In Addition …

Integrating a Hearing Center Into Your Practice

By Peter J. Polack, MD, FACS

In these times of economic uncertainty, physicians are no different than other business owners: they're always looking at the bottom line. Over the years, medical practices have turned to new sources of revenue to offset decreases in reimbursement. As ethical physicians, we must ensure that we're providing a procedure or service that benefits our patients, is consistent with our core business (caring for patients) and is (ideally) profitable.

Five years ago, we were approached by PHSI Services Inc. (www.phsimd.com) to be one of two practices to pilot a hearing program using a novel turnkey approach. Although patients frequently asked if we offered hearing services, we had never considered doing so. However, this program sounded intriguing. So we surveyed our patients and asked if they would trust their eye doctors to evaluate their hearing. An overwhelming majority said yes.

Since this was a fairly new venture, we had our share of growing pains, so we've tweaked our model and processes over time. Now it in its fifth year, our hearing program is quite profitable and has allowed us to provide a valuable service to our patients who otherwise wouldn't have had this need addressed, or who may have turned to a high-pressure retail hearing aid store.

We have subsequently been involved with PHSI in spreading the word to other ophthalmology practices. Naturally, there have been varying levels of doubt and skepticism. Here, then, are some of the myths related to opening a hearing center in an eyecare practice:

The incidence of hearing loss is overrated. In fact, hearing loss may be the next great health crisis. A Georgetown University study found that more people under the age of 65 have hearing loss than people over 65 and a study by the Massachusetts Eye and Ear Infirmary found that nearly 20% of adolescents suffer hearing loss.¹

Another study from the Department of Otolaryngology at the Johns Hopkins University reports that patients with hearing loss had up to five times higher risk of dementia than patients with no hearing problems.² Although the exact causal relationship is still unclear, there's speculation that the social

isolation that occurs in patients with hearing loss leads to an earlier onset of dementia, and that the effect of chronic stress associated with trying to decode sounds can be a contributing factor.

Hearing programs are just a “novelty.“ Indeed, they're now a major contributor to the bottom line for many practices. PHSI is in over 130 locations nationwide.

My patients don't want their hearing checked by their eye doctor. How do you know this? Have you asked? We did. And 80% of our patients surveyed said they would trust us to evaluate their hearing. Hearing programs in an ophthalmology setting make sense. Few other specialties see the volume of geriatric patients that ophthalmologists see. Hearing is an additional clinical service your patients may be seeking. We have certainly found this to be the case in our practice, as have other practices.

James Dawes, chief administrative officer at Center For Sight in Sarasota and Venice, Fla. says, “Last year, we received more ‘thank you’ letters from patients and families on hearing than we did on vision.” Diabetic patients, who need an annual eye exam, also should undergo an annual hearing evaluation since they're at a 40% increased risk for hearing loss compared to other patients their age.

Routine hearing evaluations should be performed by ENT surgeons. According to the Better Hearing Institute Market Trak VIII 2009 study, 95% of hearing aids sold in the United States are sold out of a retail store — with no physician oversight. So there should be no debate about ophthalmologist versus ENT. It is estimated that only about 20% of people with significant hearing loss are seeking medical attention for their problem. It would simply be impossible for this volume of patients to be seen in ENT practices alone — there are one-third as many otolaryngologists as ophthalmologists in the United States and many spend a significant portion of their time in the OR.

And there are other reasons that ophthalmologists are uniquely positioned for hearing services:

► They're used to seeing a high volume of patients
► They have experience with retail operations, such as an optical shop
► They're used to dealing with elderly patients
► Hearing loss is correlated with vision loss

Offering hearing services will alienate us from our ENT colleagues. To be frank, when word got out about our hearing program, the large ENT group in town was not very happy about it, and they let us know. But once we explained that we had certified professionals performing the tests, they adopted a wait-andsee attitude. Within a short time, our referrals to their practice increased substantially. It turned out that our screening evaluations were identifying significant pathology in a number of patients, who otherwise may not have found their way to an ENT specialist. Not long after, they proposed that we partner with them in this endeavor, but we've decided against this because we were concerned about issues involving referrals and potential anti-kickback violations.

Setting up a hearing program is an expensive proposition. Although we had significant startup costs when we began our hearing program 5 years ago, we quickly recouped our initial investment. PHSI has since significantly reduced start-up costs and now offers three program models, two of which require no initial capital investment.

Hearing evaluations will cause a significant disruption in the clinic workflow. When we first started our hearing program, we filed for the Medicare professional portion. This required our physicians to examine patients' ears. Although there were some initial hiccups in our workflow, eventually we streamlined this process. Now, we no longer charge for the professional fee, and our certified hearing instrument specialist performs the examinations.

Patients don't like to be sold anything, especially by their own doctor. Sometimes that's true, but the same could be said about selling eyeglasses to your patients.

Tips for Successful Implementation

Decide on your fee model beforehand. If you're going to bill Medicare for the professional fee, you'll need to check with legal counsel in your state to make sure you're in compliance. Your doctors will need to examine the patients' ears and order the evaluation. Another option would be to hire an audiologist, who can bill Medicare directly. If you're not going to bill Medicare for the professional fee, a licensed hearing instrument specialist can perform the testing and the physicians don't need to perform the ear examinations. Be especially careful when it comes to Medicaid. Again, seek the counsel of an attorney familiar with the healthcare laws in your state.

Expect some resistance from within your ranks. As with any new service or technology, there may be some push back from colleagues. No major project such as this should be forced on any doctor; it should be a consensus decision. It needs to make sense for your practice and it needs to make sense to each of your doctors. When we no longer required our physicians to examine the patients' ears, everyone came on board, especially when the program became profitable.

Don't be penny wise and pound foolish by trying to eliminate the middleman. You could probably buy intraocular lenses on eBay, but the money you'd save wouldn't make up for the cost of your time and hassle. Hearing is a multibillion-dollar industry and as a small player, you don't have the access or buying leverage that others do, so partnering with a hearing service makes sense.

Partner with a firm that has a proven track record. Check their references. Some of the questions you should be asking include: Which hearing aid manufacturers do they work with? If they only work with one, that's not a good sign. Different patients have different needs and no single manufacturer can cover the entire spectrum. Would your practice sell only one line of lenses in your optical shop?

For whom does the hearing professional work? Although the hearing services company should help with recruiting, ultimately the hearing professional should be your employee — not theirs. The company may know a lot about recruiting a hearing professional, but you or your administrator know how best to manage your practice.

Who owns and controls the hearing business? You're taking the risk and they're your patients, so you should own the hearing business that's in your practice. But you're also getting expertise, buying leverage, and marketing savvy from the hearing services company, and that's worth something. So, ultimately, this should add to your bottom line, not detract from it.

What else am I required to pay for? You should expect to pay a search fee for recruiting the hearing professional, to pay for the testing equipment and some basic supplies and materials. But be wary if forced to pay monthly fees for items such as marketing and promotion. ■

Ocala Eye, PA, is an investor in PHSI Services, Inc.

References

1. Shargorodsky J, Curhan SG, Curhan GC, Eavey R. Change in prevalence of hearing loss in U.S. adolescents. JAMA 2010; 304: 772-778.

2. Agrawal Y, Platz EA, Niparko JK. Prevalence of hearing loss and differences by demographic characteristics among U.S. adults: data from the National Health and Nutrition Examination Survey, 1999-2004. Arch Intern Med 2008;168:1522-1530.