Hello and welcome back to another year of Future Ear Radio! Thanks to all of you who tuned in, listened and supported the podcast in 2021. I was blown away by the amount of messages and positive feedback I received about the podcast last year, and I really can’t overstate how motivating all of that is to me to continue to find the best guests and produce the most thought-provoking conversations that I can. Thank you!
I’m pleased to kick off the new year of discussions with the great Joe Sakumura. Not only is Joe a fellow Jayhawk, but he’s also one of the sharpest young Audiologists that I’ve met and had on the podcast. I thoroughly enjoyed this conversation and am excited to kick off the new year with such an interesting guest and topic.
We begin the convo with Joe’s backstory of why he went into Audiology, how he ended up studying and specializing in vestibular under Dr. Sam Bittel during his time at KU, and how he ultimately ended up being hired by Richard Gans, PhD, at The American Institute of Balance (AIB).
From there, Joe dives into his role at the AIB, as the Director of Centers of Specialty Care (CSC). Joe makes the case for why he believes Audiologists should strongly consider including a suite of vestibular offerings into the clinic offerings, and explains how the AIB supports Audiologists with the implementation, monetization and daily operations of running a vestibular offering, through its CSC program.
We go into a lot of detail about how exactly the process of becoming an AIB CSC works, including the initial implementation, the training, the series of tests that can be performed, the “crawl, walk, run” approach, and how to maximize revenue through vestibular services. There’s a ton of information packed into this conversation.
Joe also shares some of the success stories of the early adopters of the CSC program, which largely pertains to the ways in which this added offering can help to drive physician referrals.
This conversation is so reminiscent of the conversation I had with Jill Davis on episode 86 when we were discussing Cognivue and the significant advantages that “medicalizing” one’s hearing practice yields. Ultimately, it allows practices to differentiate themselves apart from the pack by offering a more holistic suite of services that not only appeals to patients, but fellow medical professionals as well.
-Thanks for Reading-
Dave
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:
All right. So we are joined here today by Joe Sakumura. Joe, tell us a little bit about who you are and what you do?
Joe Sakumura, AuD:
Hey, Dave, appreciate you having me. So I am a, and actually I’m the director of Centers of Specialty Care at the American Institute of Balance. I’m actually an audiologist by training. So I graduated actually the way you and I met was at, or know each other, I guess, through the University of Kansas. Originally, I was a Kansas guy, graduated with an undergrad in biology and communication sciences. Ended up getting into audiology by way of the University of Kansas Medical Center, met a gentleman there, a brilliant audiologist named Sam Bittel, who’s a vestibular specialist, still does a great job of practice [out of 00:01:17] here in the KC Metro. Through those connections and those relationships got in touch with Richard Gans, who’s obviously the founder CEO of the institute and the rest is history. So I’ve practiced audiology, vestibular, and equilibrium audiology for the duration of my career. And we are now through our centers of specialty care program and education paradigms and things, the world leader in equilibrium and vestibular science and medicine. And that’s kind of my story in a nutshell there.
Dave Kemp:
I love it. So the reason I wanted to have Joe on is, he mentioned he’s part of the AIB and everything that Richard Gans has been doing, huge Richard Gans fan. I love your boss. He’s a whole hilarious person. But I’ve just really enjoyed over this last really year, seeing you present on the specialty centers and really the offering that you have, and kind of this whole idea of adding a vestibular element into any given hearing healthcare practice out there.
Dave Kemp:
So before we really dive into it, I actually do want to pull up a little bit and give you a chance to kind of share a little bit more about your story. So you’re at KU and you get connected with Sam. How did you originally even find your way into the world of audiology? And then I think it’s interesting that right away you sort of went into this specialty track. And I don’t know if that’s just sort of, because of the fact that Sam is a specialist and sort of just by means of he being the audiologist that you were able to connect within the Casey area, or if that was part of your passion, as well as that particular specialty within this field.
Joe Sakumura, AuD:
Yes, that’s a great question. I started and I was kind of a biology nerd and undergrad. I took all the organic chemistry. The biology was fascinated by particularly neurophysiology and the way that nerve cells and muscle and things kind of communicate. So I was actually doing animal work on lab rats, where we would damage the auditory nerve and take nerve studies and do ABRs and different kind of audiological tests. And I wanted to get a PhD in physiology, but realized quite quickly that working within animal research and sitting in labs and these kind of things wasn’t my shtick. I needed to be involved with people. I loved interacting with people and whatnot. So basically, I’m stuck between, I can either go into some of these allied health, I’ve got a couple different opportunities in allied health, there’s physical therapy, there’s occupational therapy, there’s audiology, there’s speech pathology, and basically was familiarized with a lot of these audiology terminologies, thresholds, these tests, particularly the electrophysiology tests.
Joe Sakumura, AuD:
So one of my mentors at the time tells me, you should go into audiology. It’s a clinical study, it’s becoming more medical, it’s a great profession. So I show up to a one and it’s basically what these programs kick off with is its hearing aids. You’re learning how to program technology and very, very important skill set to have. Obviously, audiology’s critically important, but my interest was always more in the medical model of things and not so much retail, which it seemed like that’s kind of where audiology is going now. This’ll be important when we get to the end of the story here in a minute.
Dave Kemp:
Totally.
Joe Sakumura, AuD:
So basically I start on this field of audiology and I’m paying, the loans are no joke, so I’m paying a ton of money and I’m not really in love with it. So I’m thinking about potentially switching fields, cause my exposure was largely hearing aids. So I actually, Sam Bittel teaches the vestibular course at the University of Kansas Medical Center, was able to link up with him. And if any of the listeners have ever met Sam, he’s brilliant. He thinks more along the lines of a medical model. It’s more of a the way he practices. And now the way that we do at the institute obviously is more the totality of equilibrium, science, and medicine with multi-specialty, with physical therapy and components of certain different kind of things. So it’s basically eye-opening that, okay, there is this side of medical audiology, and this skillset and this [inaudible 00:05:38] that I’m going into can be really, really well utilized.
