Monday, June 28, 2010

Hearing Aid “Sticker Shock” and Things to Consider When Purchasing

Steve Barber, Hard of Hearing Consumer and SHHH Member

We’ve all heard about the guy that knows the price of everything, but the value of nothing? It turns out the price of things is not always linked to some intrinsic value, their materials or their size.

The price of gasoline has risen dramatically. It seems obscene that we could be paying $2 or more for a gallon of gas, but then again…there’s a lot of value that gallon of gas provides. The ability to travel 20 or 30 miles (unless you bought one of those SUVs) is certainly worth 2 dollars; at least it is to me, so I pay it.

When you consider the specific costs involved, in some respects, there’s more value in a gallon of gas than a gallon of bottled water. The gallon of water probably bubbled out of the ground, almost directly into a bottle and required no serious processing or transportation costs. The gallon of gas required major cost for exploration, drilling, pumping, transporting half way around the world, refining, transporting again, and retailing … yet, some bottled water costs more than gasoline.

So although gasoline is indeed far more expensive than we’re used to, what makes gasoline so cheap when compared to water? And -- what’s that got to do with the price of hearing aids?

With hearing aids, some of the same issues apply. Everyone knows the cost of hearing aids isn’t based on the materials that go into them – that’s a given. From a “materials” standpoint, there’s a little plastic, a wire or two, a tiny microphone or two, a speaker and the equivalent of millions and millions and millions of digital chips, but still, the actual dollar cost of raw materials is fairly low. Then again, based on raw materials, the average human being is worth less than $1. Both human beings and hearing aids are worth (and cost) a lot more than the cost of their materials.

PART ONE: Why Do Hearing Aids Cost So Much?
I will address a few of the specific things that contribute to the retail price of hearing aids, but please understand, the list below is not comprehensive. Some of the factors that go into the price of hearing aids include:
  • Technology
  • Durability and Reliability
  • Personal Fitting
  • Professional Costs
  • Product Lifecycle
  • Manufacturing Costs
  • Marketing Costs
  • Warrantee Costs
  • Free Trial Costs
  • Inflation
  • Customization
1- Technology:
Just 20 years ago, most hearing aids were analog; they were not programmable and certainly not digital. Hearing aids had no software, they were adjusted using a screwdriver, and generally, there were only two adjustment screws. Most hearing aids didn’t have telecoils, and very few had directional microphones. FM, remote controls and Bluetooth didn’t exist. In 2005, all those things are common.

These things didn’t just “happen”. They are the result of hearing aid manufacturers investing heavily in developing new technology and features. They are the result of hearing aid users being willing to pay for the advantages that these (and future) “bleeding edge” improvements provide.

The cost to the manufacturer for staying on the bleeding edge of technology is a killer. Consumers, of course, pay for those advances, but that’s the cost (and benefit) of staying on the bleeding edge. Very good hearing aids with older technology are available at lower prices, but when most people buy a hearing aid, they want the best they can get, not the best that was available 20 years ago.

When I bought my first home computer in 1983, the retail price was $6,000. It was an amazing piece of equipment and a good bargain to me, at that time. I’d worked on mainframe computers that cost millions of dollars, and I recall being blown away that I could actually buy a personal computer for only $6,000, which 22 years ago seemed very fast (4 MHz.), had lots of memory (it came with 16 kilobytes, although I bought the 48 kilobyte upgrade), and it had not one, but two floppy drives -- holding a mammoth 180 kilobytes on each diskette, for only $6000. But remember, 20 years ago, that was a bargain.

Now, you can buy a PC literally 1000 times faster with 8000 times the memory and 10,000 times the disk space and other amazing things (too numerous to mention) all for one-tenth the cost of my original computer. That kind of price reduction is not going to happen with hearing aids; because so few hearing aids are sold compared to computers, but the rapid and uncertain direction of technology caused early personal computers to be very expensive … just as that same factor has affected hearing aid prices.

