Consider Adding a Hearing Center

This needed service appeals to the growing senior patient base.

BY PETER J. POLACK, M.D., F.A.C.S.

Over the years, the physicians in our central Florida practice had grown accustomed to fielding a common question: "Doc, where can I get my hearing checked?" Our first response was often, "I don't know." What we really wanted to say is, "Why are you asking me? I am an eye doctor."

But then we started to wonder about the benefit of offering hearing services to our patients. With the volume of elderly patients that we see, who better to screen the very population that needs it the most? After all, the eyes and the ears are a person's most important sensory organs and they both begin to fail at the same stage in life. So, it makes sense to treat them both at the same time.

But how exactly would that concept fit within our practice? And would it be the right thing to do? Our practice has always stuck to the philosophy that any new service or technology needs to meet all of the following criteria: (1) it must be beneficial to our patients, (2) it must be ethical, and (3) it must have an adequate return on investment. This service would have to meet those criteria as well.

The Potential Market is Vast

First we needed to determine whether or not this would make financial sense. Just how much of a market is there for hearing services? For starters, here is some background on hearing loss in the United States:

► 50% of older patients have significant measurable hearing loss

► 80% have never been tested or treated

► 90% of all cases of hearing loss are irreversible and irreparable — only hearing aids will help

► 78 million baby boomers are approaching senior status — the market is growing exponentially

► the bottom line: For every 100 patients who sit in your waiting room, at least 50 have a hearing problem, and at least 40 have never done anything about it.

Ocala Eye hearing specialist Kate Maen tests a patient.

Medicare reimbursement codes exist for the four tests which are performed for hearing evaluation. The hearing aids themselves are not a covered device under Medicare or most private carriers, but this may vary from state to state. And Medicaid is a different case altogether.

What Did Our Patients Think?

But the worst thing one can do is fall in love with a great idea. So we asked our marketing director to devise an open-ended, non-leading survey and find out from our patients the likelihood of their utilization of a hearing program if we implemented one. We were pleasantly surprised to find out that more than 80% of those patients surveyed said they would in fact do so. We were also surprised to learn the number one reason that they would have us do their hearing screening rather than go elsewhere: it's because they trust their Ocala Eye doctor.

We were not under the illusion that there wouldn't be some growing pains incorporating hearing services. After all, we were going into uncharted territory. We had heard that there were perhaps a couple of ophthalmology practices in the country that had started offering hearing services but we were one of the first to use a new business model.

One of the first challenges we faced was acceptance by our physicians, who questioned its fit with eye care and worried that the time commitment might slow down patient flow. Interestingly enough, our staff members — who were used to having to raise their voices to patients who couldn't hear simple commands or instructions — were quite excited about helping our patients with a fairly common problem.

Obtaining Physician Buy-in

To gain acceptance, we first needed to educate ourselves on hearing loss and its possible solutions. When our physicians learned to treat hearing screening and sales of hearing aids just like refractions and sales of glasses, they realized that both addressed and solved a patient's problem. This went far in dispelling their misgivings.

Another challenge was integrating the process into our normal workflow. We had to be sure that screening and examining patients for hearing testing would not adversely our core business of eye care. The successful marriage of the two came about in part by careful discussion and planning, but also by trial and error. We calculated that this model would be profitable if each doctor referred at least one patient for evaluation per half day. This certainly would not have a significant impact on the clinic flow — and as it turns out, it did not.

A third challenge, and one which turned out to be less than we initially feared, was acceptance by the rest of the medical community, particularly our ENT colleagues. Sure enough, when word got out that we were offering hearing services, one of our partners received a call from a local ENT group. Decorum prevents my relating the conversation verbatim but let's just say that they were not overly enthusiastic about eye doctors invading their turf.

A Quick Word About Scope of Practice

As reimbursements have declined, we have all seen physicians from different specialties add complementary (and not-so-complementary) services: the family practice doctor offering Botox, the Ob-Gyn performing tummy tucks or the dermatologist doing blepharoplasty. It is up to each individual physician to determine whether or not these value-added services make sense. Once again, it is advisable to apply some sort of acid test to a prospective program as we discussed earlier.

Although historically we didn't really see that many patients who warranted a referral to ENT, that quickly changed. Not long after we implemented our hearing program, the number of patients we found with pathology rose sharply and, subsequently, so did the number of patients that we referred to our ENT colleagues. The initial complaints quietly dissipated. Oh, by the way, the ENT group also offers their patients complementary services: aesthetics and skin care products.

So, going back to why this is such a natural fit in ophthalmology, it is because:

► as ophthalmologists, we see the ideal patient population

► we see a high patient volume

► vision loss is correlated with hearing loss

► we have a unique familiarity with retail operations

► patients trust their own physicians.

And what about the benefits to our patients? There are well-documented effects of hearing loss on the quality of life, including depression, social withdrawal and isolation, as well as clinical effects such as the correlation of untreated hearing loss with early-onset dementia.

