Cochlear Implants Offer Revenue Stream for Private Practice Audiologists

Since cochlear implants were approved by the FDA for adults with bilateral hearing loss in 1985, the external and internal components have undergone significant technological improvements.www.shutterstock.com. Cochlear implants, cochlear provider network.Over time, every component of the external system of a cochlear implant has seen upgrades, from the magnets and microphones that capture acoustic signals to speech processors that transform sounds into electrical signals sent to the nerve fibers of the cochlea. The internal portion of the device consists of a receiver-stimulator and electrode array that offer better control of electrical signals that stimulate the cochlea and provide patients with more detailed pitch and improved loudness. Some cochlear implant manufacturers also offer FDA-approved bone-conduction devices for patients with conductive hearing loss, mixed hearing loss, and single-sided deafness. The bone-conduction device uses different technology than the cochlear implant, in that, instead of transmitting electrical signals to the auditory nerve the acoustic signal is transduced into vibrations to stimulate the inner ear directly. Because of the ongoing technological advances, more patients are candidates for an implanted hearing loss treatment than ever before. Yet, only a fraction of eligible patients have undergone the surgery—less than 10%, in fact, by most estimates. “The thing that has me concerned is that penetration is still very low,” said Dr. William Shapiro, AuD, CCC-A, Co-Director of the New York University (NYU) Langone Health Cochlear Implant Center. The problem, he said, “is paradoxical.” “As technology improves and the criteria for selection expands, more individuals with hearing loss become candidates for cochlear implants—but we’re not getting to them,” he continued. “And so we need to do a much better job of raising awareness, which is why I say it’s paradoxical. Because although we have better technology, we aren’t reaching the number of patients we need to serve.” To help increase patient awareness and adoption of cochlear implants, Shapiro serves as a liaison of sorts between the community audiologists and the cochlear provider network (CPN) of the world’s largest manufacturer of surgical implants for hearing loss, Cochlear Limited. The relationships portend more CI surgeries to benefit the private practitioner, the Implant Center, and mostly importantly the patient. This, of course depends on the degree of buy-in by the private practitioner, Shapiro said. The buy-in varies from audiologist to audiologist. “Some audiologists in private practice just want to be able to explain the benefits of a trusted treatment and give them some CI brochures,” he said. “And then other audiologists want to be involved in all aspects of the cochlear implant process.” “These are the audiologists who want to do the pre- and post-operative testing,” he continued. “They want to refer their patients to our surgeon, and then have us refer the patient back to them for the post-op programming.” A TRIANGLE OF TRUST NYU has relationships with private practice audiologists all around the New York City tri-state metro area, east to Long Island and throughout Manhattan. The CPN has provided NYU with a group of local audiologists vetted based on several factors, including their familiarity with CIs and their desire “to offer their patients every available treatment option for hearing loss,” Shapiro said. There are no set criteria a private practice audiologist must meet to partner with NYU and the CPN, apart from following “all good clinical practice guidelines,” he said. “Certainly, we want them to have been in the field for a certain number of years, have a loyal patient following, and are comfortable partnering with a hospital,” Shapiro added. “There has to be a real level of trust in the audiologist,” he continued. “And it is difficult because we are going to be doing surgery based on the results that they give us, so we have to be very careful about that.” Ongoing communication is important. “Private practice audiologists will call and say, ‘Hey, I have this patient. I will email you their results. Can you tell me what you think?’” he shared. “And so we have this impromptu conference about a patient, after which I will say to them, ‘OK, why don’t you go ahead and start the pre-op testing,’” he continued. “So there’s kind of a triangle created between the CPN, the Cochlear Implant Center, and the private practice audiologist who all work together with open communication in the best interest of the patient.” INTERPRETING THE RELATIONSHIP A profile of the audiologist partner most likely to succeed has begun to emerge, Shapiro said. “These are audiologists who are open to another revenue stream other than hearing aids,” he said. “Additionally, they want to be looked at in the community as a hearing health expert who offers patients all of the latest solutions.” A local audiologist who can handle all aspects short of CI surgery is especially helpful, for example, to patients who live a long way from the implant center at NYU, Shapiro noted. “Audiologists have many tools in their toolbox. And there are a lot of very good practitioners out there who want to be able to present to their patients the full array of solutions to their patients’ hearing problems,” he said. “And it has been my experience that the local audiologist has a lot of very loyal patients who are more likely to listen to them when they say, ‘I think you are a good candidate for a cochlear implant.’” The surgeon, meanwhile, needs to have a willingness to communicate openly with audiologists and also recognize the value of the entire care team. “Cochlear implants are a very interesting treatment in that they involve a multidisciplinary approach to delivering patient care,” Shapiro said. “Nowhere else in otolaryngology do you see that sort of team effort, and so it’s important that the surgeon is supportive of the audiology team.” After entering a relationship with a local audiologist, Shapiro serves as a liaison with the CI surgeon. “It’s not that the audiologist can’t speak directly to the surgeon, but I serve as the interpreter,” he said. Like any relationship, good communication is paramount, Shapiro noted. “The relationship is going to wax and wane. Sometimes we have more referrals in a 3-month period, and sometimes less,” he said. “And so, like any relationship, it is important to check in and say, ‘Hey, I haven’t heard from you in a while. Is there anything you need?’” Recently, NYU started a relationship with a second CPN, which has no conflict with the initial CPN as they are in geographically different areas. For private practice audiologists, however, “it’s probably not a good idea to offer all three FDA-approved devices,” Shapiro offered. “Although our surgeon can implant all of them, you need to be able to program it. So it’s always good to start off with just one device and then go from there.” A WINNING SCENARIO Despite stubbornly low adoption rates, CIs have become much more mainstream, while the internet has influenced patient’s expectations, said Shapiro, who has been a practicing audiologist since 1978. “When we first started working with cochlear implants, they were investigational devices and we took a lot of time seeing our patients and testing them,” he said. “Now, because of financial concerns and therefore increased need for efficiency, we don’t see our patients as much as we used to. But they are coming in with a greater idea of what a cochlear implant can do.” Audiologists also know a lot more now about what the devices can do for patients, Shapiro said. “We didn’t know what we could expect from cochlear implants back in the early ´80s,” he said. “If a patient could tell the difference between a noise and a voice, or a question and a statement, or a male voice from a female voice, then we didn’t implant them.” “It wasn’t a matter of them understanding something, because they didn’t understand anything,” he clarified. “And so if they could hear the difference between these things, then we thought that they weren’t a candidate because we didn’t really know what we could provide them with.” Today, NYU hosts community meetings and schedules other special events regularly to help increase public awareness about advances in CI systems and also share information with interested local audiologists and those who might never have considered the benefits of partnering with a hospital-based surgical center. “The CPNs need to be able to talk to these local audiologists to explain to them that there are many more patients out there who are candidates for CI now who haven’t been in the past few years,” said Shapiro. “And it’s changing constantly. But again, the part that is paradoxical and a little bit concerning to me is that our penetration is low and getting worse as technology expands.” Any number of reasons might explain why CIs are not as popular as might be expected—from primary care providers being unaware of the widening selection criteria for the treatment, to competition from technologically advanced hearing aids, or just the fear of surgery. “Whatever the reason is for that, we need to increase patient access to cochlear implants, which is at the core of what we are trying to do in building a provider network,” Shapiro said. “It’s good for the patient, it’s good for the manufacturer, it’s good for the cochlear center, and it’s good for the audiologist in private practice. It’s a win, win, win, win for everyone!”