Download Audiological services for adults in New Zealand

Accessible services for
New Zealand adults with hearing loss
A discussion paper
prepared for the
New Zealand Audiological Society Inc
August 2004
Greville Consulting
PO Box 26 506, Epsom, Auckland 1030, New Zealand
Phone: +64 27 281 3072; Fax: +64 9 625 8546; email:[email protected] ; www.grevilleconsulting.co.nz
Greville Consulting
Accessible audiological services
CONTENTS
Executive summary ............................................................................................. 3
Current situation................................................................................................. 4
Population .................................................................................................. 4
Socio-economic factors associated with hearing loss ................... 5
Services for hearing impaired people ................................................ 5
Funding for hearing aids ....................................................................... 7
The hearing aid subsidy ............................................................ 7
Enable/Accessable ..................................................................... 8
ACC ................................................................................................. 8
War Pensions................................................................................ 8
WINZ ............................................................................................ 9
Issues .......................................................................................................10
Effects of untreated hearing loss ........................................10
Disparities between hearing loss surgically correctable
/non-correctable ........................................................................10
Efficacy of hearing aids........................................................... 11
People with congenital/prelingual hearing loss ...................12
Bureaucratic categorisation of hearing loss/deafness
within disability framework ....................................................12
Provision for the elderly ..........................................................13
Adult cochlear implant candidates ........................................13
International comparisons ...............................................................................15
Australia ..................................................................................................16
United Kingdom ......................................................................................18
United States .........................................................................................19
Europe...................................................................................................... 20
References ........................................................................................................21
Appendix: Cases falling through the gaps................................................... 22
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Executive Summary
Approximately 10% of the total New Zealand population reports a hearing
loss of some degree. This rate is slightly higher than other
Western countries, mostly because of our Maori & Pacific
populations.
An estimated 90,000 adults use hearing aid/s – a hearing aid fitting ratio
of approximately 28%.
Hearing loss is associated with low income level, and low employment
rates.
Audiological services for hearing impaired adults are fragmented and
poorly funded.
There are major shortages of audiologists employed in the public health
system. Audiology, however, has flourished within the private
sector. The quality of audiology services is high by international
standards.
Funding for hearing aids and assistive listening devices has not kept up
with inflation, with a gradual erosion of the relative value of the
universal hearing aid subsidy from 100% to less than 10% of
hearing aid costs.
Selection criteria under the Enable/Accessable schemes have been
chosen for physically disabled people, & are not relevant for most
hearing impaired people.
People with hearing loss do not identify themselves as being disabled.
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Current situation
Population
Approximately 10% of the total New Zealand population reports a hearing
loss of some degree (Greville, 2001).
A total of about 320,000 people over the age of 15 years have
self-reported hearing loss.
Approximately 18,500 adult New Zealanders were fitted with
hearing aids in 2003 – equivalent to about 6% of the total hearingimpaired/deaf population. If it is assumed that adults replace their
hearing aids every 7 years, this equates to a total of about 90,000
adult hearing aid wearers – a hearing aid fitting ratio of
approximately 28%. This compares favourably with the US, where
it is 22%, and Canada, where it is around 17%.
Current data suggest that only about 40% of hearing aid fittings
are binaural. This compares unfavourably with the Australian
situation, where about 2/3 of fittings are binaural.
Approximately 90,000 more men than women have hearing loss. The
most likely reason for this discrepancy (also reported in other
Westernized countries) is noise exposure, whether occupational or
recreational (or both). Presumably many in this section of the
population would be eligible for funding for hearing aids by ACC.
The non-noise attributable population with hearing loss would
therefore be about 130,000 in the 15-64 years age-group, and
about 95,000 over the age of 65 years.
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Socio-economic factors associated with hearing loss
Hearing loss is associated with low income level, and low employment
rates.
40% of people with hearing loss are eligible for a Community
Services Card, compared with 31% of people with no hearing loss.
23% of people with hearing loss have an annual family income below
$20,000 (1991 figures), compared with 18% of people with no
hearing loss.
19% of people with hearing loss have an annual family income above
$40,000 (1991 figures), compared with 28% of people with no
hearing loss.
49% of people with hearing loss are not in the labour force (1991
figures), compared with 35% of people with no hearing loss.
Services for hearing impaired people
Audiological services for hearing impaired adults are fragmented and
poorly funded.
Publicly funded services have traditionally been based within
hospitals in New Zealand. This has created problems over the years
because of the fundamental differences in service provision
between audiology services and more mainstream doctor-nurse
structured services. Through the various changes to the health
system, funding for services has been eroded, to the point where
funding is adequate only for services provided to ORL (ENT)
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clients.
