This week on the Future Ear Radio podcast, I’m joined by Dr. Amyn Amlani, President of Otolithic Consulting. Amyn is a longtime Audiologist and hearing industry veteran who has worked in private practice, hospital settings, academia as a professor, and at various industry-specific groups. Amyn is also a researcher who has focused a lot of his efforts studying the economics of the hearing health industry and the root causes of low hearing solution adoption.
The bulk of what we talk about during this episode revolves around the existing value proposition of the HCP and exploring ways that the provider can help to enhance their value proposition in the eyes of the consumer. As we discuss, with the advent of the OTC hearing aid era, it’s going to be increasingly important for providers to determine what types of value-based services they’re going to focus on in order to compel prospective patients to come through their doors. In an era that’s fast approaching where the accessibility of low-cost, self-programmable devices (that are appreciating in performance) becomes more widespread, there will have to be tangible aspects to the providers’ service delivery model that set them apart.
As I mention during the episode, this whole theme brings to mind a post I wrote back in 2018 that illustrates two relevant frameworks to today’s hearing professionals. Those frameworks are Clayton Christensen’s, “Jobs-to-be-Done” and Simon Sinek’s “Golden Circle.” The essay that I wrote can be found here.
In essence, I believe that it’s really important for providers to understand two key takeaways from these frameworks. One – there’s a growing number of solutions entering the market that represent products/services for “hire.” These solutions are by-and-large getting a lot better due to the component innovation transpiring (see my essay on the, “Peace Dividends of the Smartphone Wars.”).
Two – it’s critical for providers to understand their, “golden circle.” As I concluded in my 2018 essay, I believe that the HCP’s golden circle is to provide patients with a higher quality of life, and their role is to match each patient to the product or service that is going to best provide each specific patient with a higher quality of life.
In other words, in a market where the dispensing of devices is on a path to becoming commoditized, the key to differentiation lies in the HCP’s ability to serve as a provision of knowledgeable expertise.
As Amyn and I discuss, there are a variety of exciting new paths leading to differentiation. Some opportunities lend themselves to the clinician’s service delivery offering feeling more like a premium-type experience, while others help to further “medicalize” the clinician’s offering. For example, on the medical side of things, we highlight the advantages to a practitioner who chooses to implement cognitive screening into their practice and how this ultimately elevates the practitioners standing with other medical professionals.
Another topic that we explore is around some of the research that Amyn has conducted about the growing shortage of practicing Audiologists. We discuss how the industry might be able to reverse this shortage and return to labor growth, ways to augment the Audiologists with other types of ancillary labor, and how to maximize the current labor pool through emerging technologies like telehealth.
There are challenges ahead for hearing professionals and the industry that surrounds them, but I remain optimistic as I believe the demand for the HCP’s knowledgeable expertise will continue to grow. It’s thus a matter of figuring how to capture and service said demand in a way that’s compelling for hearing professionals.
In other words, the key to success seems to lie in formulating a stronger value proposition.
-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. Okay. We are joined here today by Dr. Amyn Amlani. Amyn, tell us a little bit about who you are and what you do.
Amyn Amlani, PhD:
Well, Dave, I appreciate you having me on. Yeah, I am the President of Otolithic, LLC, which is a boutique consultancy. And I’ve been in this role now for a little bit over a year after the pandemic kicked in. And I’m really enjoying the opportunity to engage with various stakeholders and getting them ready for what’s coming in the future here.
Dave Kemp:
Fantastic. So why don’t we go back to your origin story, share with the audience, how you came into the field of audiology. We were just chatting before we started recording. And I think you had a very interesting pivot during your dissertation, which I think will segue into what today’s topic is going to be about. So I will let you just share how you came into this whole field. And then if you could maybe go through the timeline up until you had this pivot, if you will.
Amyn Amlani, PhD:
Yeah. So I’m raised in Dallas. And when I was a younger person, I had a friend who was deaf. And I always wanted to be an engineer, but wasn’t quite smart enough to go down that track. And so when I was an undergrad, I initially started in economics and quit about halfway through. And when I say quit, I should actually rephrase that, I got kicked out of the institute. After some soul-searching in a great conversation with my paternal grandfather, late grandfather, ended up going to the University of the Pacific. And when I was there, ended up in the communication sciences and disorders program.
Amyn Amlani, PhD:
From there, I ended up at Purdue, which was a really, really enlightening opportunity for me to really understand audiology. And I got involved in research with Dr. Goldstein, who’s the father of the AuD. And we were really looking at some of the things that were coming out. And at that point in time, the Hearing Industries Association had just hired Sergei Kochkin. And so we were looking at his paper called the Marlboro Man and how there were opportunities to increase the adoption rate in the profession. And so David and I did a couple of things with some pricing and some other things that were masters related. I ended up writing my thesis on the International Hearing Aid Fitting forum for those of you who have been around that long.
Amyn Amlani, PhD:
And then when I finished my clinical fellowship year, ended up going to Michigan State with the premise that signal processing and digital hearing aids were going to be the future. And it wasn’t until I got into my dissertation and almost finished it that the conversation was not about signal processing, but it was more about the value proposition that the product provided the individual. In other words, it wasn’t how the hearing aid was going to provide a cleaner signal. It was what that patient was going to do with that signal and how it was going to improve their quality of life. But at that point, it was too late for me, because I didn’t want to go back when I had just gotten married, had a child it.
Amyn Amlani, PhD:
And so when I went out for my first job, one of the things that I wanted to do was circumvent this issue of is it really signal processing or is it something else? And so we started looking at some of these things as it related to price elasticity and value propositions and perceived value. And what we ultimately came up with, and I still strongly believe this, the product is not the be-all and end-all of this industry. It’s the services that are provided that change the lives of the individual. And that’s the message that’s missing still 20 years after I began this research.