2- Durability and Reliability
Hearing aids have to work and endure some nasty situations. Most people wear their hearing aids some 12 to18 hours daily. They wear them in freezing winter weather and on hot summer days. They wear them when it rains, maybe with an umbrella, maybe not. They wear them when they play tennis and sweat trickles around their ears. Worse still, is when you consider that the majority of all hearing aids sold (perhaps 2/3rds or so) are custom made to be inserted in the ear canal, the product is has to function in an ear canal that literally exudes wax and humidity. Dr. Beck (editor of assures me that even the cleanest of all ear canals have bacteria, fungi and viruses too. So beyond moisture, heat and earwax, we have unimaginable germs working to negatively impact the environment in which hearing aids live every moment of their life cycle.

Speaking of life cycles, digital custom-made hearing aids are expected to survive nicely in even the nastiest ear canals for approximately 5 to 7 years. Behind-The-Ear (BTE) instruments generally last longer than in-ear models.

Durability and reliability that can handle that kind of abuse is not cheap. When NASA wants a transistor for a spacecraft, they don’t pop over to Radio Shack, choose a bubble pack and hope it works all the way to Saturn. They need to know that their transistor will handle the rigors of space. You can bet that the transistors NASA does buy are going to be a lot more expensive than the ones you can buy in a bubble pack.

Likewise, most hearing aid manufacturers have to invest heavily making sure their switches, mics, receivers, chips, cases, connectors, and even battery contacts hold up through years of normal and abnormal use, too. If they use cheap parts and crummy assembly techniques, they will pay over and over again to correct very costly errors.

I’ve got a remote control for my hearing aid. I love it, but was horrified a couple of weeks after I bought my hearing system as I picked it up from the parking lot after a car had run over it! You might be surprised that 6 years later I’m still using that same remote. It didn’t even need to be repaired. Don’t try this with your hearing aid or assistive technology, but it gave me a good deal of respect for the reliability and durability of my remote.

3 - Personal Fitting
When you buy glasses, the doctor measures your vision, writes a prescription, and you buy glasses from someone who inserts the lenses in the frame and adjusts the frames so they fit correctly. With hearing aids it’s similar, but a lot more problematic. With glasses, the prescription is almost always a near perfect match for your needs. With new glasses you can immediately see quite well. It doesn’t matter how bright the light is or whether the colors are properly adjusted; you can see almost perfectly in all situations.

With hearing aids, the prescription is less likely to result in an immediate perfect fit. Your hearing loss and your hearing test is just the starting point. Hearing aids can make a huge difference in your ability to hear, but no hearing aid can achieve near-perfect hearing right out of the box. Considerable and highly specialized attention throughout the fitting process is required to adjust the hearing aids, not just to your hearing loss, but indeed, to your hearing needs.

If your hearing aid just had to match your hearing loss, that would be easy. Like glasses, the “first fits” would likely all be perfect. But it’s just not that simple. Your brain is really where hearing occurs, and your ears are merely the transmitters of the information. The professional has to adjust the hearing aids to amplify the soft sounds you don’t hear well without making the other sounds too loud. All the amplified sounds have to be placed in your comfortable listening range. Ear molds, or the aid’s body itself, have to be designed with appropriate bores and vents to match your needs and to straddle a, sometimes, thin line between that “plugged-up” feeling and feedback. Features that can minimize background noise must be properly set so that you can hear your best at parties, in restaurants or in the car. Getting the aids to work well for you on the phone adds another challenge to the fitting, with telecoils, or assistive technology requiring special attention.

The amazing thing about all this personal fitting stuff is that it has to be done without the professional being able to actually hear what you are hearing. No one can hear what you are hearing.

Fitting glasses is more like a science and fitting hearing aids is more like an art ... and it’s likely to remain so. Frequently, several visits are required for you to get the most comfortable and effective fitting. A lot depends on your ability to convey your experiences and needs to your fitter, and a lot depends on their skill, training and ability to work with you.

4- Professional Costs
Fitting hearing aids is indeed a complicated affair. Most people buying hearing aids expect to be fitted by someone who is really good at what they do. An audiologist in the United States must have a bachelor’s degree and also, at least a master’s degree in audiology, and many of them have doctorates too, such as an Au.D. (Doctor of Audiology) or a Ph.D. degree. Degrees cost a lot of time and money! Another important issue is that technology changes so rapidly that anyone licensed to fit hearing aids (audiologists and hearing aid specialists) must attend seminars and other training events to stay current and to maintain their licenses. They can’t fit hearing aids with a $2 screwdriver anymore; special computers, adaptors, experience and skill are needed to fit them correctly.