Compounding the funding issues, management within the public
health system has seldom been supportive of audiology services,
because of its essential differences from the normal model - the
ambivalent position of “allied health professionals” within the
hospital system - & a subsequent lack of understanding of issues.
One of these issues is the financial management required, because
of the high unit cost of hearing aids – public hospitals are seldom
set up to handle the challenges associated with this.
These two main factors have resulted in major shortages of
audiologists employed in the public health system.
Probably at least partly because of the problems within the public health
system, audiology has flourished within the private sector.
While the quantity of audiological services in New Zealand is problematic
in some parts of the country, the quality is high by international
standards. New Zealand audiologists are well trained, are quick to utilise
new technologies, and have a high level of interest in ethics.
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Funding for hearing aids
Concurrently with service shortages, funding for hearing aids and
assistive listening devices has not kept up with inflation.
The hearing aid subsidy
The only across the board funding system for adults, the hearing
aid subsidy, was originally an entitlement, until the introduction of
the RHAs around 1990. Despite the assurances of the four RHAs
that they would continue to purchase equivalent services, not all
Crown Health Enterprises remained vigilant, and in some areas (one
example is Canterbury), funding for hearing aid subsidies was lost.
The subsidy originally covered the cost of a simple NZ-produced
hearing aid (₤12 + the cost of an earmould) when it was introduced
in 1947. Over the years the value of the subsidy was only
occasionally increased, with a gradual erosion of its relative value
from 100% to less than 5%.
The subsidy was increased from $89.10 to $198 in 2003. This
amount is now sufficient to contribute towards private audiological
services (the public services typically having prohibitive waiting
times –often exceeding 2 years - for adults requiring hearing aid/s
who tend to be given the lowest priority), leaving the client to fund
the entire cost of the hearing aid/s.
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Enable / Accessable
These agencies provide funding for disabled individuals, including
limited funds for those with hearing loss. The selection criteria,
however, have been chosen for physically disabled people, & are not
relevant for most hearing impaired people, who tend to be older
people, and frequently with no other handicaps. The criteria focus
around working, tending for children, or remaining living
independently. For many elderly people, hearing aids enable
continuing participation in society, and enhanced quality of life.
This would not be sufficient for them to obtain funding through
these funding streams. Case examples of people refused funding
are included in the Appendix.
ACC
People with noise-induced hearing loss or hearing loss resulting
from an accident can be funded for audiology services and hearing
aids, on the referral of a medical specialist.
War Pensions
People with hearing loss resulting from war experiences can be
funded for audiology services and hearing aids, on the referral of a
medical specialist.
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WINZ
Provides loans (a total of up to $1,000) for devices such as
spectacles, dental work, as well as hearing aids. Even if the person
has no need for funding for the other devices, $1,000 does not
cover the purchase price of a hearing aid.
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Issues
Effects of untreated hearing loss
In the US the National Council on the Aging carried out a major study on
untreated hearing loss in 1999.
They found poor communication, greater social isolation,
withdrawal, reduced sensory input, depression, anger, and severely
reduced overall psychological health among hearing impaired people
not using hearing aids. Many other studies have replicated these
findings.
There is some evidence (primarily from animal studies) that neural
damage may occur if an ear remains unstimulated for too long.
The implication from this body of work is that hearing aid use
should not be delayed too long after the onset of hearing loss,
because the quality of the outcome may be limited by the history
of auditory deprivation.
Disparities between hearing loss surgically correctable/non-correctable
A person whose moderate degree of hearing loss is surgically correctable
will typically be eligible for fully-funded surgery within New Zealand’s
public health system. It is inequitable that a person whose site of
pathology means that surgery will not be appropriate is required to meet
the cost of ameliorating the hearing loss. Not only do they have to pay
for their hearing aid/s, but in over half of public audiology clinics, partpage 10
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charges and/or mark-ups are also made to cover service costs.
Efficacy of hearing aids
Dutch studies have shown that hearing aid fitting is highly cost-effective
compared with other health interventions. A paper by Joore et al (2003)
showed a base-case cost of outcome on the EuroQol of €15 807/QALY.
In an earlier paper, in 1999, the authors found that hearing aid fitting
for a person 65-69 years of age rated similarly to breast screening for
cost/benefit, and for an equivalent gain, was 25% the cost of knee
replacement, and 15% the cost of peritoneal dialysis.
A wide-spread survey of US hearing aid users over the last ten years has
found 62-71% satisfaction among users of hearing aids less than a year
old (Kochkin, 2002).
