This week on the Future Ear Radio podcast I’m publishing the other panel discussion that I moderated in March for the Future of Hearing Health Virtual Conference, which was hosted by Hearing Health & Technology Matters. Last week’s episode featured the panel I moderated on device innovation, while this week’s episode features a panel discussion based around the business model innovation and future economics of hearing healthcare.
The panelists for this discussion, going clock-wise in the picture are Chris Cardinal (President & COO of Amptify), Amyn Amlani, PhD (Founder of Otolithic Consulting), Bob Traynor (Longtime Audiologist and Private Practice Owner of Audiology Associates), and Nancy Tye-Murray (Founder & CEO of Amptify).
During this discussion, we talk through the following topics:
- New technologies and ancillary offerings to include in one’s scope of service
- New methods of testing and gathering patient data
- The role of remote services and different ways to bill for them
- Re-examining the AuD program and the student debt dilemma
- The growing demand for assistants and technicians
- Fostering more business acumen training
- How professional service might be layered onto the OTC offering
- Enhanced training programs for specialty offerings
EPISODE TRANSCRIPT
Dave Kemp:
Hi, I’m your host Dave Kemp. And this is Future Ear Radio. Each episode, we’re breaking down one new thing, one cool new finding that’s happening in the world of hearables, the world of voice technology. How are these worlds starting to intersect? How are these worlds starting to collide? What cool things are going to come from this intersection of technology? Without further ado, let’s get on with the show.
Dave Kemp:
Hey, everyone, Dave here. For this week’s episode, I’m releasing the other panel that I moderated at The Future of Hearing Health summit. Last week I put out the one that was all around Device Innovation. This one is all around the future of the economics and the innovation around the actual business models in this industry. So I hope you enjoy this episode.
Dave Kemp:
Hello and welcome to what I think is going to be a great panel discussion here for The Future of Hearing Healthcare Virtual Conference, I’m joined by four excellent panelists. I will be the moderator. My name is Dave Kemp. I am with Oaktree Products. I also have a blog and podcast called Future Ear where I cover the intersection of emerging technology and hearing healthcare.
Dave Kemp:
And so, to kick things off, I’m going to let our four panelists introduce themselves, one by one. So we’ll go ladies first, starting with you, Nancy.
Nancy Tye-Murray:
Okay. Thank you, Dave. I’m Nancy Tye-Murray, I’m a professor in the Department of Otolaryngology at Washington University, School of Medicine. I’m also the CEO and founder of clEAR, which is the parent company of Amptify.
Dave Kemp:
Lovely. And Chris?
Chris Cardinal:
My name is Chris Cardinal, and I am the COO and President of clEAR, customized learning Exercises for Aural Rehabilitation. And as Nancy mentioned, the developers of Amptify Hearing Health program. Prior to being with clEAR, I was a co-founder and CEO of a company called Welltodo, where we developed digital therapeutics for chronic disease separators. Our main one was for migraine sufferers and I’m happy to bring some of the learnings from that digital health space at large, over to the hearing health industry.
Dave Kemp:
Awesome. Amyn?
Amyn Amlani:
My name’s Amyn Amlani, I was formerly an academic for about 16 years, spent the last couple of years in industry and I have recently opened up a boutique consulting company called, Otolithic Consulting, and Dave, I’m happy to be here and looking forward to participating.
Dave Kemp:
Perfect. And last but not least, Bob Traynor.
Bob Traynor:
Hi, I’m Bob Traynor, and for a long time, I was an academic, as Amyn, for many years and I still do quite a bit of off and on academics as well. But for 46 years, I ran an audiology clinic in Greeley, Colorado, sold out a couple years ago and I’ve always said that after four or five years, you’re dead meat in knowing much about anything if you haven’t been in practice.
Bob Traynor:
And so, in addition I’m part of… These days I have a company called, Robert Traynor Audiology, where I do a lot of [inaudible 00:03:20] courses as well as consult for companies and so on. And it’s my pleasure to be here with this great group of colleagues to provide interaction over some of the things that we think are going on.
Dave Kemp:
That’s excellent. Well, thank you all for introducing yourselves and for being here today. I’m so excited because I think we have a very diverse set of perspectives into what we’re going to be talking about today. So, the purposes of this panel is going to really explore the future of the economics of the hearing healthcare industry. I think that anybody who’s listening to this can attest that there is a lot of change that’s happening right now.
Dave Kemp:
Things are moving fast. And so, for the sake of the profession and the sake of the industry, I think we’re all trying to wrap our heads around, what does a lot of this different change entail? And so, the five of us are going to talk through some of the different changes that are happening right now in the industry and how we think that they, ultimately, might be able to be solved and we can all adapt to.
Dave Kemp:
So, one of the first things, I think one of the most obvious things, that’s happening is that as more avenues of access to hearing solutions exist and open up referencing, in particular, the OTC Hearing Aid Act, which at some point should officially come into the market, I think that it begs the question, what will happen to the existing business models?
Dave Kemp:
Will we see a cannibalization of device sales? Will this be an entirely new facet of the market that we haven’t really tapped into? And so, I wanted to kick things off talking about, at a high level, the way in which we’re interpreting this in terms of the existing model, that can be one direction that we go with this. Another would be looking at ancillary services. New services that the professionals can begin to consider incorporating into their practice.
Dave Kemp:
So, I figure, we’ll kick things off with that idea, with you Nancy, give you an opportunity to speak a little bit more about Amptify and how it, I think, represents this idea of new services that might be catering nicely to this new version of audiology.