Dave Kemp:
Yeah, I think it’s obviously very relevant to where we stand today because all of this focus is on this new slew of products that are due to hit the market, the over-the-counter hearing aids and everything that is coming from the consumer electronic side. And I think that one of the themes throughout this whole podcast, especially over the last year has been this idea of like, it’s such a multi-pronged approach as to why the penetration rates of hearing aid adoption are so low and stagnant.
Dave Kemp:
And I think that where I’ve come to the conclusion is that there’s really three big culprits, it’s price does play a role, but it’s a combination of price, stigma, and access. And I think that ultimately you can roll the three into the value proposition of the patient. And I think that what you’re left with is we currently have a value proposition that the byproduct is a seven to 10 year waiting period for them to take action. And I think that it’s interesting where we sit now because I think OTC will certainly have an impact on potentially all three. But I think that there’s a lot more going on here. And I do agree with you that I think that the provider actually is a big part of the equation as well with in terms of how they can ultimately increase the value proposition. They can make it more compelling for the patient.
Amyn Amlani, PhD:
Yeah. No, absolutely. So to your point, and I absolutely agree, there are determinants of health, right? So you’ve got these social factors, you’ve got these psychological factors, you’ve got these environmental factors that preclude individual from seeing you, whether it’s health insurance, or whether it’s transportation or whether it’s culture or whatever it might be. But then we have all these people that come into people’s practices.
Amyn Amlani, PhD:
So if we, let’s assume, and I’m going to go back to the market track AidData, about a 25% adoption rate, just because the math is easier, right? So there’s a 25% adoption rate. So if you see a 100 people, only 25 people will fit with these devices. So it’s not a flow issue. And these social determinants, they do play a role, but the biggest role as you pointed out is actually the provider. And we did a study a couple years ago where we’ve paired up with a very large health organization and we basically tested the predisposition and the post expectations of patients. And what we found was is their expectations, their predisposed expectations were not being met because the provider was doing things to increase the barriers to amplification in patient compliance or provider recommendations.
Amyn Amlani, PhD:
And so to your point, the value proposition that the patients are coming in with is not being met. And so the question becomes, how do we change that? It’s not the product, it’s the service delivery and the commentaries that we’re having with these individuals that’s hurting us. And when these over-the-counter products come out, you’re now allowing for a new avenue of acquisition that didn’t exist before. And so as a community, as a tribe, we now have to do a better job and one number, understand what the patient really needs, meet them where they are, and then look at our own behavior. And when we do that, we’ll be successful. If we miss one of those pieces, we’re going to be in trouble.
Dave Kemp:
Yeah. So I think that talking about the value proposition, again, I think it’s just super relevant and I think a good thought exercise. I had mentioned this to you. One of the times I had a conversation with Nancy Tye-Murray on the podcast, who, she’s with Amptify now and her life’s work is all around aural rehabilitation. I think that she made a good point. She said, if you are a dispensing professional and you can’t justifiably, you can’t justify the premium that you charge when somebody asks you, why should I come and see you as opposed to Costco? I think that we’re in a really precarious position as an industry right now.
Dave Kemp:
And I think that that gets at the root of what you’re mentioning, which is there has to be a premium more or less that the provider is placing on their particular service delivery model in an era that’s fast approaching where you really will have a commoditization of just strictly the dispensing of devices. Now you have a lot of the self-fit programming that’s going to be capable through apps. I think that the days in which if you’re just programming hearing aids and maybe not even abiding by some of the best practices in that regard, it’s just going to be harder and harder for you to exist with this current business model that does have a premium associated with it as that particular portion of the audiologist and the hearing professional’s role does become commoditized, I think, over these coming years.
Amyn Amlani, PhD:
No, I absolutely agree with you and I’ll use an analogy. So let’s assume that we’re going to go on vacation and we’re going to stay at a three star hotel, whatever it might be. Well, what do you get? You get a bed, you get a shower and you might get a free breakfast or you might get a happy hour in the evenings. And that’s the retail model that we have now. It’s pretty simplified. But if you really want service, you might end up at a five star resort, right? So you walk in, what happens? They know your name, your drink is never empty, there’s all kinds of amenities there, whether it’s working out or a pool or a spa or whatever. You’ve got a number of different restaurants in which you can consume these meals and what have you, there’s evenings where there’s entertainment.
Amyn Amlani, PhD:
And it’s the same thing in audiology. We’re going to have to move from this three star retail outlet that we’ve created into this five star where people want to come in. And not only do they want devices, but they want counseling. They may want a vestibular testing. They may want some auditory processing testing or what other things that you might be able to provide them. So you become a one-stop shop. And not only that, but then you also become a larger player within the healthcare landscape that audiology has been missing because we’ve been so siloed on the retail side.
Dave Kemp:
There’s a couple things that I want to break out there, because I agree with you. I think that this is a very interesting moment and I’ll actually defer to you on that because you’ve been in the industry for a while now. And I think that you’ve seen a lot of these different eras transpire, but I guess tell me if I’m on the mark here with, it does feel very unique in the sense that I think my biggest takeaway from OTC is that the biggest thing it’s going to do is it’s going to more or less remove “the gatekeeper status” of the professional. It will reduce that barrier of entry so that you’re going to have a lot more avenues of access. And so I think that if you were resting on your laurels as being a dispensing professional simply because it was either you or another dispensing professional, there was only a finite source of supply essentially. And so now as the supply side starts to open up more, I think that that’s going to lead to this situation where you really do have to justify your position in the market.