The National Council on Aging (1999) reported that the areas most
improved by the use of hearing aid/s are:
50% report an improvement in social life, ability to join in groups,
and relationships at home.
40% report improvements in their self-confidence, personal safety,
relationships at work, and sense of independence.
30% report improved emotional/mental health and mental/cognitive
ability.
20% report improved physical health.
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People with congenital/prelingual hearing losses
Clients with congenital hearing loss are provided with fully-funded
hearing aids until they leave school or tertiary training under the Special
Aid Fund. As adults, if their hearing losses are moderate or worse, they
face significant costs equipping themselves with hearing aids.
Frequently they have low incomes, because of the lower average
educational achievement of people with congenital hearing loss.
Some are currently able to access the Enable / Accessable
schemes, but many fall outside the criteria and face extreme
financial hardship or functioning at a lower level than optimal,
reducing their quality of life in many ways. Others are clearly
within the criteria for the Enable / Accessable schemes, but lack
the communication skills to make a successful application. Case
examples are included in the Appendix.
There needs to be a seamless transition in audiological service
provision when deaf students leave school. This is currently lacking,
and many young deaf adults are unsupported vis-a-vis their hearing
needs.
Bureaucratic categorisation of hearing loss/deafness within disability
framework
People with hearing loss do not identify themselves as being disabled.
This leads to problems eg with the design of the last two censuses,
which, presumably because of the bias of the Ministry of Health’s
subdivision into health and disability, only asked questions relating
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to hearing loss of people who first identified themselves as being
disabled. The data produced by the 1996 and 2001 censuses
underestimated the hearing impaired population by over a third
(approximately 140,000 people).
Moreover, by this design flaw, the rate of multiple handicaps among
those with hearing loss has been greatly over-estimated. This may
have resulted in appropriate policy development, on the assumption
that people with other handicaps in addition to hearing loss should
be prioritised over those with no other handicaps.
Provision for the elderly
For the few people who fit into the ACC or War Pensions schemes,
hearing aid/s can be fully funded. However, for those that do not – and
elderly women are particularly poorly provided for - there may be no
financial assistance available apart from the hearing aid subsidy, which
was originally designed to provide adequate, though not “top-of-therange”, hearing aid/s for all those needing them. This provision needs
upgrading so that elderly New Zealanders can continue to experience a
reasonable quality of life.
Adult cochlear implant candidates
Severely or profoundly hearing impaired adults who would benefit from
cochlear implants and who receive little or no assistance from hearing
aid/s, have been denied funding in New Zealand, because of prioritisation
given to children.
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This raises serious issues of inequity, for a small group of people,
but one with significantly reduced quality of life as a consequence
of this policy.
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International comparisons
New Zealand has a slightly higher prevalence of hearing loss than other
Western countries.
This phenomenon is probably largely related to the higher
propensity towards hearing loss of Maori & Pacific Island peoples.
The effect is ameliorated somewhat by the lower life expectancy
of these population groups, but there remains a difference of
about 1.5% in the rates found in New Zealand and the US (where
very similar methodologies have been employed).
The hearing impaired in New Zealand have not been well served by the
state services over the last decade and a half.
A coherent framework for policy development has been lacking, and
funding streams have subsequently fragmented.
For example, the National Audiology Centre was originally set up by
the Department of Health as a Head Office unit, with policy
responsibilities as well as responsibilities for local service
provision. During the health reforms, these responsibilities were
reduced to a few key outputs in a small national contract.
There has been a loss of the national policy instituted in the 1940s
whereby all New Zealanders had the right to access state funding
sufficient to purchase a simple hearing aid/s.
Primarily this has been by bureaucratic inertia, with successive
governments failing to ensure that funding levels kept up with
inflation. More recently, because of this failure, alternative
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funding has been sought from physical disability funding streams,
subject to entirely different values-based criteria, which are
unsuitable for hearing impaired people, the majority of whom are
elderly, and relatively rarely with other handicaps.
Australia
In Australia, low-income elderly adults are entitled to funding for hearing
aids, the amount varying with the complexity of their hearing needs.
Not only are they funded for the hearing aid/s purchase and
fitting costs, but also for maintenance of their hearing aids &
provision of batteries.
In 2002/3 the Australian Government spent A$120 million (an
equivalent for the NZ population level would be $24 million) on
hearing aid provision & hearing assessments for eligible adults
(Australian citizens or permanent residents who are 21 years or
over & pensioners, sickness beneficiaries, holders of a repatriation
card, a dependent of a person in any of these categories, members
of the Australian Defence Force, or persons undergoing a
vocational rehabilitation programme). In addition to the hearing aid
provision costs, A$33 million (NZ equivalent level: $6.6 million) was
spent on hearing aid maintenance & batteries. The Australian
Office of Hearing Services also funds hearing aids for children &
special groups such as aboriginal & outback communities.
