The majority of hearing aids in Australia are purchased from hearing aid clinics contracted by the Australian Government’s Hearing Services Program. This chapter discusses the structure of the hearing clinic industry, the cost of hearing aids, available subsidies and the possibilities for expanding assistance.
The recent release of a report by the Australian Competition and Consumer Commission has brought increased attention to practices used in hearing clinics to motivate clinicians to sell hearing aids. This chapter discusses the use of commissions and related sales practices and their potential impact on the advice provided by clinicians to clients. Also discussed is the provision of post-sale support and rehabilitation for hearing aid users, as well as the regulatory requirements for practicing audiologists and audiometrists.
Structure of the Hearing Aid Clinic Industry
The Department of Health’s Hearing Services Program (HSP) subsidises, or partially subsidises, approximately 80 per cent of the hearing aids sold in Australia, with Australian Hearing dispensing approximately a third of the subsidised devices.
The HSP Voucher Scheme accredits approximately 300 private operators to provide subsidised hearing devices. Between Australian Hearing and the private providers, Voucher Scheme devices are available at approximately 3700 locations across Australia.
Large hearing clinic chains account for the majority of the hearing aid industry, with just six chains (including Australian Hearing) responsible for 85 per cent of sales in the Voucher Scheme. At the other end of the scale, Independent Audiologists Australia (IAA) represents more than 200 businesses across Australia that are at least 50 per cent owned by audiologists.
Another business model is operated by Neurosensory, which runs 22 hearing and balance clinics across New South Wales, Queensland and Victoria and is jointly owned by 61 Ear, Nose and Throat Surgeons.
Some of the major hearing clinic chains are owned, or part owned, by international hearing aid manufacturers. This is known as vertical integration. For example, Connect Hearing is part of the Sonova Group and Audioclinic is part of the William Demant Group.
The Hearing Care Industry Association (HCIA) commented that ‘all of the vertically integrated HCIA members provide a full range of devices to suit every type of audible loss.’
Country Hearing Care suggested that vertically integrated chains have ‘access to hearing aids at much reduced costs … making competition for smaller independent clinics more difficult’.
Role of Australian Hearing
Australian Hearing provides free audiological services to Community Service Obligations patients (the majority of whom are children and young people). Australian Hearing also operates in the Voucher Scheme market on a commercial basis in competition with private providers.
The IAA described Australian Hearing’s practices in the Voucher Scheme market as ‘aggressive’ and stated that it was ‘completely bizarre’ that its members had to compete with a government agency. The IAA stated that ‘Australian Hearing ought to be a resource that we can all tap into rather than it be competing with us’.
The IAA also drew attention to Australian Hearing’s increasing profits, from $4.2 million in 2013 to $29.7 million in 2016, and stated that they have been:
… achieved through increasing the number of voucher holders who select Australian Hearing as their preferred provider and by encouraging pensioners to select partially subsidised hearing aids so that top up fees can be collected.
The Hearing Business Alliance (HBA) advised that many of its members believed Australian Hearing has a competitive advantage in the Voucher Scheme market, stating that ‘no other hearing service providers competing with Australian Hearing in the [Voucher Scheme] market enjoy the significant taxpayer-funded promotions afforded to Australian Hearing’.
The HBA contended that practices which provided Australian Hearing with a competitive advantage included:
promotion on the Department of Human Services website;
the automated delivery of HSP voucher applications directly from software commonly used by general practitioners (GPs) to Australian Hearing rather than providing the patient with the voucher application to take to a provider of their choice; and
actively seeking partnerships with GP clinics and major pharmacy chains to encourage these clinics to direct Voucher Scheme clients to Australian Hearing.
Australian Hearing responded to the comments relating to GP software systems and stated:
Australian Hearing has a commercial arrangement with Healthlink, an Online Health Directory and Booking System … of all our referrals only about 10 per month come via this method (at this stage) … paper GP referral remains the primary method [of referral].
The Hearing Aid Audiometrist Society of Australia (HAASA) stated that it had learned about reports of Australian Hearing setting up hearing screening tests in Centrelink offices while private hearing service providers ‘cannot even put a brochure in a Centrelink office’.
National Hearing Care stated that it would be ‘unfair’ if, due to being a government agency, Australian Hearing is able to advertise on Centrelink’s website and its offices.
Australian Hearing advised that there are ‘multiple mentions’ of Australian Hearing on the Department of Human Services website due to the fact that Australian Hearing is a Commonwealth entity and the Minister for Human Services has responsibility for administering the Australian Hearing Services Act. Australian Hearing added, however, that the website had ‘only one direct link to Australian Hearing in regards to the provision of hearing services.’
Australian Hearing also added that its commercial arm undertakes ‘a few screenings in Centrelink offices’ but that this is a commercial arrangement and it pays Centrelink for the use of its facilities.