Joe Sakumura, AuD:
And so I start to get real passionate about studying vestibular system. So Sam through his mentorship and things says, if this is really where you want to take your career, you’ve got to go speak with Richard Gans at the American Institute of Balance. That’s where I did my fourth year. He’s brilliant, tons of textbook chapters, publications. They do a great job. If this is your thing, you need to go study down there, period. So I basically decide that’s where I want to be. So I go down, I interview with Richard, they actually offered me a fourth-year position on the spot. So I do my fourth year there and study. And I’m part of, really what I foresee as being the future of audiology, this medical model with brilliant minds multi-specialty and truly as cliche as it might sound helping people with these dizziness and balance problems where there’s a huge, huge gap in healthcare.
Joe Sakumura, AuD:
So based basically from that time, I spent my first couple of years at the institutes, seeing patients and studying this and perfecting and crafting this craft that I’m getting into, then things start to expand. So, well, I know we’re going to talk a little bit about AIB and who we are in a moment, but basically, the ability to… Everything is predicated on the science and the clinic. And we’ve got a ton of exciting stuff going on, obviously, but that’s kind of how I got into this niche model of medicine and vestibular.
Dave Kemp:
Yeah. I think that’s super interesting to hear that you sort of gravitate toward that. And then one thing just sort of serendipitously leads to another, you get linked up with Sam. Sam helps you to kind of connect with Richard. You end up down in Tampa at the AIB and here you are today a few years later, why don’t you start to kind of dive into the AIB and then lead into what you’re all doing now with the specialty centers? Because what’s interesting to me is, I actually met Richard as one of the first people I met in this industry a while ago. And the reason I remember him so vividly was because of the fact that he owns the web URL of dizzy.com. And everybody that I had sort of were introducing me to Richard was like, yeah, he is like the king of vestibular work.
Dave Kemp:
Like he’s one that has pioneered a lot of this stuff. And when I met him, he was very much sort of like an ac… It was in this academia setting. And then flash forward to when I saw you all down in Miami and you were presenting there, one of these different trade shows and I’m learning all about the specialty centers. What really [dawned on me 00:08:19] is like, wow, he’s kind of commercialize this in a way. And it’s now becoming so much more widespread and pervasive and available as an offering. So I don’t want to kind of like get ahead of ourselves here, but I do just find this whole evolution even in the last five years to be pretty fascinating. So help me to kind of understand what that’s been like actually living through this and how this whole thing’s kind of unfolded.
Joe Sakumura, AuD:
Yeah. So AIB is first and foremost. So we’re celebrating our 30th anniversary this year, which is really, really exciting. For our 30-year history, we are first and foremost, the world’s largest dizziness and balance clinic. So it’s not like we’re teaching people to do something that we don’t ourselves do. We walk the walk and we talk the talk. So we actually own and operate six clinics up and down the west coast of Florida, multi-specialty with physical therapy, ENT, audiology, but it’s basically exclusively balance and dizzy patients. And we actually do about 800 patient visits per month at those six clinics. So a ton of traction and things within the Tampa Bay market. AIB also is unique in that we’ve got a couple of different business silos. Another of which that’s one of our more longstanding being our education model.
Joe Sakumura, AuD:
So we are also along with owning and operating our own physical clinics. We’re the world’s largest educator of physical and occupational therapists along with physicians and vestibular and concussion rehabilitation. So we’ve got a strong, strong presence in network and brand recognition within the physical and occupational therapy world. So we’ve taught, we have our own clinics, for years we’ve taught these courses and taught the gold standard of the science and the medicine behind how to help dizzy people, how to evaluate and how to treat patients with dizziness, vertigo, and balance problems. So a couple of three year… I believe it was the summer of 2018, groups had started to come to us and say you guys are great. We loved your courses. We love coming to take workshops.
Joe Sakumura, AuD:
But as you know, Dave, in a capitalist society and in America, unless you can teach somebody how to monetize something, unless you can create a feasible business, you knit for them, no matter how good for the patients it is. It’s not going to [ring home 00:10:43] with a profession until you’re able to show them how to make a business out of it. So basically people are coming to us and saying it’s great that you can show us how to do a VEMP or how to do a rotary chair, any of these diagnostic tests, or how to rehabilitate these patients.
Joe Sakumura, AuD:
But I got to ask you Richard, and they’d come to Dr. Gans and say, I got to ask you, how have you been so successful in business? Because there’s this proliferating fake news idea within audiology that you can’t make money in vestibular. So for that reason, a lot of people, they hear vestibular and it’s like, “yeah, dizziness is part of our scope, but I’ve never really messed with it.” If you pulled a 100 audiologists, probably a vast majority of them would say, “yeah, balance is okay, but I’ve never really gotten into it.”
Joe Sakumura, AuD:
So people start coming to us and saying, how do we do this? How do we market these services? How do we perform the clinical side of it? How do we build for this? How do we train our front office staff, basically asking these business development questions that are critically important to the success of a balance practice. So three years ago in 2018, we developed what’s called our centers of specialty care licensing agreement. And basically, the best way to think of this is almost like a virtual franchise. If you buy a McDonald’s, they teach you how long to cook the burgers, how long to cook the french fries, how to run the register, right? How to build this out and what this looks like. Not only from one component, but it’s really the best way to describe the CSC licensing agreement is a business development and support model of implementation.
Joe Sakumura, AuD:
So we start this model in our initial early adopters. We’ve got three to five clinics that jump on board with us. We’ve now of course grown this to over 90 clinics nationwide. These consist of audiologists, ENTs, and neurologists. So they’re multi-specialty, they range anywhere from, we’ve got groups with 1 audiologist to major health systems with 9, 10, 12 neurologists or ENTs. So this is really first and foremost about teaching people how to do well by doing good. So that’s kind of in a nutshell, the big 30, [that 00:12:59] 35,000-foot view of the CSC license.