New Zealand performs well in provision of hearing aids for children, but is
providing a much lower level of funding for hearing impaired adults.
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If eligible Australians choose a hearing aid more expensive than the basic
model/s available within the scheme, they pay the difference (the “TopUp” scheme).
Any provider who meets specified criteria may access the scheme.
Problems with the Australian scheme
The scheme is extremely bureaucratic.
Clients have to seek prior approval from the Office of Hearing
Services (OHS) before they can even have their hearing assessed.
The core of the scheme revolves around competitive contracting
for supply of hearing devices. This has the advantage to the
Government of keeping the unit cost of devices low, but the
downside is that quality is sacrificed. Hearing aids available under
the scheme are seldom “state of the art”, but are older technology
which tends to be cheaper, and which is specifiable under the longterm contracts entered into. Very low prices are paid to hearing
practitioners for service provision – this results in services who
contract with OHS having to limit time spent with clients, with a
consequent reduction in service quality.
A recent national survey found that overall 30% of OHS-funded
clients used their hearing aids for more than 8 hours daily on
average, and a further 26% used theirs for between 5 and 8 hours
daily. In a survey carried by practices under the Ear Associates
umbrella in Australia, 66% of privately funded clients (who tend to
be fitted with high-technology hearing aids) have recently been
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found to use their hearing aids more than 8 hours daily, a further
15% using them for 5-8 hours. This improved performance can be
related to a combination of better devices together with better
service unrestricted by unrealistic financial limitations.
Many practitioners are now choosing not to supply hearing aids
through the OHS scheme.
United Kingdom
Hearing aids are supplied free to patients referred by their GP to the
NHS.
Direct referral to audiologists is generally made for people 60
years or over, but others may have to wait to see an ORL surgeon
first.
A limited range of devices is available – digital technology is only
available in BTE (behind the ear) models, and no ITC (in the canal)
or CIC (completely in the canal) devices are available. ITE (in the
ear) devices are only available in standard-shapes, to be fitted in
to custom-made earmoulds.
Problems with the British scheme
Public audiology services are extremely poor quality, as are the devices
supplied. This results in low efficacy of hearing aid/s – a recent normative
study by Stephens in Wales found that 55% of NHS hearing aid wearers
used their devices less than 5 hours a day on average. Digital hearing aids
have only been made available recently in parts of the country, as part of
a national “modernisation” programme. Overall, 23% of those with hearing
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loss own hearing aids. Waiting times in public hospitals for hearing aid
fitting extend up to 2 years – recent increases have been blamed on the
modernisation programme, with high demand for digital hearing aids, and
staff shortages.
United States
Schemes vary considerably from state to state. There is currently a Bill
before the Federal House of Representatives to provide a tax credit of
up to US$500 per hearing aid for people over 55 years, or their
dependents.
In the US, about one-third of all people with hearing aids received
third-party payments of some kind.
Problems with the US situation
Relatively few people (22%) with hearing loss use hearing aid/s.
30% of those with hearing loss who do not use hearing aid/s cite
financial constraints as the core reason.
Those who do use hearing aids face average out of pocket expenses
of US$1,400 per hearing aid.
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Europe
In western Europe, most hearing aids tend to be dispensed by hospital
clinics, and are usually fully funded by the state. Services are generally
much more adequately staffed than in New Zealand.
In Denmark, waiting times for hospital audiology clinics are
published on the internet for clients to access. Waiting times vary
from 6 weeks to 60 weeks. In Finland, waiting times vary from 2
months to 2 years. In Norway, the average wait for hearing aids is
7 months. The major limiting factor in Norway is said to be the lack
of trained staff.
Over the entire European Union, 24% of those estimated to have hearing
loss have sought help.
In the Scandinavian countries, 40% of those with hearing loss own
hearing aids. In the Netherlands hearing aids are provided to over
30% of those who could benefit from them. Germany, France,
Switzerland and Italy average about 23-24%. In less developed
European countries such as Spain and Poland hearing aids are
accessed by only about 7% of the hearing impaired populations.
