- Published on 02 December 2013
The new Dutch system for hearing aid provision means a world's first. 'Evidence-based medicine' as a basis for the provision of hearing aids cannot yet be attained. With 'practice based evidence' the Netherlands have chosen the second best option, Wouter Dreschler assures. An inventory of all provided hearing aids will show the quality of devices, fitting process and even health insurance. When you perform well, it will show. Dreschler:“Thanks to this new basis the minister was prepared to keep the hearing aid within our package of basic health insurance.”
The introduction of a new system for the provision of hearing aids caused a tumultuous time in the Dutch audiology sector. Not in the least for prof.dr.ir. Wouter Dreschler, professor of Clinical and Experimental Audiology at the Amsterdam Academic Medical Centre. He was – together with dr. Mark Laureijns of Amplifon – closely connected to the development of the protocol for the provision of hearing aids, an issue that was cause for a lot of....'opinions'.
“Adjustment of the existing practice was a necessity”, he concludes. “The old system was too costly and offered insufficient evidence that the hard of hearing got what they needed. The cost hampered the position of the hearing aid as part of the basic insurance packpage”, Dreschler states. Prices had exploded as a result of the fixed reimbursement.
The new system distinguishes five patient categories, from relatively mild to severe hearing problems. The protocol offers a percentual reimbursement of 75% of the price of a hearing aid in the indicated class. “That works better. It is in line with the basic perception that more severe demand leads to more technical means and more fitting time. It is the answer to the patient's question: 'Why do I, with my complex hearing loss, get the same rehabilitation as someone with less severe hearing loss?'”, Dreschler knows from his clinical practice. “Provision was up to now, by lack of an alternative, mainly 'trial and error'. It was impossible to make a transparent link between hearing characteristics and hearing aid characteristics. In that way, we learned little from each other's experience. Furthermore it couldn't be excluded that commercial reasons were sometimes the basis for advice. For clinicians as well as health insurance companies that was unsatisfactory.”
Retention of quality
The book: 'Compensation of hearing impairment' by the PACT Foundation in 2010 drew the outlines for a new prescription system. Starting point is a uniform classification of hearing aids. This has to be linked to, among other things, the type and amount of hearing loss, demands by the patient and his daily living environment. Dreschler: “Literature gave surprisingly little scientific evidence to make this link. So you can't build a system on 'evidence based medicine'. Therefore you have to go for the second best option: 'practice based evidence'. This refers to knowledge build up according to extensive inventarisation of practical experience. A system on the basis of these starting points eventually offers more possibilities for transparency. It goes together with a differentiated reimbursement: for a simple hearing aid when possible, for a complex hearing aid when necessary.”
Thanks to this new basis the minister of health was prepaired to keep the hearing aid in the basic insurance package, says Dreschler. “Otherwise it would have been an enormous loss. The high quality audiology care and the triage system, lots of what has been built up carefully, would be at risk. Many people would experience a high threshold to enter a audioprothesist's shop and the hearing aid would become a counter article. The Dutch NOAH field norm, which contributed to securing good audiology care, would largely loose its value. All that has now been prevented. We can be very glad for that.”
Incentive and inspiration
The challenges for the introduction of a new system were severe. Dreschler: “Keeping the hearing aid in the basic package, preserving the value of the field norm - possibly even improving it. All insurance companies should be held on board, commercial extravagance should be banned and afforability be guaranteed. To conclude, the possibilities for more transparency on the trajectory of hearing aid choice and its meaning should be capitalised.”
A year ago Dreschler would not, given these challenges, have thought it possible that the most expensive hearing aids in category five would now be attainable for a contribution of only 350 euros per device. “Someone who just before the system change, in December 2012, wished to acquire hearing aids for fear of the new rules, now sometimes turns out to have paid more than a thousand euros too much - per hearing aid.” This sustainable affordability is an important feature, but according to Dreschler there is another important added value to the new system: “Because we now start to lay down every detail of every purchase, the new system offers the opportunity to learn a great deal of what works and what doesn't. We no longer rely on minor field studies for that, but use the complete practise of hearing aid provision in the Netherlands.” In this way a permanently self-learning system is created, eventually leading to better client results. In the new method, the client is the leading factor.