Dave Kemp:
Yeah. I love the fact that, again, kind of like what I was saying earlier with Richard is like, it’s, he had this brilliant concept, and to your point, I think, it was hard for people to actually implement that. And so I think that’s the big change that really caught me off guard almost, and was so exciting to hear all about was this franchising element of it, which is, look, I’ve already sort of mastered the implementation of this thing and how to make real money off of vestibular. And I think that this really ties into a lot of the conversations that I’ve been having on the podcast lately, which is like this reoccurring theme of here we are, it’s now 2022. There are all kinds of new perceived threats in the market as a private practitioner.
Dave Kemp:
And I just continue to think that there are so many different ways in which you can differentiate yourself in your market. And one of the most compelling ways, in my opinion, are these avenues to become more medical. And I think that the conversations I’ve had with Cognivue and a little bit further in the conversation, we can even talk about the recently announced partnership between you two companies is very emblematic of this too, which is like taking these things that are very much linked to the world of audiology. And I think as a practitioner and a hearing professional, like really planting a flag in this ground and claiming it as your own. And I think that what’s really like a… What’s really eye-catching for me is when you were presenting and I was looking at some of these statistics, these dizziness and these vestibular issues are so widely pervasive.
Dave Kemp:
And it begs the question who is the right person to treat those things. If your grandma, for example, has like, she’s at really high risk for falls, where does the average American think to take that person? And why can’t that be something that over time, we as an industry and this profession is able to really cement that and condition the public into thinking that this is something that’s within this domain, so that’s what gets me really excited about it. And I want to now kind of like talk through because you’re the director of these specialty centers. And I know this is a relatively recent program that you guys have and it’s growing like wildfire. So just kind of walk me through, what these last few years have been like, what are some of the kind of things in which you try to articulate of the most compelling reasons as to why you should implement something like this? Just kind of walk me through your pitch, if I were a practitioner, why I should consider being one of these centers of specialty care?
Joe Sakumura, AuD:
Yeah. So thanks, Dave, the story is so easy to tell. And the reason for that is because there’s this huge gap in access to care for these patients. So the first statistic and the first kind of thing to work through, just to kind of help all the listeners wrap their mind around how big these issues are and how many Americans [inaudible 00:16:14] to mention globally how many people are affected by this [inaudible 00:16:16] dizziness and balance problems are the number one complaint of individuals over the age of 65 to their physician. You can back that up with statistics about falls, the leading cause of hospitalization in the elderly, the leading cause of accidental death in the elderly, the list kind of goes on and on. So falls are obviously, and they have been for a long time a huge deal of dizziness and balance problems, 65 and up it’s the number one complaint.
Joe Sakumura, AuD:
It’s actually the number three complaint of all individuals across the lifespan proceeded by lower back pain and headache. So listen, we’ve got to look ourselves, I think in the eyes as a field a little bit, and understand that we have all been holding a fishing pole with a line in this pond, trying to drive business from this group of patients through hearing care and hearing devices and all these other kind of things. The reality of it is, every day there are more fishing lines dropped into that pool, into that well. Lively, Costco, Miracle-Ear, Beltone, Bose, Apple, look at everything, all of the disruption that’s been going on as a field, the good news for us and the good news for these dizzy patients is it’s forcing audiologists to wake up. We can longer be one-trick hearing aid ponies because unless you’re able to diversify yourself as a medical practitioner and the way I’ll typically say this to practice owners is you’re either in one of two models as an audiologist, you’re in a, where most of us live, in a retail space with medical undertones or you’re in a medical space with retail undertones.
Joe Sakumura, AuD:
Your podcast is so incredible because you bring these disruptors on that are looking at tinnitus, auditory processing, implants, cognitive screening, ways to differentiate yourself from your run in the mill. We’re not going to survive as a hearing aid dispensing culture and profession. So when you look at the opportunities that are out there, we’ve got 10,000 people, Dave, turning 65 every single day, these people are looking for care. So the traditional model in healthcare that we run into, and I actually, this is a perfect story. My grandparents have run into this, “oh, Joe, your grandpa’s dizzy.” We took him to the primary care doctor who wasn’t really sure, is it a blood pressure problem, might be crystals in the inner ear. Maybe he’s just getting a little bit old and he needs to use a cane or a walker. He gave him some Meclizine and said maybe this will take care of it.
Joe Sakumura, AuD:
Maybe that’s one direction that things can go. The other direction that things can go is, oh, you need to see a physical or occupational therapist. The therapist is set up for failure, because guess what without a functional diagnosis, without understanding where the problem is coming from, their outcomes are not going to be nearly as strong as if they understand, if the ear is in good status, if the ear is talking to the brain. If the eyes and the sense of touch are working well. So we, as a profession of audiology, need to plant our flag. And I know a lot of the industry leaders are already preaching this message. We’ve got to take these patients as ours. Guess what, neurologists, you can do an MRI on these patients. Maybe it shows minor white matter hyperplasias or lesions that maybe are related to age, but it’s not going to tell the patient why they’re having vertigo when they roll over in bed.
Joe Sakumura, AuD:
ENTs can look up your nose, in your eye, down your throat, right? Their surgeons at the end of the day, most of these patients, the vast majority of dizzy patients, do not get better with surgery or medication. So the audiologist as an ancillary allied provider is a perfect person to really take the reins on this and provide a service that’s vastly, vastly, it’s hurting. This is becoming a really, really big problem for our medical economic system. And just look at what it’s costing the system at the end of the day. And just to bring another stat into the equation, we know that the most common cause of vertigo is BPPV, benign paroxysmal positional vertigo. Something that audiologists [inaudible 00:20:25] within our scope and should be treating. The average cost, Dave to the medical economic system to evaluate and treat someone with something as simple as BPPV costs our system about $2,800 US with imaging, cumbersome medical evaluation.
