Over-the-Counter Hearing Aids Are Only Partly the Answer

By Todd A. Ricketts and Erin M. Picou

This article is a part of the March/April, Volume 35, Number 2, Audiology Today issue.

This is a time of rapid changes for audiology. Perhaps most notable right now is the advancement of direct-to-consumer devices that do not require professionals to dispense. These changes are the direct result of the establishment of the Food and Drug Administration (FDA) category of over-the-counter (OTC) hearing aids for adults with perceived mild-to-moderate hearing loss. 

The category became effective October 17, 2022, but the field has been abuzz preparing for hearing aid service delivery changes for more than a decade (e.g., Donahue et al, 2010). This article will examine what is new in research related to hearing aid cost and service delivery models and will also preview some future findings by briefly describing ongoing projects in our laboratories. In addition, because success with hearing aids is one of the ultimate goals of hearing-health care, we also will consider the role of cost and service in hearing aid outcomes, specifically satisfaction. 

Hearing Aid Adoption

Is cost a primary barrier to hearing aid adoption?

Several notable reports proposed that hearing aid cost is a driving factor limiting hearing aid adoption rates (e.g., Donahue et al, 2010; Grundfast and Liu, 2017). Yet, the data supporting cost as a primary barrier are not clear. Some have argued that cost is not the primary limiting factor in hearing aid adoption because, even in countries where hearing aid costs are partially or fully subsidized, adoption rates are still low (Valente and Amlani, 2017). 

Recently, the MarkeTrak 2022 survey results support this, demonstrating small differences in hearing aid adoption rates in the United States (~38 percent) compared with countries with universal health care (44 percent; Jorgensen and Barrett, 2022). In addition, when asked if they would pursue hearing aids if they were fully covered by insurance, only about half of survey respondents indicated they were likely to pursue hearing aids (Windmill, 2022). 

It also appears that cost and perceived hearing difficulty interact. People with greater perceived hearing difficulties are more likely to be influenced by costs than are people with mild-moderate perceived difficulty, where cost might be a less influential factor for adoption (Jorgensen and Novak, 2020). 

Given these data showing that cost might not be a primary barrier for people with perceived mild-moderate hearing difficulties, it will be interesting to see whether access to OTC hearing aids removes enough of the affordability barrier to be truly meaningful, especially given the relatively high price point of many of the first-generation products we have seen to date (often $1,000–$2,000).

Is access to professionals a barrier to hearing aid adoption?

In addition to device acquisition cost, access to professional services has been identified as a barrier. For example, Windmill (2022) reported that lack of coverage or cost of the hearing test is a commonly reported barrier to hearing aid adoption. Fortunately, there are many ongoing research efforts to explore ways to reduce accessibility barriers to professional services. 

For example, a recent scoping review summarized work demonstrating that, under ideal conditions, several automated methods of hearing assessment have similar accuracy, reliability, and time efficiency as current manual methods (Wasmann et al, 2022). These automated assessment methods could increase accessibility by increasing the number of people who can get their hearing tested and ultimately seen by audiologists. 

Similarly, recent systematic and scoping reviews have demonstrated that many current telehealth tools (also referred to as m-health or tele-audiology services) can be effective solutions for providing remote care and are similar to in-person appointments, particularly for hearing aid follow-up care (Tao et al, 2018). Researchers also are exploring further enhancement of telehealth hearing applications via, for example, machine learning and virtual reality (DiFabio et al, 2022). 

Although these remote or distance support tools have the potential to increase accessibility for some people, there are numerous barriers to implementation, including licensing and reimbursement challenges (Hall, 2020). Furthermore, access to even current distance support services remains more common in high income areas, demonstrating that much work remains to remove current barriers to accessibility of professional services (Frisby et al, 2022). 

Can alternative service delivery models increase hearing aid adoption rates?

If access to hearing testing is expanded through remote testing or automation and hearing aids are more affordable because they are available directly without the need of a professional, one would hope that hearing aid adoption rates would increase. Is there evidence to support this hypothesis? Not yet. 

The 2022 MarkeTrak survey was conducted prior to the official establishment of the OTC hearing aid category, so there is no clear answer regarding the effects of direct-to-consumer hearing aid availability on hearing aid adoption rates. The data that are available reflected low-market penetration of direct-to-consumer devices available at that time, which were greatly underrepresented relative to devices fit in a traditional, in-person fit model (Picou, 2022). 

One of the top reasons hearing aid owners report that they acquired hearing aids was they trusted their hearing-care professional, second only to “hearing test clearly demonstrated” a need for a hearing aid (Jorgensen and Barrett, 2022). In the direct-to-consumer service delivery models, the effects on adoption rates of not having a clear hearing test result or a hearing-care professional making recommendations are unclear. 

It will be interesting to see how these adoptions rates look in the next few MarkeTrak surveys, which will be conducted after the OTC category of hearing aids has been established for a couple of years. 

In addition to device acquisition cost, access to professional services has been identified as a barrier.