Nancy Tye-Murray:
Oh, for sure. I get the question all the time from my compatriots, “Why should I go to an audiologist when I can get a hearing aid so much cheaper at Costco’s?” And it’s a question that all audiologists and hearing healthcare professionals are going to have to start answering. And my answer has been, “You are hearing health care professional, and not simply a dispenser of hearing aids.”
Nancy Tye-Murray:
And so, we excel at the diagnostics and what the goal standard clinics excel at, is follow-up in patient care after the hearing aid fitting. And so, I’ve spent a 30-year career developing our rehabilitation strategies and interventions. And I, always, am confronted with the roadblock, and I can’t use a better description of, “Yeah. I believe in aural rehab, my patients want it, but at the end of the day, I’ve got to make money, and I only have so many people in my clinic to provide services.”
Nancy Tye-Murray:
And so, I’ve spent the last five or six years addressing that problem, “How do we efficiently and economically provide quality aural rehab to patients once they get the hearing aid?” And we came up with Amptify, which is a digital hearing health care therapeutic. The very first of its kind. And it has four key components.
Nancy Tye-Murray:
One is evidence-based auditory brain training games. And I emphasize some words, “Games,” because, historically, auditory training has been boring, tedious, and, as a result, has poor compliance. So, we game up by training. Number two, we have online hearing health care professionals providing support and coaching. And with this, I’m addressing the possibility of audiologists. So, instead of going the audiology assistant route, I’m going the certified hearing healthcare professional who’s online.
Nancy Tye-Murray:
Three, we have a daily interactive curriculum. So, you’re teaching patients, all those things should learned in the graduate school about managing communication, breakdowns, speech reading tips, counseling. You’re having that on a day to day basis. And then, number four, a peer support group. Hearing loss is isolating, in and of itself. And always somebody with hearing loss can understand what somebody else with hearing loss is going through.
Nancy Tye-Murray:
So we have a group, chat-groups. And in a very small, if I had to summarize all that and just a very small way, I would say what we are allowed an audiologists to do is to outsource aural rehab to our company, Amptify, and we’re providing that online support. And right now we are really pitching audiologist because we want to enhance what they do. So that’s it in a nutshell.
Dave Kemp:
That’s lovely. And I think that… I want to now go to Chris because I know that your background in digital therapeutics, clearly you come from outside of this space, but I think that your background is really relevant to today. So, how do you see services like Amptify fitting into the overall business model of a professional, clearly, as Nancy alluded to, you can outsource it, but from a monetary standpoint, how would this be beneficial to the professional? And then, maybe, a broader representation of how you see Amptify fitting into the longer-term vision of this industry?
Chris Cardinal:
So, in the immediate… Really, what Amptify does, this digital therapeutic for hearing healthcare, is it improves patient satisfaction, it reduces the costs associated with managing an aural rehabilitation program. It’s very expensive to bride AR, the clinic, right now, needs to generate $225 per productive hour. And there’s only about six productive hours in the day in order to keep their doors open, and aural rehabilitation is a time-intensive process.
Chris Cardinal:
And so, by us being able to provide that to the patient and not have that audiologist on staff doing that, we are saving the clinic time and money, as well as the risks associated with the staffing and the overheads associated with that. And so, that’s the immediate benefits to the clinic beyond being able to provide ASHA and AAA best practices in the long-term which is where I like to live a lot.
Chris Cardinal:
There are a number of different factors, as you had mentioned early on, that are putting pressure on the audiologists and on the industry at large, and that includes the changing payment paradigms that shift with NASA to be covered and get reimbursed for the services. And then we start to get into things like population health management and value-based care and fee for service, which is what the structure looks like right now.
Chris Cardinal:
And so, in the longterm, the bigger picture of where things are going, hearing health care, we know that it is costing the system a lot of money, that if individuals do not get treated with hearing loss, they are generating 46% more costs to the system over a 10-year span. And that’s a really big deal. And so we should actually, as an industry, be very excited about the prospect of capturing more of the value that we’re creating in the system. Whereas, right now, generally, the revenue that is created is from that distribution of that hearing aid.
Chris Cardinal:
And so, what we’re doing is creating a paradigm shift in providing a tool for audiologists to allow them to take advantage, not only in the immediate, but over the long-term of these trends in reimbursement and in payments for hearing healthcare.
Dave Kemp:
Amyn, you’re nodding your head. Do you want to follow on to what Chris said there?
Amyn Amlani:
I mean, I absolutely agree. And I’ll take this in maybe a little bit of a different direction. The market, as we know it, we will see two things, I think. Number one, when the OTCs and the direct to consumer products have a little more regulation, we’re going to see some cannibalization in the sense that there’s going to be a downward push on price. Now, at the same time, we’re also going to see an increase in the number of individuals that are going to be entering the market, which is a huge positive.
Amyn Amlani:
And, I think we really have to be mindful that the current service delivery model that we have is archaic, and if we don’t adjust, we’re going to be in trouble. And so, to Chris’s point and Nancy’s point, and I’m sure Bob will have a couple of comments here as well, we have to find new tools, we have to find new mechanisms and we have to deliver a better service than we ever have in order to really have a value proposition within the healthcare landscape.
Dave Kemp:
Bob, why don’t you go ahead and share your two cents here? Because I think Amyn’s touching on something I know that you can speak to as well.
Bob Traynor:
My turn?
Dave Kemp:
Your turn.
Bob Traynor:
Well, you don’t want to ask an old guy because he’s always got more to say, for some reason or another, but, my take on things that are happening, it will take all of my colleagues who are on the panel to amplify that just a little bit. And in my talk, here at this meeting, we talk a lot about differentiation and how to build a strategy and those kinds of things.