Joe Sakumura, AuD:
That’s not even talking about what it costs the patients and loss of quality of life, fear, avoidance, anxiety, depression. So it’s a big deal. These conditions are really, really debilitating, and understanding [inaudible 00:20:56] that we have a scientific clinically-based protocol that can help them. That’s the first thing audiologists have to understand. And number two, we have a reimbursement model that is actually very, very favorable. And if you ask AIB centers, you should be adding, it can add anywhere from a quarter of a million to a half-a-million dollars to a practice annually.
Joe Sakumura, AuD:
We know with a hearing aid what a hearing aid provider is able to generate, this is very, very competitive. The other good news about this shifting in your model from retail base to medical base is going to do nothing but elevate your dispensing practice. Because patients that come in with very, very serious complaints of balance problems, falls, vertigo. If you’re able to give them an answer or give them guidance into a plan of care, they’re much more likely to forward with technology if that’s part of treating them. So this relationship between dizziness, balance problems, vertigo, untreated hearing loss, cognitive decline, there’s a whole lot of overlap there. And the audiologist is really in a unique position to address all of this.
Dave Kemp:
Yeah. Wow. That is really compelling. And just awesome breakdown of that, Joe, thank you for going through all that. And I agree. I mean, this is what really stood out in my mind when I talked with Jill Davis of Cognivue was this idea that, one of the things that she mentioned was just the uptick in physician referrals that she’s gotten since adding this cognitive screening element to it. And of course, that’s going to increase her overall success rate in closing hearing aid sales and stuff like that. Because again, when you come through the doors of that provider on the behest of a medical professional, like your physician that is referring you in, it’s not really a sales cycle anymore. It’s more of like, what do I need? It changes your spot on with this whole notion that there are these two types of offerings, there’s retail with the tones of the medical setting that’s underneath it or vice versa.
Dave Kemp:
And I think that there’s such a clear path of differentiation if you go that more medical route. And I think that what’s really exciting to me is to think about, as you pull apart from the pack, it changes the whole nature of what it means to be an audiologist, I think, in your community. And I think that balance is another really good example of just another area that can be carved out and can be your niche. And I think that it really does translate really nicely into all these different areas.
Dave Kemp:
And so for me, if I’m watching your presentation, I’m a private practice owner and like this all sounds really great. How does this actually work logistically? Help me to understand how you guys come in, cause I know that’s one of the really big appeals that I’ve come to learn with AIB is that there is the implementation and the training process is kind of [bar none 00:24:13], it seems like. And so I feel like this would be a good opportunity for you to kind of walkthrough, okay, look, conceptually, I think this is brilliant. I want to move forward with this. What does that next phase look like?
Joe Sakumura, AuD:
Yeah, that’s a great question, Dave, so thanks. So number one, we’re professional educators. What people like about our program and our models is that it really is a turnkey, scalable approach to this really, really kind of in some people’s minds, esoteric model of overwhelming how do I add this [news 00:24:45], where do I begin? So a lot of times people will come to us and they’ll say, “okay, I found a vestibular audiologist and I’m ready to go. I want to do this. We just bought equipment.” The first thing that we tell people is just because you buy a Keurig does not make you Starbucks, just because you know how to cook a really good hamburger does not make you McDonald’s. So you’ve got to understand the totality of this business unit and the way I always will break it down is really, we have four categories where our training, onboarding, and support are really kind of focused.
Joe Sakumura, AuD:
So the four categories, our first and arguably the most important is the clinical technical silo of this. Most audiologists, Dave, do not learn unless you go to a specialized residency or fourth-year position, most audiologists simply don’t know how to do these tests. And don’t know how to write these reports and don’t know how to take care of these patients because they’re not trained. You don’t know what you don’t know. So unless you’ve had a specialized residency or training, the first thing that we need to do is educate you on the clinical background and the science of this, as well as how to perform these tests from a technical standpoint. So the clinical technical is one silo. The next and arguably equal important silo is patient acquisition and marketing. Most audiologists don’t understand how to market vestibular services because we’re not talking about exclusively ENTs and neurology here. You’ve got to have talking points and you hit it spot on Dave, 99% of AIB’s patients are physician referral.
Joe Sakumura, AuD:
Physician referrals are the lifeblood of any balance practice, but in order to market effectively to those physicians, you better know what you’re doing because you have to tell a different message to a primary care, to a rheumatologist, to an endocrinologist, to a cardiologist, et cetera. So that’s another silo of training is educating the practice and helping them implement marketing campaigns to put butts in seats, so to speak. So understanding the marketing critically important, finally, there’s billing and coding. It’s actually simple, but there are some caveats and some things to understand about the CPTs, about the IC 10s, some practices that are really retail heavy may not participate in insurance and these kind of things. So we help them understand how to navigate with specifics to vestibular, how to navigate the reimbursement world.
Joe Sakumura, AuD:
Finally, front office staff training. Your folks have to understand if a patient calls up and wants to be seen for dizziness and balance problems. Is there a script that your front office staff person can read? What if I’m a dizzy patient and I call and I say, “Hey, I’d like to be seen, but I’m extra dizzy today. I don’t think I can come in, it’s still a good idea. Are the tests going to make me vomit? Is this going to make me worse?” You better have a really, really repeatable script for your front office staff to be reading and help patients understand that they’re going to be taking good care of. So the way that we do this is our onboarding process. So it’s actually a hybrid approach where we use both online modules through our tech, our education portal, 20 plus hours of online educations on the conceptual knowledge, we then actually bring the practice on-site to do the procedural knowledge. Where does the electrode go? How do you do this maneuver?
Joe Sakumura, AuD:
And also it helps the practices from ownership to employee to drink the Kool-Aid if you will, it’s a cultural buy-in. You’ve really got to have a change and a shift in belief system. As audiologists we’re kind of trained to think in this glass ceiling, our belief lids are here in order to practice vestibular medicine effectively, you better be able to lobotomize to a certain degree that part of your audiology brain that tells you not to live with an equilibrium medicine, because the reality of it is we don’t actually teach groups how to do vestibular testing and treatment. We teach our groups to be equilibrium specialists and to offer neurodiagnostic evaluation, which evaluates how the three modalities of balance function, eyes, ears, and sense of touch, the things that are keeping us on our feet.
