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International Hearing Society

International Hearing Society







July 14, 2015

Chairman Benishek, Ranking Member Brownley, and esteemed Members of the Subcommittee:

International Hearing Society thanks you for the opportunity to comment on H.R. 353.  IHS stands in full support of the bill, which would create a new provider class for hearing aid specialists within the Department of Veterans Affairs (VA), thereby enabling the VA to hire hearing aid specialists to help deliver hearing aid services to Veterans.  The bill would also require the VA to report annually to Congress on appointment wait times and the utilization of providers for hearing-related services, which would make the VA’s efforts to address the backlog more transparent and provide much needed data to inform Congress about Veterans’ experiences in accessing hearing aid services through the VA.

The International Hearing Society, founded in 1951, is a professional membership organization that represents hearing aid specialists, dispensing audiologists, and dispensing physicians, including the approximately 9,000 hearing aid specialists who practice in the United States.  IHS promotes and maintains the highest possible standards for its members in the best interests of the hearing-impaired population they serve by conducting programs in competency accreditation, testing, education and training, and encourages continued growth and education for its members through advanced certification programs.

The VA continues to see a dramatic rise in the demand for audiology services.  According to the VA the number of unique Veterans that received VA audiology services in FY 2014 was 903,075, an increase of 19% since 2011, with 52,138 new Veterans in 2014 alone (a 5.8% increase)[1],[2].  The number of hearing aids ordered per year by the VA has also dramatically increased with more than 800,000 ordered in 2014[3], up 34% since 2011[4].  With tinnitus and hearing loss being the two most prevalent service-connected disabilities for veterans receiving federal compensation combined with the aging Veteran population, the demand will continue to rise.  And despite clinical audiologist-hiring within the VA following a similar growth track with a 26% increase in staffing between 2011 and 2015,[5],[6] the high demand and subsequent backlog continue to affect the VA’s ability to deliver timely and high-quality hearing healthcare.

IHS and its members have a great deal of respect for VA audiologists.  They provide a wide variety of critical services to our Veterans, including compensation and pension exams (over 151,000 performed in 2012[7]), programming and providing support for cochlear implant implantation and use, vestibular (balance) disorder services, tinnitus services, hearing conservation, hearing aid services and assistive device use, and advanced hearing testing.  They also partner with several medical disciplines and are part of the Traumatic Brain Injury and Polytrauma teams, addressing balance and auditory issues.  Further, VA audiologists also responsible for training and supervising audiology health technicians.

The high demands on VA audiologists’ time and expertise means that the VA is not currently able to meet all Veterans’ needs for hearing healthcare services.  To that point, in February 2014, the VA Inspector General released a report, “Audit of VA Hearing Aid Services” that found that “during the 6-month period ending September 2012, VHA issued 30 percent of its hearing aids to veterans more than 30 days from the estimated date the facility received the hearing aids from its vendors.” The audit also found that deliveries of repaired hearing aids to Veterans were subject to delay partially due to “inadequate staffing to meet an increased workload, due in part to the large number of veterans requiring C&P audiology examinations.” Further, in an April 2015 presentation to the Institute of Medicine’s Committee on Accessible and Affordable Hearing Health Care for Adults, VA Rehabilitation and Prosthetic Services Department Chief Consultant, David Chandler, PhD, cited that “nearly half of all patients awaiting care in the VA are for audiology services.”

In a practical sense, as a result of the backlog and delays, many Veterans are experiencing long wait times for appointments, shortened appointments, and limited follow-up care and counseling.  Hearing aid specialists are observing an increase in the number of Veterans who seek care in their private offices as well.  These Veterans request hearing aid specialists’ help with hearing aid adjustments and repairs, oftentimes because they do not want to wait for the next available VA appointment, which may be months away, or because the distance to the closest VA facility that offers audiology services is too far to travel. There are also many Veterans who choose to purchase hearing aids at their own expense through a private hearing aid specialist, rather than using the benefits they’ve earned and are entitled to, because they want to work with someone local who they trust and ensure their hearing aids are properly programmed, address their loss, and can be adjusted or repaired in a timely fashion. This relationship also enables them to obtain support from their hearing professional on demand, which is important to those with daily commitments or who are employed, and is especially critical to those who are new users of hearing aids.  For a point of reference, in the private market, a new user would typically see their hearing aid specialist 4-6 times in the first three to six months to help them to adapt to a hearing world and optimize their success with hearing aids.

