Internet Hearing Aid Sales: Our New Reality. April 4, 2013 Kayce Bramble, AuD HearUSA

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1 Internet Hearing Aid Sales: Our New Reality April 4, 2013 Kayce Bramble, AuD HearUSA

2 American Academy of Audiology BEST Committee ult.aspx Direct-to-Consumer Information Toolkit Reaching Physicians CD May is Better Hearing Month The BEST Guide to Marketing for Audiologists State Licensure Information on Audiology Assistants Tip of the Month Practice Management Articles Practice Development Tools Resource Library

3 Academy committees Volunteer for a AAA committee Minimal time investment Valuable experience

4 Learner objectives Describe the different online business entities that offer online sales of hearing aids. Identify varieties of hearing aids for sale online. Create strategies for serving patients who have purchased hearing aids online.

5 Evidence based practices As audiologists we are committed to providing quality hearing healthcare to our patients. We strive daily to follow evidence based practices. Evidence-based practice is described as integrating individual clinical expertise with the best available external clinical evidence (Sackett et al, 1996). These practices include a detailed patient case history, otoscopy, and a comprehensive audiological assessment prior to making any hearing aid recommendations. Many audiologists today also employ needs assessments, speech in noise tests, and hearing aid outcome tools as well. We set high standards for ourselves as hearing healthcare providers.

6 Hearing aid delivery models Traditional brick and mortar hearing aid dispensing practice Big box stores Mail order Internet

7 Who are these organizations? There are a variety of organizations attempting to join the hearing aid dispensing market via the internet. There are internet start-ups, large corporations, major brand companies and even a managed care organization.

8 Just Google it Hearing Planet MD Hearing Aid Hear Pod Nature Ear Embrace Hearing America Hears Audicus

9 Why these new retailers? These groups have varying reasons for entering the hearing aid dispensing market but the bottom line is always in dollars and cents. The various websites and blogs representing these groups usually spell out some reason why they have entered the hearing aid manufacturing and delivery market.

10 Market potential Some see a large untapped market of hearing impaired individuals who have yet to purchase any hearing aids and a great opportunity. Marke Trak VIII estimates million hearing impaired in the US alone. Worldwide those figures may be around 600 million (Adrian Davis, British MRC Institute of Hearing Research). Internet opportunities are staggering considering such a large market of potential hearing aid wearers.

11 Increasing hearing aid adoption rates Other s imply that they simply want to make better hearing affordable for everyone. In an environment with lower prices, it is highly likely that many of the 27 million Americans with untreated hearing loss would purchase hearing aids and achieve an improved quality of life. And shouldn't that be the goal of everyone involved in the hearing care industry? (EmbraceHearing)

12 Retailers Tactics/Perspectives Retailers offer to provide free programming software to the local audiologist on the customer s behalf. Audiologists bundle the service in order to charge exorbitant prices for the hearing aids. Finally, we believe that since 27 million Americans are living with untreated hearing loss, the legacy distribution system of brick & mortar audiologist practices is failing many of the people it is theoretically supposed to help -- largely because the inefficiencies of running individual practices with high fixed costs forces audiologists to charge through the nose, pricing millions of consumers out of the market. (Embrace Hearing) Hearing aids will be more affordable and accessible thus increasing hearing aid adoption rates.

13 Guide to Buying Hearing Aids Online Successfully : ebay Guides Compare prices online Once you have got all the information from your doctor's office, it's time to do some shopping online to compare the prices. Most of the time, your doctor will charge you a very expensive fee for hearing aids. This is not without reason, as their prices come bundled with their high associated costs of running their physical clinics e.g. rental, wages, advertising, follow up visits etc. In fact, the hearing aids you find at a reputable online shop are exactly the same quality product that your doctor will supply to you. That means they come from the same manufacturers together with complete manuals, user guides, and warranties.