Cost of Hearing Aids and Available Subsidies
In 2015-16, the Office of Hearing Services Voucher Scheme provided services to nearly 700 000 clients, 85.7 per cent of whom were Pensioner Concession Card holders. Voucher Scheme recipients have access to fully or partially subsidised hearing devices as well as maintenance and support.
Voucher Scheme recipients are eligible for fully subsidised base level, or standard, hearing aids. Australian Hearing stated that the Office of Hearing Services pays providers approximately $2000 on average to fit a person with hearing aids in both ears (comprising $400 to $500 per device and $1000 or more in fitting fees).
Voucher holders may choose to purchase a more expensive model of hearing aid, in which case the voucher will partially subsidise the device with the consumer contributing the remainder of the cost. This type of purchase is known as a ‘top-up’. The IAA commented that ‘top-up hearing device sales can be lucrative and the market for voucher holders has become highly competitive.’
The HCIA stated that the sale of top-up devices cross-subsidised the provision of ‘free to client’ (fully voucher subsidised) devices suggesting that the:
… industry can only sustain the best level of ‘free to client’ products in Australia if the balance between ‘free to client’ and ‘top up’ is maintained … without this cross subsidy, client access and choice would be diminished.
The HBA stated that there are generally five levels of hearing aids (and different styles within each level). The HBA described the base level hearing aids, available free to eligible clients through the Voucher Scheme, as ‘very good hearing aids’. The HBA also stated that ‘there are benefits’ from more expensive devices and so the question for the client becomes ‘do you want to spend more money for a more sophisticated device?’
The HBA explained that in a quiet environment where people are speaking on a one-to-one basis there was ‘very little difference between a basic hearing aid and a very sophisticated one.’ In an environment with more background noise, the more sophisticated devices can ‘narrow down the directionality’ of sounds and ‘smooth out unwanted sounds’.
Australian Hearing stated the most expensive hearing aids in its standard range cost approximately $7800 for two hearing aids. William Demant Holding (William Demant) stated that the most expensive aids it sells were ‘up to $6000 or $8000’ (per device) but that these were ‘not a high percentage of what we sell’.
National Seniors Australia advised a recent survey had revealed that 75 per cent of its members had been deterred from buying hearing aids due to their cost. National Seniors added that it was ‘disappointed with the lack of competition [and] price transparency in the retail market for hearing aids.’
Hearing Aid Banks
Hearing Aid Banks, which receive donated hearing aids and repurpose them for resale at a low cost, are available in each state and territory except Western Australia and the Australian Capital Territory. National Seniors Australia advised that ‘hearing aid banks offer cost-effective hearing services to people ineligible for free or subsidised services offered through the Australian Government Hearing Services Program.’
Self-Help for Hard of Hearing People Australia (SHHH Australia) outlined the services provided by the Hearing Aid Bank it runs in conjunction with Macquarie University. SHHH Australia stated:
Under this program hearing aids donated by the public are reconditioned at Macquarie University, fitted and resold at low cost to clients who hold a Commonwealth Health Care card, a doctor’s referral and a current audiogram. In the last 12 months around 20 applications for this service, mostly asylum seekers, have proceeded through to final fittings.
National Seniors Australia advised that the services which hearing aid banks can provide are ‘limited’, mainly due to ‘a lack of supply of second hand hearing aids that can be reconditioned’. In order to boost the supply of second hand hearing aids, National Seniors recommended that:
a national hearing aid register be established to enable hearing aid users to register to donate their hearing aids when no longer needed;
hearing aid providers be required to give information to their hearing aid clients about registering to donate their hearing aids to a hearing bank; and
the Australian Government consider offering a financial incentive to encourage people to donate hearing aids.
National Seniors Australia further recommended that eligibility for hearing aid banks ‘be extended to Commonwealth Seniors Health Card holders and Health Care Card holders aged under 65 [years].’
Subsidies for Working Age Australians
The HBA stated that ‘eligible Pensioners, Veterans, and young people up to the age of 26 years’ are eligible for government subsidised hearing assessments and hearing devices but that this ‘leaves a large gap for those people who fall between these safety nets’. The HBA suggested that, unless they can afford private fees, working age people may ‘go without hearing assessments and possible early intervention for their hearing health issues’.
William Demant suggested that for Australians between 26 and 64 years who cannot afford private health cover experiencing a hearing loss would make it difficult to ‘fully participate in our community’. William Demant recommended that the Government provide support to those ‘with a hearing loss aged between 26 and 64 years of age from a low
Goulburn Valley Hearing Clinic supported the extension of subsidies for hearing devices to people of working age and stated:
… extension of the [HSP] program would ensure that anybody with a hearing disability would be able to access hearing services and devices and would solve the problems currently faced by those with low incomes who face significant obstacles to their participation in the workplace and participation socially but cannot afford to buy hearing aids.
Goulburn Valley Hearing Clinic added that the cost of extending subsidies would be relatively low as the incidence of people with hearing loss under the age of 65 years is much less than among those over 65 years and highlighted that it would make ‘a huge difference’ to the lives of low-income people with hearing loss.
