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Hearing Industry Summary

This document is a brief summary of the hearing aid and assistive listening system market in the United States. It is intended to provide the reader with a basic understanding of the current and potential future market size, the hearing enhancement technologies currently available, and reimbursement sources.

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Hearing Enhancement Technology Market Size and Users

Technologies presently exist that could improve the quality of sound for up to 95% of the estimated 20+ million people in the United States who experience some form of hearing loss. This "Treatable Population" of over 19 million people can be further divided into those who can be treated through medical intervention and those who can benefit from an assistive device as seen below.

Unfortunately approximately 80% of people who experience non-medically correctable hearing loss choose not to make use of available technologies. Reasons for low usage seem to rest primarily on cost factors. Other factors include a lack of understanding of hearing aid and assistive listening technologies, the societal stigma associated with hearing aids, and dissatisfaction with previously used technologies.

In 1999 the penetrated hearing aid market size was estimated to be only 1,900,000 units sold in the United States. This number can be broken down into types of hearing aids as follows: Behind-the-Ear (372,400 units), In-the-Ear (893,000 units), Completely-In-the-Canal (195,700), In-the-Canal (385,700), Body Aids, Eyeglasses, and others (53,200) (Hearing Industries Association, 1999).

This still leaves more than 16 million people with substantially correctable hearing loss who are not using hearing aids as a means of addressing their hearing loss.

According to the 1990-91 National Health Survey on the Prevalence and Characteristics of Persons with Hearing Trouble, 3.6 million people, or 18% of those who identified themselves as having hearing problems, use hearing aids (over the age of three and non-institutionalized). Use of hearing aids is highest among those 18 years of age and older. People whose hearing loss became significant after the age of 19 are most likely to use hearing aids.

The largest percentage of persons with hearing loss was reported in the 65 year and older age group. Age related hearing loss occurs exponentially with advancing years, rising sharply around age 55 (see Figure 2). This group increased by 24.8% from 1971 to 1991. This corresponds with the overall aging of America. Therefore, it is assumed that the largest increase in the hearing market will come from the increasing elderly population. The 1990 Census indicates that 13% of the population was over age 65, and projections indicate this figure will double over the next three decades as baby boomers enter their senior years.

There are three types of hearing loss: conductive, sensorineural, and mixed.

• Conductive hearing loss can occur if the structures of the outer or middle ear do not work correctly. Conductive loss is more likely to respond to medical or surgical treatment.

• Sensorineural hearing loss (nonprofessionals sometimes call this nerve deafness) can occur if inner ear structures do not work correctly. Sensorineural hearing loss is more likely to be permanent. See Figure 3 for common causes.

• Mixed hearing loss involves both conductive as well as sensorineural components.

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Hearing Enhancement Technologies Currently Available

Without surgical or medical treatment to adjust a person's ability to hear, people with conductive and/or sensorineural hearing loss have the option of using a variety of technologies. These technologies have been categorized into two areas: hearing aids and assistive listening systems.

Hearing Aids

Hearing aids are amplification devices that compensate for partial hearing loss. The individual must have some residual hearing in order to benefit from a hearing aid. Hearing aids come in many styles and use several types of technologies. Regardless of the appearance or inner?workings of the aid, the intention is to amplify sound in order to compensate for poor hearing and help the user to function better in daily communication situations. Hearing aids do not restore normal hearing.

The hearing aid that best fits the user will depend upon many factors, including the degree of hearing loss and the daily listening situations to which the user is exposed. The best way to determine the optimal hearing aid user fit is to have a hearing test done by a licensed audiologist, who will discuss the available options.

Types of Hearing Aids (American Speech Language Hearing Association, 1997)

In-the-Ear (ITE): all parts of the aid are contained in the outer part of the ear. Offers easy positioning and adjustment by user. Generally, for mild to moderate hearing loss.

Completely-in-the-Canal (CIC): entire aid is inside the ear canal; smallest, least visible hearing device.

In-the-Canal (ITC): aid contained in a tiny case that fits partially in the ear canal.

Behind-the-Ear (BTE): all parts are in a small plastic case that sits behind the ear; case is connected to earmold by a piece of clear tubing. Used for severe to profound hearing loss, as well as by people who may encounter difficulties with manipulation.

Eyeglass Aids: aid parts contained inside the frame of eyeglasses in the earpieces; clear plastic tubing connects hearing aid to earmolds. Rarely used today.

Body Hearing Aids: Microphone, amplifier, and batteries are combined into a small rectangular case, which the user carries; cord connecting case to receiver runs along neck; receiver snaps into earmold. Used for most severe hearing loss. Rarely used today.