Dave Kemp:
And so if you are going to charge a premium, this is where I think things get really interesting, which is how do you differentiate yourself? Is it by becoming more medical? I’ve had some really interesting conversations lately on the podcast along that vein, or do you remain semi retail, but adding a more premium level approach? To your point, kind of that five star theme where you go above and beyond the commodity experience that you might get at one of these major brick and mortar retailers that is simply looking at it as just another add-on into their overall business. It’s not their core business by any means. It’s something that is secondary as part of a much, much bigger business. And so there seems to be some pretty clear paths to differentiation that I wanted to just get your thoughts on. And again, make sure that I’m on the mark of, does this time feel unique in your eyes or have we seen this before?
Amyn Amlani, PhD:
So have we seen this before? The answer is no. Some will argue that we’ve had these over-the-counter piece at devices on the market. So I remember when I was a grad student a number of years ago, we had a device for $59 called the Whisper XL. And you could purchase it at the local store. And we tested a couple of these in the lab and what have you. And so certainly those were available. Now this is a different era because the types of electronics that are coming in are much, much better in terms of what they can do, in terms of the value proposition that they offer the user, and then the accessibility of these things, because you can download it on your phone, you can get it in the mail, you can pick it up with somebody. So it’s a whole different game.
Amyn Amlani, PhD:
In terms of the individual, we have to be careful here not to box anybody in because it’s going to depend on their market. And what I mean by that is you really have to understand your customer base. There’s going to be some places where the premium retail outlet is going to flourish and there’s other places where it isn’t. So let’s preface that conversation with that. But the key point is you’re going to have to change. And what I mean by that is, and again, going back to some of the things that we’ve talked about earlier and some of the conversations that you’ve had with other guests, you’re going to have to think about what that patient needs and what’s the best thing in their interest. Patients don’t come to you to buy a hearing aid.
Amyn Amlani, PhD:
So I’ll give you an example. I didn’t go into a Home Hardware store this weekend just to buy a hammer for the sake of buying a hammer. I bought hammer because I needed to do something with it, whether it was fix something or take something down, right? People buy hearing aids because they can’t communicate. And so when we’re selling these devices or when we’re dispensing these devices, it’s not about just simply purchasing the device and sending the person out the door. We have to be able to ensure that this individual is taking this device and it’s working in their best interest. And I think we have forgotten that.
Amyn Amlani, PhD:
And what I mean by that is set up objective goals, hey, you know what? You’re struggling, you haven’t left the house. I’m making this up, of course, in several months because of COVID. You’re socially isolated, so you’re depressed. Your diabetes is through the roof. Your depression is through the roof. Let’s now take this device. And maybe you go out a couple times, come back and report to me how well you were able to hear. And it’s now a team effort. So come and think of it as a physical therapy effort in getting this person to become a better individual communicating. And when we do that, we’ve now improved what they’re doing.
Amyn Amlani, PhD:
So it’s not just about audiology. It’s about these other psychological and medical issues. And I think that’s what you’re getting at. And we have the opportunity to engage with our fellow peers outside of audiology and say, you know what? There’s an audiological intervention that’s taken place you year. And by going in and looking at this person’s diabetes, we should see that it decreases. And so now we’re co-managing this person in a way that they’re improving their quality of life. The audiologist has a hand in it and the physician doesn’t have to have as much of a hand in it because the person is taking care of themselves.
Dave Kemp:
Yeah. I actually, this really brings to mind a piece I wrote for Future Ear back before I started the podcast. So this was like two or three years ago. And it was very much aligned along these lines, which is, it was a combination of Clayton Christensen’s Jobs to Be Done and then also Simon Sinek’s the Golden Circle. And in, in the Golden Circle, this is a pretty famous TED Talk that Simon Sinek gave where he basically says that there’s like three rings. And on the outside ring, it’s what. On the inside, the first inner ring, the middle ring is how, and then the center is why. And he said that the vast, vast majority of companies of all different types, they go outside in. So you start with what, how, why.
Dave Kemp:
And you just nailed it on the head, which is people aren’t really coming to see you for because they’re like, I need to buy a hearing aid. They’re coming to see you because of the why. And so you need to rethink the whole thing from an inside out approach to think about everything should start with why and you should figure out why is this person coming to see me? Well, chances are they can’t hear well in any given certain situation.
Dave Kemp:
So again, and it’s a subtle thing, but I think it helps to reposition the whole picture of what the audiologist could be doing here, which is you are really, your golden circle, if you will, is to be a provision of knowledgeable expertise. It is to guide them to whichever solution hardware, software, no technology, something more along the lines of rehabilitation or APD, something like that, where it’s an individual needs based assessment where you’re really understanding this. And again, that’s to me where if things are framed in that line of thinking, the sustainability and the viability of this profession seems very, very sound. Because again, it’s like, who else is going to do this? Who else is that positioned to see these kinds of people and troubleshoot and diagnose these kinds of problems? And I think that by just, again, reframing your mentality here and thinking about why are all of these individual people coming to see me?
Dave Kemp:
And I know some people already do this. So this isn’t like a sweeping statement that applies to everybody. But it’s I think at large, it is a bit of an issue where if you’re just simply viewing everybody as square peg and you have this round hole, which is set of hearing aids and you’re just trying to fit every single person into that, that’s how you end up with a 25% attachment rate, like you said, where you have the vast majority of people who come in the doors and they leave empty handed because they feel like, well, I didn’t really feel like I got the thing that was actually solving the problem in which I came into this place to begin with.