Deloitte Access Economics recently undertook a cost-benefit analysis of providing hearing aids free of charge to unemployed hearing impaired Australians. Deloitte Access Economics estimated that providing unemployed hearing impaired Australians with hearing aids would increase employment by almost 50 000 people. This intervention was estimated to result in a $1.7 billion productivity gain at a cost of $326.4 million, a benefit to cost ratio of 5.2 to 1.
Deloitte Access Economics also observed that ‘it would only require one person in every fifteen given new aids to move [from unemployment benefits] to the equivalent of a full time minimum wage position’ to have a positive impact on the Government budget.
Another option to assist working age Australians with the cost of hearing devices would be to make them tax deductible. This option was recommended by the Deafness Forum of Australia (Deafness Forum) which compared hearing devices to mobile phones and laptops used in the workplace. The Deafness Forum stated:
Like [mobile phones and laptops], hearing devices are communication and productivity aids in the workplace, yet they are not afforded the same tax deductibility arrangement. By making hearing devices and their batteries more affordable for working Australians via tax deductibility or similar means, the national economy will benefit from better workforce participation and keeping people in the workforce longer.
SHHH Australia supported this recommendation, but suggested that rather than being analogous to mobile phones and laptops, hearing devices were comparable to ‘academic qualifications or industry experience, in that without them people with hearing loss are unlikely to be able to perform the duties of the job’.
The Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) stated that ‘it is estimated that only ten per cent of the population who would benefit from a cochlear implant have received one.’ The ASOHNS added that this could be due to low community awareness of hearing loss treatments and a lack of access to publicly funded services in some states and territories. Australian Hearing raised a similar issue, stating that ‘cochlear implantation has been shown to improve outcomes for adults with a severe to profound hearing loss, yet this technology is still under-utilised within Australia.’
Australian Hearing advised that ‘the majority of Australians who are suitable for a cochlear implant can access this technology through private health insurance or public funding.’ The ASOHNS stated that ‘in some states you can be on the waiting list [for a cochlear implant] for a very long time, and this is an issue, particularly for young children.’
Following an implantation, the CSO program covers repairs, batteries and replacement speech processors for Australians aged under 26 years. The National Disability Insurance Scheme (NDIS) does not fund implantation surgery but may provide funding for speech processor upgrades.
Those who do not qualify for Government assistance ‘must fund repairs, replacement parts and batteries themselves’. Australian Hearing advised that private health insurance does not usually cover maintenance of cochlear implants, but may be available for replacement processors or upgrades.
Cochlear recommended speech processors be upgraded every four to six years to obtain design and hearing performance benefits. If processors are not upgraded by about the eight year mark they become obsolete and cannot be viably repaired. The cost of upgrading speech processers is approximately $8000.
Box 5.1: Cost of Hearing Devices
Many individuals were concerned about the cost of hearing devices:
‘I have spent well over $120 000 over the years on hearing aids [and] hearing tests and have had limited success claiming the costs of these on my tax … the access to and cost of hearing services and the inability to afford the best hearing aids means I have to settle for less and fight constantly just to maintain a standard existence.’
‘Without aids I can’t hear. We aren’t looking forward to the day my cochlear processor breaks. We don’t live at all and struggle to pay even everyday bills.’
‘… due to my age I do not qualify for any government rebates, my private health fund extras level does not cover any rebates, and due to the costs of raising a family on only my husband’s income, we cannot afford hearing aids … I am in a Catch-22 situation — I find it hard to work in a workplace with my level of hearing loss, but without working I cannot afford to fund the purchase of hearing aids.’
‘To stay at the level of employment in my career or to consider moving to the next level, it was important, like a mobile phone, that ideally I secure an updated hearing aid every two to three years. However in reality it is, for me, between four to six years, after saving up the funds to afford it.’
‘As a parent of a child with hearing loss I am concerned about what happens once my son turns 26. I look around my workplace and realise that open plan offices, most meeting rooms and auditoriums are not hearing loss friendly. I hope that as an adult my son chooses to pay for his hearing expenses rather than a holiday or a night out.’
‘I was appalled when I discovered that my hearing impaired children were making-do in difficult working situations with old, inadequate hearing aids because as parents they felt that they could not justify the $8500 to $10 000 cost of adequate hearing aids and supplementary devices.’
Hearing Aid Clinic Sales Targets and Commissions
On 3 March 2017 the Australian Competition and Consumer Commission (ACCC) released its report Issues around the Sale of Hearing Aids: Consumer and Clinician Perspectives. This ACCC investigation was instigated after ‘potential consumer protection issues’ were identified in an ABC Radio National program, and included a survey of consumers and clinicians and discussions with major hearing clinic operators.
The ACCC report investigated the use of commissions and other sales incentives and found that they are ‘commonly used to motivate clinicians to sell hearing aids, particularly in clinics run by major operators’. The ACCC stated that ‘commissions can be as much as 15 per cent’ and that ‘more expensive hearing aids generally attract higher commissions’.