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Technologies of Hearing Aids

Analog: Sound pressure waves are transformed into an electrical signal by a microphone. These electrical signals are then filtered and transformed by electronic circuitry. The transformed signals are then amplified and presented to the impaired ear by a speaker.

Digital (DSP- Digital Signal Processing): Different from analog in the way it "recognizes" noise and separates it from speech. In digital technology, the electrical waveform is converted into a digital code of a series of zeros and ones. This digital signal is then filtered and transformed by microcomputer and digital signal processing electronics. The transformed signal is then amplified and presented to the impaired ear by a speaker. Digital hearing aids are generally more flexible than analog hearing aids in their ability to give a customized response.

Hybrid (digital controlled analog hearing aid): More common than purely digital hearing aids. A hybrid hearing aid uses digital electronics to control the characteristics of the analog signal processing. A computer is used to program the hearing aid parameters.

Advantages of DSP capable hearing aids may include: Adaptive Signal Processing:

• Automatically adjusts the amount of amplification (gain) hearing aid provides according to the loudness of the sound reaching its microphone.

• Multi-Channel Capability: The amount of gain a hearing aid provides at each pitch or frequency is called its frequency response. Frequency response can be divided into two or more channels of control, allowing the hearing aid to respond differently to low and high-pitched sounds.

• Multi-Memory Capability: Hearing aids can store more than one programmed set of frequency responses. This allows the user to select the program that responds best in the hearing environment.

• Multi-Microphone Capability: Two separate microphones allow the hearing aid to either pick up sound from a broad or narrow view. (Much like a wide angle vs. zoom lens.)

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Assistive Listening Systems

Assistive Listening Systems (ALSs), also known as Assistive Listening Devices (ALDs), are amplification systems designed specifically to help people, both hearing and hard-of-hearing, to hear better. ALSs are used to amplify desirable sounds and to reduce undesirable sounds in the environment. ALSs can be used in combination with hearing aids, or by themselves, to overcome background noises and to "reduce" the distance from the sound source.

There are several types of ALSs currently available, including infrared systems, FM systems, loop systems, and personal amplified systems. Although the various types of ALSs use different technologies, they all pick up sound from the source and deliver it directly to the user wearing a receiver.

ALSs are used to enhance sound in large public facilities or in-group situations. The Americans with Disabilities Act requires that ALSs be available at public places, such as courtrooms, schools, theatres, and concert halls. They can also be used by individuals to improve the sounds of television, radio, and conversations. Additionally, many of these technologies can be used for education, public displays (museums, galleries), talking signs, library access, kiosks, etc., in order to separate the signal source from noise, allowing multiple signals to be heard distinctly and clearly.

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Types of Large Area Assistive Listening Systems

Conventional Induction Loop Systems (Architectural and Transportation Barriers Compliance Board, 1999): This technology converts the input sound signal to electromagnetic waves that radiate from wire loops placed around the listening area. The wire loop must be placed around the room and the user must remain within the loop in order to stay within the electromagnetic field necessary to receive transmission.

To use an Inductive Loop System, a person speaks into a microphone that is connected to an amplifier. The acoustic energy of the person's voice is changed to electrical signal by the microphone. The electrical energy is sent to the amplifier. The amplified electrical signal is sent through a loop of wire placed around the room. This coil of wire changes the electrical energy to electromagnetic energy. The electromagnetic energy is picked up by the hearing aid telecoil. The hearing aid telecoil changes the electromagnetic signal to an electrical one, which travels through the hearing aid to the hearing aid's receiver (loudspeaker). The hearing aid loudspeaker changes the electrical signal to an acoustic signal (sound) that is delivered to the ear.

3-D Loop Systems (Architectural and Transportation Barriers Compliance Board, 1999) similar to conventional inductive loop systems: An individual's voice is transmitted from the microphone to a 3-D loop processor box. The system's processor transmits the voice signal to the listener's telecoil (or receiver) by means of special "loop mats" that are placed beneath the room's carpet. Reception is not significantly affected by the orientation of the telecoil.

FM Systems (Architectural and Transportation Barriers Compliance Board, 1999): Radio Frequency Modulated (FM) systems transmit sounds via radio waves. There are two kinds of FM transmissions, wide band and narrow band. Ten wide band frequencies can be used for FM transmission. Forty narrow band frequencies are available in the 72-76 MHz band and the 216-217 MHz band. These frequencies are not reserved for hearing aid transmission, making them susceptible to interference.

With a FM System, the person speaks into a microphone. The microphone then changes the acoustic energy of the person's voice into an electrical signal that enters the person's body worn transmitter. The transmitter modulates the electrical signal into a radio wave that is sent through the air to the receiver. The receiver, worn by the listener, picks up the radio waves and changes (demodulates) them back into an electrical signal. The electrical signal is sent to the coupling system worn by the listener.