Amyn Amlani, PhD:
No, I absolutely 100% agree with what you’re saying. And you’re absolutely right with these new legislative pieces that will be available here hopefully in 2023 or 2022 here at the end of the year. What you’re going to see is a couple things. So for years, the audiologist has been protected or guarded because of the way that the legislation has been set up, meaning that people could only get hearing aids if you were a licensed individual, whether a hearing instrument specialist or you’re an audiologist. Those barriers are going to come down because you’re going to have direct to consumer products that we talked about.
Amyn Amlani, PhD:
And so as we’re having this discussion, there’s a couple things that are going through my mind. Number one, the guard is going to come down. And you’re right, we’re going to have opportunities to have these other discussions, whether it’s a product, it’s a traditional product, I’ll use the word alternative product, which is not a nontraditional product, or you’re just going to counsel the individual. Where the provider is probably going is, well, how is that going to help my bottom line? And the idea here is you are going to have to rethink not only the services you provide, but how you provide them. And that may mean that you need to hire other individuals that are maybe not audiologists to help with that service delivery. And so in the states that allow for audiology assistance, you might be able to do that. There may be opportunities in states, which don’t, where the front office is more engaged.
Amyn Amlani, PhD:
And then you’re also going to have to rethink about you can’t spend an hour to an hour and a half with each patient now. You’re going to have to reduce it, because every patient is going to count more, because the flow in the clinic is going to be reduced. So every patient is going to count more. And so as you’re thinking about not only the services you provide, you’re going to have to think about how you’re providing them. And if you act now, because if you wait until this thing comes out, you’re going to be in trouble, but if you act now, it’s going to give you the opportunity to ahead of the curve and see what works and what doesn’t. And as I said earlier, it’s not a one box all fits everybody. You’re going to have to figure out what works in your particular bag and then apply that.
Amyn Amlani, PhD:
And so we’re, as you pointed out, in a really, really interesting spot as a provider. Yeah, you have to run your business, but you also have to think about what those next steps are. And it’s almost like moving from a first house into the house of your dreams. Can you afford it? How much of my stuff am I going to take with me? How am I going to redecorate my house? And it’s all about those major decisions. And it takes time to do those. And so for those of you listening, my advice would be, it’s not the end of the world. I think the world is going to be in a better place. And you just have to prepare yourself for this large arduous move that you’re going to make that will allow you to be the clinician that audiology was set up to be when our forefathers put it together.
Dave Kemp:
Yeah. You hit the nail on the head there because I do agree with you. It’s like, from where I sit and everything I’ve learned, I just think there’s so much that’s happened. In awakening, I’ll use the example of cognition. So I started full time here at Oaktree in like 2016, 2017. And I want to say that very first Lancet paper came out right around that time, like 2017, where you really did start to see research that was indicating that there was a pretty well-defined link between hearing loss and a lot of cognitive dysfunction. And it makes so much sense as time goes on and I’ve learned more about it. Of course, as your brain, it’s a muscle, it will occur atrophy and it’s going to, if it’s not stimulated and it’s not engaged, of course, there’s going to be some bad things that that leads to. And so I think that just from a common sense standpoint, it makes a lot of sense, but now we see it in the data.
Dave Kemp:
Well, flash forward to today and you have companies that have come out that are now actually trying to implement cognitive screeners within the audiology clinic. And again, it’s like one of these things that makes so much sense because you think about, well, who’s typically the patient demographic? It’s older adults that are the most predispositioned to have these cognitive effects. And so you look at every thing that’s taking place, and again, that’s just one small example, but the glass half empty is to think, well, crap, the current business model is under siege. It’s going to be harder and harder to from a bottom line standpoint, generate the kind of revenue and profit that you had been traditionally through strictly device sales.
Dave Kemp:
However, on the flip side, the glass half full view of this is that it might actually be the best thing for the field of audiology in the sense that it’s allowing everybody to come up for air and realize maybe we need to be going and reprioritizing where we fit in to the broader medical equation. So you’ve had some shout out to This Week in Hearing. This is how I really got to know you and doing that YouTube show together with all the other people that are doing those interviews.
Dave Kemp:
And when you interviewed the folks from Cognivue, I think it was the former now Chief Medical Officer of Cognivue. And this is somebody that is an MD and he’s clearly worked in a lot of different settings and for big companies, big medical companies. And he’s saying that audiologists have a real opportunity to be the first line of defense here in terms of screening for cognitive impairments. So it’s like, what an opportunity that is, where I go back to the conversation I had with Jill Davis, where she implemented Cognivue into her clinic. What was one of the biggest byproducts? Her referrals from physicians are through the roof now so much so that that’s the bulk of the patients that are coming through her doors are ones that primary care physicians are sending her way because they know that she’s well-suited to do a lot of these in-depth cognitive screenings where she’s a better person to refer them onto.
Dave Kemp:
And I had Joe Sakumura on last time, where we were talking about The American Institute of Balance, everything in that regard where implementing a real comprehensive vestibular offering, it opens the door to these becoming a part of a more holistic medical approach where you’re elevating yourself in the eyes of your fellow medical professionals, where they’re now perceiving you differently than they had before in such a way where you follow of this out.
Dave Kemp:
And this is what makes me so excited and bullish about this industry is if it, I think if this profession is able to pivot properly, I think that they will dramatically elevate themselves from a perception, whether it’s fair or unfair of more or less hearing aid programmers into something that is much more comprehensive that you have this view, this portal into the brain from the ear. And I think that that to me is where there’s going to be so many new doors that start to get opened, where in time as everything gets sorted out with just like you said, how do you properly implement this into your practice to where it’s not super, super disruptive? You can grow into it, but maybe we’ll reach a point where the revenue potential from the services of all of these new things dwarf that of the revenue dispensing products and devices. So I think there is definitely a glass half full argument that’s bubbling up right now as more and more companies, I think, start to cater to this pivot, if you will.