In addition to commissions, other sales indicators were used to measure clinicians’ performance. These included the number of hearing aids sold, their average price, and the number of high-end and ‘top-up’ devices sold.
Some clinicians surveyed by the ACCC stated they believed their employers were more focused on sales than providing independent advice or serving the consumer’s best interests. Clinicians also stated that ‘devices may be recommended based on commissions rather than consumers’ needs’.
The ACCC was critical of the use of commissions in a ‘healthcare setting’ where consumers would expect clinicians to ‘provide independent and impartial advice and have as their primary consideration the wellbeing and best interest of the consumers they are consulting’. The ACCC expressed concern that these sales practices could jeopardise the impartiality of clinicians, and stated:
… commissions, incentives and other mechanisms designed to drive sales can create a conflict with clinical independence, professional integrity and the primary obligation to consumers. This conflict is particularly troubling in the sale of hearing aids, given that consumers who require hearing devices are often disadvantaged or vulnerable due to their hearing loss, age, other medical conditions, disability, income, or a combination of these things.
The ACCC commented that the information it had received was often anecdotal and it was therefore ‘difficult to find instances that we were able to pursue from an enforcement perspective’.
National Seniors Australia criticised the up-selling of hearing aids, stating ‘our members often feel pressured into purchasing more expensive hearing aids without any real understanding of the comparative cost benefit of the product being sold.
The Deafness Forum was critical of the lack of transparency around the use of commissions stating that the ‘practitioner is not obliged to declare whether they receive a commission for fitting a particular device.’ The Deafness Forum further stated that ‘the payment of commissions should be discontinued or at the very least be made transparent so the client knows that the practitioner is obtaining a benefit from recommending a particular device.’
The Department of Health advised that service providers contracted under the Voucher Scheme were required to ‘disclose preferred provider arrangements for hearing devices, including payments of commissions or incentives.’ The Department of Health also advised that ‘service providers must not encourage a client to purchase a partially subsidised device where an approved free-to-client device would reasonably meet their needs.’
Inquiry participants from smaller or independent clinics, and the peak bodies representing these clinics, tended to be critical of the use of commissions. Arafura Audiology described commissions as ‘relatively reprehensible’, stating ‘they do influence the way clinicians behave’. The IAA stated that commissions are ‘unacceptable in any healthcare setting’.
Goulburn Valley Hearing Clinic contended there was a difference between hearing providers that operate as clinical practices and focus ‘on the needs of clients’; and those that operate as retail practices and focus on ‘profit in hearing aid sales’. Goulburn Valley added that retail practices ‘pay commissions to and set sales targets for their clinicians, with pressures on clinicians to upsell hearing devices’.
National Hearing Care, which uses commissions as part of its remuneration packages for clinicians, explained that the purpose of commissions and incentives:
… is not to encourage upselling and the prescribing of devices that are not required … It is a remuneration structure that National Hearing Care and our clinicians have been very happy with in the past. I think the most important point here is that it is not a remuneration structure that has led to any material complaints from our customers.
The HCIA commented on the difficulty of defining what would be considered a commission or incentive, for example questioning whether profit-sharing would be included. The HCIA also stated that the motivations for an independent operator may be the same as an audiologist working for a commission, stating ‘with an independent operator who owns their own business, the more people they see, the more work they do and the more devices they prescribe the [better the] commercial performance of their business’.
The Can:Do Group recounted that it had originally paid commissions to its clinicians, due to believing it was an industry norm and a concern that as a not-for-profit business it would not be able to ‘match base [salary] rates with government or corporate owned clinics.’ In 2015-16 Can:Do made the decision to ‘cease paying any commissions, a decision reached in consultation with [its] clinicians.’ Can:Do stated that its staff were ‘happier with this arrangement’ and that ‘client satisfaction numbers remain high’. Can:Do stated that the abolition of commissions had not changed the number of top-up hearing aids sold.
The HBA commented that its members were aware of other providers who set sales targets and used ‘league tables’ of clinicians to highlight who is ‘letting the side down’ in meeting these sales targets. The HBA believed that these employment conditions ‘must influence the clinical judgement of clinicians when providing hearing advice’.
On 21 June 2017, the Australian College of Audiology (ACAud) released a position paper stating that ‘the use of sales commissions and sales based incentives may lead clinicians and businesses to make decisions that are questionable and may, in fact, be unethical.’ The ACAud recommended that ‘sales commissions and sales based incentives should cease to be a part of the salary packages of ACAud members as soon as it is feasible to make changes in the workplace’.
Audiology Australia and the IAA were both opposed to the practice of selling hearing aids as bundled packages. Audiology Australia explained the practice and the reason for its opposition to it and stated:
… the term “bundled” refers to the bundling of the audiologist’s service fee and the device into one package – a practice that Audiology Australia is opposed to as it simultaneously minimises the value of the audiological service and obscures the true cost of the device.