Considering the safety risks involved as well as the impact untreated hearing loss can have on one’s personal relationships and mental well-being, the VA needs an immediate solution to deal with the backlog and get Veterans the help they need.  We also know that our working-age Veterans are anxious to contribute to society through employment, and properly fit and programmed hearing aids are necessary for their success in obtaining and maintaining meaningful employment.

H.R. 353 provides the VA a much needed solution by creating a new provider class for hearing aid specialists to work within the VA.  Hearing aid specialists can help the VA hearing healthcare team by providing hearing aid evaluations; hearing aid fittings and orientation; hearing aid verification and clinical outcome measurements; customary after care services, including repairs, reprogramming and modification; and the making of ear impressions for ear molds – just as they are currently authorized to do in the VA’s fee-for-service contract network.

By adding hearing aid specialists to the audiology-led team to perform these specialized hearing aid services independently, audiologists will be able to focus on Veterans with complex medical and audiological conditions, as well as perform the disability evaluations, testing, and treatment services for which audiologists are uniquely qualified to provide – thereby maximizing efficiency within the system and supporting the team-based approach, a common model in the private market.  Adoption of the hearing aid specialist job classification at this juncture will also be advantageous given the fact that VA Audiology and Speech Pathology Service management will be developing staff and productivity standards as a result of the Inspector General’s audit and recommendations,[8] and would be able to consider the use of hearing aid specialists as they develop their model.

Also, by virtue of the report language in H.R. 353, which would shine a light on the VA’s utilization of hearing aid specialists in its contract network, it is our hope that the VA would take better advantage of this willing and able provider type to help address the need for hearing aid services.  To open up additional points of access, the VA can and should eliminate unnecessary policy restrictions that impact VA clinics’ abilities to utilize hearing aid specialists in the contract network.

Hearing Aid Specialist Qualifications

Hearing aid specialists are regulated professionals in all 50 states and in the non-VA market, hearing aid specialists perform hearing tests and dispense approximately 50% of hearing aids to the public. They are licensed/registered to perform hearing evaluations, screen for the Food and Drug Administration (FDA) “Red Flags” indicating a possible medical condition requiring physician intervention, determine candidacy for hearing aids, provide hearing aid recommendation and selection, perform hearing aid fittings and adjustments, perform fitting verification and hearing aid repairs, take ear impressions for ear molds, and provide counseling and aural rehabilitation.

Training for the profession is predominantly done through an apprenticeship model, an accepted and appropriate path given the hands-on and technical skill involved in the profession.  And while licensure requirements vary from state to state, in addition to the apprenticeship experience, candidates generally must hold a minimum of a high school diploma or an associate’s degree in hearing instrument sciences. These requirements merely create a floor, evident in the fact that 87% of hearing aid specialists have obtained some college coursework, or an associates or higher academic degree.[9]  In nearly every state, candidates must pass both written and practical examinations, and in many states a distance learning course in hearing instrument sciences is required or recommended.  Ultimately, when making hiring decisions, the VA will have the ability to determine which candidates meet their needs. 

Hearing aid specialists are already recognized by several Federal agencies to perform hearing healthcare services.  The Standard Occupational Classification (SOC) identifies hearing aid specialists within the Healthcare Practitioners and Technical Occupations category (29-2092), and the Federal Employee Health Benefit program and Office of Policy and Management support the use of hearing aid specialists for hearing aid and related services.  And while Medicare does not cover hearing testing for the purpose of recommending hearing aids (a policy that applies to all dispensing practitioners), hearing aid specialists provide hearing testing, hearing aids, and related services for state Medicaid programs around the country.  Further, most insurance companies contract with hearing aid specialists to provide hearing tests and hearing aid services for their beneficiaries. 

