Over-the-Counter (OTC) Hearing Aids
- Part 3

by Mark Ross, Ph.D.

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OTC hearing aids are designed for people with mild to moderate hearing losses. For people with this degree of hearing loss whose audiometric configuration is flat or gradually sloping, I have no doubt but that a good quality OTC hearing aid could provide significant hearing benefit. The problem is that many people do not know the threshold configuration of their hearing loss unless they've had a recent audiometric evaluation. They may think they have a mild to moderate hearing loss indeed, on the average, they may well have but the hearing thresholds could be taking a sharp drop at 1000 Hz or 1500 Hz without them being fully aware of this. There's simply no way that a "one size fits all" hearing aid would provide an appropriate pattern of amplification to such people.

I suspect that many, if not most, people purchasing OTC hearing aids would opt for one rather than two. However, binaural amplification usually offers listening advantages that do not occur with monaural hearing aids. And not only this, but we know that long-term monaural amplification may result in adult-onset auditory sensory deprivation, which, while not affecting thresholds, can reduce the speech perception capacity of the unamplified ear. Without professional advice regarding the advantages of binaural amplification, it is unlikely that many people would purchase a binaural set of OTC hearing aids unless, of course, OTC aids were sold in pairs in the same way reading glasses are sold (anybody ever see a "reading monocle?).

There is the danger that a bad experience with OTC hearing aids may discourage some purchasers from seeking professional assistance with professionally fit hearing aids. We already know that this occurs. Some people who have a bad experience with hearing aids not only swear off hearing aids for themselves, but discourage other people from trying them. Of course, the reverse may also be true: a good experience with OTC hearing aids may convince some other people to pursue more sophisticated assistance for their hearing problems. At this point, it is fruitless to speculate which of these possibilities is more likely. Both are possible and both would likely occur.

We do know that OTC hearing aids will not include many of the advanced features now incorporated in top-of-the-line hearing aids. Additionally, right now there does not appear to be any plan to include telecoils in these hearing aids. Of course, not including these features is one reason why they could be sold for a relatively modest sum. Presumably, people with mild to moderate hearing losses will have less (or no) need of many of the special features found in current hearing aids (such as feedback management and wide-dynamic range compression). But even people with moderate hearing losses could hear better in noise with directional microphones, a feature that would probably not be included in OTC hearing aids.

With OTC hearing aids there would not be any personal involvement by any professional. Frankly, this worries me. It's not that I think that professional hearing aid dispensers "prescribe" a unique set of performance characteristics for each of their clients that only a professional can accomplish. (I have no doubt, however, that most sincerely believe they do.) Hearing aid prescriptions (or targets) are not that finely drawn. There are a number of them out there, each somewhat different from others, and none of them are set in concrete. All of them often partake of a post-fitting trial and error process; none have consistently demonstrated a clear-cut superiority over the others, but all seem to help most of the people fit with them. Indeed, I would be willing to bet that if a number of audiologists were asked to fit a trial subject with hearing aids from different companies, the range of the final performance characteristics of the hearing aids would vary greatly. None would necessarily be "wrong," since human beings are usually very tolerant of and can adjust to minor differences in the performance characteristics of their hearing aids. No, it's not the actual fitting process that worries me.

What does concern me is the rest of the hearing aid selection process. Hearing aid users need to have an understanding professional to whom they can relate their hearing problems. We know that, regardless of the type of hearing aid, a person's hearing aid satisfaction increases with the number of hours devoted to counseling. This can take the form of information sharing about hearing loss and other types of devices, hearing tactics and repair strategies, resolving problems with the hearing aids, etc. Just because someone has a mild to moderate hearing loss does not mean that he or she cannot also benefit from this type of information. Personal perception of one's communication problems may well be greater than the audiogram would suggest.

Of course this statement has a corollary, and that is the need for hearing aid dispensers to actually provide the kind of information and counseling that people require. This is, indeed, one of the major rationales given by hearing aid dispensers for the high cost of hearing aids, that they do provide the range of personal services that people with hearing loss require. The reality today, however, is that hearing aid dispensers spend the overwhelming majority of their time on issues relating directly to the fitting process (testing, earmolds, etc.) and little on what could be called the "rehabilitative process." In a study reported in this journal in May/June 2002, we reported on the services that 942 people recall receiving from their hearing aid dispenser. Half the people did not recall receiving information about telecoils, and only 31% received information about other hearing assistive technologies. Only 20% reported that their hearing aid dispenser discussed the specifics of the hearing loss with them and with a family member. Even fewer reported receiving information about communication or coping strategies. Finally, only about 5% of hearing aid dispensers offered their clients an opportunity to participate in a group hearing aid orientation program (as recommended by one of the SHHH position papers).

So what can we conclude from this discussion? As noted above, this is not a black and white issue; the color gray may be a more realistic descriptor. I think the basic rationale presented by the petitioners is indisputable: hearing aids are expensive, and this does deter some unknown number of people from purchasing their first or replacement aids. Many of these people can undoubtedly be helped with OTC hearing aids. Furthermore, if someone was one of the "ideal" candidates no cerumen in the ear canal and a relatively flat audiogram I suspect that he or she could achieve as much measurable benefit from an OTC aid as from a more costly, personally fit hearing aid. (One exception I would make is aids that contain effective directional microphones.) I can also see where experienced hearing aid users who have some basis to compare their performance with previous hearing aids, may find an OTC aid worth a try. This is not a trivial number, since they comprise some 57% of new hearing aid sales. But for new users, who may have little idea of the configuration and nature of their hearing loss, particularly those who have needs that transcend what a simple amplifier can do, an OTC is probably not a good idea.

Perhaps this debate will help serve as a wake-up call to the dispensing community. The provision of services beyond the actual hearing aid fitting is what justifies the high prices paid for hearing aids. A hard-of-hearing person sees an audiologist not so much to purchase a hearing aid, but for help with his or her hearing problems. These may require services that extend beyond the help that hearing aids can provide. To the extent that hearing aid dispensers restrict their focus to hearing aids, they are easily replaceable by OTC hearing aids, internet outlets, and automatic computer fitting of some sort (plug the audiogram in and out comes a hearing aid incorporating some recommended "prescription"). However, understanding and responding to the many life-inhibiting consequences of a hearing loss is something that can only be done by a human being. The challenge facing the hearing industry is how to accomplish this, and still provide lower cost alternatives to the many people presently unserved who require hearing aids but cannot afford them.