The Evolution of Service Delivery Models With Amyn Amlani

Oct 14, 2020 | Operations

How did we go from a traditional medical model to more of a consumer-driven model?

The landscape of health care in general is changing. Consider the example of you getting ill.

You’re running a fever, so you make an appointment with your primary care doctor. After spending who knows how long in the waiting room, are you really going to see your primary care doctor? Probably not — more than likely, you’ll see a nurse practitioner or physician’s assistant.

But honestly, in the interest of saving time, you’ll probably skip your primary care doctor’s clinic entirely and go to an outpatient clinic such as CVS or a standalone urgent-care clinic. These kinds of clinics are called ancillaries — they’re not considered the primary medical avenue.

The current health care model encourages this push toward ancillaries, because health care reimburses based on complexity. The more complex the case, the more a physician gets paid. The more simple the case, such as a cold or scratch, the less incentive your primary care doctor has to take those on.

We’re also moving into a more retail-based model, where the consumer has more input and shared decision making as to what their treatment is and how they go about it.

Which brings us to hearing health care: Where are the ancillaries? The otolaryngologist or otologist is at the top, where they’re taking on the more complex medical cases. They do have the licensure to fit hearing aids, but not many of them do.

The audiologist is the top-tier ancillary. Their job is somewhat medical, but their focus is treatment, such as amplification, counseling, and aural rehabilitation.

The hearing instrument specialist is the second-tier ancillary. They can’t do much diagnostic testing — though it does depend on the state — but they are involved in the treatment process.

There’s currently no third-tier ancillary. That’s where the over-the-counter bill comes in. This is where we move from a medical model to a fully retail model. The consumer can purchase a product for mild-to-moderate hearing loss, fit themselves, and (hopefully) treat themselves.

What opportunities exist for these private-practice audiologists in the model you described?

“Patient-centered care” is the new mantra in hearing health care. What this essentially means is making the patient a partner in the diagnosis and treatment of their hearing. It allows the patient to have a voice in maximizing your services in this new landscape.

In the medical model, the practitioner tells you, “This is the best device for you.” But in patient-centered hearing care, it might look something like this: Your provider describes your type of hearing loss, they review with you the benefits of several devices, and then you decide together, considering your lifestyle, budget, and needs, what device will be best for you. Then you put together a comprehensive treatment plan to maximize your outcome.

How would patient-centered care benefit the patient?

They are now involved in their own health care, so self-efficacy kicks in. The likelihood of them complying with their provider’s recommendations increases. The ownership of performing and keeping data in order to inform and maximize the provider’s recommendations and strategy benefits the patient.

But it also benefits the provider, because they can provide services and increase their value. They can also create a new revenue stream, because now they can charge for things that insurance typically wouldn’t pay for. That can take the form of either a service package or itemized charges.

Do you find better patient outcomes if the patient has a little skin in the game?

Oh, absolutely. And if you look at the literature, those individuals who are on subsidized government-based insurance are more likely not to show up for an appointment, whereas if you’re paying for private insurance, you are more likely to show up because you’ve got more skin in the game. You’re paying for those services.

What do we know about these patients who are more involved in their health care and moving toward a retail model?

Historically, patients were tested using medical-based models, such as the health belief model or the transtheoretical model. These models were based on education and the application of education.

An example using the transtheoretical model is smoking cessation. The first step in this is pre-contemplation. Do you know whether you smoke? Are you aware it’s hazardous to your health? The second step is contemplation. You admit you’re a smoker. You’re not denying it, and you know that this could cause you harm. The third step is decision-making — you should go see a physician. The fourth stage is action. You know they’re harming your lungs, maybe even your cardiovascular system, so you stop smoking based on a treatment recommendation in order to reverse this issue and maintain it.

This model doesn’t work for hearing health care because hearing loss isn’t reversible. Hearing loss is permanent 90% of the time, if it’s cochlear or sensorineural. So, for lack of a better term, we’ve tried to dovetail the treatment part onto the hearing loss.