Finally, evidence shows that there is no comparable difference in the quality and outcomes of hearing aid services based on site of service or type of provider (audiologist or hearing aid specialist).  A well-respected industry study found that instead the best determinant of patient satisfaction is whether the provider used best practices like fit verification, making adjustments beyond the manufacturer’s initial settings, providing counseling, and selecting the appropriate device for one’s loss and manual dexterity.[10]

VA Strategies to Address Demand

To address the demand for audiology and hearing aid services, the VA has been relying on the use of teleaudiology, audiology health technicians, and contract audiologists outside the VA setting.  While IHS applauds the VA for its efforts to better serve the needs of Veterans, each of these strategies has its limitations. Though teleaudiology can make audiological services more available in remote settings, the cost of staffing and facilities are needlessly high, especially given that hearing aid specialists have fully-equipped offices, oftentimes operate in rural settings, and perform home and nursing home visits.  Audiology health technicians have a very limited scope of duties, which does not include hearing aid tests or the fitting and dispensing of hearing aids, and they must be supervised by audiologists.  Hiring hearing aid specialists to work as health technicians, as the VA currently does, significantly limits their role and effectiveness.  Finally, increased reliance solely on audiologists may also limit access as there are not enough audiologists to fill the current and future need for hearing care services.  In order to fill the need, the number of licensed audiologists needs to double in size within the next 30 years to 32,000; however only about 600 are entering the profession annually.  Even the best case scenarios for increasing the number of graduates and reducing attrition still fall short. [11]

In a June presentation, VA Deputy Chief Patient Care Services Officer for Rehabilitation and Prosthetic Services, Dr. Lucille Beck, PhD, cited several barriers to the delivery of hearing health care services for the VA, including “Some VA sites having space constraints that challenge expansion of current audiology services”, “Some veterans are very old or sick and cannot travel outside of the home”, and “Lack of developed hearing health care networks and standards for VA to partner with the community.”  In each of these areas, hearing aid specialists, both internally and through their expanded use in the fee-for-service network can help.

As the federal government seeks to become more efficient and cost-effective, we urge the Subcommittee to pass H.R. 353, which will round out the VA hearing healthcare team to mirror the private-market model, and increase Veterans’ access to care, improve overall quality, and reduce cost.  Again, using hearing aid specialists as health technicians is not the answer; this limits service delivery and underutilizes the skills and expertise hearing aid specialists can offer to the VA hearing healthcare team.  Now is the time to embrace hearing aid specialists in the role they are trained and licensed to play to help meet the hearing healthcare needs of our Veterans, which will only continue to rise in the coming years.

Thank you for your consideration and for your service to our Veterans.  With questions, please contact government affairs director Alissa Parady at 571-212-8596 or

[1] David Chandler, PhD, “Perspective from Department of Veterans Affairs,” Presentation to the Institute of Medicine’s Committee on Accessible and Affordable Hearing Health Care for Adults, April 27, 2015

[2] Lucille Beck, PhD, “Meeting the Challenges of VA Audiology Care in the 21st Century,” presentation to the Association of VA Audiologists, March 19, 2012

[3] Chandler, “Perspective from Department” (see footnote 1)

[4] Beck, “Meeting the Challenges” (see footnote 2)

[5] Chandler, “Perspective from Department” (see footnote 1)

[6] Beck, “Meeting the Challenges” (see footnote 2)

[7] VA Office of Inspector General, “Audit of VA's Hearing Aid Services,” February 20, 2014

[8] VA Office of Inspector General report “Audit of VA’s Hearing Aid Services,” February 20, 2014

[9] International Hearing Society, Health Policy and Payment Survey, June 2013

[10] MarkeTrak VIII: The Impact of the Hearing Healthcare Professional on Hearing Aid User Success, The Hearing Review, Vol 17 (No.4), April 2010, pp. 12-34.

[11] Demand for Audiology Services: 30-Yr Projections and Impact on Academic Programs, Journal of the American Academy of Audiology, Ian A. Windmill and Barry A. Freeman, 24:407-416, 2013