5 - The High Cost of Low Volumes
Not sound volume -- I’m talking about sales volumes. Hearing aids are typically not high volume products. In fact, less than two million units are fit per year in the USA. When you consider the number of manufacturers (many dozens) and the different models and circuits offered, the “number of units sold per model” is relatively low, never really achieving the “economies of scale” apparent with lap-tops, cell phones, PC computers, DVD players, TV, CD players, iPODs automobiles, eyeglasses, sunglasses, digital cameras, calculators or contact lenses. The lack of sales drives up the cost in at least two important ways:
Research and Development: When a company manufactures a product, the pricing of that product must recover the cost of research and development (R&D) for that product. Because hearing aids are often “bleeding edge” products, the research and development costs can be substantial and must be spread over a relatively small number of units sold.

Manufacturing Costs: Most hearing aids are not manufactured in huge volumes (see above). Manufacturing costs for any product are high (on a per unit basis) when volumes are low. Costs, such as bricks and mortar, leases/mortgages, insurance, warrantees, production equipment and personnel, administrative staff, phones, shipping, packaging, returns for credit, marketing, heat, lights, taxes and on and on…. all add to the per-unit cost of hearing aids.
Interestingly, the cost of research is relatively fixed. For example, it takes a team of engineers X amount of time (and equipment and related costs) to design a new hearing aid circuit. However, if only one person purchases that circuit, that one person pays the whole bill. If ten people purchase that circuit, they each pay a tenth, and if a hundred people buy it they each pay one one-hundredth. Economy of scale is an important issue.

6 - Marketing Costs
There’s a lot of competition in the hearing aid industry. The Sunday papers sometimes have full page ads offering “free hearing screenings.” They say you should come in and be tested because it “might just be wax“ and you can get a $1000 discount if you buy now. Yawn. These ads are typically from the “mass marketing” distributors that typically sell one brand (theirs, of course). Somebody’s got to pay for those ads, right?

Even major name brand hearing aids marketed through independent hearing aid dealers and audiologists require a substantial amount of money for marketing. A lot of money is needed for to market any product. Advertisements, web pages, slick brochures, product launch events, seminars, training, nice packaging, and toll-free numbers are examples of marketing costs. Someone has to pay for all of those things too! Of course, the local professionals need their own marketing materials too, and computers, and offices, and administrative staff, and business cards, and telephones, and lights and signs, etc.

7 - Warrantee Costs
When you purchase hearing aids from a reputable dealer or audiologist, it will come with a warrantee. If you have any problems, they’ll fix it or replace it for free (see above). Some warrantees even cover problems that aren’t the fault of the hearing aid or fitting itself. For instance, if you step on your hearing aid and crush it, or if your dog chews it up, the professional will generally replace it for free, or perhaps charge a slight “refit” fee. Try that with your car, iPOD, DVD player, CD Player, cell phone or TV. It pays to understand what your warrantee covers, but whatever it covers, somebody’s got to pay for maintenance or replacement when something does go wrong.

Obviously, when a hearing aid fails, it costs money to repair it, and of course, if it’s under warranty, you don’t receive an additional bill. However, the manufacturer does pay dearly.

Imagine if even a ten-cent switch breaks during the 11th month of hearing aid ownership. You bring the hearing aid to the professional, they fill in the paperwork, send it via air express, the factory takes it apart, troubleshoots it, fixes it, re-assembles it, sends it back to the professional air express, the professional receives the hearing aid, calls you, and you pick up the instrument…what did the ten cent switch cost the manufacturer to repair?

That’s why durability and reliability and warrantee costs are very real issues for the manufacturers too!

8 - Free Trial Costs
Most states require that hearing aids can be returned within a 30-day period for just about any reason, with only a small fitting fee kept by the professional. Try that with your travel agent (“But I didn’t like visiting Greenland!), or with your automobile dealer (Can I have my money back for that new car I bought last week, please?). Obviously, it’s not really free, and such costs are just one more reason that hearing aids are expensive.