National Seniors Australia supported the unbundling of clinical services from the sale of devices stating that ‘ideally, hearing assessments should occur separately from sales so that an individual can receive a hearing assessment and then take the audiogram result and shop around to find the best product and service.’
The HAASA suggested that the hearing clinic industry was moving towards a system of unbundling the cost of devices and service provision. The HAASA raised concerns about this trend and stated:
In the past, our hearing aid fittings were part of the service. You walk into a clinician's office, you discuss the issue with them and they will give you an option that would fit your hearing loss. And that option would include the cost of the hearing aid, the hearing fitting, the rehab … There is a mixed feeling about [the move towards unbundling] within the industry. Do we really want to go that way? … We have prided ourselves on having probably one of the best hearing systems in the world. And it has worked because we have taken a holistic approach [to] it.
William Demant commented on a current review into services and technology supply in the HSP being undertaken by Pricewaterhouse Coopers on behalf of the Department of Health. William Demant was critical of proposals within the review which considered:
… uncoupling the funding of a device acquisition from the clinician who prescribes, supports and provides rehabilitation throughout the lifetime of that device. If uncoupled, this could lead to clients acquiring devices not clinically suited to their needs, resulting in poor clinical outcomes and wastage of Government dollars.
National Seniors Australia suggested that free hearing tests are being used as a means of generating sales for hearing clinics. National Seniors relayed the story of a member who had a free test and then was immediately pressured to buy a hearing aid and asked how much they were able to spend. The IAA stated that ‘there is no such thing as a free hearing test … it is just bundled into the price of the hearing aid’.
Agreements between Hearing Clinics and GP Clinics
The HBA raised concerns about Memorandums of Understanding (MoUs) between hearing clinics and GP clinics. The HBA stated that MoUs enable GPs to undertake and bulk bill hearing screenings which result in a referral to the specific hearing clinic in the MoU agreement. The HBA stated that these:
MoUs tend to advantage the large hearing chains and the result is that the hearing chains and large GP chains/super clinics have formed alliances which have the effect of excluding the local small to medium hearing service providers from their market place.
Australian Hearing confirmed that it does offer GPs ‘an opportunity to enter into a memorandum of understanding so they [can] offer hearing checks within their own practice’, but there was no clause in these MoUs preventing the GPs also engaging with other hearing service providers. Australian Hearing added that the ACCC had investigated these arrangements and found that there was ‘no anticompetitive behaviour’ and that they did not involve a financial arrangement between Australian Hearing and GPs.
National Hearing Care suggested that hearing clinics would regularly set up temporary clinic sites and that these could be in GP clinics and stated:
… you have your part-time shops or your visiting sites. They will often be where you rent out a room in a GP’s site for a day per week or a day per month … often it will be in a GP clinic or a pharmacy or anywhere that is deemed appropriate.
Methods of Regulating Sales in Hearing Aid Clinics
Goulburn Valley Hearing Clinic suggested that HSP contracts with providers should be used to remove top-ups and regulate the provider ’rather than practitioner behaviour’. Goulburn Valley highlighted that ’80 per cent of hearing aids in this country are paid for by the government … Because the [HSP] is ruled by a contract, provisions could be written into the contract to say that these behaviours are unacceptable under the terms of the contract.’
The ACCC suggested that a potential regulatory model for hearing aid clinics could involve the ‘separation of the provision of health services from the delivery of retail supply of products’. The ACCC added that changes such as the banning of commissions could be made through the use of the administrative requirements of government programs.
The Department of Health advised that the ‘prohibiting of commissions within the Hearing Services Program would require a decision of Government to amend the program legislation, [the] Hearing Services Administrative Act 1997’ (Cwlth).
EARtrak, a company which provides measurement of hearing clinic client outcomes, stated that the HSP program currently ‘rewards providers simply for fitting hearing aids to clients rather than for achieving outcomes which reduce the burden of disease’.
EARtrak recommended the development of a system where clients of hearing clinics would be surveyed six months after they have been fitted with a hearing aid in order to assess whether the fitting had resulted in an improved clinical outcome. Individual results would be compiled and used to assess the quality of care being provided by clinics. Clinics would then be rated based on the clinical outcomes of their clients and this information would be publically available to assist consumers to choose a clinic providing a high quality of care.
Arafura Audiology questioned the need for a medical review (for example by a GP) prior to seeing an audiologist and stated:
Studies from other parts of the world show that 80 to 90 per cent of these people do not actually need a medical review before they have audiology. Audiologists are well versed, with over five to six or more years of training, as to where patients should go once they are seen. If there is a disorder that is not manageable by an audiologist, we are to refer onwards.
The Department of Health advised it is currently reviewing the ‘Hearing Service Program Schedule of service items and fees’ and as part of this review consideration would be given to the ‘Voucher Program model of service delivery’ and ‘other reimbursement models which might better support client outcomes, business processes, and simplify administration’.
Australian Hearing commented that the provision of hearing devices is only one aspect of addressing hearing issues:
While technology is beneficial for people with hearing impairment it is not the answer on its own. Support, training, counselling, auditory rehabilitation and connection with other family members are all critical to successful outcomes for clients.