Infra-Red (IR) Systems (Architectural and Transportation Barriers Compliance Board, 1999): Light waves are used to transmit audio signals by converting them to "invisible to the human eye" light waves, at a wavelength below red light. These waves are picked up by special receivers, which change the signal back to audio. Receiver must be within direct line of sight with the light beam from the transmitter.

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Personal Assistive Listening Systems

The following devices are intended for use by a single listener:

Pocketalker: The most common type of device used by an individual is the Pocketalker. This device consists of a small processor about the size of a hand-held radio, a microphone and output device, which both connect by wire to the processor. The person talking speaks into the microphone, and the person with the hearing loss uses the output device to improve speech comprehension of the speaker. The output device can be headphones, earphones, or a wire with a jack that plugs directly into a hearing aid.

Personal FM Systems: Personal FM systems are also popular devices used by a single listener. These devices are more flexible than the Pocketalker, in that they are wireless. Acting much like a radio station, this device has a transmitter that accepts microphone input, and transmits the electronic equivalent of the sound into the air. The receiver grabs the electronic signal and provides the acoustic equivalent to the listener. The speaker wears a compact transmitter and microphone and listeners use portable receivers and earphones.

Wireless Headphones: One technology that many users have found especially useful for television listening is wireless headphones. Available in both FM and Infrared, the input can be through an audio jack plug on the TV, or through a microphone placed near the TV speaker.

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Sources of Financial Aid for Hearing Care Technologies

There are a number of options for reimbursement of hearing enhancement technologies. Programs that support these devices include Medicaid (not Medicare), Private Insurance, Community Service Programs, the Department of Veterans Affairs, and others. Assistive Listening Devices, however, are not normally covered by third party reimbursement. Health plans may limit coverage to diagnostic audiology services only, or they may limit coverage to illness/accident-related hearing disorders, excluding hearing services related to congenital causes. Hearing aids are not frequently covered by private health plans, though some benefit packages may include such items. Audiological services delivered to inpatients are routinely included in basic hospital coverage.

Reimbursement for services may be restricted to certain provider settings (hospitals or clinics), or to licensed practitioners. In addition, a primary care physician may have to refer the patient, or "prescribe," audiological treatment. Nearly all insurers will cover audiological diagnostic services when required by a physician to establish a diagnosis. Some companies cover audiologic services and hearing aids when the hearing loss results from illness or injury, but most insurers specifically exclude hearing aid coverage. Recently though, some of the Medicare HMOs have been including a hearing aid benefit in their Medicare plans (American Speech Language Hearing Association, 2000).

Medicaid

Medicaid is a joint state and federally funded program, which provides services on a state-by-state basis to financially needy individuals. It may cover any service fees (health care provider visits), hearing aid at invoice cost (only basic, analog hearing aids), and sometimes an allowance for other equipment.

• Eligibility is based on financial need and medical necessity (as determined by health care provider).

• Medicaid HMO plans which provide hearing plans include MediService, Community Care, and Partners.

• Individual states are permitted to offer the following types of optional services, provided they are specified in that state's approved Medicaid plan: clinical services; treatment for speech, hearing, and language disorders; other diagnostic, screening, and rehabilitative services; and any other type of medical or remedial care recognized under state law and approved by the Secretary of Health and Human Services.

Medicare

Medicare specifically excludes hearing aid coverage. An initial diagnostic visit may be covered if it is determined a patient does not need a hearing aid (or it is not reported that a hearing aid is needed). Individuals must meet standard qualifications for Medicare program.

Rehabilitation Services Administration (Vocational Rehabilitation)

State-federal program authorized by the Rehabilitation Act of 1973, which provides services for individuals with disabilities in order to assist them in obtaining employment. Approximately 7.3% of the rehabilitation services provided by VR in 1998 were devoted to qualified, hard-of-hearing individuals (U.S. Department of Education, 1991). Individuals must meet eligibility requirements to participate in VR program.

U.S. Veterans Administration

Veterans must contact a VA medical facility near their home. All World War I Veterans are eligible to receive free hearing aids. Other veterans can receive free hearing aids if their hearing loss is at least 50% service-related. The Veterans Health Care Act provides free TeleCaption decoders to veterans who have a profound hearing loss that is service-related. The VA will also provide TTYs and telephone amplification devices to veterans with service-related hearing loss. Some assistive devices may also be reimbursable (Gallaudet University, 1999).

• VA will pay for hearing aids, batteries and repairs - classified under Audiology and Prosthetics & Sensory Aids.

