American Academy of Ophthalmology Web Site: www.aao.org
Clinical Update: Comprehensive
A Look at Hearing Services in Eye M.D. Offices
Nearly a third of Americans between the ages of 65 and 74 have a hearing impairment, and the proportion rises with age, according to the National Institutes of Health. Ophthalmologists, of course, are aware that the aging process impairs not only visual acuity but aural acuity as well—and a small of number of eye care providers are responding to this confluence of medical need by adding audiology testing and hearing-aid sales to their practice. Depending on one’s perspective, this development accomplishes the following:
The Story So Far
In the last few years, the company that has become emblematic of promoting audioscreening in eye care practices is Physician Hearing Service Inc. of Bonita Springs, Fla. Four years ago, PHSI stopped marketing the idea of audiology services to primary care medical practices and zeroed in on ophthalmology and optometry because it was a natural business fit, according to the company’s chief executive, John Olive. By late March this year, the number of multispecialty ophthalmic practices working with PHSI was approaching 70, Mr. Olive said. Some practices have found this to be a successful fit while others have not.
Screening is simple. Success does not require a big, external marketing push by ophthalmologists, Mr. Olive said. Instead, PHSI helps practices learn how to use simple screening tools in the office—for instance, as a patient’s pupils are dilating—to find candidates for hearing evaluations among their existing patient population. “Approximately 80 percent of the patients who have a hearing loss bad enough to benefit from hearing aids have never been diagnosed,” Mr. Olive said. “Ophthalmology practice is ideally suited to encounter those patients in very high concentrations.”
In a 2009 press release, the company described its business model in this way: “Physician Hearing Service, Inc., provides you with a step-by-step, out-of-the-box solution to building and operating a successful hearing program. From day one, you will be guided through the process of equipping, setting up, staffing, stocking, opening and operating your hearing program, all while retaining complete ownership.”1
But is ear care by ophthalmology practices appropriate? The rise in hearing services at eye care practices has caused consternation in some quarters of both ophthalmology and otolaryngology. Charles M. Zacks, MD, chair of the Academy’s Ethics Committee, advises colleagues to consider whether such an arrangement has the potential to breach provisions of the Code of Ethics related to competence, informed consent, truth in advertising and financial conflict of interest, among others. “Ophthalmologists, by reason of their education, training and experience, are best qualified to treat diseases of the eye and the ocular adnexa,” said Dr. Zacks, a cornea specialist practicing in Portland, Maine. “We can’t have ophthalmologists representing that the medical services they provide are identical to those of someone who, by training and experience, practices otolaryngology.”
However, Dr. Zacks pointed out that antitrust laws prevent the Academy from prohibiting members from providing services outside the traditional realm of ophthalmology.
The question of liability. The potential for medicolegal liability from adding hearing services appears to be “fairly low,” according to an analysis done for OMIC last year. Ophthalmologists’ requests to add audiology services to their policy coverage are being granted with limited underwriting, according to OMIC. OMIC representatives acknowledge that fewer than 10 practices have applied for coverage, and the company will continue to monitor the practice for issues of potential risk exposure.
Who, Exactly, Is a Trained Specialist?
Mr. Olive said that PHSI helps its affiliated practices recruit industry-trained hearing-instrument specialists as well as doctorate-level audiologists who are experienced, board-certified and fully state-licensed to practice. In many states, these clinical personnel could practice independently, without an MD’s oversight at all, he noted.
Marilyn Larkin, AuD, who operates an independent hearing center, Harbor Audiology, in Punta Gorda, Fla., said she is uncomfortable with some aspects of the addition of hearing services to eye practices. “On one hand, I don’t think it matters where audiologists practice. I do worry, though, that they really shouldn’t be the employees of people who are not able to supervise that practice. It is outside the scope of practice of ophthalmology to supervise the hearing care given by an audiologist,” Dr. Larkin said. “I also worry about these practices that just go hire a hearing-aid salesman and put him in an eye care practice to do hearing tests. Then there is nobody really taking care of the hearing health of the person,” Dr. Larkin said. “Hearing-aid specialists are very much like opticians. It would be like having your optician doing your refraction and your intraocular pressure test. Do you really want them interpreting those results?”
Rules are in place. In PHSI-affiliated practices, the hearing-instrument specialists and doctorate-level audiologists are trained to comply with FDA rules on hearing aids, Mr. Olive said. These rules require a referral to an ENT specialist if any of seven “red flag” conditions are present (such as signs of infection or a sudden hearing loss).
Adherence to this strict protocol was confirmed by an Ocala, Fla., cornea specialist whose multispecialty ophthalmic group was one of the first two PHSI partners. “If things are done not just ethically but logically, and if the proper safeguards are put in place, then you will identify these patients who need to go to ENT,” said Peter J. Polack, MD, co-managing partner of Ocala Eye.
