003446-200502000-00002 [CrossRef]
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- Lin, F.R., Ferrucci, L., Metter, E.J., An, Y., Zonderman, A.B. & Resnick, S.M. (2011). Hearing loss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology, 25, 763–770. doi:10.1037/a0024238 [CrossRef]
- Lin, F.R., Metter, E.J., O’Brien, R.J., Resnick, S.M., Zonderman, A.B. & Ferrucci, L. (2011). Hearing loss and incident dementia. Archives of Neurology, 68, 214–220. doi:10.1001/archneurol.2010.362 [CrossRef]
- Lin, F.R., Thorpe, R., Gordon-Salant, S. & Ferrucci, L. (2011). Hearing loss prevalence and risk factors among older adults in the United States. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 66, 582–590. doi:10.1093/gerona/glr002 [CrossRef]
- Marmor, T.R. (2013). Health care politics and policy: The business of medicine: A course for physician leaders. Yale Journal of Biology and Medicine, 86, 407–411.
- Moyer, V.A.U.S. Preventive Services Task Force. (2012). Screening for hearing loss in older adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 157, 655–661. doi:10.7326/0003-4819-157-9-201211060-00526 [CrossRef]
- National Institute on Deafness and Other Communication Disorders. (2010, June16). Quick statistics. Retrieved from http://www.nidcd.nih.gov/health/statistics/Pages/quick.aspx
- Pullman, D., Zarzeczny, A. & Picard, A. (2013). Media, politics and science policy: MS and evidence from the CCSVI Trenches. BMC Medical Ethics, 14, 6. doi:10.1186/1472-6939-14-6 [CrossRef]
- Ross, M. (2011). Personal sound amplification products (PSAPs) versus hearing aids. Retrieved from the Research Engineering Research Center on Hearing Enhancement website: http://www.hearingresearch.org/ross/hearing_aids/psaps_vs_hearing_aids.php
- Social Security Act Pub. L. No. 74-271, 49 Stat. 620 (1935).
- Stock, K. (2013, July11). Why Costco rules in hearing aids…and gummy bears. Retrieved from http://www.businessweek.com/articles/2013-07-11/why-costco-rules-in-hearing-aids-dot-as-well-as-gummie-bears
- Vance, S. (2012). The influence game: 50 insider tactics from the Washington D.C. lobbying world that will get you to yes. Hoboken, NJ: John Wiley & Sons.
- Wallhagen, M.I. & Pettingill, E. (2008). Hearing impairment: Significant but underassessed in primary care settings. Journal of Gerontological Nursing, 34(2), 36–42. doi:10.3928/00989134-20080201-12 [CrossRef]
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- Zeng, F.-G. (2013). The highs and lows of hearing healthcare in 2013. The Hearing Journal, 66, 2. doi:10.1097/01.HJ.0000441056.78666.13 [CrossRef]