Access is the new focus in the world of cochlear implants. Traditional distribution channels lack the ability to absorb the future growth of this proven treatment modality. Do your clinical skills and your practice location have the potential to provide services in this underdeveloped market?
The world of cochlear implants (CIs) is evolving. What was once a treatment pathway for a limited population of patients with profound hearing impairment has expanded to include individuals with moderate to severe hearing loss. CI technology, which began as basic sound processing through an electrode array, has grown to include Bluetooth streaming and cell phone connectivity.
Above all, through the years, outcomes, as reported by patients, continue to improve. Now another aspect of this industry is changing—access—getting the right patient to the right provider, at the right place and in the appropriate time frame.
The change in the CI industry is being driven by a number of factors, with the most urgent being poor use of this treatment pathway. Of the adults with severe to profound hearing loss, less than eight percent have been implanted and only 11 percent of audiologists specialize in CIs (Taylor, 2018).
Unlike 30 years ago when CIs were first approved for clinical use, the process of identifying and programming patient care has become much more streamlined. What once was a process defined by research protocols in limited geographic locations has moved to treatment protocols that drive quality outcomes and clinical efficiency in local communities.
CI manufacturers now have dedicated networks and countless resources for private practice audiologists who have integrated CIs and other implantable hearing solutions into their technology portfolio. Is adding these services right for your practice?
Do Cochlear Implants Make Business Sense?
To answer this question, we will examine several factors. First, let’s look at demand. Given the statistical data cited earlier, we know that, within the United States, there is a high need to provide this service.
What about local demand? In an article published in 2009, Huart and Sammeth sampled the patient files of five audiology and hearing aid clinics. Of the 7,000 files sampled, 3.2 percent of the patients appeared to be candidates for a cochlear evaluation (Huart and Sammeth, 2009). This would indicate that, for a clinic with a base of 4,000 patients, approximately 120 patients should be evaluated for CIs—and that is just one clinic in a community.
The conclusion: There is strong demand for these services in your community.
The next thing to consider is the operational variables of your current practices. Below is a summary of some characteristics of successful practices offering CIs. A review of your clinic profile should reveal that you and your team possess many, but not necessarily all, of these factors.
Characteristics of successful practices offering cochlear implants
- Long-established practice and/or large patient database
- Motivated, licensed audiologist willing to commit to the process and training
- Open to the medical model and can collaborate with surgeons
- Open to revenue streams other than hearing aids
- Participate with Medicare and other commercial insurance payers
If your clinic seems to meet the criteria of a successful practice offering CIs, a simple business exercise will be the final step. When considering the addition of goods or services to an existing business, the business owner should ask the following three questions:
- Is this good for my customers (my patients)?
- Is this good for my employees (my providers)?
- Is this good for my bottom line (my practice)?
If the answer is “yes” to all three questions, it is reasonable to proceed with the product or service.
To provide clarity to these three questions, industry periodicals were reviewed and input was solicited from several audiologists who have adopted CIs into their private practices in the past five years. Using industry data and the input from these audiologists, let’s examine the impact of CI services by asking the three questions.
Is This Good for My Patients?
There is overwhelming positive clinical evidence regarding the benefits of CIs. Whereas the majority of these feel-good stories are coming out of the traditional implant channels, a growing number are happening in private practice settings across the country.
The expected benefit for CI patients is an improvement relative to benefits from hearing aids in terms of word-recognition and quality-of-life scores. Reviewing studies of benefits provided through CIs independently, and also in the bimodal condition (one CI, one hearing aid), clinical evidence reveals strong patient outcomes for adults with CIs.
Bittencourt et al (2012) demonstrated that a group of CI users had significantly higher word-recognition scores, one year post implantation, when compared to an equally matched group of hearing aid wearers.
More recently, in April 2019, results were shared from a study involving 100 adult subjects across 13 sites who received the Cochlear Nucleus CI532. All of the subjects were fit in a bimodal configuration. All bimodal hearing aids were dispensed in the same time frame of the CI activation.
Speech-understanding scores at six months post activation revealed significant improvement in speech perception, in both quiet and noise (Sycle Continuum of Care 2020) (FIGURE 1).
Additionally, using a seven-point Likert scale, 95 percent of patients reported they were satisfied or very satisfied with their bimodal hearing solution, compared to only nine percent of individuals wearing appropriately fit hearing aids alone, pre-operatively (FIGURE 2). While not every patient achieves these performance levels, the evidence is very favorable for CI outcomes.
Audiologists also are reporting strong outcomes.