It only took a couple of patients returning with their new hearing aids and heartfelt thanks to the staff for our doctors to realize that this was having a positive impact on our patients. It is no different than recommending high-quality progressive lenses to a patient who couldn't comfortably read and use a computer. In fact, some of the stories of patients hearing things for the first time in years (such as chirping birds or children's voices) were so powerful that we have incorporated them into our marketing materials and our Web site.

Do Your Homework

Because every state has its own legal and regulatory requirements, as well as each state and regional insurance carrier, it is incumbent upon a practice to perform due diligence to ensure that it is in compliance. Some issues that may arise include whether or not an optometrist can order the hearing evaluation, which entity (the practice or the optical) can legally do the billing, whether Medicare or private insurance will accept a claim for a hearing evaluation from an ophthalmologist and how Medicaid fits in. I would strongly suggest you consult with an attorney who is experienced in health care law.

Partnering Was Our Answer

We started doing our own research into how we could implement our hearing program. You won't exactly hit the mother lode by doing a Google search on the subject. Coincidentally, we were contacted by an ophthalmic rep we trusted who knew of a company that had a turnkey business model for family practice groups to offer hearing services. He had suggested to them that it might make more sense to structure this around ophthalmology practices instead.

At the time, we were only one of two practices that helped develop the model in cooperation with Physician Hearing Services, Inc. (www.phsimd.com). They help to recruit a certified hearing specialist, or audiologist if you prefer, and give you a short list of candidates to interview. They also help set up the diagnostic equipment which, to our surprise, did not require a fancy, expensive sound-proof chamber but merely a room that is in a quiet part of your office. Lastly, with their connections in the hearing aid industry, they enable us to get competitive costs on the devices and have access to the latest technology. To our knowledge, there currently aren't any other companies that offer this turnkey approach. And in the last couple of years, they have grown to now include 45 ophthalmology practices and counting.

We didn't want to take a crash course in the economics of hearing aids. And there were many questions that we didn't know the first thing about:

► Where do we purchase the hearing aids and how much should we pay for them?

► Which are the best brands to carry?

► How much inventory should we carry?

► What is the usual mark-up on a hearing aid?

So we were happy to partner with people who were well-versed in the business of hearing care, particularly in the physician practice setting. In return for an exclusive arrangement with them, we have a single source for hearing aids, accessories and warranty and repair services. We also have access to unlimited consultation as well as marketing strategies and "best practices" (usually in the form of joint teleconferences) from other ophthalmic practices that have since joined the fold. In addition, we completely own and control the program ourselves, so we can make adjustments to the model as we see fit.

Because we already have a substantial patient base, we have initially confined our marketing to posters and information sheets in the lobby and our initial screening questionnaire, which is designed to be quickly scanned by our physicians to determine whether or not an evaluation or referral to an ENT doctor is warranted, based on their answers.

Structuring the Interactions

In the end, the integration of hearing services into an ophthalmology practice makes a great deal of sense. Ultimately, we are not in the business of selling hearing aids but rather in the business of meeting deep-seated human needs. In this regard, dispensing hearing aids is no different than dispensing glasses or contact lenses. The biggest hurdle you will encounter in this endeavor is your own acceptance of this mindset.

While we examine the patient and bill Medicare for the evaluation, only M.D.s can perform this function. We incorporated this into our workflow and it has had little impact on our clinics. We have a forced-entry evaluation form that the doctor signs and orders the evaluation with the hearing professional. With nine M.D.s seeing patients, the revenue from the testing is not insignificant.

Other practices, however, have gone with a simpler model. They opt not to look in patient's ears and thus forego the billing for the evaluation. They feel that offering hearing testing as a free service to their patients can increase the volume of hearing aid sales and more than offset the lack of revenue from the free testing. In addition, if you are not billing for the testing, O.D.s can also refer patients for testing.

In either case, a hearing program requires only a brief doctor-patient interaction and an appropriate handoff to be in compliance. Your hearing professional takes it from there: testing, counseling, fitting hearing aids and follow-up care. You are serving a ready-made patient population with minimal impact to your already busy practice.

Patients Will Thank You

Don't underestimate the positive effect that the treatment of a hearing problem can have on your patients. One of my patients — a self-described ‘bionic man’ — had bilateral cataract surgery and DSAEK procedures. But he said the thing that changed his life the most was when we fit both ears with state-of-the-art digital hearing aids and he could hear things he had been missing for years. OM

Peter J. Polack, M.D., F.A.C.S., is co-managing partner for Ocala Eye, a twelve-physician, multisubspecialty ophthalmology practice with five locations in Ocala, Fla. A specialist in cornea, external disease and refractive surgery, Dr. Polack is also founder of Emedikon, an online practice management resource for physicians and administrators. He can be reached via email at ppolack@ocalaeye.com.