Bob Traynor:
But, it was pointed out a couple of years ago, very obviously, a AAA by Windmill and Friedman and Hall and Friedman, and those guys, that the evaluation that we do for hearing testing, God bless the colleagues in the 40s that developed those things because they’ve lasted 75 years. But, we really need to be using something that is, now, from our current generation of researchers, as well as the technology and so on.
Bob Traynor:
So, we need to change the audiologic evaluation to get more information because we can. We need to do things to facilitate better interactions with our patients, and no longer can you just walk in a clinic and have old papers laid around and ring around the collar and a frayed carpet in the sound room and all these kinds of things. These are bad clues.
Bob Traynor:
It doesn’t present the professional image. Also, the other component that I think is really something, that Nancy touched on, and Chris as well, and in Amyn’s discussion as well. The whole bottom line is, nobody ever teaches young clinicians how to interact with patients. Yes, we might have aural rehab class, but we don’t get to know… Each individual patient is a different person.
Bob Traynor:
And therefore, differentiating your clinic by relationships is huge. You need to know their personal style. You need to, not only know their personal style, but maybe use some motivational interviewing to facilitate your discussions in and out and supplement the aural rehab that Nancy and Chris have referred to.
Bob Traynor:
Probably the last thing before I monopolize the whole deal here is, I also think that you need to modify pricing, substantially, and as colleagues have mentioned here, you can’t just offer a bundled pricing system, because we’re going to have people purchasing hearing aids at the grocery store, because we’re going to have people purchasing products in your clinic, by the way, you should handle anything that’s hearing. Don’t just take hearing aids and evaluations. Need to handle anything that’s hearing.
Bob Traynor:
Anyway, having those kinds of products… And then you need to have an unbundled program for each and every different type of product at each and every different type of patient. And I have about five or six other things, but I think some other people want to talk here a little bit to see where we’re going from there.
Dave Kemp:
No. I think those are excellent points that you mentioned. I mean, from what I’m understanding, from all of you, is that, the status quo is being disrupted. Not to overuse that term, but I think that what has worked in the past in a lot of the traditional methods of which this particular type of experience has been done, is now being threatened by new ways in which people can access those.
Dave Kemp:
Like you said, Bob, you can, probably in the not too distant future, you’ll be able to buy a pair of hearing aids or something that resembled them from CVS, Walgreens, or your local grocery store. And so, I think it goes back to Nancy’s point, which is, “How do you justify coming and seeing me, and maybe charging a premium, or paying a premium as a patient.”
Dave Kemp:
And so, I’m curious to just hear a little bit more on this point as to, in that notion, what are the ways that you can stand apart in being cognizant of the time constraints? Because it seems as if one of the biggest challenges for this profession is that you’re always limited to the amount of time that you can dedicate to these things. And so, you need to figure out how to maximize it. And so, obviously, you have options like the additional services, but also things such as figuring out new methods or utilizing new technology that better maximizes your time.
Nancy Tye-Murray:
So, I’ll take a shot at that to start our round table here. There’re only about what? 14, 15,000 audiologists in this country, and they’re 40 some odd million people with hearing loss. So, there’s plenty of business to go around. And the question is, how do you maximize the time of the audiologist? And there’s a lot of buzz going on about tele-audiology. And I think that is going to be a powerful tool in our toolbox.
Nancy Tye-Murray:
And that’s why we’ve gotten the direction we’re going in with online hearing healthcare professionals who can extend the audiologist reach. So, you can interact with more patients more intimately, on a day-to-day basis and develop brand loyalty. So we’re allowing brandy within the Amptify product. So when they need their new hearing aid, you’re up front and center in their brains.
Nancy Tye-Murray:
So, it’s a combination of being savvy, marketing-wise, taking advantage of current and future technology. And I think something that we have a hard time as a profession, and Bob, you just said it is, we are slow to change and slow to adopt things. We’ve been doing the same thing for 70 years and that mindset has to change. And these young people coming into the field, I hope, are going to bring a new vitality to it.
Amyn Amlani:
I’ll jump in real quick. I’ll even take this down a little bit lower here and the question that pops into my mind is for these alternative products that are direct to consumer, is there even a need for service. And if we start looking at the literature and we just look at technology as a broad category, there’s research that’s coming out of Europe and out of Asia, and what we’re finding is that, because of space, those individuals tend to purchase or procure their technology through vending machines.
Amyn Amlani:
And what happens is, once they’ve made that purchase, they then seek, or prior to seek, the assistance, or the knowledge, or information that is provided by someone who’s a specialist in that area. So, going back to the whole conversation here, there’s a need to promote the skills and the expertise that you have because people are looking for it, not just the product.
Chris Cardinal:
And I’ll jump in. I think that, from my perspective, as you both have touched on, hearing loss challenges exists beyond the ears. So, we have these comorbidities that need to be managed and that we can reduce the likelihood of, although a lot of the data that we have, let’s see, falls in social isolation and depression. It is correlative, at this point, we’re growing on that path, speaking to the fire here, but coaching and providing that add-on Benefit, those services, and arming yourself with the knowledge about those comorbidities and about the steps that you can take as an audiologist or the services that you could provide to address those, like ours, arm yourself with those things. Learn about that and start to manage the person, not just the ear.
Bob Traynor:
I’d have this in my talk as well, but, Amyn taught us a couple of years ago, what a provider market segment is, and you have one market segment that’s mostly just direct to consumer. You have another market segment that is big box stores and others, then you have the value segment, which is us. And so, the whole thing boils down to, how much value do we offer each and every patient that comes into the clinic? And we can’t just be the people that sell hearing aids.