14 Other guides to buying hearing aids online Senior living. ( nline-hearing-aids/)

15 Consumer Perspectives Today we all look on the internet to gain information about where we will go for products and services. Our prospective patients as well as their family members do the same thing. From a consumer s perspective they see online options as a way to improve their hearing with hearing aids but without the hefty and sometimes impossible price tag. Internet hearing aids range in price from as low as $279 from HearPod (HearPod, 2012) to $1299 from America Hears (America Hears, 2012). MarkeTrak VIII indicated that the retail price of hearing aids was one factor considered by users, but not the most important factor in their decision to purchase. What consumers often don t realize is that hearing aids are more than just a product. This lack of knowledge is to their detriment.

16 Hard of Hearing Forums Spam like customer testimonials Unbundling versus bundling discussions Program your own Engineers suggesting hearing aids can be built for $100 and sold at Radio Shack. The hearing aid market is a closed cartel! You are at the mercy of the audiologist and hearing aid vendors when you buy. If the market was open and competive you would be amazed at how prices would drop and quality would improve.

17 It s so easy to buy online Audicus online purchase demonstration Just a few clicks

18 Retailer Disclaimers This manufacturer requires face-to-face sales of their hearing products. Currently they do not allow online sales of their hearing aids. Please Note: According to the laws of the State of Florida, if you live in the State of Florida, your "hearing aids cannot be shipped to the ultimate consumer". Please use an alternate shipping address when checking out, or you can come to our S. Florida office to get your hearing aids and full hearing aid services.

19 hihealthinnovations video

20 Poll Practice Question

21

22 Internet hearing aid delivery models The online hearing aid delivery models can be broken into three broad categories. 1. Combination of online and 3 rd party facilitator 2. Preprogrammed and mailed to consumer 3. Programmed by consumer

23 Online, third party facilitator model This group advertises online and offers hearing aids from the major manufacturers. They require their customers to first see a participating provider for audiologic testing and hearing aid recommendations. The hearing aids are purchased online by the customer through the website and are shipped to the participating provider. This provider then fits the aids and provides counseling as well as follow up care. Hearing Planet is one organization that uses this delivery approach (Hearing Planet, 2012). Individual dispensers can choose to sign up and dispense for Hearing Planet. The dispenser is paid a fee from Hearing Planet for their services.

24 Preprogrammed and sent directly to consumer The next category of retailers sells online, programs the hearing aids at the factory based on an audiogram or information provided by the customer and then ships the hearing aids directly to the customer. This is a very common model and used by a number of organizations. This is the model that hi HealthInnovations is using for the United Healthcare hearing aid program. There is quite a bit of variety with regards to how patients provide these retailers with their audiograms.

25 Other preprogrammed aids HearPod (HearPod, 2012) uses a list of 10 questions about your hearing to determine hearing aid candidacy and product recommendations. Although an audiogram is still recommended. Embrace Hearing (Embrace Hearing, 2012) allows the customer to select the hearing aid and then the customer can fax or an audiogram to the company. This seems to be the most popular format for providing audiometric information to the retailers.

26

27 Obtaining hearing tests Have your hearing tested by a local hearing care provider. Testing at audiologists offices may be covered by insurance. Available free at select Costco and Walmart stores.

28 Retailers comments about the hearing test requirement Federal law requires that every person, prior to being fit with hearing aids, must have their hearing tested by a hearing professional. Please ask for a copy of your hearing test results (or audiogram) be provided to you. Be prepared for the local hearing professional to try to sell you their own hearing aids. Please decline their invitation. Under federally mandated HIPAA regulations, health care providers must provide you with copies of certain documents upon your request, including Medical Exam / Clearance forms and hearing test results / audiograms.

29 Programmed by consumer The final category of delivery models provides hearing aids and software that are both shipped to the customer. The customer has the freedom and the responsibility of programming the hearing aids. For the interested and capable customer this can be a great opportunity to take ownership in their hearing. Unfortunately for a lot of individuals programming hearing aids is way beyond their capability.

30 Consumer programmable hearing aids AmericaHears HearSource Aids are initially shipped preprogrammed.

31 America Hears programming

32 Hear Source programming

33 Some patients enjoy programming There are many threads on hearing aid forums where patients share tips and ideas for programming their own hearing aids. They help one another find cables and software for major brand hearing aids. Some patients have asked their local audiologist to explain the programming screens to them. Many patients state that they are very satisfied with how well they hear with these aids.