But the existing models don’t work because they don’t take emotion and cognition into account. Thus, when we started moving in the patient-centered direction of health care, we started looking at something called a consumer-decision model, which is based on several factors.

The two most important factors are cognition and emotion, followed by opportunity and affordability. In other words, do I have the motivation? If so, do I have the necessary money, time, and resources to follow through with this?

It’s as though you have an internal dial. For example, you recognize you’re having trouble hearing — that’s your actual state. Then you consider where you want to be — that’s your desired state. If my actual state and my desired state are equal, then I’m not going to do anything. In other words, I’m OK with my hearing loss. If my actual state is preferable to my desired state, then I’m not going to do anything. It’s only when your desired state is better than your actual state that you’re going to do something.

This consumer-decision model actually measures that. I was fortunate to pair up with the AARP to conduct a study that was published in the Journal of the American Academy of Audiology. Each participant took the same survey both two weeks before and two weeks after they saw an audiologist. We had no hand in what provider that they went to see. They went to their local provider based on whatever criteria they decided.

We were able, then, to compare their desired state and their actual state. And guess what? There’s a huge disconnect. When a patient walks in, they have high expectations. We looked at 10 of these specific expectations, such as confidentiality, competency, lack of bias, etc., and found that these expectations are not being met. As a profession, we are not moving in the direction of a retail-based model. And because of it we are constraining the market.

We need to move away from the medical model. Becoming more consumer-centric and consumer savvy, as well as embracing them as partners, will lead to more conversions. Flow is not the issue — conversion is. Converting more opportunities helps more people and grows your practice.

How does this help create better provider and patient relationships?

This shared accountability that results from the consumer-centric model makes you more than just a provider and a patient. It becomes a relationship, which, as we know, tends to have more gain than does an acquaintance. This whole model is about being in it together. Both parties help each other.

How does this philosophy align with how Audigy partners with their Members?

This is very similar to Audigy’s relationship with their members. It’s a partnership. We’re in it together. That’s why we call them members. There’s a mutual accountability. We’ll both grow together.

There’s magic in this partnership and among the collective owners. You’re not on an island. You’re with other people who are going through the same thing you are. You don’t need to handle it alone. A provider falls ill — Audigy can make sure the practice doesn’t miss a beat. A financial issue arises, something beyond their control, and Audigy can step in order to help rectify that issue.

That’s why Audigy isn’t a buying group: It’s me helping you, you helping me, and together we’re in it. We are a team supporting one another so that practices can grow and Audigy can grow.

What’s the key takeaway from the consumer decision-making model?

The key here is to embrace the patient perspective. Allow them to have a voice in their hearing health needs. It’s OK to ask them what their expectations were when they walked in the door. If they expect A, B, and C, but you’re not providing it, reflect on whether patients in general could be expecting those things. That’s a hard thing to do, as an individual or as a business. But it’s the only way we can move forward in the turbulent times we’ll see very, very soon.

Do you have an estimate of when the turbulence will be over? Or will it just be a new turbulence?

Some economists have estimated that anywhere between 20% and 50% of people who would buy hearing aids now will try these over-the-counter products or PSAPs, which are available to individuals who don’t necessarily have hearing impairment.

Assuming that the FDA drops this legislation in Q1 of 2021, economic theory suggests it will take about a quarter for us, as providers, to actually see a decline in the number of units sold. The next three quarters will continue to be painful as the early adopters try OTC hearing aids, then you will see a rise in traditional hearing aid sales about a year after the FDA releases its protocol.

Then we’ll see another dip as the people who are not early adopters start to investigate the new OTC technology. This will be a much deeper, steeper decline than the first one, but then we’ll get past it and level out. If I had to estimate, there will probably be about three years of turbulence in this market starting in 2021.

What is most important for private practices to know?

The takeaway points are this: The provider and the medical model are no longer it. Those days are gone. The consumer is going to be more engaged in their hearing health care and also, to some degree, how much time they invest with you.

It’s a partnership. The better we, as providers, can embrace that partnership, the more opportunities we’ll have. If we can embrace these changes, the coming turbulent times won’t be so turbulent.