Bob Traynor:
That’s been a role that we went down and we need to crawl back from that and look at all the roads that we could go down. For example, the last couple of years have been involved a lot in here at conservation. And I really had no idea that people that present themselves for earplugs, 47% of those patients all need hearing aids. And they’re about 20 years younger than the usual and customary patients that we see in the audiology or hearing care clinic.
Bob Traynor:
So, there’s a whole market there. The other market was, a colleague told me the other day, who has a practice these days, that, had it not been for leasing hearing aids, he would have really had a hard time during the pandemic era, and leasing, I think, is something else. People don’t want to blow seven grand out of their bank account, but they may have 150 or so, left over every month from a social security check or other source. So, between that and, of course, people have branched into tinnitus which we see happening, my concern with that is they need to have a background in tinnitus and not just a little background.
Bob Traynor:
Need to have the right CEUs, or the right certificates to interact with tinnitus patients, and I’m sure Nancy’s program does some significant things with tinnitus, as well, as part of their aural rehab program. And, I guess, the last area is technology. You can’t just squirt a bunch of stuff in somebody’s ear to do an impression in 2021, we’ve been doing that since 1957 with one pertinent stuff or another.
Bob Traynor:
So technology, the equipment and things that you work within the clinic, sends a marketing impression to each and every patient and everybody they talk to. So, indeed, in 2021 ear impressions are really scans and you need to… Don’t break the bank, but you need to maybe hurt, just a little bit, and get a scanner. Wow. What a marketing tool that is for you and your practice against all the other clinics in the area.
Dave Kemp:
Yeah, those are great points, Bob. And so, this now concludes the live portion of the panel discussion. We’re going to continue the conversation because we still have a lot of material to cover. So, for that, you can head over to YouTube. We will have a link for you for the remainder of this discussion. So, I want to, now, get back into something that Chris had mentioned, which is the comorbidities. I mean, I know you’re very familiar with some of the work at Johns Hopkins that Nick Reed and his team is doing with the ACHIEVE trial. Something that I think might be quite significant to the future of this industry.
Dave Kemp:
So, if you could maybe speak a little bit to the broad picture here as it relates to insurance coverage, the broader impact of comorbidities on the healthcare system and how that ultimately might lead to broader insurance coverage for devices and the implications of that for the professional.
Amyn Amlani:
It’s an exciting time, In audiology, it’s a really, really exciting time. But I’ll also preface that, but it’s also a scary time because we don’t have the rudimentary training for some of this. So, I think we have to look at it as a double-edged sword. So let’s look at it from the positive. Massa was just reintroduced in the Congress yesterday on World Hearing Day, and the hope is that, collectively, with ADA, ASHA, AAA, and HLAA sponsoring this we’ll have the opportunity to become providers, or, I hate this word but I’ll use it, for now, the gatekeepers for Medicare and allowing us to see the patient before they actually see the physician, which is important and reduce some of the costs.
Amyn Amlani:
In addition to that, as we start looking at some of these comorbidities, it’s been, and I don’t know where I got this, but, in some of the marketing tools, the ear is now becoming the window, if you will, to other health issues.
Amyn Amlani:
So, I’m working on a project and what we’re looking at is diabetes. And if you look at the trajectory of diabetes over age, it correlates at about 80%, once you get an arm about 8.8, with the trajectory of hearing loss as a function of age. And so, as we’re starting to look at our abilities to, not only treat hearing, we may have the opportunity to work with other professionals in an interdisciplinary way, or interprofessional way, where we are now referring to them and they’re referring to us.
Amyn Amlani:
And in order for us to do that, we’ve got to make some changes, as I talked about earlier. So, as I said, I was an academic, I know Nancy is an academic now, and Bob has been one for a while, the educational model has to change. It is not a whole body education.
Amyn Amlani:
We typically just look at the ears, we look at the product and we really miss out on some of the components. So, there needs to be a change there. And that, also, then moves into the externships. Most of our students do not see medical-based issues. They typically end up in a private practice and don’t need dispenses devices, and in order for us to get the right experiences for those individuals who are being trained, we probably need to reassess what it takes for an experience to count. And it has to be a little bit of medical, a little bit of rehab, and some other components as well.
Dave Kemp:
I want to just… I think you touch on something that’s really important, is the whole notion of the workforce and the labor force within this profession. If you wouldn’t mind, Amyn, can you speak again to some of the numbers that relate to this, because I know you’ve done some research back when you first conducted some of the research as to what the estimates should have been, I believe it was in 2020, in regards the amount of professionals in the workforce and where we’re at and how this might also be presenting a bit of a challenge for the industry.
Amyn Amlani:
Absolutely. So I’ve got some notes here in front of me, so I’ll give you the right number. So, I’ve been on a task force with Victor Bray, at Salus University, where we’re looking at a workforce analysis of audiology and we’re comparing it to other professions, and those are physical therapy, speech-language pathology, occupational therapy and optometry. We started by looking at the BLS, or the Bureau of Labor Statistics, database.
Amyn Amlani:
And we started in 1999 because that was the first year that audiology was separated from speech. So that’s when our data starts to count. In 1999, and I’m looking at my notes here, we had 12,950 audiologists as a function of this database. In 2019, there are 13,800 audiologists. We should have, made another graph here, we should have, if we look at the other professions that grow at three and a half percent, and we’re not growing at even 1%. But if we look at these other professions that I pointed out, they’re growing at three and a half percent, if we use that three and a half percent benchmark growth, we should have over 22,000 professionals in the marketplace assisting or supplying services to the demand that’s needed, and we just don’t have it.