“One of the startling aspects when you incorporate cochlear implants into your practice is how grateful the patients are with the improvements in understanding and level of audibility they achieve with cochlear implants,” Dr. Kimberly Allred, the owner of ACI Hearing and Balance Center in Lafayette, Louisiana, said.
“Once you start taking care of your longtime patients by offering the ‘next level of technology,’ CIs, you begin to see how satisfied they are and how grateful they feel for regaining a level of audibility. Is it good for my patients? I would say absolutely yes. I know they like a 10- or 15-minute drive, compared to an hour-and-a-half commute for services.”
“Our patients have definitely seen a benefit having local access to cochlear implant services,” Dr. Ram Nileshar, the owner of The Hearing Center of Lake Charles, located in Lake Charles, Louisiana, said.
“We also work with a local speech therapist to provide auditory training. The most notable change with our implanted patients is the change in their quality of life. Our patients who are still working are reporting they are functioning more effectively. And a few weeks ago, I was in the grocery store and was stopped by the wife of one of our recipients. She was almost in tears telling me the difference implants have made in his life. Yes, I would say our patients are benefiting from this local service.”
Is This Good for My Providers?
One of the key issues when introducing a new product or service into a practice is the stress placed on the providers and other staff members. The stress can be manifested in a number of ways, including through a steep learning curve, increased clinical pace, or additional caseload.
Although CIs are not as specialized as they were several decades ago, there is still formal training required and, more importantly, opportunities are needed to apply this training in the clinic with patients. The manufacturers of CIs understand how critical training is and offer solid programs, as well as on-site support resources.
Clinics that offer CI services do not see the same volume of patients as large CI centers. However, most audiologists can feel confident and proficient to provide services to most of their CI recipients if they are seeing 10 to 12 patients per year, on average.
Another issue to address with staff is the variable pay plans that exist with other clinical activities. Providers don’t want to relinquish time with hearing aid patients if the variable pay is extensively less with other procedures. Given the issues with Medicare reimbursement, a clinic must be sensitive to adjustments in pay structures relative to adding a service to the practice.
“Our providers are eager to learn,” Dr. Nileshwar said. “As they learn and gain experience, they want more skills to handle the advanced cases. The providers seem to enjoy the trust that patients instill in them with providing this service. The benefits far outweigh the downside of initiating a program like this.”
“Once you get comfortable with the paperwork and the protocol, it all works a lot smoother,” Dr. Allred said. “You have to jump into the pool and change how you have done things in the past. Once we mastered the ‘language’ of the implant world, things got better. It’s definitely worth the learning curve.”
It’s clear that the learning curve is the biggest hurdle for providers. However, once you push through the learning, the professionals all agree the reward far outweighs the risk. The audiologists report that providing CI services satisfies many of the emotional reasons they chose the profession of audiology. CI services appear to fit right in the wheelhouse of audiologists.
Is This Good for My Practice?
Although there are a number of factors that can make a CI program beneficial, let’s begin by answering the most obvious question. Is it financially good for the practice? To answer this question, we need a clinical revenue benchmark to compare revenue generated through CI activities relative to other clinical products and procedures.
In a 2019 article, Taylor established the margin per clinical hour for a median single provider/single location clinic to be $186, based on 2,080 clinical hours per year. The calculated margin per hour rose to $204 when adjusted for paid time off (PTO) and holidays (1,890 hours). For our comparison, we will measure the strength of the program based on the range of $186 to $204.
The typical CI journey for a patient starts in their local audiologist’s office with a CI evaluation. Once surgery is complete, the patient returns to their audiologist for initial activation and all programming follow-up. On average, a patient would typically need six to eight appointments within the first year, which includes the CI evaluation, totaling approximately nine to 10 clinical hours.
Next, we need to review revenue generated directly from activities associated with the CI patient. These activities include revenue generated in three ways: billable CI services, revenue charged for non-billable activities, and the fitting of a bimodal hearing aid.