Private Insurance

Private insurance hearing coverage is limited and varies among companies and individual policies.

Civic & Service Organizations (Gallaudet University, 1999)

Many community service organizations receive charitable donations to purchase hearing aids and other devices for low-income individuals who are deaf or hard-of-hearing. Community clubs often recondition hearing aids and donate them to needy individuals.

Local Agencies & Programs (Gallaudet University, 1999)

Local agencies sometimes receive donations or private funds to assist with various needs. Speech and hearing centers may provide hearing aids at a reduced rate for clients who have used their services for audiological assessment. Some areas have hearing aid banks that distribute reconditioned hearing aids to individuals ineligible for financial assistance. These banks are often affiliated with local service organizations.

Additional Funding Sources

Although there are limited additional sources of funding available, some do exist. In some cases, for example, people have been able to convince an individual company (i.e., in the case of an employee funded medical plan) to reimburse an employee for their own, or a family member's, hearing aid expense (Hearing Industries Association, 1999).

• Trade-ins: If a hearing aid purchaser already has a hearing aid, it may be possible to receive a trade-in value on the old hearing aid when purchasing a new hearing aid. Although not common, this option does exist. This trade-in value is determined by the hearing aid dispenser on an individual basis.
• Leasing: There has been a trend in recent years of hearing aid dispensers offering patients the option of leasing, rather than buying, a hearing aid. This not only allows payments to be spread out over the useful life of the aid, but also permits the user to update technology without worrying about a huge lump sum payment. The terms and conditions of this arrangement must be worked out with the hearing aid dispenser on an individual basis.
• HEAR NOW (Gallaudet University, 1999): This unique national program provides assistance to individuals and families with limited financial resources. HEAR NOW maintains the National Hearing Aid Bank, which provides new and reconditioned hearing aids to people who are deaf and hard-of-hearing who cannot otherwise afford them. These hearing aids are distributed through hearing health care providers in communities nationwide. HEAR NOW also has a Cochlear Implant Program that raises funds to provide cochlear implants and related services to both adults and children.

ADA Compliance Reimbursement

The ADA requires, "No person shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, facilities, privileges, advantages, and accommodations of any place or public accommodation." The Architectural and Transportation Barriers Compliance Board (also known as the Access Board) states that FM, infrared and induction loop assistive listening systems are acceptable for meeting the requirements of the ADA.

The 1990 amendment to the Americans with Disabilities Act permits eligible small businesses to receive a tax credit for certain costs of compliance with the ADA. An eligible small business is one whose gross receipts do not exceed $1,000,000 or whose workforce does not consist of more than 30 full-time workers. Qualifying businesses may claim a credit of up to 50% of eligible access expenditures that are between $250 and $10,250. Examples of eligible access expenditures include the necessary and reasonable costs of removing architectural, physical, communications, and transportation barriers; providing readers, interpreters, and other auxiliary aids; and acquiring or modifying equipment or devices. Assistive listening devices may fall under this reimbursement category (The US Equal Employment Opportunity Commission, 1990).

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References

American Speech Language Hearing Association. (1997). How to Buy a Hearing Aid. Available: http://www.asha.org/consumers/brochures/hearing_aid.htm [April 25, 2000].

American Speech Language Hearing Association. (2000). Reimbursement of Speech-Language Pathology and Audiology Services Under Private Health Plans and Managed Care FAQs. Available: http://www.asha.org/professionals/governmental%5Faffairs.man%5Fcare.htm [April 25, 2000].

Architectural and Transportation Barriers Compliance Board. (1999). Table A2: Summary of Types of Assistive Listening Devices and Systems. Available: http://www.access-board.gov/bfdg/texta2.htm [April 25, 2000].

Gallaudet University. (1999). National Information Center on Deafness: Hearing Aids and Other Assistive Devices: Where to Get Assistance. Available: http://www.gallaudet.edu/~nicd/548.html [April 25, 2000]

Hearing Industries Association. (1999). Hearing Industries Association: Quarterly Statistics Report for the fourth quarter of 1999. Alexandria, VA: HIA.

Self Help for Hard of Hearing. (1999). SHHH Fact Sheet. Available: www.gwha.com/~gohear/tech.insure.html [April 25, 2000].

The US Equal Employment Opportunity Commission. (1990). Americans with Disabilities Act. Available: gopher://trace.wisc.edu/00/ftp/PUB/TEXT/ADA_INFO/HANDBOOK/H_FAQ.TXT [April 25, 2000].

U.S. Department of Education, National Institute of Disability a Rehabilitation Research. (1991). Chartbook on Work and Disability in the United States. Washington: GPO.

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