EARtrak SUBMISSION: PRODUCTIVITY COMMISSION LONG-TERM CARE AND SUPPORT SCHEME ENQUIRY.
The cost of untreated hearing impairment is well-documented in Australia1.
Less well-documented is the cost of poorly treated rehabilitation of hearing impairment.
Approximately 80% of hearing aids fitted in Australia are fully or partly subsidised by government funding, under the Commonwealth Hearing Services Program (HSP), administered by the Office of Hearing Services (OHS).  This has increased uptake of hearing rehabilitation services by adults with hearing impairment from 25% to 37%, an outstanding result by world standards. 
Yet the effectiveness of the HSP is poor, both in terms of cost-benefit to the government, and benefit to clients of the program. Dr Harvey Dillon, Director of Research with the National Acoustic Laboratories, has determined that nearly one third of the hearing aids fitted under this HSP are either never used, or worn on a very limited basis2.  These poor outcomes are a tragedy on all levels.  It is a tragedy for clients and their families who are left with continuing communication problems.  It is a tragedy for those in the community with hearing problems who decide against seeking hearing care based on the poor reputation for the effectiveness of hearing aids fitted under the Program. And it is a tragic waste of money in a program that at times delivers wonderful results. 
Up until now, the program has been judged to be effective, based on the low rate of complaints from clients of the HSP and by the increased access to hearing services by eligible clients.  Yet with increased financial pressure on government spending due to applications for hearing services growing at approximately 9% per annum, and with service providers continuing to be paid for hearing care services regardless of whether the hearing aids are worn or not, it is time for a serious review of the Program.
At present, OHS “monitoring of outcomes” merely documents general outcomes. As one senior OHS staff member said, “We measure and we measure, but we still don’t see any improvement.” In other words, the current monitoring process adds very little to improvements in the system, or improved outcomes for clients of the HSP. In addition, outcomes of the program are not measured against external benchmarks, and thus any systemic shortcomings of the program remain unidentified. 
It is time to raise questions about why hearing service providers continue to be paid for fitting hearing aids where nearly one in three are not worn, and where the rest are used on a limited basis (only 13% are worn most of the day). Comparison of outcomes for OHS-funded clients as reported by Dillon, and OHS-funded clients of services that engage in performance monitoring as part of a program for Continuous Quality Improvement indicates the non-use rate is more than halved, and hearing aid daily usage is more than tripled for clients of the latter group (Figure 1). 

Figure 1: Daily useage of hearing aids by OHS-funded clients.  Data for general sampling of OHS clients (Dillon 2006) compared to clients surveyed by practices using independent performance measurement (EARtrak).
Clients who achieve poor outcomes typically do not formally complain to OHS or their service provider – they put their hearing aids in the drawer, or severely limit use.  But they do complain to those around them (“I got hearing aids and they didn’t work”).  This negative reporting discourages many people who have untreated hearing-loss from seeking help.
The aims of the HSP cannot be met while limited benefit and limited usage are the outcomes for the majority of clients of the Program (66% use their hearing aids less than 4 hours/day). As Dillon recommends3, it is time to stop paying for inputs (fitting hearing aids) and start paying for successful outcomes (hearing aids worn with good benefit). 
Hearing service providers should be held accountable for the quality and effectiveness of the services they provide. There is sufficient data to show it is not what is fitted, but who fits it, that makes all the difference between successful and unsuccessful rehabilitation outcomes4.  If clinicians continue to fail to monitor their performance, they will continue to be unaware of where they are failing their clients. But as long as they continue to be paid for poorly fitted hearing aids and unsuccessful rehabilitation outcomes, they will never see the need for performance measurement. 
EARtrak offers performance measurement services to the hearing care industry, but very few clinics are involved (less than 30 across Australia).  EARtrak data indicates that where clients have the chance to honestly report their outcomes to an independent organisation, and where clinics can confidentially compare their results against performance benchmarks, improved outcomes are delivered. 
Improvements to the effectiveness of government-funded hearing services cannot be made unless there is commitment to outcomes measurement as part of a program for Continuous Quality Improvement. EARtrak offers a means of improving accountability of service providers and improved outcomes for their clients.
REFERENCES:
1.	Access Economics “Listen Hear! The economic impact and cost of hearing loss in Australia. February 2006.
2.	Dillon, H  “Hearing Loss: The Silent Epidemic.  Who, why, impact and what can we do about it” Libby Harricks Oration, Perth, Australia, May 2006
3.	Dillon H “Outcomes for wearers of hearing aids and improving hearing aid technology” Dennis Byrne Memorial Oration, 18th Conference of the Audiological Society of Australia, May 2008
4.	Kochkin S et al MarkeTrak VIII: The Impact of the Hearing Professional on Hearing Aid Success. Hearing Review April 2010, 63(1):11-19