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REFERENCES
Greville, KA. Hearing impaired and deaf people in New Zealand; population
numbers and characteristics. Greville Consulting Report
www.grevilleconsulting.co.nz October 2001
Joore, MA, van der Stel H, Peters, HJM, Boas, GM & Antenuis, LJC. The
cost-effectiveness of hearing aid fitting in the Netherlands. Arch
Otolaryngol – Head & Neck Surg 129 297-304 2003
Kochkin, S. MarkeTrak VI: 1—year customer satisfaction trends in the
US hearing instrument market. Hear Rev 9 October 2002
National Council on Aging. The consequences of untreated hearing loss in
older persons. The National Council on Aging Report www.ncoa.org May,
1999
Stephens, D. The International Outcome Inventory for Hearing Aids and
its relationship to the Client-Orientated Scale of Improvement. Int J
Aud 41 42-47 2002
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Appendix
Cases falling through the gaps
Mrs A is an 85-year-old superannuitant with a moderate to severe hearing
loss who was turned down for funding by ACC. She had previously been
fitted with hearing aids, but was left without any functional device, and
had struggled for a long time with no hearing help. She lives with her very
elderly husband on very limited income.
Ms B is a 23-year-old part-time student with asymmetrical hearing loss
caused by middle ear disease, incapable of further surgical help. Because
she studies part-time, she is ineligible for Accessable funding, & is now
too old for the Special Aid Fund. She is completing her last year of
tertiary education & is finding it difficult to participate in a lecture
situation when questions come from her right side. She gets lost in work
groups when more than one person talks. She is convinced that her
education is suffering because of her hearing loss.
Ms C is a 33-year-old nurse in part-time employment. She has a congenital
hearing loss which is deteriorating over time. Her current hearing aid is
ten years old, and is no longer providing her with much help because her
hearing loss has changed. Her hearing is worse in the middle frequencies,
and because of the audiometric configuration, she will require a more
sophisticated hearing aid. She does not work sufficient hours to qualify
for Accessable funding.
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Mr D is an 80-year-old superannuitant with a profound hearing loss on the
left, and no measurable hearing on the right. He is currently using two
hearing aids more than 10 years old, which were given to him by his
brother some years ago, and are inadequate for hi hearing needs. His wife
is ill and undergoing radiotherapy treatment. He has been struggling and
frustrated with his hearing limitations.
Mrs E is a 65-year old woman on the Domestic Purposes Benefit, with a
severe hearing loss. She is unable to pay for repairs to her current
hearing aid, let alone a replacement. She is heavily involved in Maori
health councils in a provincial town and finds it difficult to contribute in
meetings because of her hearing loss and inadequate amplification.
Mrs F is a 40-year-old sickness beneficiary with a severe to profound
hearing loss. She recently lost her hearing aid, which was bought with a
WINZ loan she is still paying off, and WINZ will not lend her any more
money.
Mrs G is a 43-year-old sickness beneficiary with a severe to profound
congenital hearing loss. Her current hearing aid is over 5 years old, and no
longer meeting her requirements. She lives with her husband who is
currently unemployed and looking for work. He is also profoundly deaf.
She needs a hearing aid for safety reasons.
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Mrs H is a 48-year-old beneficiary with a long-standing hearing loss from
chronic otitis media. ENT opinion is that further surgery would not
improve her hearing. A recent car accident left her with expensive dental
bills and she cannot afford a hearing aid. She cares for her nephew and is
unable to work.
Mr I is a 46-year-old man with a severe hearing loss who currently cares
for his sick wife and 18-month-old child. The family has very little income,
and they need to purchase expensive medication for his wife, but he does
not qualify for Enable funding.
Mrs J is a 77-year-old superannuitant with chronic middle ear problems
causing a moderate hearing loss. She cannot be operated on any further.
She struggles to hear even one-on-one conversations, and particularly
group situations. She would love to use hearing aids, but cannot afford
them.
Ms K is a 49-year-old sickness beneficiary with an asymmetrical hearing
loss. Her husband has recently died, and she is still repaying a loan for his
funeral. WINZ will not advance her funds because she owns a rental
property, which she is trying to sell, but is having legal difficulties in
doing so. She is totally cash-strapped, and struggling with a significant
hearing loss.
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Mrs L is a pensioner living alone, with a faulty hearing aid, which is unable
to be repaired. Her hearing problems are resulting in social isolation. She
does not have sufficient funds to purchase a new hearing aid, and she is
ineligible for funding from all of the state funding schemes, apart from
the hearing aid subsidy, which is woefully inadequate.
Mrs M is severely deaf, and has worked in the same factory for 30 years.
She fears approaching her employer for documentation verifying her
place and hours of work in case she loses her job. She is unlikely in any
case to receive funding under the Accessable scheme because she does
not meet current priority criteria. She will almost certainly lose her job
if she cannot obtain new hearing aids.
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