Joe Sakumura, AuD:
We’ve got to understand how all of those are working and communicating with one another because dizziness and balance problems can result in hiccups anywhere along that pathway. So the onboarding process is completed. It’s very, very intensive. We make you have certain competencies and we make you achieve certain milestones before we’re going to co-brand with you and list you as one of our preferred centers of specialty care. Beyond the onboarding, Dave, there’s also ongoing support for the duration of the five-year licensing agreement. So not only do you get this bulk front-loaded download of valuable information, but you also get business and support and things along the way to ensure that you’re successful.
Dave Kemp:
Yeah. I mean, I think that that whole, again, it goes to this whole idea of, I don’t necessarily think that audiology as a whole has shied away from vestibular because there hasn’t been a perceived interest or [knowing 00:30:15] of the demand that exists. I do think you’re right that it’s, just from my sort of pedestrian knowledge of this is that I think a lot of people don’t even know where to begin, it feels daunting, and you don’t know what you don’t know and not only that you’re so busy with your day to day that times might be good right now. We kind of all see the writing on the wall that like the world of just relying on a business, that’s entirely dependent on one revenue stream, which is hearing aids might be in jeopardy. And so I think that now is probably the best time than ever, it’s like the adage about planning, when’s the best time to plant a tree, 10 years ago. Well, when’s the next best time, today.
Dave Kemp:
It’s like the same thing with this where I think that whichever direction you go as a practitioner, I think that there’s lots of really exciting new options available to them. And I think that what’s so cool about what you all are doing is that it is so collaborative. And I think that you’ve done a good job of articulating that upfront support and that initial training goes into it. And there’s so much to this, but I do think that this ongoing support, one of the really interesting things that I learned when I was talking with you and Richard about this was, it’s that you guys do support of the overreads, right? So if I’m one of these specialty centers, I collect the data.
Dave Kemp:
I don’t actually even need to assess that data. I can send it down to AIB and your staff down there will actually provide an overread and an assessment so that I can then provide the patient with that. So in a sense, really all you’re doing is you’re gathering the data and then feeding that data down to the AIB. So can you talk a little bit about that portion of it, because that stood out in my mind as again, it just makes this feel a little bit more feasible and a little bit more like, yeah, you know what, this isn’t as big of a stretch as I thought it was? When it felt like man, I read all of this stuff from Richard and his textbook and conceptually I get it and this would be great, but I have no idea where to go in terms of how to actually turn this into a business unit like you said, and this, everything that you all are doing now is so exciting because it does feel like the whole focus is how do we make this actually feasible for these practices?
Joe Sakumura, AuD:
Yeah. And scalable and almost passive revenue generation. So first I’ll speak to the overreads in just a moment, but speaking of what you’re talking about with the hearing aids face and whatnot, we’ve got countless examples of center given [inaudible 00:32:55] with all of the flux and things with COVID right now and the virus and the fact that that’s having on the economic status of audiologists and things, we’ve got a number of centers that have come to us, we’ve got [Rachel Garcia 00:33:08] in Texas, [Craig Casper 00:33:09] in Manhattan. We’ve got [inaudible 00:33:12] in Virginia have come to us a number of times and said, you know Joe and Richard, I got to tell you throughout this whole COVID thing, we saw our hearing aid faucet dry up or turn off almost completely. Do you know what it is that kept us afloat throughout that whole time was the vestibular diagnostics because people that have dizziness and balance problems, it’s not viewed as an option or, oh, I can put off my hearing loss for another year, finances aren’t so good or offices are shut down.
Joe Sakumura, AuD:
If you’ve got vertigo and balance problems, you can’t live your life. So we like to tell people regardless of not to get into politics, but regardless of who’s in the white house, regardless if Congress is red or blue, regardless of COVID 19 people with these problems are going to be seeking out desperately healthcare here. So again, regardless of maybe the hearing aid stuff is still 5, 10 years down the future before audiologists are really hit hard with it. Probably not that long, but regardless of that, there have been countless examples throughout the last two years of the tumultuous things that have gone on in our, in the world, really in our country that have exemplified how important it is to be diversified and to grow your business wide and deep.
Joe Sakumura, AuD:
So the other, just to speak to the overread for a second. So you’re exactly right, Dave. So one of the most challenging things about this testing is we like to say that we can teach almost anyone to push the buttons. Right? If I go into a cardiologist, they’re not going to be the ones weighing me taking my blood pressure. If I go into my primary care doctor, they’re not going to necessarily be involved with me until they’ve got the whole picture and I’ve been weighed and my meds have been evaluated and all these other kind of things. So the test itself does not, we, you don’t need your doctor of audiology brain necessarily to do this. It’s clicking buttons, it’s setting protocols, it’s putting on electrodes things that actually, and with our physician colleagues, ENTs, and neurologists, we have technicians do the tests. That’s build [incident 00:35:21] to the office visit, so the testing itself isn’t necessarily the part that requires a great deal of critical thinking, background knowledge, and a doctoral-level education.
Joe Sakumura, AuD:
The biggest challenge is going to be writing the report, specifically, writing a report that brings value. In a lot of audiology and physician minds, you do these diagnostic tests and then basically you’re sent back a report that says normal or abnormal. It doesn’t bring value to the physician. So if I’m a client of an audiologist and I’m a physician sending my patients over because an audiologist has told me, we help people with balance problems and all I get back, my product that I just sent you over for, is just a report that says normal, why am I going to use that service? So at the end of the day, the physician is the audiologist’s client. The product that we’re selling those physicians is obviously taking great care of their patients but also making their lives easier. You talk to any physician, Dave, and the first thing they’re going to tell you for the most part, unless they’re a real, real specialized doc is I don’t like dealing with dizzy patients because they’re complex. They take a lot of time and I don’t really know what to do with them.
