Good news for people with hearing loss.
Last week CMS, which runs Medicare and Medicaid, reversed itself on an earlier proposal to eliminate coverage for bone-anchored cochlear implants, like Cochlear’s Baha and Oticon’s Ponto.
This is good news for two reasons.
First, it preserves coverage for an important and expensive technology. People with certain kinds of hearing loss, including that resulting from acoustic neuroma, can’t be treated with hearing aids or conventional cochlear implants. The bone-anchored devices, which have been implanted in 40,000 Americans since they were approved by the FDA and accepted for Medicare reimbursement in January 2006, affect people of all ages. Only 20 percent of these 40,000 procedures was covered by Medicare, according to the Hearing Industries Association. And in fact when CMS made its original proposal to end coverage it noted that it wouldn’t save Medicare a substantial amount of money.
Medicare’s decision not only ensures that these devices will continue to be available on Medicare but also will have a so-called ripple affect. Private insurance companies often follow Medicare’s lead in coverage guidelines.
And these devices are expensive (although not as expensive as conventional cochlear implants, which both Medicare and private insurers generally cover). Cochlear Americas estimated that the national average “bundled” rate (which includes physician and audiologist services), is $9732 if the surgery is done on a hospital outpatient basis.
The second piece of good news is that this was accomplished as a result of a public campaign against the proposed changed. Cochlear Americas got it started but CMS received more than 4,070 comments, and 11,300 signatures on a petition, according to the Acoustic Neuroma Society. The people’s voices were heard!
Let’s all remember that the next time CMS or some other seemingly behemoth government agency proposes to cut back coverage of an essential device or procedure.
An Invisible War Wound: Out of sight, and mostly out of mind.
When we think about the injuries our servicemen and -women endure, on this Veterans’ Day, we naturally focus on major life-changing injuries like Traumatic Brain Injury and Post-Traumatic Stress Disorder. We worry about suicide in veterans. We see veterans struggling to learn to walk again with prosthetic limbs or learning to hug a child using a prosthetic arm. These are all horrifying consequences of war and no one would minimize them.
But there is a war wound we don’t see, and for the most part don’t think about. Hearing loss and tinnitus are the two largest categories of disability in the military, and have been for some time.
These are not comparable injuries in terms of the scale of destruction, and they are not life-threatening. They are often secondary to TBI or other debilitating injuries. But they’re permanent. And long after a veteran has begun to recover from these other wounds physically and emotionally, he (or she) begins to realize the hearing loss or tinnitus is not going away.
Captain Mark A. Brogan of the United States Army was injured in a suicide bomb attack in 2006. He spent months in a coma at Walter Reade Medical Center. It was not until his traumatic injuries had been treated that he began to think about his hearing loss, and to realize how it and his TBI were entwined.
At a panel discussion with other veterans earlier this year, he talked about the lasting effect of the TBI on his hearing. The part of the brain that controls speech perception was injured in the blast, and combined with the injury to the ear itself made speech very difficult to understand.
Hearing loss and tinnitus also combine negatively with other injuries. Trouble hearing in a noisy place can trigger his PTSD, said Sean Lehman, US Air Force,. The PTSD in turn exacerbates the tinnitus. “It makes my brain get irrational, you know? It makes my PTSD more difficult to deal with.”
Sgt. Lehman sustained third-degree burns over 40% of his body, and his physical injuries obscured the fact that he’d also lost his hearing — for almost two and a half years. “Things I considered unimportant turned out to be important,” he told the audience. It was only when his three-and-a-half year old daughter was impatient with her father’s inability to hear her that he sought help for his hearing loss.
In June Captain Brogan and a panel of other veterans gave a workshop at the annual Hearing Loss Association of America Convention. They are part of a group called Heroes With Hearing Loss, and they’ve banded together not only to raise awareness of hearing loss in veterans but also to give veterans the opportunity to talk about hearing loss to another vet.
“I was 25 years old at the time,” Captain Brogan recalled when he realized the severity of his hearing loss. “I don’t want to wear these [hearing aids], you know. Are you kidding me? You, know, I’m young, freshly out of the military.” The others nodded in agreement. “It was a battle to accept it. Kind of a grieving process. It’s something that visibly says, ‘Hey you’ve got a problem.’”
Sean and the others all talked about the issue of credibility, how important it is for an injured vet to hear from other vets ways to come to terms with it.
Master Sgt., Donald Doherty, a retired Marine and veteran of Vietnam, lost his hearing as a result of gunfire and artillery noise. “Noise is an occupational hazard for warfighters,” he said.
“Marines, and anyone in the armed forces, have been instilled with a sense of pride, the need to act independently, to do it yourself. It’s a sign of weakness if you reach out for help.” But, he added, you begin to realize you do need help. You realize it’s affecting “not only yourself but everyone around you.”
Sgt. Lehman was the first to use the word “credibility” about the trust soldiers put in each other. “Dr. Jones [Amanda E. Jones, Aud-D, CCC-A)] can tell me what works, and I’ll listen. But if Mark tells me, I’ll take his word for it.”