9 - Inflation
I mention this only because others frequently bring it up when explaining why the price of anything is high. Yes, inflation affects everything, even hearing aids. But, it’s not really the main reason, or even a primary reason that hearing aids are expensive. One recent article even tried to show that since the first hearing aids were produced almost a century ago, that the current price isn’t all that far out of line after it’s been adjusted for inflation. Of course, it’s pointless to compare the price of things over so much time and technological advancement. An airliner costs a lot more than the Wright Brothers’ plane did in 1903 even after adjusting for inflation. Does that mean that airplanes are too expensive now? Of course not! Even if they are too expensive, it’s not because of inflation.

In some ways, hearing aids are like airplanes. Just as a 747 has much more capability than did the Wright Brothers’ plane, today’s hearing aids are dramatically improved compared to even aids of 20 or 30 years ago. So, while inflation does matter, it’s not really the key price factor for airplanes or hearing aids.

10 - Customization
The vast majority (approximately 2/3rds) of all hearing aids sold are custom made devices. That means the hearing healthcare professional has to physically examine your ear, safely take an ear impression with appropriate medical grade silicone, using universal precautions (to protect you and the professional) and then safely remove the ear impression from your ear, and then ship the ear impression to either an ear mold lab for BTE instruments, or to the hearing aid manufacturer for custom made in-ear instruments. The hearing aid shell is manufactured before the circuit is installed, and by the way, it takes a computer to figure out how to place an amplifier, miscellaneous computer chips, a microphone, a receiver, a power supply, a vent and other wires and components into a shell that has been custom built for your ear canal, which may be the size of a pencil eraser, in such a way as to not cause electrical “cross-talk” problems or acoustic feedback. Remember the “Economies of Scale” from earlier? Well, each hearing aid is brand new, and has never before been assembled in a shell to exactly fit your ear!

PART TWO: Things to Consider When Buying Hearing Aids
Here are a few tips on saving money … or at least, not wasting money. Taking these things to heart can help more people become happy hearing aid users, and that will eventually encourage quality hearing aids at lower prices.
  • Watch out for Scams: It’s important to not waste money on hearing aids that don’t give you a reasonable improvement in your ability to hear and understand speech. There are many products that claim to help with hearing, but many are not effective. Don’t be taken in by products that make exaggerated or ridiculous claims. In fact, be very careful if the product claims to NOT to be a hearing aid! Some products claim remarkable similarity to hearing aids; they claim you will hear “whispers across a room”. and that’s a clue to you, as a consumer, to be suspicious. Ads for products sneaking in under the FDA’s radar by stating they are “NOT a hearing aid” is usually a secret code for products so useless; that the company offering them could get into legal difficulties if they claimed it was a hearing aid! Being a hearing aid is not easy. Hearing aids are regulated by the FDA and they have to be well made and must incorporate safety, quality and health standards that most “mail order” and over-the-counter products cannot achieve. Of course, those “come on” ads prey on people in denial and those who think they don’t need or want a hearing aid, or perhaps purchasers who believe they can save lots of money by purchasing unregulated products…they can’t. You get what you pay for.
  • Check your Insurance: Most insurance policies don’t cover hearing aids, although some do. Often it’s only partial coverage, but don’t miss out if your insurance covers hearing aids.

    Here’s an interesting and common scenario: Some insurance programs tout their “hearing aid benefit,” indeed they claim to “cover hearing aids” but what you’ll learn as you go through the process, is that they may only pay 400 or 500 dollars towards a hearing aid, which costs the professional perhaps twice that. If the professional were to supply you with a product completely paid for by your insurance, you would get the equivalent of an 8 track player in the iPOD age, or simply, a very bad product that does not meet your expectations or your needs. But before you get upset with the hearing healthcare professional, understand that it was the insurance company that sold you the “hearing aid benefit” and not the hearing healthcare professional!
  • See if You Qualify for Veterans’ Administration Benefits: If you’re a veteran, and if your hearing loss has been demonstrably connected to your military service, it’s possible that the VA will provide aids for you. You must contact your VA to see if you are eligible for VA benefits.
  • See if You Qualify for Vocational Rehabilitation Support: People who are unemployed but are employable may qualify for help thorough Vocational Rehabilitation, within your state. If hearing loss is preventing you from being hired, and if hearing aids might make a job possible, your state’s Vocational Rehabilitation department might buy hearing aids for you.