Amyn Amlani, PhD:
Oh, 100%. So the demand for hearing care services is through the roof. I mean, just think about it. There’s roughly 40 million Americans with some form of hearing loss that need audiological care in some capacity. There’s only 14,000 audiologists according to the Bureau of Labor and Statistics. So we’ve got a huge demand. We’ve got a workforce shortage as you pointed out. And so the issue is not that there’s not enough people, okay? So let’s get that out of the way. There’s going to be some segment of these 40 million folks that are going to go down the direct to consumer market. There’s going to be another segment that are going to go through these retail chains. And there’s going to be another segment that are going to come to you. The ones that come to you that are in these premier clinics, the cognitive screening aspect, I think as you pointed out, really, really critical.
Amyn Amlani, PhD:
And so yeah, we had the webcast with Dr. Fred Ma, who is retiring at the end of this month at Cognivue. He’s the Chief Medical Officer. And then we also had the Head of Geriatrics at Cleveland Clinic, Dr. Ardeshir Hashmi. And these gentlemen got on and basically said the same thing that you just did. We have this Lance report, hearing loss is the number one modifiable risk factor that’s available on the cognitive side. It’s not necessarily that you’re fitting these hearing aids, but it’s the fact that you’re able to test the individual and communicate with them what’s the best avenue for them to reduce the social isolations and get the medical help that they need.
Amyn Amlani, PhD:
What’s interesting about cognitive screenings and regardless of the instrument that you use, the brain is the one place that as your body starts to change, there are changes in that area. So to give you an example, if you have diabetes, diabetes is not only affecting your body, it’s also affecting your brain. And you can see those things. Thyroid disease, not only is it affecting your body, it’s also affecting your brain. Hearing loss, not only is it affecting your body through social isolation and depression and these things, it’s also affecting your brain.
Amyn Amlani, PhD:
And so I’m not saying that the cognitive screening is going to be able to differentially diagnose that this is the area in which this is happening, but it’s telling you that something’s going on. As the audiologist, these physicians are having an open invitation to us as a profession to say, you’re seeing these older people and you’re seeing them earlier than we’re getting them. And because we’re getting them when they’re in late stage dementia or severe dementia, we can’t do anything other than make them comfortable through pharmaceuticals. When you see them and you have these cognitive screening results, you can now not only take that individual and help us co-manage them through these other family physicians and through endocrinologists and other physicians, you can co-manage them by putting hearing aids on them that allow them now to communicate with these individuals.
Amyn Amlani, PhD:
And so this holistic integrated care of an individual is where the audiologist future, I think, lies. And again, you’re going to have to think about reshaping your clinic to include some of these things. There’s no reimbursement code for them at this point, but you’re able to charge for your services. And then that allows for you now to create a physician network. And that physician network is going to bring in that flow of patients that I would think overwhelmingly need some sort of audiological intervention, whatever it might be. And that’s where the audiologist is going to be successful as we move into this new frontier of private practice.
Dave Kemp:
Yeah, because I think, again, it goes to that, like you segmented it beautifully there, you’re like, look, there’s going to be people that undoubtedly go the self-fit route. Those people probably don’t need a provider of any type to begin with. And so I think that if we’re looking at this realistically, we can say that those people are just new people entering into the funnel. There probably will be some cannibalization of people that maybe were going to go and see a provider, but those are going to probably be the people that we’re on the fence to begin with.
Dave Kemp:
So I think that in one regard, you have a lot of these people that historically have never been part of the market because they’re entering in earlier. They’re the ones that are the seven to 10 year candidates that were going to just be on the sideline, they’ve identified it. It’s gradual, whatever, I’ll take care of it next year. It never happens. Seven years later, this is a problem I need to come and see somebody. So I think that’s a portion of people in the market. Some clinicians out there might say, I really want to go after those people, great, come up with a strategy, and again, which you differentiate yourself in some way or another that people actively want to come to you rather than do this on their own.
Dave Kemp:
Then you have this next bucket that’s going to be people that are probably more along the lines of I’m cost conscious. I know I need to go and see this. These are people that you’re probably going to see go into either one of the manufacturer owned retail outlets of brick and mortar, something like a Costco or any of the other brick and mortar chains that will eventually adopt something like a hearing center in them. I think Best Buy is a probably a very likely candidate to have something similar to what Costco has now, a retailer that doesn’t sell any of its own products per se. They’re going to look for probably service-based revenue themselves.
Dave Kemp:
So it then leaves you with this medical portion. And I think that that’s where things get really, really interesting is this becoming more medicalized. And I think it goes back to what I said earlier with this whole idea of the Golden Circle and understanding your why. And that was such a revelation when I talked to Jill. This is going to be like, that particular episode’s my most referenced episode now, but it’s so good. And I think there’s so much that you can take away from it because the revelation I had was this sense of like, she is really uncovering the root of what’s going on. It could be that part of the issue is the medication that they’re on, or it could be any of the comorbidities associated with this person.
Dave Kemp:
And so I think that the more comprehensive, and I think a lot of this stuff with all these new tests that are being issued around [inaudible 00:36:19], but like everything else that’s ancillary to that where these questionnaires and really gathering as much of a total picture as possible with this patient, that solves the why. You’re trying to really understand why are you coming to see me today? It’s not because you have a preconceived notion in your head that like, I need to walk out of here with hearing aids. They’re coming to see you because you’re the expert and you’re the one that can really help them to get to the bottom of this to understand what’s really going on with me.