Joe Sakumura, AuD:
At the end of the day, I guess you could go to therapy. I guess you could use a cane, but they take time and I can’t generate money with them essentially. So what we want the audiologist to do is educate the physician on how they can make their lives easier. So what this means is you better have a report, not that reads bad left ear or left-sided vestibulopathy, but rather report that reads something to the nature of findings are remarkable for depressed left labyrinth theme function. The patient has a left vestibulopathy. They remain uncompensated for the aforementioned vestibulopathy and this is likely contributory to their complaints of blurred vision with head movement, oscillopsia, balance problems. This is the origin of their problem. On top of that, the patient would be a good candidate for vestibular rehab therapy.
Joe Sakumura, AuD:
Ideal protocols would include gaze stabilization, adaptation, substitution, all of this. Of course, if it’s in agreement with your medical plan of care. Now, if I’m a physician, I receive that and that made my job a whole [inaudible 00:37:41] “Oh great. The Institute thinks you need this. Here’s the problem. You got a weak left ear, good news. You’re going to go to therapy. They’re going to help get you better.” So it’s ultimately about getting the patient better more quickly. So what you can do as an audiologist is either you can learn through us and through the onboarding and through the ongoing support, how to write these reports. But to your point, it’s time-consuming, 15 to 20, we started to learn this early on. Even if you’re good at this, it’s going to take you 20, 30 minutes to write the report.
Joe Sakumura, AuD:
Well, let’s say you’re seeing even just modestly 10 patients per week, what’s 30 minutes times 10, 300 minutes. That’s five hours per week. So the audiologist, what could they do with that time? Could they be dispensing? Could they be doing other revenue-generating services? So we began to offer this overread service where basically it acts like an MRI. The tech does the test, they perform it, they run it. The neurologist that reads the MRI is actually typically offsite. So the audiologists or their team uploads the data in a HIPAA compliant manner to AIB. Our docs, we’ve got now 12 doctors of audiology read the report, or sorry, read the data, write the report, send it back to the audiologist’s office. They simply then give it to the physician or use that to triage the patient. So it’s a win for everyone. You’re saving the audiologist’s time and money. You’re helping the physician. There’s also certain level of quality assurance when you do this, this way. So the overread is a critically important component.
Joe Sakumura, AuD:
The other thing to interject there is with that overread we discuss that most of these patients are going to end up in physical or occupational therapy. That’s the gold standard treatment for most patients, right? The difference is do they have diagnostics beforehand or not. Something that I recommend to audiologists, would you ever, ever, ever fit amplification or treat a patient with a hearing device for management, if you didn’t first have the audiogram, the comprehensive diagnostics? The answer is, of course, no, it’s not the gold standard. So the way that I encourage audiologist to think about the vestibular test battery is almost like the audiogram for the vestibular system, but instead of treating and managing this patient with hearing aids, you’re treating and managing them with vestibular rehab therapy with an AIB certified provider. So we close the loop now. We’re training and educating and licensing neurodiagnosticians as well as therapeutic interventionists so that the continuum is seamless and ultimately it leads to a product that gets the patient better. That’s what the goal is here.
Dave Kemp:
I think that when you were talking about making the life of the physician easier, that to me is like, I mean, I can’t think of a more attractive proposition for… Again, if the lifeblood of not only a vestibular offering, but really we know this to be that if you get a referral from a physician, the likelihood of you converting that into some sort of sale is just going to be leaps and bounds better because there’s such an element of “my doctor sent me here,” right? And so I can’t think of a better way to build inroads with physicians than to make their lives easier through something like this. And so there’s so many layers to this, right? It’s not just about adding vestibular as an offering. It’s also about using this as a method and a tool to build inroads to increase your patient referrals from physicians.
Dave Kemp:
And that ultimately is going to lead to a healthier top line and a bottom line. You’re going to be seeing more people and you’re going to be closing more deals. And so I just, it’s to me from a business standpoint, this is such a slam dunk in so many different ways that it’s hard not to look at this and say… Again, when we look at like, what is the future of audiology, a lot of these different specialties, they lend themself in these multifaceted ways that aren’t just simply, I’m going to add a new diversified revenue stream. It elevates your standing within your fellow allied medical professionals and your patients and everything. And so that makes a ton of sense. With the reimbursement side of things, again, another thing that really stood out to me when I saw you present was this piece you had said earlier there’s opportunity to generate upwards of like 500 grand of additional revenue from this. But even at the individual patient level, kind of walk me through what the reimbursement compensation opportunity looks like?
Joe Sakumura, AuD:
Yeah. So when we speak with practices, obviously, we know that Medicare is the gold standard. They set the bar for all commercial payers. So the sort of bar that we set that we always look at are the Medicare maximum allowed rates for certain CPT codes. We know that as audiologists, we get paid on a per test basis. So let me just walk through now kind of the science, as well as the reimbursement of the test protocol that we recommend. So, first of all, it’s important to understand when most audiologists think vestibular test, they think about what’s called the VNG, a videonystagmography test. It’s really an old antiquated test. It’s been around for decades. And actually part of that test, the caloric was discovered by the ancient Egyptians. They figured out that if you put well water in somebody’s ear, you can make the eyes move.
Joe Sakumura, AuD:
So this test has been around from the days of ENG, now VNG, that is only one piece of the puzzle. So the VNG pays you. If you do a VNG with a caloric test, it pays you about $140. It’s limited for two reasons. One that reimbursement is very, very weak. You show me an ROI on that, if it takes you 45 minutes to do a VNG, and it’s paying you $140, it’s not great. If I’m a business owner, I’d rather my audiologist be dispensing hearing aids. So that’s one limitation is the return on that? Number two, it’s not doing the patient any good. The VNG is looking only, almost exclusively for central issues and active, acute, and issues that really most VNGs end up being normal. So it looks at one part of the peripheral vestibular system and one pathway up into the brain.