The Bionics Institute further explained:
It is not just a matter of sticking a hearing aid on somebody; you need to advise people not only about what they need to do or how they can improve their communication skills but also how they can improve their use of the hearing device.
Speech Pathology Australia advised that speech pathologists ‘are usually part of a multidisciplinary hearing team, but not always.’ Speech Pathology Australia outlined the role of speech pathologists in assisting people with hearing impairments:
Typically, speech pathologists would be involved at the onset and, after assessment, with device intervention and the provision of aural rehabilitation services, which in speech pathology is management designed to assist the person with maximising their hearing, speech, language and communication given their hearing impairment.
Speech Pathology Australia further advised that ‘aged care pension recipients fitted with hearing aids as part of an Office of Hearing Services funding package, are eligible for five aural rehabilitation sessions’.
The Australian Society of Rehabilitation Counsellors (ASORC) advised that for hearing services, ‘best practice service models are not offered to the Australian community.’ Features of best practice models included ‘client education, effective communication training [and] psychological support for individuals and their families’, in addition to the provision of hearing devices.
SHHH Australia observed that ‘hearing health professionals generally have limited knowledge of the rehabilitation aspects of managing hearing loss.’ As such, SHHH Australia advocated for greater recognition of the value of rehabilitation in treating hearing impairment. The ASORC also stated that while the Office of Hearing Services provides funding for rehabilitation services, ‘barely five per cent of clients were offered this service by existing eligible service providers.’
Better Hearing Australia Canberra suggested that the payment model for audiologists needed to move to an ‘outcome-based funding model’ where audiologists are paid for ‘solving the problem of the person with the hearing loss, not just selling them a hearing aid.’ SHHH Australia recommended the Government increase regulation of the hearing industry to ‘ensure that the focus is on professional diagnosis and support.’
SHHH Australia also stated that there is a need to develop a management plan to assist new hearing aid users, as this is ‘the time that a new user will experience frustration and just give up.’ SHHH Australia advised that a management plan could outline communication strategies for a range of scenarios, such as in the house, the car and in public venues.
A number of submissions supported greater funding for rehabilitation services. Better Hearing Australia recommended that ‘organisations be funded to provide aural rehabilitation using properly trained staff (e.g. social and welfare workers, psychologists and counsellors).’ SHHH Australia drew attention to the role of consumer advocacy groups in providing practical advice and support from people who have had ‘lived experience’ of hearing loss, and recommended funding be provided to these organisations to deliver services. The ASORC recommended the Government accredit and fund Rehabilitation Counsellors to provide psychosocial support programs for people receiving hearing services.
In order to increase access to speech pathology services, Speech Pathology Australia recommended the Government:
Increase the number of speech pathology consultations that can be rebated per year through the MBS Chronic Disease Management Items (currently less than five per year).
Provide MBS rebates for speech pathology service provided through telepractice format for Australians with hearing loss.
Alternatives to Using Hearing Aids
The ASORC estimated that the Government is spending hundreds of millions of dollars on providing hearing aids to people who rarely or never end up using them. The ASORC further stated that many people who do use their hearing aids experience difficulty doing so.
The ASORC advised that Rehabilitation Counsellors can provide assistance to people who have not yet received a hearing aid, to assess their readiness for such a device. The ASORC explained that rehabilitation programs:
… introduce people to alternate communication strategies and have been shown to reduce stress associated with hearing impairment ... only one third of people undertaking these programs immediately proceed to purchasing a hearing aid, with others choosing instead to use other communication strategies or assistive hearing devices that aid with hearing the TV etc.
Speech pathologists can develop communication strategies for people who choose not to use, or are not eligible for, hearing devices. Speech Pathology Australia advocated for the ‘development of information materials’ outlining ‘alternative communication strategies’ for hearing impaired Australians who do not want to use a hearing device.
Speech Pathology Australia further recommended funding mechanisms be used to ‘encourage more interdisciplinary [work] between audiologists and speech pathologists’, which would result in more comprehensive care and an enhancement of communication strategies for hearing impaired people not using hearing devices.
SHHH Australia considered that, in some cases, assistive technologies ‘are all that is needed’ to address a hearing impairment and can ‘negate the need for more expensive technology’, such as hearing aids.
Assistive technologies can also be used in conjunction with hearing devices. SHHH Australia listed assistive devices as including ‘Captel phones, shake awake alarms, earphones and head phones for TV, induction loops and door chimes.’
Training, Registration, and Skills Shortages in Audiology and Audiometry
Regulatory Settings in Hearing Health Professions
The audiology and audiometry industries are currently self-regulated. The ACCC described the regulatory settings in the hearing health sector by stating:
… there are some associations for audiologists and audiometrists, and they provide some level of oversight and standards. Of course, participation in the government schemes is a further check and balance that provides some regulation. Beyond that, my understanding is that there is not that level of regulation that you see in other health sectors.