FIGURE 3 shows a hypothetical revenue generation and the time spent by hour for all activities for 10 patients over five years. Interestingly, it is estimated that approximately 25 percent of the time spent by a provider with a patient is non-billable. Therefore, a clinic should recognize these activities, bill them independently, or create a service package to cover the non-billable events.
|REVENUE SAMPLE FOR 10 PATIENTS (60% Bimodal | 25% of Time with CI–Unbillable)|
|COCHLEAR IMPLANT REVENUE CALCULATION||TOTAL
(Per Hour by Activity)
|Billable Services for CI Evaluation (Medicare)||$2.100||$0||$2,100||$140|
|Hours for CI Evaluation||15||0||15||–|
|Billable Services for CI (Medicare)||$9,000||$7,000||$16,000||$178|
|Billable Hours for CI (CA Protocol)||60||30||90||–|
|Bimodal Margin Generated (ASP $2,500/COG 40%/Unbudled) 60% Bimodal||$9,000||$0||$9,000||$188|
|Hours for Hearing Aid Fitting and Services||24||24||48||–|
|Service Package (Non-Billable Services CI and HA)||$13,000||$0||$13,000||$224|
|Total Clinical Hours Commited||44||14||58||–|
As professionals, we must understand that our time is the way we generate revenue. A service package and bimodal charge will be less costly than what patients have paid for hearing health care for most of their adult lives. And, in almost every case, patients will be receiving better hearing results with implants.
In addition, we must weigh the revenue generated relative to the time spent by the clinician. The values were based on approximate national average rates (the numbers were rounded for clarity).
In comparing the revenue per clinical hour generated through all CI services provided in the mapping of the CI and the fitting of a bimodal hearing system to the benchmark of $186 to $204, it is evident that the numbers fall into the benchmark range in all but two categories. Those categories are CI evaluations and billable CI services. Service contracts and bimodal fittings are important financial tools within your CI program. CI programs can be financially stable.
Additional significant value in CI programs is also realized in what we call the “halo effect” provided by other benefits.
Here is a quick list of the additional benefits a CI program can bring to your clinic:
Approximately half of your CI evaluations will not lead to candidates for implantation and very often will lead to hearing aid upgrades.
People who wear implants are patients for life. They use your services again and again.
These patients need related services and products, including batteries, repairs, and assistive listening devices.
These patients know other people and are more likely to recommend you.
A CI program establishes your practice as a center of hearing excellence.
Some observations from audiologists about the benefits of a CI program in their practice follow.
“Being part of a cochlear implant network has changed the way we view our clients,” Dr. Marlene Bevan, the owner of Audicare Hearing Centers in Traverse City, Michigan, said. “We see this more as a continuum of care and, even if patients don’t move forward, they feel more prepared and make better decisions when they know it’s a continuum.
“I’m billing for something I wasn’t able to bill for a year ago. It has helped my bottom line. We are able to reach out and educate a whole new demographic. I’ve made connections with other professionals and also expanded our marketing network.”
“The financial return with each patient is, I would describe, reasonable,” Dr. Nileshwar said. “It is not a huge profit center, given the volume of patients. But there are spinoffs.
“The number of hearing aid fittings go up. I’m receiving more referrals from two ENTs in my community. Perhaps the best benefit is that it elevates our status in the community. This makes us different than the other hearing providers in our town.”
“Relative to value, our CI program is definitely not a loser,” Dr. Allred said. “Our CI patients say it’s the best thing since sliced bread. I get more referrals from our CI patients. They sing our praises.
“As professionals, we all feel better educated and find our CI outcomes to be significantly rewarding. Overall, it’s great. But it’s not all about what we get. It’s about what we give. You have to be in this for the right reason.”
Yes…we will let that be the last word.
ASHA. (2019) 2019 Medicare Fee Schedule for Audiologists. https://www.asha.org/uploadedFiles/2019-Medicare-Fee-Schedule-for-Audiol… (Accessed April 15, 2020).
Bittencourt AG, Ikari LS, Della Torre AAG, Bento RF, Tsuji RK, Neto RVB. (2012) Post-lingual deafness: benefits of cochlear implants v. conventional hearing aids. Braz J Otorhinolarngol 78(2):124–127.
Clinical Evaluation of the Cochlear Nucleus CI532 Cochlear Implants in Adults Investigator Meeting. (2019) April.
Huart S, Sammeth C. (2009) Identifying cochlear implant candidates in the hearing aid dispensing practice. Hear Rev 16(5):24–32.
Sycle. (2020) Bimodal Patients Are Thriving: New benchmark study reveals clinic growth opportunity linked to bimodal hearing solutions https://web.sycle.net/wp-content/uploads/2020/01/Bimodal-Patients-Are-Th… (accessed February 14, 2020).
Taylor B. (2018) Changing the course of care at the local level in adults with severe hearing loss. Audiol Prac 10(2):10–16.
Taylor B, Quall D. (2019) The rise of managed care in audiology warrants a different economic model with separate KPIs. Audiol Prac 11(3):13–17.