    Don’t assume because you’re not employed or looking for work that you don’t qualify. Some states have companion programs for “independent living” associated with their Vocational Rehabilitation programs to help people who might be able to remain independent with financial aid for a disability, including hearing loss. You’ll need to check with them personally. There are strict guidelines, stringent limitations and red tape, but you may get help in obtaining hearing aids or assistive technology and maybe even a job.
  • Check with Civic Organizations: Lions International has programs to help people obtain hearing aids. Sertoma also helps people with hearing loss. Sometimes even local organizations can help; at least one SHHH Chapter has gotten a grant to help local people who can’t afford hearing aids. Your hearing healthcare professionals are usually aware of the civic and charitable groups available to you based on your specific situation; speak with them about this issue.
  • Learn about Overcoming Hearing Loss: Most people who purchase hearing aids have very little understanding of hearing loss or hearing aids. For many people, the two factors they initially consider when shopping for hearing aids is they want hearing aids “so small, no one will know” and frankly, they usually want the “least expensive.” Neither of those factors will typically steer you in the best direction!

    Before you shop for hearing aids, speak with successful hearing aid users, not someone who bought hearing aids and returned them, or doesn’t use them. Of course, you can learn a lot from someone else’s negative experiences, but realize you are looking for the “right way” to acquire hearing aids, and learning what some people did wrong is probably not as valuable as learning what successful people did right!

    One of the very best things you can do is to join Self Help for Hard of Hearing People (SHHH). Learn more at

    SHHH members get a wonderful magazine about hearing loss from which you can learn a great deal about overcoming hearing loss. SHHH also has hundreds of local chapters. If there’s one near you, attend a meeting and meet people who have been successful in overcoming their hearing loss, and they’ll be happy to share the lessons they’ve already learned.
  • Choose hearing aids that help you hear best: That seems obvious, but too many people choose the aid they think is the smallest, the cheapest or the most invisible. However, Behind-The-Ear (BTE) models usually are cheaper, more reliable and have more impressive features than smaller, custom made in-ear hearing aids. The smaller aids aren’t necessarily the wrong choice, but their main sales point is usually their size, and that comes with a higher price tag and fewer features.
  • Learn about Hearing Aid Features: There are plenty of weird words and acronyms related to hearing loss. If you don’t know about telecoils, DAI, directional microphones, ALD, clipping, compression, digital, analog, FM, IR, neckloop, feedback suppression, noise reduction, etc., then go to and open the consumers’ hearing loss glossary.

    Of course, another excellent resource is the website you’re reading at this moment ( . If you place any key words in the search engine, you’ll retrieve lots of useful information. You might also want to visit the section called “Testimonials” where you’ll be able to read the experiences of hundreds of people, who have already gone through what you’re going through. No one needs much training on how to wear glasses, but there’s a lot to learn about hearing more effectively with hearing aids and assistive listening devices.
  • Consider These Features: Hearing aids have several features you should understand. You may not need or want these features, but if you don’t know about them, you could be missing something that could help you hear a lot better than you can hear without such features.
    • Volume control: Some people think that the more automatic a hearing aid is, the better. Modern digital hearing aids are very good at keeping the loudness just about right where you want it…but sometimes you may want to turn it up or down. For some people with hearing loss, the ability to increase or decrease the volume is important. So you may actually want a volume control (VC). Many hearing aids offer them as an option, and even many automatic aids offer them as a manual override in case the automatically selected volume isn’t what you feel is best for you. People who are unable to properly control their hearing aid’s volume may be better off without a volume control, but many people appreciate having one. The VC is something you certainly should consider before ordering a hearing aid.
    • Multiple Microphone Noise Reduction: Some hearing aids have more than one microphone, which can filter out some of the background noise -- allowing you to actually hear speech better in noisy situations. These are referred to as “directional mics.” It’s one of the most effective and important features on hearing aids. If hearing in noise is one of your problems, this feature is a “must consider.” Directional mics are available on most BTE aids and on many custom-made in-the-ear aids.
    • Telecoil: A telecoil (T-coil) is nearly standard in most BTEs and is an option on some in-the-ear custom made hearing aids. T-coils “hear” magnetic signals, such as the signal transmitted by most phones, representing an audio signal. The T-coil is an important way to “couple” your hearing aids directly with audio sources such as the TV, telephones, and assistive listening devices. However, the smaller the aid is, the less likely it is to have a telecoil. When you couple your hearing aid directly to an input signal, you automatically eliminate background noise, you maximize the signal, and you get the best sound signal possible directly to your hearing aid. Many experienced hearing aid users will not buy a new hearing aid without a telecoil.