Catching ENT patients who could be missed. Dr. Polack noted that the multiphysician ENT practice in his community at first was alarmed by the audiology center at Ocala Eye—but then the ENTs began receiving his practice’s referrals of patients who otherwise would have been under the radar. “They’re primarily surgeons, and they don’t see the volume of patients we see. So we were catching a lot of indicators of hidden pathologies that might otherwise not have been diagnosed as early,” Dr. Polack said. Those included two unsuspected acoustic neuromas, one malignant tumor and two perforated eardrums. “And we have a pretty good relationship with this ENT practice now,” he added.
Ear to Eye Communiqué
In early March, the Academy received a letter of concern about hearing services in eye practices from the American Academy of Otolaryngology-Head and Neck Surgery. David R. Nielsen, MD, executive vice president and CEO of the organization, said in an interview that he did not intend the letter to accuse anyone of ethical violations, but merely was trying to raise the issue for Academy leaders and members to consider. “Selling hearing aids as a revenue generator, without the clinical experience, training and equipment to examine the ear, hearing and balance function, and oversee the medical aspects of diagnosing hearing loss, is less than optimal care,” Dr. Nielsen said. “The question is: Does the American Academy of Ophthalmology condone or endorse ophthalmologists selling hearing aids in their offices as a revenue generator?”
In at least one arena there is a compelling argument against Eye M.D.s offering ENT care. “The provision of hearing services in ophthalmic offices has made it more difficult sometimes to persuade otolaryngologists to support the Academy on optometric scope of practice issues,” said Cynthia A. Bradford, MD, the Academy’s senior secretary for Advocacy. Dr. Bradford is a professor of ophthalmology at the University of Oklahoma. “This has come up in some states where we are lobbying to prevent expansion of optometry into the scope of practice of ophthalmology,” Dr. Bradford said. “The ENT doctors said to us, ‘Why should we join you in your battle with optometry when you seem to feel that you’re qualified to diagnose and treat ear problems?’ We’ve received formal letters from the ENT societies in some of the states.” Relevant to that, a number of optometric practices also begun offering hearing testing.
What do patients want? Dr. Polack and Mr. Olive contend that the addition of audiologic exams does offer patients a very real and important medical service. When Ocala Eye surveyed patients before adding these services to their practice, the patients said they would welcome hearing services because they did not trust the strip-mall retail outlets where most hearing testing occurs in their community. “It’s not really a question of whether we are intruding on the practice of otolaryngology,” Dr. Polack said. “The real question is: Should a medical practice be screening these patients for a remediable hearing loss, or should a retail outlet be screening them? Of course we have to be honest—yes, we do make money from this. But first and foremost we’re physicians, and we have to do what’s in the best interests of the patient.”
Dr. Polack said he and his partners have been amazed to see the human consequences from their service expansion. “Some of us found it hard to believe, when we started to get return visits from the first patients who had been fitted with hearing aids,” he said. “They would say things like, ‘I stepped out to get the newspaper and heard birds for the first time in 20 years. Thank you, thank you, thank you!’ And that’s what it’s really about.”
And what do patients need? After a large ophthalmic practice in Omaha, Neb., began offering hearing services under the PHSI aegis, Britt A. Thedinger, MD, an otologist/neurotologist subspecialist in Omaha, began speaking out on this issue. “This large group of ophthalmologists hired a hearing-sales specialist—not an audiologist—and now every one of their patients is offered a free hearing screening in the waiting room. This is a service that is very low quality and, in my opinion, somewhat unethical. This is not what’s in the best interest of patients.”
Dr. Thedinger employs four doctors of audiology in his practice in Omaha. His is the only practice in the region devoted solely to otology-neurotology, the ENT subspecialty in the medical and surgical treatment of ear, hearing, balance and facial nerve disorders. He said he does not expect his patient load to be affected by the aforementioned ophthalmology practice, but he is concerned that other ophthalmologists in Omaha also will try to boost their revenues in this way. “I think it’s wrong to start selling hearing aids out of an eye physician’s office or for them to try to portray themselves as ‘ear experts.’ It’s very unprofessional. It would be like me hiring an optometrist, giving every one of my patients a free eye exam and then selling them eyeglasses or contact lenses.”
Dr. Nielsen emphasized the importance of providing patients with the best possible care through a collaborative team model. “It’s not illegal for an ophthalmologist to sell hearing aids. I don’t even think that it’s strictly unethical,” he said. “But your professionalism is justifiably called into question if you are engaging in any practice that is less than a best practice. Consumer Reports studied multiple models of identifying, evaluating and treating hearing loss from a cost and quality perspective, and it concluded that the best value for consumers comes from an otolaryngology office with a combined team of otolaryngologist and audiologist.”2
Randolph L. Johnston, MD, president of the Academy, said, “For me, the issue is about providing the highest-quality patient care in an appropriate, professional environment. That should drive practice decisions above all other things.”