Amyn Amlani:
And so, the question becomes, what’s happening? And if you look at some of the other data, and we’re not quite there yet, the Freeman and Windmill paper, back in 2013, showed about a 40% attrition rate within five years of getting the degree. We have, depending on the data that we look at, somewhere between 25 and about 45%. So, the numbers are actually showing that individuals don’t stay in the profession for a long period of time, and there’s a number of different factors for that.
Amyn Amlani:
And some of it is due to their home life. Some of it is due to other things that are more attractive, and there’s, of course, the big thing is just the student loan debt that they incur for the degree that they earn.
Dave Kemp:
So, student loan debt? I think that is maybe at the crux of the whole thing. What do you think, Nancy. Do you think that there are… Do you think that we need to rethink the way in which the whole AUD is considered and should we just have a bit of a conversation around the whole notion of a student incurring hundreds of thousands of dollars of debt, and then you have this very high attrition rate among the labor force.
Dave Kemp:
I feel as if these two are connected and I feel as if you might have some thoughts to this.
Nancy Tye-Murray:
I do. And it’s a perspective that has, maybe, not very popular. But, think about… So, I recently wrote an article about the student education system and I made the point that we require students to get four years of undergraduate and then four years of post-graduate education. And so, these students come out with just a humongous amount of debt. And so, we have put them in a position of having to make a lot of money and having to make it quickly. And that’s why we have almost this single focus on selling hearing aids to anybody who comes through the door.
Nancy Tye-Murray:
And that’s probably a harsh way to put it, but there is a big focus is, a guy sells so many units each month in order to keep the lights on. Fair enough. I personally think that probably a master’s degree is a better way to go and then have specialty training as an option there after, like the medical residency program.
Nancy Tye-Murray:
And, my perspective, is that, say an audiologist in private practice is never going to have to perform intraoperative monitoring. So why are we incuring a cost in that as part of standard training? An educational audiologist will never, probably, perform [inaudible 00:34:06] screening. So, I think if we could change our educational model, we would take the onus off of having to earn a lot of money quickly.
Nancy Tye-Murray:
The other thing that would happen, is a downstream effect of possibly reinvigorating the research doctoral program. And my sense is, having been in academia for as many years as I’ve been, is that fewer and fewer students are pursuing a research doctorate because they’ve incurred so much expense and spent so much time getting the AUD. And I believe that this is one reason why our diagnostics have stagnated since 1990/1999, almost say 1919. I guess we’re beyond the Pitchfork, tuning fork.
Nancy Tye-Murray:
But I think that’s one reason why our practice has stagnated, both in diagnostics and in aural rehab is because we have fewer talented people doing research. So, that’s my soap box on the educational system right now.
Bob Traynor:
I might throw out to that, ADA did a study a few years ago where only 20% of the people that come out of school have had any orientation to the business world at all. And, of that group of 20%, many times, a significant number of those individuals teaching the courses have never been outside the university to do a whole lot of much of anything. So, the bottom line is, when they do enter their practice, if indeed they go to that side of the house, if they do enter their practice, they really are lacking in knowledge as to, number one, the real world, and number two, how to interact with the business world.
Bob Traynor:
And then, they really do lack, to some degree, some idea of how to interact with the professionals that can facilitate the success of their practice, also. Instead, they listen to some brand new person out of a hearing aid manufacturer telling them, “This is what you need to do and this and this and this, and all these things have to happen.” And number one, these days, our ethics are going to get compromised doing those things. But secondly, more than that, the person telling them things are what the corporate line is. And they need to know how to interact with the world and business to facilitate things.
Bob Traynor:
And we’ve seen a number of universities come across with adding those things into their program. But it’s also the first thing to go when they start having financial issues like the pandemic and some of these other kinds of things. So, I think the business world knowledge is lacking, even in the doctoral level of people.
Bob Traynor:
And to Nancy’s point about the AUD, yes, that was a prob… But I remember the days in the 80s and 90s, when there wasn’t enough time in a master’s program, and you may remember this too Nancy, there wasn’t enough time in a master’s program to teach all this stuff that we had to do. We had to teach them, all the things were coming out, new diagnostic treatments were coming out, new rehabilitative things, new… All the noise and hearing conservation, all that stuff, all that was all coming out at same time.
Bob Traynor:
And you can only teach so many courses in a master’s degree program. Now you can only teach so many courses in an AUD program as well, but at least you get a better breadth of the profession by facilitating some of those [inaudible 00:38:01]
Nancy Tye-Murray:
But that’s my point. No new stuff is coming out now, number one. And number two I questioned whether you need the breadth of knowledge that you stuff into four years to be a certain audiologist.
Bob Traynor:
Some of those programs that are three years, which may make some sense that might be a reasonable compromise, but you are correct, they do come out [inaudible 00:38:28]
Nancy Tye-Murray:
And you make a great point about the lack of business training. And I think Amyn made a great point in that. We also have a lack of interaction with other healthcare professionals and diabetes is a great one because a common denominator, for some hearing loss and diabetes, is nutrition. When you get the high blood pressure, you’re cutting off the blood flow to the inner ear, and you’re also creating a risk for diabetes.
Nancy Tye-Murray:
So, you both make great points. One is that, we need to be more savvy in business, if we’re going into private practice, if we’re going to be hearing healthcare professionals and consider the ear, the window of the body’s sort of thing, then we have to be able to… We have to be equipped to interact with the other professionals dealing with these comorbidities that Chris’ talked about.
Bob Traynor:
And, Nancy, I’ll add in one more piece that you threw in. And that is, we need more people with a deeper knowledge, because we have, at least when I was in the academic world, we moved it to an adjunct model where we would bring in AUDS. And it’s not to say that the AUD doesn’t have the right training, they just don’t have a deep enough knowledge in order to teach some of the courses. And if you’re going to get into these comorbidities, and you’re going to get into a deeper dive into some of the more exotic and more complicated kinds of treatments that are needed, you need someone with that kind of training. And that’s where the PhD would come in.
