Professionalism: The Audiologist’s Opportunity

1. Professionalism: The Audiologist’s Opportunity Alison M. Grimes, AuD University of California Los Angeles Medical Center Past-President, American Academy of Audiology

3. What’s New at the American Academy of Audiology? • Over 11,000 members • Incoming President Pat Kricos • San Diego—greatest AudiologyNow! attendance ever! • Next year—Chicago • Association Research Conference • This year Aging • Next year Tinnitus • Accreditation and Education Challenges • Gold Standards Summit outcomes • Student Academy of Audiology • Future Leaders • Audiology Assistants • Long-range planning • There aren’t enough of us to meet the demand!

4. Are Audiologists Professionals? • How do we know? • What do we do to demonstrate professionalism? • What do we do that runs counter to being viewed as a professional? • Why should we care? • Without professional actions, concerns, we become technicians

5. Culture of A Professional • Demonstrating professionalism, and being recognized as a professional • Distinguishes us from “technician”, “salesperson” or “the girl” (77% of our profession!) • Culture of professional excellence is communicated to • Students • Other professionals with whom we interact • Consumers • Legislators • Third-party payers

6. Our History… • Grew from an affiliation with Speech Pathology • Placed our training programs in Education and/or Liberal Arts Departments • Kept us from knowledge and experiences relating to running a business, billing for services • Prohibited us from selling hearing aids and other devices • Disincentive to private practice • Grew a culture of subservience to ‘the physician’ • Encouraged an employee-employer relationship

7. Our Transitions • Dispensing hearing aids legally • Led to growth in independent private practice • Transitioning to a doctoral degree • Acknowledging the tremendous growth in our Scope of Practice • From ASHA to the AAA • Every state in the US has licensure or registration of audiologists • Able to bill 3d party insurance independently

8. Opportunities for Professionalism • Writing Clinical Practice Guidelines • Conducting/publishing research in peer-reviewed journals • Consumer of our own research, teaching based on our own research • Collaboration with, as equal partners, physicians/educators • Patients and consumers looking to us for information, resources, diagnosis/treatment, program development/management • Public Awareness as “Audiologist”, not “Hearing Healthcare Provider” • Accrediting our own training programs based on our own professional standards

9. More Opportunities • Own the research in all of the areas of our practice, teach our own research • Develop and promulgate evidence-based practices or clinical practice guidelines to govern practice • Ethics • Not only have a code, but follow and enforce it! • Public Policy/Advocacy • Advocate for policies and laws/regulations that support our profession, our patients, and public-health issues (e.g., noise, early diagnosis, funding for treatment, etc).

10. What is a Profession? Wiki says… • “A profession is an occupation, vocation or career where specialized knowledge of a subject, field, or science is applied. It is usually applied to occupations that involve prolonged academic training and a formal qualification.”

11. Wiki… • Professional activity involves systematic knowledge and proficiency. • Professions are regulated by professional bodies that set examinations of competence, act as a licensing authority for practitioners, and enforce adherence to an ethical code of practice.

12. My Additions to Wikipedia…Professionals… • Advocate, for their beneficiaries/consumers (individually and affected groups) • Advocate for public policies and decisions that impact the consumers of the professionals’ services, e.g., • Noise levels in public places • Prevention of conditions that lead to hearing loss • Improved access to services (health insurance) • Advocate For public policies and decisions that impact the profession itself: reimbursement, autonomy, direct access • Provide pro-bono work • Work more than a 40-hour week when the need is there… • Volunteer to work in their professional organizations

13. More Additions to Wiki… • Professionals • Write their own professional standards, based on evidence and research generated by audiologists and other professionals • Accredit their own training programs • Determine their own scope of practice • Design, conduct and publish their own research in peer-reviewed journals • Not just have a code of ethics, but adhere to it, and have consequences for lack of adherence

14. Scope of Practice • Defines the range of interests, capabilities and professional activities • Defines audiologists as independent practitioners • Provides examples of settings in which they are engaged in practice • Academy members/licensees will provide only those services for which they are adequately prepared • Through their academic and clinical training and experience • Scope is consistent with the Code of Ethics

15. SOP—Audiologic Assessment/ Diagnosis and Treatment • Administration and interpretation of behavioral, physiologic, and electrophysiologic measures of the peripheral and central auditory systems • In order to determine an audiologic diagnosis • Assessment is accomplished using standardized testing procedures and appropriately calibrated instrumentation, employing evidence-based best practices/guidelines, and leads to an audiologic diagnosis and related treatment plan. the diagnosis of hearing • Audiologic Treatment is patient-centric, patient-specific, and respects patient choice and autonomy. Treatment options are evidence-based and rely on evidence-based clinical practice guidelines for best outcomes.

16. AAA Code of Ethics PRINCIPLE 4: Members shall provide only services and products that are in the best interest of those served. PRINCIPLE 5: Members shall provide accurate information about the nature and management of communicative disorders and about the services and products offered.Rule 5a: Individuals shall provide persons served with the information a reasonable person would want to know about the nature and possible effects of services rendered, or products provided or research being conducted.Rule 5b: Individuals may make a statement of prognosis, but shall not guarantee results, mislead, or misinform persons served or studied.