There are three Practitioner Professional Bodies that represent audiologists and/or audiometrists:
Audiology Australia, the peak professional body for audiologists;
The ACAud, which represents both audiometrists and audiologists; and
The HAASA, which represents audiometrists.
These three Practitioner Professional Bodies developed a joint Code of Conduct for their members, based on the National Code of Conduct for healthcare workers.
In order to provide hearing services under the Australian Government’s HSP, an audiologist or audiometrist must be a member of one of the Practitioner Professional Bodies, as well as meeting other qualification requirements. Audiology Australia further advised that ‘private healthcare funds also require that the audiologist is a member of Audiology Australia for hearing service fees to be reimbursed.’
Audiology Australia stated that it provided a ‘high standard of self‑regulation’ for the audiology profession, and that ’95 per cent of audiologists in Australia are members of Audiology Australia.’ Similarly, the HAASA advised that for the audiometry industry, self-regulation ‘has worked really well for … many decades.’
William Demant expressed concern that there is ‘no formal centralised registration of audiologists and audiometrists as a registered profession’, and that although practitioners providing government services must be registered with a Practitioner Professional Body, ‘this information is not accessible to consumers.’ The IAA stated that ‘the consequence of not having a compulsory register of audiologists in Australia is that any person can undertake audiology work regardless of their qualifications.’
Audiology Australia recommended the Government:
… formally recognise the role of self-regulation by officially endorsing the [National Alliance of Self-Regulating Health Professions (NASRHP)] model and recommending members of the public to see only those clinicians who have been certified by a NASRHP professional body.
The IAA stated that self‑regulation has not prevented ‘corrupt practices’ from taking place. The Goulburn Valley Hearing Clinic expressed similar sentiments, stating that in the current self-regulatory environment ‘there is no mechanism for controlling the more avaricious and exploitative behaviours of the large providers, who between them control over 80 per cent of the market.’ Country Hearing Care also stated that self-regulation in the industry is ‘failing miserably.’
As such, the IAA considered that:
… mandatory registration for audiologists and audiometrists, each with their own and separately defined scope of practice, and with a professional board under the Australian Health Practitioner Regulation Agency—AHPRA—that regulates influences from industry as well as clinical practices is essential to enforcing professional standards acceptable in health care within the audiology field.
The Goulburn Valley Hearing Clinic agreed and stated that ‘we need to bring audiology under AHPRA.’ Audiology Australia also stated it ‘would welcome any consideration by the COAG Health Council to include audiology as a registered profession’.
The IAA further stated that Australia’s hearing services regulatory system ‘contrasts with regulation around the world.’ The IAA cited examples of regulation from comparable countries, including:
United Kingdom (UK): Audiology in the UK is regulated by the Health Professionals Council (HPC). Registration as a Clinical Scientist (Audiology) with the HPC is required. The title of 'Clinical Scientist' is protected, meaning it is illegal to work under this title in the UK unless registered with the HPC.
United States of America: Licensing (by state) is required to practice the profession of audiology. The minimum educational level is a doctorate.
Canada: Provinces regulate the profession of audiology. Registration with the regulatory body (known as colleges) in a regulated province or territory is required.
William Demant commented that the Office of Hearing Services established a steering group in 2016, with representatives of the hearing industry, to ‘review and recommend the most appropriate regulatory model for hearing services in Australia, including governance arrangements.’ William Demant recommended the Government introduce a regulatory model for hearing services that:
Ensures a nationally consistent approach to quality hearing services to clients that is cost effective and will not impose unnecessary burden on service providers and practitioners; and
Establishes central regulatory oversight of qualifications and professional training in the hearing health industry, which is made accessible to the public.
Skills Shortages – Audiology and Audiometry
William Demant stated that:
There is a shortage of clinically trained audiologists and audiometrists in Australia, which is limiting the industry’s capacity to support an increasing number of Australians who need hearing healthcare.
William Demant further advised that as Australia’s population ages, and hearing needs and treatment becomes more complex, demand for hearing services will increase.
Regional areas in particular may experience shortages of hearing health professionals. According to National Hearing Care, this is largely due to difficulties in attracting hearing health professionals to regional locations, but may also be due to the ‘clear shortage’ of audiologists and audiometrists in Australia.
William Demant recommended the Government address the current enrolment shortages in audiology and audiometry courses to increase the number of hearing health workers. The HCIA made a similar point, urging the Government to ensure the Diploma of Audiology continues to attract government financial assistance.
William Demant also recommended the Government address barriers to recruiting audiologists and audiometrists from overseas through the skilled migration program. The HCIA similarly stated that ‘the industry needs to utilise the 457 Visa program to meet workforce need.’
The HBA put forward a different view, stating that it has ‘concerns about the use of 457 [Visas] in the hearing industry’. In fact, the HBA questioned whether there was a workforce shortage in the hearing services market:
It was brought to our attention by some of our members who have started seeing competition in regional areas where there was really no need for another clinic, but the chains were trying to get market share. So they believed they advertised however many times … and, when you cannot fill the position, you say, 'I have a shortage' and bring in a foreign audiologist.