Hearing aid characteristics
The detailed characteristics of all hearing aids purchased in the Netherlands now become known. The data can be linked to the results from diagnostics, fitting and the results of evaluation measurements. The end results will be centrally stored and used for analysis. Dreschler: “This offers all market parties the opportunity to learn how they can further improve. In this sense it is a stimulus and source of inspiration.”
He continues: “Regretfully, you cannot introduce such a system gradually. And if you don't dare to take this step, you will never get to detailed knowledge. You will have to start with a classification of hearing aids on the market on the basis of expert opinion. There is no other way; you want to gather data form experience that isn't there yet. So you know the initial classification will not be perfect, but only the best you can do. To say that a classification in five categories means that an audioprothesist can no longer bring his craft into practice - like was suggested by some - sounds stange to me. It is not more than 'presorting'. In my opinion the craft of an audioprothesist means a lot more than that.”
There was also criticism from manufacturers that hearing aids cannot be judged on the basis of separate charasteristics. Dreschler: “This only refers to some aspects. Furthermore, no one has presented a better alternative. Until such an alternative occurs, the new system represents the best attainable approach.”
Bridging the gap
As next step to making an inventory of hearing aids, function oriented prescription was started. This aspect received by far the most criticism within the Dutch audiology community. “It was clear from the start that there were insecurities, as we couldn't know all details from the start. The present change is a paradigm shift, so transition problems and side effects could be expected”, Dreschler admits. “So you have to try to solve these. Part of the critisism involves these transition problems, another part is mere resistance against change. It is a pity that the transition coincides with major budget cuts. This makes it more difficult to judge the system on its merits. For most hard of hearing the change means a huge price fall. But for some small, independent audioprothesists it can admittedly turn out unfavfourably.”
The fact that after the transition adjustments should be made was already foreseen, Dreschler says. “The delay in filling the indication portal of Zorgverzekeraars Nederland, the association of health insurance companies, really is a pity. The delay creates unnecessary extra uncertainty. I am by no means blind for these side effects, but I am convinced by the perpective of the benefits: affordability, transparency, improved quality of care and unique knowledge. Eventually, a bridge can be built between 'Product Related Intended Use' and the 'Human Related Intented Use', between characteristics of hearing aids and what the patient needs. The Netherlands are the first country in the world to bridge that gap. The system will in all tranparency prove how good or bad it is.
The knowledge resulting from that is unique and long awaited. Dreschler: “It presents opportunities. When you perform well, it will show. This goes for hearing aid manufacturers as well as audioprothesists.” He knows that the influence of the health insurers will grow under the new system. “They have taken the initiative and the responsibility. But in the working group it struck me that they also go for quality. All insurers draw one line; they use the same protocol and the same field norm. That is beneficial to the field. The numbers of hearing aids in the survey, 140.000 to 150.000 a year, are this large, that an unequalled refinement in quality analysis becomes available. Health insurers with the tendency to go for (too) cheap solutions within the same framework conditions, will probably pop up in the analysis of results. Not only the performance of hearing aids and the fitting process, but also that of the health insurance company can be generated from the data.”
You cannot include the newest hearing aids in a system like this immediately, Dreschler knows. “They can only be included after the delay caused by classification. That is a drawback. It might even result in some manufacturers not launching certain products on the Dutch market. That would be a pity, but not a real problem for hearing care.” Dreschler does not believe that the system will harm innovation. “Think of the opportunities! When a manufacturer launches an innovation, this system can establish independently within a year whether it works or not. That is why I am a little surprised that some manufacturers are a bit hesitant about this development; apparently not everyone is too keen on transparency. It is exciting for all parties involved. Quality will prove itself from now on.”
Leendert van der Ent, editor in chief of Audiology Infos North of Europe
Photo: Prof.dr.ir Wouter Dreschler (on the left) and the team of Clinical & Experimental Audiology in the Amsterdam AMC. © Bureau Lorient Communicatie