Nancy Tye-Murray:
And you also need somebody who can perform the science.
Bob Traynor:
Absolutely.
Nancy Tye-Murray:
An auditory scientist can not do what an AUD does, but an AUD can’t do what an auditory scientist does. You need the research training and you need the wherewithall to get funding, to perform the research. So, there’s a role for the AUD. There’s a role for the PhD. I completely agree with you.
Dave Kemp:
So I want to… Go ahead Bob.
Bob Traynor:
Sorry, Dave, but also the… How tough is it to take a blood pressure as a part of a clinical regimen when patients come in. With the use of assistance, you could have the assistants do those things if you chose to do so. How tough is it to do a little clock thing, then, if you have some suspicion that there may be some Alzheimer’s going on? Or interact with them on depression?
Bob Traynor:
And if you know your patients you’d have a relationship with them where you’re interacting on a daily basis or a routine basis, I guess, you’re going to have some feelings for some of these things, and the comorbidities, I think, will add to the professionalism that the doctor bodyology presents as well as the… And the lack of researchers and the lack of PhDs was predicted 25 years ago, or more. Because, as the AUD rose, a lot of the people who were getting the research doctorates, the graduate school doctorates, wanted it because they wanted to be on par with the physicians in the ENT clinics.
Bob Traynor:
So, that was predicted quite a long time ago and my guess is we had not done a very good job of preparing for that lack of the researchers.
Dave Kemp:
Well said. And I wanted to actually take this in two different directions, because there’s two different derivatives of what we were talking about that I think are really interesting. The first is, the use of assistance. I’m curious to get all of your thoughts on… That’s kind of a hot button topic right now, and I’m curious to hear how you see that evolving, more or less. And then the other is around the specialization.
Dave Kemp:
And I go back to the beginning of this conversation where Nancy and Chris were describing Amptify as a means in which you can outsource to a particular facet of your offering. And in my mind, much of the value, even if you’re outsourcing, is that you’re steering your patient to trusted sources. And I think there’s a tremendous amount of value with regard to that.
Dave Kemp:
And so, if the future of this profession is that it, more or less, fragments into various specialties with the use of online tools, remote consultations, those types of things, I wonder if that might present more of an opportunity, again, with the notion of it being that part of the value of seeking the hearing healthcare professional is that you are guided to the appropriate referral affiliates that they’ve deemed to be the appropriate ones.
Dave Kemp:
So two topics that we can take in any other direction, Chris, you haven’t talked in a little bit, so, I want to give you a chance to jump in on either of those two, as you see fit.
Chris Cardinal:
Well, there’s one thing that I wanted to add that necessarily hasn’t been a part of this conversation, but I think it’s integral to the future economics of hearing healthcare. And that is the way that we are producing data, and the way that we’re sharing data, and the type of systems that we’re storing data in, inside of the industry right now. So again, back to the digital health industry at large, we are opening up data. We have new standards, fire, fast healthcare interoperability resources, where the main electronic health records are standardizing how information is exchanged and shared across systems.
Chris Cardinal:
And that information includes that blood pressure information, includes diabetes, it includes all these other factors that do play into hearing health, but are trying to wall. We have our own practice management systems and that’s not being integrated right now.
Chris Cardinal:
And so, how that leads into the assistant, for example, right now the audiology assistant is primarily trained in dispensing. How to work with vendors, and how to manage the systems and reimbursements. And they’re not being trained in rehabilitation techniques and in helping people manage their hearing healthcare, to manage their socialization, to manage their environment. And I think that the data is a huge missing piece and we need to bridge that.
Chris Cardinal:
We need to bring those systems together to [inaudible 00:45:20] communicate. And so, that both sides… So again, we’re treating the person and we’re not just treating the hearing loss or the ear. And then, those audiologists assistants, our hearing health coaches, I had to adapt a version of the standard training for an audiology assistant to include our rehabilitation and techniques that we can, then, pass on to our members or to the patients that are being referred to the Amptify program. And that’s a problem, right?
Chris Cardinal:
That’s a problem in my eyes. The fact that we’re not arming them with, at least, a basic overview of some of this knowledge, is as a disservice, ultimately. So I’ll leave that one at that.
Dave Kemp:
No. I think, you make a great point, though, with the data, in general. And I do think that’s a big, new development that’s happen. That’s really exciting is that there is a… If the notion is that data is the new oil I think this industry in many ways is swimming in that data and it becomes a matter of, how do you make the most out of that? What sorts of things can you infer from all of those different connections? And it definitely brings to mind part of the conversation that we had around cross-physician marketing, suddenly when you’re able to monitor something like blood pressure, or heart rate variability, you might then become elevated in the eyes of, say, a cardiologist.
Dave Kemp:
And so, I think that there are tons of opportunities that are on the horizon as the devices become increasingly more sophisticated with new sensors, new ways in which they can capture some of those different metrics. But I think you make a really good point too, about having to rethink the use of a assistant.
Dave Kemp:
And I want to stay on the topic of assistance for a little bit here and get the others’ thoughts on how this particular subset of the labor force can be, either added to, maybe that’s part of the way you can compensate for the shortfall that Amyn had mentioned earlier, and are there ways in which you can better utilize that particular type of professional in the setting?