Joe Sakumura, AuD:
We are now in 2022, we have at our fingertips access to much more science and a much more comprehensive protocol. So the best way to think about this is if I had arm pain, Dave and I went into a doctor and all they did was an x-ray. Yeah, that might be good if I’ve got a fracture, but what if I’ve got a soft tissue injury? What if I’ve got some sort of ligamentous problem? So we’ve got at our disposal now, we’ve got at our fingertips, cervical VEMP, ocular VEMP, rotational chair, video head impulse, electrocochleography, [rate study 00:45:06] ABRs that can look at certain space-occupying lesion. So when you look at the full [monty 00:45:12], the comprehensive, we’ll call it the Mayo Clinic workup or what you would get if you went to a Cleveland Clinic, a Hopkins, a Mayo Clinic, you’re talking about a test battery, Dave, that evaluates all five peripheral vestibular [end organs 00:45:26], both branches of the nerve after it bifurcates and also all of the neural substrates, both ascending and descending pathways of integration of the balance system.
Joe Sakumura, AuD:
So we’re looking at a much more comprehensive protocol. If you do this protocol with all these tests, not only is it going to help you take better care of the patient, right? But it’s also going to generate you just shy of $600 per patient. If you use the AIB protocol, you do this in 75 to 90 minutes. So again, doing just a VNG would be like doing the equivalent of fitting a hearing aid with only information if you did [pure tones 00:46:12] at 125 Hertz. So audiologists are perfectly okay using [tymp 00:46:17], reflux, OAE, right. Air conduction, bone conduction, speech, all of the different, beautifully, scientifically rooted tests that we have. But for some reason, there’s this proliferate idea that VNG is all that it exists when it comes to balanced dysfunction. So again, the idea here is to take great care of the patient, to do well by doing good. And by maximizing your protocol and using what AIB teaches, you’re going to increase your ROI and you’re going to take better care of patients and be able to come up with a more accurate, thorough, comprehensive treatment plan.
Dave Kemp:
Yeah, that’s fantastic. I guess, as we kind of come to the close here, you’ve walked through how you get reimbursed, what this looks like from an implementation process, some of the different ins and outs of this whole offering from the vantage of the provider. I guess my question to you would be, again, as the director of these centers of specialty care, I think you guys have only been doing this for a handful of years, what have been sort of like the takeaways that you’ve had so far. You’ve named a few different providers that are part of your network and it seems like another really big advantage of this is that as the network grows and as people become more familiar, that serves as a lead source as well, is that you’re part of the network, right?
Dave Kemp:
And so that people are going to be able to look you up and see that you’re the local AIB provider. But I guess just like help me to understand things that maybe were surprising to you or just some of the things that have been takeaways over the first few years of this and how 2022 is going to look because I know that you are growing like crazy and this seems to really be catching on within the industry. So I’m just curious of… It’s always interesting to hear kind of like in these first stages of this, of something like what you’ve all built with this, what have been some of the takeaways?
Joe Sakumura, AuD:
Yeah. So number one, overwhelm… So like I said, we started this program officially, so we’ve done and we’ve taught this stuff for 30 years, but this specific business silo has been around about three years. So the really interesting unique thing is we just had our conversation, we had three early adopter practices, three groups that we spoke with them at its inception and they said, sign us up, we’re going to come on board. So what’s been really, really incredible about having conversations with them because initially we actually did our licensing agreement lasted three years. So you signed a contract, you’re an AIB licensee for three years, and then you have the opportunity to re-sign on after your license expires. So in having conversations with these first three licensees, it’s been really eyeopening that before we could even get to a discussion point of would you like to renew your license or at about that time is all of them came with these beautiful stories of, we have done so much for our community.
Joe Sakumura, AuD:
Our patients are so happy. Our staff has been, they’re ecstatic about this. The revenue has been incredible. Physicians view us in a completely different, through a completely different lens. All of them have come to us with this overwhelmingly positive feedback and said, we want to re-sign. Could we re-sign for 10 years now? So the feedback’s been really incredible. And Dave specifically, we talked a little bit earlier about physician perception of audiology. And when you’re talking with physicians about hearing loss, even as important as we as a field know that this is, all the stuff about cognitive decline and quality of life and all these kind of things.
Joe Sakumura, AuD:
The bottom line, when you talk to primary care physicians or non-specialist physicians about hearing loss, unless it’s a barrier to them in the exam room, most of the feedback that we get is, yeah, great, we’ll send, we like you guys, we’ll send you patients, but one of the most standout things that we’ve found is that when you market to them and you speak with them about falls, dizziness, balance problems. When with our guidance, our centers walk into physicians offices, they’re viewed as colleagues and as peers and as bringing a service that is extremely valuable in order to be profitable. And in order to be successful as a field moving forward, we have to elevate ourselves within the eyes of our colleagues in medicine and be able to bring something as an ancillary service that is valuable. And that’s kind of the biggest, greatest compliment that we’ve received from a lot of our groups is it’s really changed how the medical community views us.
Dave Kemp:
Yeah. That’s so well said. It’s just really cool. I mean, like you had mentioned, you kind of rattled off some of the different themes that I’ve been honing in on, and it’s hard not to think that there’s a really bright future of audiology when you start to factor in all of these new, I don’t even think the right words peripheral because I think that they are, they should almost be the focus. I think that in my eyes, I don’t see why vestibular should be taken a backseat to hearing aids. I think it’s just, again, a byproduct of, that’s sort of just the way that we as an industry have kind of been conditioned and it’s really exciting to now kind of see this renaissance of new thinking of why are we, like you were saying the proverbial glass ceiling, it’s like, why do we have to just limit our scope there?