17. Opportunities for Audiologists in 2010 • Aging population, virtually all of whom need or will need our services • With robust evidence that failure to access audiologic services has consequences for psycho-social function, cognition and dementia • (Unfortunately) Tinnitus is the #1 health hazard resulting from combat • (Unfortunately) Autism • AAP stipulates that every child suspected of autism undergo audiologic evaluation • Early Hearing Detection and Intervention • An unparalleled opportunity

18. One Thing that Audiologists Do That No One Else Does • (Or no one else should do!) • Pediatrics! • How better to demonstrate our professionalism? • Provide comprehensive services that no other professional or business group can • With Federal dollars being dedicated to EHDI, audiologists are in the spotlight to carry out this Federally-mandated program

19. Pediatrics: Start to Finish • Prevention and Identification • Newborn Hearing Screening Programs • Comprehensive Diagnosis • Infant electrophysiology/other physiologic measures • Behavioral evaluations • Treatment/Early Intervention • Hearing Aid Fitting, Verification, Validation • Collaboration with EHDI/IFSP/IEP Team, physician team(s) • Cochlear implantation • Candidacy evaluation • Follow-up and long-term counseling/validation • Parent/Family counseling

20. Why Pediatrics? • No other profession or provider can provide comprehensive services in pediatrics • The “hearing healthcare professional” or “hearing instrument specialist” or ENT physician cannot (legitimately) lay claim to expertise and professionalism in pediatrics • We publish a significant proportion of the research and set the standards for screening, diagnosis and follow-up

21. Only Audiologists… • Hearing aid dispensers don’t provide pediatric services • Typically prohibited by law • Typically do not choose to test children • Physicians (or their designees) can, but typically don’t • (and if they do, watch out!) • Electrodiagnostic technicians can, but we shouldn’t fit hearing aids based on their findings! • Audiologists have a long-term commitment to the families of their patients

22. Only Audiologists Diagnose Hearing Loss • Audiologic Diagnosis: you can’t see a hearing loss with an otoscope! • Type, degree, severity, unilateral vs bilateral • Based on measures and techniques • Developed, verified, validated in the audiology literature • Developmentally-appropriate • Determine sufficient information to proceed to treatment • Referrals • Hearing Aids • Cochlear Implants • Provide parent counseling

23. Professionalism: From Classroom to Practice to Research-Base • Classroom: • Training programs based on professional standards and accreditation developed by audiologists • Practice • Use of best-practices and evidence-based practice based on audiologic research and organizational practice guidelines • Research • PhD Audiologists’ important role in providing and sustaining the research base of our profession • We cannot advance our profession without growing our basic and translational research

24. But…Do we get Paid? • Insufficient codes for pediatric and adult evaluation/treatment • Codes are insufficiently reimbursed • Half of children in US are on Medicaid • EHDI programs cannot succeed without pediatric audiology • Unprecedented opportunity to advocate for coding and reimbursement • Shortage is being noticed! • Adult Services: payment is too reliant on hearing aid sales

25. What Does This Have to Do With Me? • So…you’re not a pediatric audiologist…

26. What Happens in One Area of Practice Affects Others • When we achieve Direct Access for Medicare, it will influence other payer sources • In California, we are paid E & M codes for children on Medicaid • This model may translate to other payers • When we give away “free hearing tests”, payers may come to expect the same for their insureds • When we bundle hearing aids and reimbursement for hearing aids changes, we may not have the codes to get paid. • So we get paid for “the thing”

27. What Happens if We Don’t Get Paid for Hearing Aids? • California Medicaid (Medi-Cal) example • Codes, or lack thereof • How do we get paid for services (at a rate that we can afford to dispense) without codes? • Importance of placing value on diagnostic and treatment procedures rather than “the thing” (HA, CI)

28. A Professional Opportunity… • To define each process in the diagnostic and treatment events • Attach a value to services/processes separate from the value of the “thing” • Advocate for new codes and related reimbursement • Advance recognition of our value-added • Hearing aids are useless without audiologists to fit • The counseling and rehabilitation accompanying the hearing aid fitting is what brings professional value added

29. What Do We Do That Diminishes Professionalism? • Free hearing tests • Be employees of ENT physicians • Bill “incident to” • Allow ourselves to be termed “Hearing Healthcare Professionals” lumped in with hearing aid dispensers • Fail to adhere to best practices, current research findings, evidence-based practice • Not distinguish between selling the thing and providing comprehensive rehabilitative treatment

30. Barriers/Obstacles/”Opportunities” • Inter-professional collaboration • Other professional groups/organizations can/should be our allies, friends, collaborators • Revenue/reimbursement • Need revenue streams other than hearing aid sales • Inadequate number of audiologists for population served • Opportunity for use of Audiology Assistants

31. Current Challenges in the US • Inadequate reimbursement from Federal payers • This becomes the model for private payers • Too many AuD programs, too few student per program • Accreditation standards not as rigorous as I’d like • Too many audiologists view hearing aid sales as only way to have a profitable practice/reasonable salary • They might be right! • Pediatrics, cochlear implants, vestibular diagnostics under-reimbursed

32. Professionalism • We’ve come a long way • Actions speak louder than words • Achieving a doctoral degree doesn’t ensure professionalism • To paraphrase UCLA’s John Wooden: • “Be concerned with your professional character… because your character is what you really are”.