Amyn Amlani:
And again, a little bit on the business side, you build a practice, and you build a practice, and you build it up a little more, and the next thing you know, “Oh, gee. I think I need another colleague to join me in my practice.” The problem is, the revenue on the revenue side, there’s not enough coming in to afford someone at 60 to 80,000 or so, to come in and work with you in the clinic. But there may be somebody that you could pay 30,000 to, who would be your assistant and allow you to do many more things.
Amyn Amlani:
Now, some of us… I mean, I was lucky enough in my practice to have an office manager that was with me for 33 years, because of that… Well, of course, sometimes those people think they know more about audiology than you do, however, the deal is that they can do a lot of things, many of the things an assistant would do. And even though we didn’t certify assistants at the time, this person did a lot of that.
Amyn Amlani:
And I think there’s, probably, a lot of colleagues out there, that use and do those things as well. The professional colleagues that are… The professional assistants that are coming out now are fabulous. And the ones that have gone through the specifics of the training programs for that. But as Nancy and Amyn suggest, I think that, their programs need to be broadened, slightly, to know a little bit about balance and a little bit about this and a little bit about other components of the profession to provide the right assistance.
Amyn Amlani:
So, I applaud the use of assistants in practice, I think it’s sound business strategy, as well as a way to treat patients and give yourself more latitude in terms of what you can do.
Nancy Tye-Murray:
I’ll just throw my two cents in. At Amptify, we started with the ASHA, the AAA training programs for assistance, and we noted that, as Chris pointed out, they were primarily focused on hearing aids. And so, we took that as our starting point, but then we really flushed it out to include counseling, information about the standard rehab stuff, managing communication breakdowns, keeping up your self-esteem, how do you disclose a hearing loss? That sort of thing.
Nancy Tye-Murray:
We take our HHP, Hearing Healthcare Professionals, through a training program, and they have to have certification before they begin to be able to manage patients online. And, also, we have them leading our group chats. So we create communities of patients. We try to group them together to get both homogeneity and heterogeneity, and then, our coaches lead them in discussions. Now, what I think is a particularly valuable part of this model is we have an audiologist supervising HHPs.
Nancy Tye-Murray:
So, if they come to a question that they don’t know, then we bump it upstairs to the audiologist and the audiologist takes over that. We also have a library or a bank of FAQ, frequently asked questions, that our audiologists answer. And so, the HHPs access to this and they’re not just can, they can tailor to meet the particular individual, as Bob said, getting to know the person.
Nancy Tye-Murray:
So, the HHP, through the chats and the supports, learns about the patient, what are their medical conditions that they’re willing to share? Who are they living with? That sort of thing. And they can take these professionally written answers and tailor it to that particular individual.
Nancy Tye-Murray:
And then, that’s very customized patient oriented services, but it’s also economically feasible. So, we’re fine tuning this so we can personalize the information and make it professionally the high standard, and yet, we’re not bringing in that additional audiologist to your practices, 60 to $80,000. So, we’re spreading… I like the octopus analogy, that this is the audiologist and we’re spreading the arms so they can touch more people, sort of thing.
Bob Traynor:
Almost the old military model, Nancy, where you had the enlisted guys, you had two, three of those guys running around doing a lot of the routine rehabilitative things. And then, when there was a question that here comes the chief of audiology and just say, “Well, that’s just the way it is.”
Nancy Tye-Murray:
Here comes the general.
Bob Traynor:
Here comes the general. So honestly, that’s a model that’s been around for a time, and I’m quite surprised someone hasn’t picked it up in the past to facilitate certain types of treatment. You see, that in some of the balanced models, as well, for exercises that people needed to do. And some of those kinds of things also, I think, and I don’t want to monopolize things, but I do think that balance is the new frontier in many respects.
Bob Traynor:
Most places, really, don’t have much going on in balance, and there are some very good, highly motivated, and well-trained research people in certain companies around the country that will actually orient you and your practice and get you the equipment and do all the things to facilitate that particular side of the house.
Bob Traynor:
My City, Greeley, Colorado is in the Northeastern section of the state. There wasn’t anybody… Yet people had to drive anywhere from 60 to 200 miles to Denver to get balanced assessment and balanced treatment. There are lots of places around the country that really are begging for some good balanced work. So balance, I think, is another frontier we may want to explore over time.
Amyn Amlani:
And I’ll just, really, quickly add in a couple of things here. So, as we’re talking about assistance, I may have vultures flying around me here, before too long. There’s the technology of automated testing. And if you look at some of this automated diagnostic testing that’s available, it’s gotten better over time. It will allow for the person, an assistant maybe, to set up the patient on the machine. The machine itself has the capabilities to do speech testing, masking and so forth and so on. And the validity and reliability of that has really gone up.
Amyn Amlani:
And going back to Nancy’s model of where the audiologist is the general and oversees everything, this is a perfect opportunity for that, if you’re looking at something that’s low cost to implement. And then, to Bob’s point with balance, which I absolutely agree with, we’ve got some practices not too far from here that have partnered with PTs.
Amyn Amlani:
And so, there’s a shared responsibility of the diagnosis and then the balance treatment with interprofessional individual. And it’s not uncommon to have that with an ENT and an audiologist and some other things. So, again, I think there’s lots of opportunities here. It’s just what works best for you and the services that you provide.
Nancy Tye-Murray:
And that’s where the idea of the medical residency program is viable. So, let’s say you get your degree in audiology and you have an elderly population you’re serving, and it will be, who do you deal, to become an expert in balance and interact with PTs. Well, then, I could envision a six month program that you would enroll in where you would learn more about the vestibular system, more about vestibular testing, and even more about interventions and how to work with a PTE. Maybe learn a little tai chi.
Amyn Amlani:
Absolutely.