Amyn Amlani, PhD:
Oh, 100%. 100%. So lots of things, and I’m not sure what order I’m going to state these in, but lots of things. So number one, this is the first time in our history that we’re seeing multi-generations. You’ve got the Gen Xs, you’ve got the Gen Ys, you’ve got the millennials, the younger people, because they’ve got things in their ears all the time. You’ve got the silent generation and then you’ve got the baby boomers, which is huge. Each of those, you have to understand a little bit, right? But that being said, and as you pointed out, you’re going to have to market to these different groups in a little bit of a different way. We can talk about that in just a sec. But the demand is there across these different generations.
Amyn Amlani, PhD:
The other piece of this is if you think about the people that do come into your clinic, and I’ll share an experience with me. There was a time when I would spend hours and hours and hours trying to appease somebody who got hearing aids. And it wasn’t the fact that they had purchased the hearing aids and the hearing aids weren’t working. It was the fact that they were on a medication and the medication was interacting with their ability to hear. Okay. Now, if you think about this from a medical standpoint, now that we’re going to co-manage this because we have that opportunity and as the Dr. Hashmi from the Cleveland Clinic said, these pharmaceuticals are not the best way to treat an individual. The best way to treat the individual is to treat their symptoms before we get to the pharmaceuticals.
Amyn Amlani, PhD:
And so if we know that this person is on this in this drug and we can get them the help that they need, or maybe they don’t need a hearing aid because the pharmaceuticals are so involved that the hearing aid’s not going to do anything, you’re not taking up your chair space and now the right kinds of help are being done for this individual to get them where they need to be. And it may not be that you’re selling them a device, but maybe a pocket talker so that they can have the conversation that they need because they have the hearing loss.
Amyn Amlani, PhD:
So to your point, we’re going to have to change how we think about these things. And you’re absolutely right in the sense that there’s a huge opportunity here, we just can’t be afraid of thinking and investing in ourselves. So if you don’t have balanced training, for example, or it’s rusty because you’ve been out of it for a while, go get it if that’s what’s in your market. If you don’t know how to do cognition, find out what tests are available, how to employ them, how to deploy them and then how to utilize them in your clinic so that you can have something like a Jill Davis. But it’s all about you having the self-discipline to reengage in the learning process to figure out what you need and then move forward. And I think that’s the message that we’re trying to get across here.
Amyn Amlani, PhD:
And I would also add, look at the comparable health professions that are around, look at the dentistry model. The dentistry model is about service provision. And the way that they’ve set it up is they see a large number of individuals and the dentist only gets involved when it’s complicated and the hygienist is doing all the work in the beginning. And that model seems to work. And that’s where I think where we’re going to have to go. You might also look at the optometry model, where you’ve got a set of optometrists that are doing the testing and then you’ve got these other individuals that are helping with the sale of these devices, the opticians and what have you.
Amyn Amlani, PhD:
So there’s different models and you’ve got to figure out the one that works best for you. But at the end of the day, both my dentist and my optometrist also communicate with my physician. And so it’s again about having that whole body-centered care approach. And by these individuals talking to one another, they’re referring to one another, they’re referring out. And these people didn’t just walk in and have these skills. They had to learn them, not only the business side, but also the treatment side and also the interventions, the diagnostic side.
Amyn Amlani, PhD:
My dentist, who we’ve known for a number of years, wasn’t doing certain procedures. And she says, “You know what? In order to survive, I’m going to have to add these pieces to it.” And I remember that she closed her shop down for a couple of months and I know not everybody can do that. So for a couple of weeks, went and took this training and then little by little advanced her offerings. And now she’s got this waiting period because she’s one of the few people that’s doing these different implants and things that other providers aren’t doing now.
Amyn Amlani, PhD:
And so it’s again about finding that value proposition in your market, servicing those individuals and then making sure that not only when you service them, but you’re keeping in touch with them because I get text messages from my dentist, in six months, your annual checkup is coming up. Hey, you know you had this implant done, as an example, how are you feeling? And they might send it out a week later, they may send it out a month later and they may send it out six months later. And it’s just those little touch points that make that ultimate difference because it shows that that provider is caring. And that’s where we have to move this profession. And you’re right, the opportunities are massive as long as you meet the expectations of the demand.
Dave Kemp:
So changing gears a little bit, one other topic that I really want to hone in on with you because you have done a lot of research around the labor, the labor pool of this industry, I think is going to present some problems. And problem might not be the best word for it. Maybe it’s just that we’re going to have to be pretty creative with how we solve these challenges. But you look at a shrinking pool of audiologists and I think you couple that with labor shortage in general right now that we’re experiencing as a country. And I think it presents a bit of a challenge in that a lot of what we’re referring to today are ways in which you can redesign the audiology clinic to look more like the dental clinic.
Dave Kemp:
And I’ve actually used that analogy before too. I think it’s really apt that you go into the dentist office, you spend 95% of the time with the hygienist and then 5% of it more times than not is the dentist coming in, reviewing your x-rays, maybe taking a quick peek at your teeth saying hello. And then they move on to the next patient, assuming that everything was run of the mill with you. And so it’s like, well, what does that look like in our industry?
Dave Kemp:
And so I see two potential paths and I want to get your thoughts on this. So one is that you grow the labor pool and you have, I guess further enable, either you make it so that the AuD is easier to come by, so going all the way back to academia. And I know you’ve spent a lot of time in academia, so I’m curious to get your thoughts there, or adding in ancillary labor. So you have audiology assistance or technicians, hearing aid dispensers, or you have front office staff.
Dave Kemp:
And then the other would be maximizing the time of the current labor pool by using things like telehealth and tapping into ways in which you can engage your patients remotely so that you’re able to actually maximize the time in your day because you don’t have all these dead periods, you do away with a lot of the formalities of the in-person visit. It just screams efficiency to me.