A number of organisations representing small audiology and audiometry businesses and their professional staff were concerned about Australian Hearing’s commercial practices in the Hearing Services Program Voucher Scheme market. The Committee understands that Australian Hearing acts as a commercial provider in this market and as such has a need to promote and advertise its services. Nevertheless, there is a perception among some businesses that Australian Hearing’s practices may be undermining competition in the Voucher Scheme market and so limiting the ability of clients to receive services from a provider of their choice.
On the basis of the evidence received it is not possible to determine whether Australian Hearing’s commercial approach in the Voucher Scheme market is having a detrimental impact on competition. As such the Committee believes that this is an issue that requires more detailed investigation.
Subsidies for Working Age Australians
The Committee notes that many hearing impaired Australians of working age are not eligible for government assistance in purchasing hearing devices or accessing hearing health services. For many hearing impaired Australians in the workforce their hearing devices are an essential support enabling them to continue in employment. Hearing devices are expensive items and for some hearing impaired Australians purchasing or updating a hearing device may not always be possible.
Deloitte Access Economics research suggests that providing unemployed hearing impaired Australians with free hearing aids would have a
benefit-to-cost ratio of 5.2 to 1. If only one in every fifteen of the people provided with free hearing aids moved into full time employment there would be an overall positive impact on the Government budget. There is also a risk that if access to subsidised hearing aids was only available to the unemployed this may create perverse incentives for hearing impaired Australians on low incomes to leave employment. Therefore, financial support for the purchase of hearing aids should be extended to unemployed and low income earning hearing impaired Australians.
Commissions and Sales Practices in Hearing Aid Clinics
The Committee is concerned by the findings of the Australian Competition and Consumer Commission’s (ACCC) investigation into the use of commissions and other sales practices in the hearing clinic industry. Although the ACCC advised that it was unable to undertake any enforcement actions against individual clinics, the practices that it described were confirmed by a number of organisations and individuals who participated in this inquiry.
The Committee believes that the use of these sales practices is not appropriate in a healthcare setting. The clinical decisions of audiologists and audiometrists need to be based on the best interests of their client’s health, not potential financial gain. The Committee considers the use of these practices as unethical as they undermine the clinical judgement and impartiality of audiologists and audiometrists and also place a vulnerable group of consumers at risk of financial exploitation.
The Committee calls on Australian Hearing to cease the use of commissions and similar sales practices as soon as is feasible. The Committee also calls on the Department of Health to begin making the necessary arrangements to prohibit the use of commissions by private providers operating in the Hearing Services Program. The Committee encourages private providers to voluntarily phase out the use of commissions and similar practices as soon as is practicable.
Support and Rehabilitation
Unfortunately some hearing impaired Australians do not get the benefit from hearing aids that they expected. In many cases training and support can help people properly benefit from hearing aids. Volunteer organisations such as Better Hearing Australia and Self Help for Hard of Hearing People Australia help hearing impaired Australians benefit from their hearing aids and learn additional techniques to improve their communication skills. The Committee commends these groups for their activities.
Regulation of Audiologists and Audiometrists
The Committee considers that the majority of audiologists and audiometrists are appropriately qualified and acknowledges that there are currently three professional bodies representing audiologists and audiometrists. Nevertheless, several representatives of hearing clinic businesses (representing both small independent clinics and large chains) are calling for the registration of audiology and audiometry under the Australian Health Practitioner Regulation Agency (AHPRA). This would bring audiology and audiometry into line with the regulatory procedures used by other, broadly equivalent, healthcare professions. The Committee believes that AHPRA registration would strengthen the professional standards regulating the professions of audiology and audiometry.
The Committee recommends a review be undertaken of Australian Hearing’s commercial operations to ensure it is undertaking a competitively neutral approach to its participation in the Hearing Services Program Voucher Scheme.
The Committee recommends that the Community Service Obligations program be extended to provide hearing services to hearing impaired Australians aged 26 to 65 years on low incomes or who are unemployed and qualify for lower income support or the Low Income Superannuation Tax Offset.
The Committee recommends the Australian Government’s Hearing Services Program prohibit the use of commissions or any other similar sales practices likely to undermine the ability of audiologists and audiometrists to provide independent and impartial clinical advice. The Committee also recommends that:
Australian Hearing cease the use of commissions and similar sales practices as soon as is feasible.
The Department of Health amends contracts with service providers operating under the Hearing Services Program Voucher Scheme to prohibit the use of commissions and similar sales practices as soon as is feasible.
If necessary, changes be made to the Hearing Services Administrative Act 1997 (Cwlth), and any other relevant legislation or regulation, to enable the prohibition of commissions and similar sales practices as described above.
The Committee recommends that the Australian Government pursue the registration of the audiology and audiometry professions under the Australian Health Practitioner Regulation Agency framework with the Council of Australian Governments.