Dave Kemp:
I agree. I think these are really excellent points. So, we’re up on the top of the hour. So I want to come to the conclusion of this. I think this has been an awesome discussion. Closing thoughts. What have we not covered? Or what points did we cover that you want to expand upon as we close this out? Whoever wants to go first.
Nancy Tye-Murray:
I think this is a terribly exciting time for hearing healthcare. There’s some people who feel threatened or afraid to look around the corner, but I’ve seen as a great opportunity, and personally the fact that more and more audiologists are looking around for ways to differentiate themselves, and one of the directions they’re looking in is followup care, aural rehab, comorbidities, it’s something I’ve been working towards my entire career. So, I find this a very exciting time that it’s happening.
Dave Kemp:
Chris?
Chris Cardinal:
What I was going to say was, looking back to what I opened with, looking at the overall cost of letting hearing loss go untreated scale, what you had mentioned, is placing immense pressure on the system, the hearing healthcare system, as we see it, took to change. And so, I think that a larger framing of this conversation comes down to, what type of acceptance of these managed care plans are we going to see?
Chris Cardinal:
And we’ve seen huge growth, of course, and there is a Medicare plan [inaudible 00:58:08], are currently, which basically offers a hearing aid discount program, but that, I believe, and this is what’s going to define things, is going to morph into not just be a hearing aid discount program, but a true hearing healthcare offer that you can get from your insurance company, or potentially, down the road from some other, either employers, or self-insured health plans.
Chris Cardinal:
And we’re already seeing that happening with credit payers. They are developing their own formularies, digital formularies, to provide services and software that allows people to manage their care that gets reimbursed for, and that audiologist, again, in this system and, in what I believe, the direction we’re going, it becomes a system in which you’re incentivized to provide the best care to the greatest amount of people possible, which would be a great reason to have those audiology assistants trained, to provide comprehensive care, so that you can manage more people as that audiologist, and have a successful practice beyond the hearing aid distribution.
Dave Kemp:
Amyn? Bob?
Amyn Amlani:
Bob, want to go next? Or you want me to go?
Bob Traynor:
[inaudible 00:59:27]. Whatever works. This is a be-kind-to-your-colleague day, I guess. Why don’t you go ahead, Amyn. I have something that I think is, probably, the key, but, you probably have a better key than I do [crosstalk 00:59:43].
Dave Kemp:
You’re saying best for last. You’re trying to save the best for last. That’s what you’re saying.
Amyn Amlani:
I don’t know. [inaudible 00:59:48] Well, I was just going to say, I just completed the health economics and outcomes research program at the University of Seattle, you got to earn that certificate, and as I start thinking about some of the things that I’m involved in, one of them is the, I’m chairing the ADA conference, that’s coming up in October. Not to take away from this conference, but the conference in October is completely public health based.
Amyn Amlani:
And one of the conversations that we’re looking at as we put together the program, is what is it going to take for audiology to make an impact in the landscape of healthcare. And the key word being, impact. We have people, we have tools, we have services, we provide an outcome, but those outcomes just really haven’t created an impact.
Amyn Amlani:
And so, the idea here is that we need to figure out what that impact is. Does it come from the educational model? Absolutely. Does it come from this awareness day that we had yesterday? Absolutely. But what are some other things that have to happen? And I think the biggest thing that has to happen is we have to change the way in which we practice, and we have to practice beyond the educational model that we have in place and just beyond the product.
Amyn Amlani:
And, I think, if we start to do that, we’ll start to see a shift in how people perceive us and that impact, that I think, as Chris pointed out, with the data that’s going to come out that we’ll be able to collect, with the conversation about the educational model, we will start to see that audiology is actually lifting itself to a higher ground in the future.
Bob Traynor:
That feeds directly into what I was going to say. I’ll refer back, once more, to Amyn’s fabulous series on pricing in HHTM a couple of years ago. The deal with this, it all boils down to the fact that if you are in practice and you are providing services to patients, because you charge a high price, you need to have a high value to match that or exceed that.
Bob Traynor:
And the way you do that is by adding some of the things we’ve all been talking about here, and learning more, continuing to learn, and then providing some of the things that are right on our fingertips to enhance what you do everyday with patients. Like the aural rehab component, that Nancy and Chris have been referring to, like many of the things that Amyn has referred to here as well, but also, things like building relationships with each and every person. That builds the trust, and that builds the loyalty for people to, not only come back, but tell all their friends and they’ll tell their friends, and you will have nothing to worry about relative to your practice.
Bob Traynor:
If you just look at some of the differentiations that are out there and be able to follow some of those issues. But value to the patient, is what they’re really looking for. And why do I go to an audiologist? I go there because I get more than at the grocery store, or another practice in the community.
Dave Kemp:
Well, really well done in terms of how you closed the loop there, because I think that was… At the beginning in the onset of the conversation was, Nancy’s, what she posed, which was just what you said there, Bob, “How do you justify somebody coming to see you?” And I think it always comes back to value. And where does that value reside? Well, it resides in your expertise, in your knowledge, in your education.
Dave Kemp:
And so, I think it’s all a matter of how do you amplify that? How do you make that more accessible and really maximize that? And so, I think that’s going to be at the core of what happens here into the future. I think this has just been a tremendous panel discussion. I thank all of you, so much, for joining me today and sharing your thoughts and thank you for everybody who stuck with us here to the end. This has been, just, fantastic.
Dave Kemp:
Thanks for tuning in today. I hope you enjoyed this episode of Future Ear Radio. For more content like this, just head over to futureear.co, where you can read all the articles that I’ve been writing these past few years on the worlds of voice technology and hearables and how the two are beginning to intersect. Thanks for tuning in, and I’ll chat with you next time.