Dave Kemp:
So maybe it’s a combination of both, but I’m curious to get your thoughts on this because it does also seem like one of these looming issues that we’re going to have to reconcile with over the course of the coming years, which is, do we have enough professionals in this field to service what I believe is going to be a booming market here as you look at a lot of, again, those macro trends in aging population, a lot of disposable income in those hiring aging brackets, a medical system, a healthcare system that is becoming a lot more patient-centered care, lot more preventative as opposed to reactionary? So I think that all of these coincide, I think, where you will have I think an increase in demand coupled with potentially a shortage in supply. And so how do you reconcile with that in your opinion?
Amyn Amlani, PhD:
Yeah, that’s a good question. So I’ve had the pleasure of working with Dr. Victor Bray on a workforce analysis over the last three, maybe four years now. And there are about four or five different databases, but we’ll use the government’s database, which is the Bureau of Labor and Statistics. So in 1999 was the first year that they separated audiology from speech language pathology. And we’ll use our peers in speech language pathology as a proxy here as we have this discussion. So at that time, there were roughly 12,500 audiologists in 1999. In 2019, which is the last year which we did the analysis, there were only 13,600 or 700 audiologists. Okay. We should have had if we would’ve grown at 3%, which is what all the other comparable health professions grew at. So this is dentistry and physical therapy and occupational health, and I mean, occupational therapy, speech pathology, and so forth and so on, we should have had another 7,000 individuals in the marketplace.
Amyn Amlani, PhD:
So the question is is one, why didn’t we grow enough? Okay. I’m going to stop there for a sec. Speech pathology at that time had X number and they grew by 80% over that same period. We only grew by 5%. Okay. So the question becomes what’s happening? It’s one of the things that we haven’t quite figured out yet. One, we’ve had some retirements, two, we’ve had some older audiologists leave the service industry, either through some sort of attrition, whether it’s health or through death.
Amyn Amlani, PhD:
And then the issue that we’re facing is is that we have a huge abandonment of practitioners leaving the industry at an early age. If you look at the Ian Windmill and Barry Freeman paper that came out in 2013, if memory serves right, there’s somewhere between 25 and 40% attrition. When Victor and I calculated this, we were somewhere at around 25% attrition. So one in every four students that’s graduating is leaving the field for a number of reasons, either it’s dissatisfaction, high student loan rates or whatever the case may be. So to your point, we have all of these AuD programs and we’re not graduating the number of students that’s needed in order to take care of the demand within the marketplace.
Amyn Amlani, PhD:
Now, there are several issues with this and we probably don’t have time to get into all of these, but some of these issues have to relate with the training that they get. Most institutions are not in a medical setting. So when the students are graduating, only thing that they know how to do is sell retail devices. And when it comes time for them to get jobs and move into these more medical entities, they don’t have the skillset in order to manage the patient flow that’s coming in. So that’s one of the issues.
Amyn Amlani, PhD:
The other issue that we face is we’ve got some regulatory pieces that either from an academic standpoint or from a licensing standpoint prevent us from having these underlings that could potentially help us with the assistance and what have you. So, for example, there’s no undergraduate AuD program. You have to get your undergraduate in speech language pathology and then basically your first year of your AuD is what you would’ve had as a senior as an undergrad. And we’ve got to change that. And I know there was some discussion when I was a graduate student back in the early ’90s about having this pre AuD segment before you went into the AuD. And I think we really need to rethink of that as a profession so that we can take those individuals that may not be qualified to go into the AuD programs that could then potentially come in and work as assistance in that realm.
Amyn Amlani, PhD:
And then from a regulatory standpoint, there’s really not a scope of practice for assistance. Some states allow it and some states don’t. Some states have these restrictions, some states have those restrictions. And so that then precludes the ability for some practices to have that type of assistant help. And then your front office staff is limited in what they can do. So we have to overcome these issues in order for these things to happen.
Amyn Amlani, PhD:
And I think, and to your point, we have that opportunity through these technologies of telehealth. So you can now remote program devices, you can troubleshoot these devices, you can do testing online to a certain capacity. And we need to be able to embrace these technologies, one, for the consumer’s that potentially can’t get to us, and then number two, just to preserve time. So if I’m doing, for example, three hours of telehealth, I might be able to see eight patients as opposed to have eight patients sitting in my waiting room. And these are the kinds of decisions and strategies that each practice needs to look at to maximize their opportunities, not only to see patients, but also to increase their revenue stream, because those are the patients that you can charge for services and those are the patients that eventually will come back to you to purchase a new set of devices or upgrade the devices that they already have.
Dave Kemp:
Yeah, that’s really interesting. You’re right, there’s so much to unpack there that we could have a full discussion about everything as it relates to how do you solve the labor pool conundrum, but I agree with you that I think that the telehealth side of things, I think it’s inevitable for a number of reasons. One, I just see it as sort of like Zoom in the sense that the pandemic accelerated the adoption of video conferencing. And so now what we’ll probably see is its just that it’s not as if Zoom and all of these other Google Meet and Microsoft Teams, they weren’t ever going to probably proliferate, it’s just that we’ve accelerated the timeline. And so what we’re now going to see are there’s going to be a lot of innovation on the actual video conferencing itself.
Dave Kemp:
I think Microsoft’s a really, really interesting company in that regard because they’ve had a number of acquisitions in the healthcare space, for example, Nuance, which is this huge voice AI company, where I think that there will be a future iteration of Microsoft Teams that will be HIPAA compliant and it will be a telehealth platform more or less. You see this with what Teladoc is doing as well.