Dave Kemp:
Why can’t we be more than what’s perceived as a hearing aid specialist, like we as a industry, I think, and again, I’m just speaking on behalf of audiologists and you as an audiologist, this is the takeaway that I’ve gathered is like, it can be so much more. And when you do, really lean into that it seems like there’s nothing but positivity that really follows because you do really elevate yourself within the standing of all these different medical professionals and your community. So it seems like whether it’s vestibular or any of these other different tracks or all of them, and I think in time, it’s going to be really beautiful to watch. You’re already seeing it. There’s this really cool groundswell that’s happening right now. Like you said, you’ve been around for, you’re in year three of this, I would imagine that over the next three years, you guys are going to be huge.
Dave Kemp:
And in this whole aspect of audiology is just going to become more of a staple. And I think that we’re going to see a lot of this where people really do kind of gravitate toward these different specialties. And as those specialties really start to become defined, and I think made aware to their colleagues and other audiologists that really understand that this is a lot more feasible and it’s being made feasible by companies that are helping to actually do a lot of the leg work and the heavy lifting of making this all viable. It all stands to make me think like there’s a really, really bright future so long as providers out there are willing to take it upon themselves to kind of go back and learn and kind of force themselves to be a little uncomfortable again terms of, I got to figure this thing out and I’m starting from scratch a little bit.
Joe Sakumura, AuD:
Yeah. And the future in my eyes and in the eyes of our are now close to 90 centers of specialty care. There’s a lot of doom and gloom. If you look at audiology as a field and a lot of fear and you just don’t have to have that viewpoint. And to me, the future’s never been brighter. And when you speak with a lot of our centers, it’s, I don’t have to go to bed worried anymore. If I’m going to be able to keep my lights on, or if Bose is going to come out with a product that blows me out of the water. So I’m with you, Dave. The future’s never been brighter. And when you look at… If you’re a listener out there and you’re wondering what’s next, can I do this? What do I need to do this?
Joe Sakumura, AuD:
Just a couple of criteria to people think that you need these great big centers, or are a great big footprint or this huge staff. Really, if you look at criteria to do this, you’ve got to be an audiologist, an ENT, or a neurologist. You can be a small single practitioner business all the way up to a large hospital or healthcare system, so that’s check mark one. You’ve got to have personal, professional, and financial goals to expand your practice offerings, diversify your services, and grow revenue. You’ve got to have belief systems and cultural buy-in to providing these offerings. You’ve got to have 190 to 100 square feet [is all 00:55:20]. Strong relationships and brand recognition within the patient and physician, community, and an excellent team. That’s really all that it takes. So the footprint, this misinformation about all this space and personnel and requirements, it really is ideal to be embedded into already existing successful dispensing practices or implant practices or groups that are ready to diversify and take on these new, awesome, awesome services that you can provide patients.
Dave Kemp:
Awesome, man. Well, thanks so much, I guess the very last question I have, what was that first day like when you went and you met Richard? Where you caught off guard? He’s so funny.
Joe Sakumura, AuD:
Yeah. So first, so Richard and I both trained under the great [John Ferrara 00:56:06], who’s a electrophysiology specialist, almost one of the forefathers of the test called ECOG. So John had told me a couple of stories about Richard, and I’d heard from Sam Bittel that you kind of hear, he is almost this figure in audiology that’s almost like a fairytale or something. So I meet him for the first time and he’s in clinics seeing patients at the time and I’m this young real excited. And so the first thing that… We were walking through the clinic and he is showing me around. So what was it, I’ve got a lot of these, just peppering him with questions because, as with anything, like I would with [inaudible 00:56:43] or another successful coach, anybody that’s an ace in their industry, you want to learn how they did it.
Joe Sakumura, AuD:
So I’m asking him all these questions and finally he kind of turns, and he’s a shorter guy maybe on a good day 5.8, and I’m close to 6 ft. So he kind of turns to me and does one of these almost like you would like a fly on your shoulder and he says, “you ask ton of questions, Joe. I like you, come work for us.” So he’s a absolute pleasure, a rockstar within the field of audiology. He’s always had this belief system that the field is important and that we can bring value. And I think that’s absolutely exemplified within the programs that he’s created and the business models and structure that he’s created. So anyone who’s listening that hasn’t had a chance to hear him speak at a [AAA 00:57:31] or a meeting or whatever, absolutely recommend going and checking out some of his talks, [some of them we kind of get 00:57:37] together and also let him buy you a soda or a drink or something, because the guy’s got endless, incredible stories.
Dave Kemp:
Yes, 100%. Where can people connect with you if they’re interested in following up, what’s the best way to contact you?
Joe Sakumura, AuD:
Yeah. So you can either call us, you go to dizzy.com. The first thing I’d recommend to do is go to dizzy.com. We actually have a free practice analysis that you can fill out that will be submitted directly to me that just asks about what you’re currently doing and might these services be a good fit for you? You can also reach out to me by email my emails, j.sakumura@dizzy.com. So, j.sakumura@dizzy.com. I’m happy to [field 00:58:20] any questions that owners or employees may have just to open a conversation.
Dave Kemp:
Awesome.
Joe Sakumura, AuD:
And I guess the last advice that I would give to anyone listening is even if you’re not ready to do this, to make investment and really to take this on as a new business unit, do something for your patients, educate yourself on even if it’s just screening for positional vertigo. Even if you’re just asking, you’re hearing your aid patients, if they’ve experienced dizziness, vertigo, balance problems, and you want to send them to somebody that knows what they’re doing, but you are doing a harm, a disservice to your patients if you are not at least giving them guidance on how to get better from these conditions that they’re dealing with. The bottom line is people do not have to learn to live with dizziness, balance, vertigo. So we want absolutely everyone in audiology to feel empowered, to practice the totality of their scope.
Dave Kemp:
Yeah, that’s fantastic. Well, thanks so much, Joe. This has been such a good conversation. Really, really looking forward to watching the progression of AIB and these specialty centers. I feel strongly that they’re going to be a big part of how we continue to move forward as an industry and where success will lie. So thanks for everybody who tuned in here to the end and we will chat with you next time.
Joe Sakumura, AuD:
Thank you, Dave. Appreciate you having me, take care.
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.