34

35 Hearing aid features Open fit design Up to 32 channels ADRO WDRC Multiple memories Receiver in the canal Directional microphones Extended bandwidth Bluetooth connectivity Remote controls Wireless technology

36 Internet hearing aids

37

38 Trial periods Ranges from 30 to 60 days Most but not all have a penalty of some sort. These fees can include 10% restocking and shipping. One company allows for one FREE adjustment during the trial period.

39 Hearing aid adjustments Mail the aid back to the retailer Ask local audiologist to program aids for a fee DIY programming of aid

40 Product instead of professional VanVliet found that the hihealthinnovations hearing aid program is of no particular advantage to consumers. He reported that if existing technology was offered through the internet to eliminate professional services that there is no considerable cost benefit. He stated that this idea of cost benefit is "grossly misleading and unfair to consumers, is not in their best interests, and is certainly not an improvement over the existing distribution model" (VanVliet, 2011).

41 Bundling versus unbundling Bundling refers to the practice of combining products and services into a single fee. Unbundling means that products and each service are listed separately in any billing statement. There are no data that definitively support either bundling or unbundling fee strategies for audiologists. The hihealthinnovations program is an example of cost savings through unbundling. The test and the selection of the hearing aid are the entire procedure. A printed user guide is provided as the source of information. Online retailers as well as hearing aid forum participants use the unbundling argument frequently. Statements from the Hearing Loss Association of America also suggest that patients want more transparency in the products and services they receive.

42 Pros and cons Disadvantages: Unbundling service from the hearing aid may confuse the patient, and lead the patient to believe that vital services could be eliminated in order to minimize cost. Patients may not understand why so many procedures are needed (i.e., probe microphone measures, COSI, QuickSIN, outcome measures, LACE, etc.) for their hearing aids to be professionally and correctly fit to their hearing loss. If the product and services are bundled, patients may not understand why hearing aids cost so much. By unbundling, audiologists can convey to their patients the true cost of product versus cost of service. Unbundling would allow for transparency (and consistency) that could produce increased confidence, trust, and understanding by patients of the professional component involved in prescribing and fitting hearing aids.

43 The race to low prices Sacrifice service Everything for a fee Instead focus on value, not price Build loyalty to your practice not your price

44 Lack of verification With all Internet hearing aid sales that ship directly to the consumer there is no way to verify audibility and comfort. In fact the customer really cannot be certain if the best aided prescription has been programmed into the hearing aids. There is a clear risk of under fitting or over-fitting the hearing aids. The American Academy of Audiology states that best practices require real-ear measures be implemented to verify appropriate prescriptive gain or real-ear aided response in SPL from the patient's ear canal (American Academy of Audiology, 2008). Real-ear measures are obviously not going to happen in the direct to consumer hearing aid delivery models. Most internet hearing aid retailers give little heed to recommended evidenced based practices. It appears as if with internet retailers the focus is on the product and its price. There is little to no importance placed on benefits of receiving services from a hearing healthcare professional.

45 How do we respond? We can choose from basically three different responses to the internet hearing aid sales situation. We can simply ignore online retailers and hope that we are unaffected. We can be reactive and just wait until internet hearing aid sales affect us individually. Lastly, we might choose to be proactive. As a profession we can evaluate and address the situation with knowledge, skill and expertise.

46 Proactive response We can come up with solutions and suggestions for helping the hearing impaired who have been impacted by internet sales. We can use the internet sales situation as an opportunity to educate the public about who we are and what we do. Several organizations including American Academy of Audiology (AAA), American Speech Language Hearing Association (ASHA), Hearing Loss Association of America (HLAA), and the Better earing Hearing Institute(BHI) have created consumer information sheets. We can define ourselves as the best choice for hearing healthcare services. We can promote our skill, education, training and our commitment to evidenced based practices. Our ultimate responsibility is to the hearing impaired and providing them with quality hearing healthcare.