Dave Kemp:
And so my point is it’s like we’re at the very early innings of telehealth in general, but the calvary is here because of the fact that there’s now so much adoption of these and you’ve got, it’s normalized, the average Joe now has a familiarity with these types of tools. And so you’re going to just see there be more incentive to build on top of that. And so I think that the end result is going to be that what we see today as like, there might be some inherent limitations with it, I think those will just incrementally get eroded over time as more money gets poured into this largely by these major tech companies that will be the foundation for which these platforms live on are just going to get that much more sophisticated.
Dave Kemp:
So I think there’s already a lot of really interesting things that can be done from a telehealth standpoint within this field. And I think that’s only going to get more pronounced as time goes on as the tool sets themselves maturate and just get more sophisticated as time goes on.
Amyn Amlani, PhD:
100% agreed. The manufacturers at this point, the ones that were the early to market folks, they’re retooling what’s available to them as the software platforms are maturing. You’ve also got independent platforms like Tuned that’s come out that have a built-in virtual clinic that’s built in and allows you to practice within a certain scope, whether it’s the direct to consumer products or whether you’re helping some individual with counseling or whether you’re helping some individual with some sort of a programming opportunity.
Amyn Amlani, PhD:
And I think all of these things together are really going to increase in proliferation and that’s going to be the future of how we see some patients. You’re going to have some that want to come in and still see you. There are going to be others where most of your engagement is going to be platform based. And I think that’s particularly going to be true with these younger generations. And so the brick and mortar, as we know it today, I think will dissipate over time and things will become more virtual over time, but we’re not quite there yet. And you have to start thinking about those kinds of transformations as you’re developing for the future.
Dave Kemp:
And I want to just say something there too, because I think a lot of people assume that when people say these younger generations, there’s an implication that that’s the actual end user. And oftentimes, it’s actually not. It’s that they’re the loved ones that’s helping to facilitate the whole thing. They’re the broker. And so as you know, I’m a millennial. So as my parents age, they’re both baby boomers. I just envision these scenarios where I’m helping them to get set up so that they can have these online consultations with all their medical providers. It’s not going to just be audiology, it’s going to be this, and it’s not to say that brick and mortar goes away or anything like that. I think it’s optionality is really what we’re talking about, it’s the ability to have the option.
Dave Kemp:
And I think that, again, that’s part of the really exciting aspect of this is how much of your time is wasted on what could be more efficiently done online, where it’s just like, look, at the end, result is the same, you get a happy customer, a happy patient, you troubleshooted the thing for them, but they didn’t have to come into your office, sign in and bog down some of maybe the processes in your time. It’s just something that could be done rather quickly like that.
Dave Kemp:
So I just think that, again, it just continues to reinforce this idea that there’s a lot of really positive macro things happening right now for the field of this, of audiology and for hearing professionals at large. But I do think that it’s like this really defining moment where each individual provider and then the industry as a whole is going to have to decide where do they want to focus their time in order to prepare for a turbulent time, a time when there is going to be a lot of conversation around in the public I think of like, do you need to go and see a provider? Or can you just do this all on your own? And I think that time will be the prevailing determinant of that, I think that over time, people will realize that there’s a ton of value that a professional can offer, but that value has to be identified and then it has to be facilitated every patient interaction.
Dave Kemp:
And I think that along with that is going to have to be the transformation of the service delivery models, whether it be, you got to start looking real closely at like, do you bring on rather than hire another audiologist, does it make more sense to bring on three technicians that you train to do a lot of the administrative or the non-premium stuff kind of ALA like the dentistry model that you outlined?
Dave Kemp:
Or do you go and you pivot more toward having a real defined telehealth offering and start to triage in a way where somebody calls in and historically you would say, come on in and we’ll get that fixed for you? You start to come up with processes and procedures in which a lot of that started to be now triaged in a way where we’re actually going to do this online for you and you’re not even going to necessarily have to see the audiologist. You’re going to see me, the front office staff, or one of our technicians that’s been trained to handle these kinds of things. So it’s just that things are in flux right now, but I think ultimately, it can be a really exciting future that we’re moving toward.
Amyn Amlani, PhD:
100% agreed. And audiologists have been territorial for a long time with the audiometer in their space. And I think it’s maybe time to let go of that a little bit and just realize that you’re still a valued component of the healthcare system and you’re just going to have to shift your priorities. It’s not that we’re getting rid of you, it’s just a shift in priorities. And you’re absolutely right, there’s more and more demand meet the consumer where they’re at. They’re going to come at you from different angles and you have to be flexible in how that happens.
Amyn Amlani, PhD:
And I’ll just share one more thing as you were talking about this telehealth piece. There’s a public health paper that came out in 2017 by a lady Dr. Ariana [Plany 00:58:55]. And what she found was is that most audiologists were living in metropolitan areas, but the number of individuals who needed hearing healthcare were actually in rural areas. And so again, that whole travel time thing is you meet your consumer where they are. And there’s a huge opportunity for people that are distant from you. So I’m in the Dallas area, you go out a 100, 150 miles, and there’s nothing out there. It’s East Texas or West Texas. If I was in private practice today, those are the kinds of people that I would try to be servicing in some capacity. And it may be that they got to come in once, but after that, I’m doing everything off of the telehealth.
Amyn Amlani, PhD:
So again, it’s about meeting these people where they are, there are huge opportunities, your revenue streams will still be there. It’s just you’re going to have to pivot on how those monies are coming in, but the opportunities are huge, huge in this particular time. And the evolution of where we’re going is going to be really, really critical. And I see audiology being on the better side of where we were five, 10 years from now. And so I’m excited about all those things.
Dave Kemp:
Love it. Perfect way to conclude this conversation. It’s a really way to say that. So I really appreciate you coming on. Thanks for everybody who tuned in here to the end and we will chat with you next time.
Amyn Amlani, PhD:
Cheers. Thanks, Dave.
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.