Don Doherty, who is also now on the Board of Trustees of HLAA, points out that “Veterans recognize the noise hazard but make the sacrifice willingly because it’s their duty and mission.” But, he says, “My brothers in arms need to reach out to the VA and get tested. Too many of them don’t.”
Sean Lehman asked Dr. Jones what differences she noticed between “normal” patients and veterans, who, he added – getting laughs from the others on the panel, “we all know are not normal.”
Dr. Jones estimated it took an average of 15 years for a veteran to address the issue of hearing loss. It’s partly a question of dealing with other medical conditions, she said, but it’s also a matter of pride. Eventually, she added, it becomes a matter of acceptance: “I’ve got an issue and I have to do something about it.”
These invisible injuries take on a larger significance not only because it is difficult for veterans to come to terms with the loss — but also because society is likely to ignore it.
“‘I would love to hire a veteran with a disability; they will get top priority when I hire new associates,” a potential employer might say. Joyce Bender, who runs a search firm that helps place people with disabilities, says that what they really mean is, “Send me a veteran with a visible disability,”
This is not to say that an employer should not go ahead and hire the veteran with the visible disability – it’s good for the soul and it’s good for business. But don’t ignore the vet with a hidden disability: PTSD, mental illness — and yes, hearing loss.
Heroes for Hearing Loss travels nationwide and can be contacted at HeroesWithHearingLoss.org
SCIENTISTS MEET THE CONSUMERS.
Yesterday I was the guest speaker at the 14th annual Forum on Hearing and Hearing Loss, co-sponsored by the Massachusetts Eye and Ear Infirmary Department of Audiology and the Boston Chapter of the Hearing Loss Association of America.
Sharon Kujawa, who originated the event and has organized it for 14 years, is an Associate Professor of Otology and Laryngology at Harvard Medical School, director of the Department of Audiology at Mass Eye and Ear, and Senior Researcher at the Eaton Peabody Laboratories at Mass Eye and Ear. Her lab focuses on noise and age induced hearing loss, and is currently investigating how noise exposure alters the way ears and the auditory system age. By understanding the underlying mechanisms, the lab hopes to develop a drug that could result in treatment or prevention.
Specifically, the Kujawa lab is involved in a biomedical and engineering research partnership that is looking to develop an implanted drug delivery system that could help prevent hearing loss. Given to vulnerable populations — those exposed to unavoidable loud noise, for instance active-duty military, as well as those with a genetic predisposition to hearing loss — the drug might help offset the effects of the noise exposure.
Dr. Kujawa spoke first. Her talk was a detailed discussion of what we now know about the causes of hearing loss, and about the underlying systems. She also talked about the lab’s current work. Her talk covered a lot of technical material but it was crystal clear.
I spoke next, about hearing loss from a personal perspective, about the need to educate people about hearing loss, about the general misunderstanding of adult-onset hearing loss (most of us are not Deaf and we don’t use sign language). I also spoke about the need for reforms in Medicare and private insurance, which currently do not cover hearing aids or diagnostic hearing tests. I urged those in the audience to write to their congressional representative and ask for support for HR3150, which would overturn the statute that currently prohibits Medicare from reimbursing for hearing aids or diagnostic hearing tests.
HR 3150 would be an immensely important corrective to the existing policy. The consequences of untreated hearing loss, are enormous — not only personally but on a public health level as well. Untreated hearing loss is strongly associated with depression and isolation (both known risk factors for dementia), anxiety, paranoia, with a three-fold greater risk of falls — and an alarmingly greater correlation with the onset and severity of dementia.
This is a power-point talk that I frequently give to hearing loss groups as well as academic audiences. For a list of upcoming appearances, you can go to my website: katherinebouton.com and look under events. Most are open to the public, and most have multiple kinds of hearing accessibility. CART — simultaneous captioning on a screen on stage — is always available. Many venues are also looped, and sometimes there is an ASL intepreter.
Dr. Charles Liberman was the third speaker. Dr. Liberman is the Harold F. Schulknecht Professor of Otology and Laryngology and Vice Chair of Basic Research in that department, which is part of Harvard Medical School. He and Dr. Kujawa collaborate on much of their work. Dr. Liberman’s current research focuses on noise: “acoustic overexposure.” His talk was also highly technical but also very clear to his mostly lay audience. He discussed the ways the inner ear connects to the brain — through two kinds of sensory neurons and and two neuronal feedback systems — and how those pathways can be affected by noise exposure.
Neither Dr. Kujawa nor Dr. Liberman spoke down to the audience, and the audience members responded with their own detailed technical questions. People with hearing loss are often well versed in the science of hearing loss, and the Mass Eye and Ear annual forums bring cutting edge science to the lay public.
Mass Eye and Ear has made a commitment to sharing its research with the public. Does anyone know if such public forums exist at other academic hearing centers? It’s a generous gesture from the scientific community to the population their research may eventually benefit.