47 AAA Toolkit

48 Toolkit sections Chapter 1: Providing non-medical treatment to patients who obtained amplification directly from the internet (or mail order) without audiologist's assistance Chapter 2: Guide to itemizing services Chapter 3: Legislative Updates (as of 2013)

49 Chapter 1 For audiologists: Managing patients who have purchased hearing aids elsewhere For patients: Customizable consumer education material

50 Managing patients who have purchased hearing aids elsewhere The average consumer of hearing care is not aware of the necessary components for successfully managing a hearing loss such as: 1. an appropriately selected and programmed device based on an individual needs assessment, 2. extensive counseling regarding adaptation and acclimatization 3. developing realistic expectations 4. the importance of communication strategies 5. long-term hearing aid maintenance. Capitalize on the opportunity to educate the consumer about the audiologist s role as an integral component of a successful and ultimately more cost-effective hearing aid fitting.

51 Compensation is expected Compensation should be expected for time and procedures rendered to obtain appropriate diagnostic and treatment measures. See Chapter 2 of the AAA Toolkit for information on billing for services

52 Cautions Avoid making negative comments about the fitting mistakes that may have been made by the patient s previous hearing care provider. Respond with what you can do for the patient rather than what wasn t done. Refrain from denigrating the patient s choice to go the online route intsead be encouraging and supportive.

53 Patient Scenarios Sound Quality Concerns Improper Physical Fit Acoustic Feedback Troubleshooting a Malfunctioning Device Additional instruction needed (hearing aid insertion/removal, battery information, cleaning and care of the device, etc.) Reprogramming to Accommodate for a Change in Hearing Cerumen Management

54 Scenario #1 I m thinking about this hearing aid my insurance company provides for just a few hundred dollars. It doesn t hurt to try, right?

55 Scenario #2 Patient comes to your office with aids purchased online. They are not a product that you recognize and you don t have programming software either. The patient reports having tried to program himself for over 6 months he s ready to throw in the towel and would like professional help.

56 What does the evidence tell us? MarkeTrak VIII 53 Influencing factors in hearing aid purchase intent (in the next 2 years) % insurance coverage 2. Money back guarantee 3. More reliable/seldom breaks down 4. Price not more than $ $1000 insurance coverage 15. Stigma

57 How can we use this information? The cost of hearing aids is a primary factor influencing consumers. We can capitalize on the fact that we are healthcare providers and have various relationships with health insurers. We can work hard to help patients discover and utilize any insurance benefits they may have. Take a second look at trial period policies. Revisit the possibility of unbundling.

58 Value of verification Marketrak VIII compared hearing aid outcomes from great successes to great failures. Significant factors included: 1. Probe microphone measures 2. Any form of validation

59 Face to face is irreplaceable Online retailers may offer phone operators, in house staff, flashy websites and blogs, and neat hearing aid options and features but in the end the face-to-face interaction is not replaceable. A majority of our patients need the service that can only be obtained in a face-to-face environment. Diabetics who receive face-to-face medication management services experienced improved outcomes.

60 Summary Know who s out there and what they offer Consider consumer perspectives and factors influencing hearing aid purchase. Be prepared to answer questions and offer solutions. Set yourself a part from online entities and give potential patients a reason to choose you.

61 References America Hears (2012): America Hears, Inc. American Academy of Audiology (2007): Guidelines for the Audiology Management of Adult Hearing Impairment. American Academy of Audiology (2013): American Academy of Audiology Direct-to- Consumer Information Toolkit. American Speech Language and Hearing Association (2012): What You Should Know Before Buying Hearing Aids Online. Better Hearing Institute (2012): Your Guide to Buying Hearing Aids. Hearing Loss Association of America (2012): Purchasing a Hearing Aid A Consumer Checklist. Hearing Planet (2012): Our Process for Buying Hearing Aids. Hear Pod (2012): Hearing Test. Kochkin, S. Marketrak VIII: 25 year trends in the hearing health market. Hearing Review. 2009:16(11): Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. (1996) Evidence-based medicine: what it is and what it isn t. BMJ 312(7023): VanVliet D. (2011): Eliminating the professional's role from dispensing is "unfair to consumers.

62 Thank You

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