    These are not the only useful hearing aid features, but they are certainly ones you should understand when considering a new hearing aid. If you understand them and still decide against them, then fine. But you don’t want miss them because you didn’t know about them.
  • Get a Professional Audiometric Evaluation: Get a serious evaluation of your hearing, not just a “hearing screening”. Many places offer “free screenings” and that’s fine, but it’s not a thorough test of your hearing. Think about the value of the “free blood pressure” check at the pharmacy, as compared to your nurse or doctor checking it…big difference. A comprehensive audiometric evaluation may involve much more than measuring which tones you hear. Comprehensive evaluations typically include things like measurement and analysis of your eardrums and middle ear, a determination of how well you understand speech in quiet and in noise, whether your hearing loss is sensorineural or conductive, how well your auditory nerve is transmitting the signal to your brain, and how well your cochlea is functioning. And importantly, when you have a comprehensive audiometric evaluation, if any warning or danger signs are observed by the professional, they are obligated to refer you to an appropriate physician.
  • See an Ear Doctor: If you haven’t seen an ear doctor recently, do that. As noted above, some types of hearing loss can be a symptom of medical problems that require medical attention or intervention. In some rare cases, certain specific types of hearing loss can be treated medically or surgically, too. Your family doctor might be a great family doctor, but is probably not an ear specialist! Choose an ear, nose and throat doctor (ENT), also called an otolaryngologist, or an otologist. Most of them have one or more audiologists working in the same office, so you’ll most likely see both at one appointment.
  • Shop Around: Prices of hearing aids, professionals, locations, sales and service policies are all important. Choose a provider you feel comfortable working with, and one who is willing to discuss options, and how your needs can be met within your budget. Ask about return policies. Ask which brands they recommend and why. Ask about payment options. Ask about aural rehabilitation (AR) programs. It is nothing less than remarkable – patients who go to few AR classes learn so much more about their hearing aids and effective and appropriate use for their hearing aids, that the return rate for these patients/consumers is less than half of the non-AR class attendees, and the AR attendees report much higher satisfaction from their hearing aid purchase.
  • Evaluate Your Hearing Aids During the Trial Period: If you’ve learned what you need to know about hearing, hearing loss and hearing aids, you’ll be well prepared to make a decision regarding the purchase of your hearing aids based on -- How does it improve your ability to hear in the situations that matter to you?

    It’s very important to keep records of what sounds are good and what sounds are not good, to explain to the professional what you like and what you don’t like, and then with this information, they can tweak the settings to make it better for you. Modern hearing aids are almost limitless in the settings, sound quality and loudness they can provide. Basically if the hearing aids fit well, they’re comfortable, and you like the way they feel, the professional can make them sound great…not on the first day, but over a few visits.
  • Take Good Care of Your Investment: Hearing aids are pretty durable, but there are some things that are bad for them. Dogs and cats love to chew them. It’s easy to leave your hearing aids in a pocket and send it thorough the washing machine. Bad move. Always place them in their case or the “dry aid” kit, and make sure the hearing aids are either in your ears, or in their storage container.
    Keeping your hearing aids dry on the inside can prevent corrosion. Keeping it clean and germ free can prevent ear infections.
  • Understand Your Warrantee: New hearing aids are usually covered for a year or more, so if you have a problem, then check to see if it’s covered.

    Also, if your hearing aid needs to be repaired, you may receive a warrantee covering the repair, even if your original warrantee has expired.

    You can usually purchase an extension to cover your aids after that original coverage ends. Check with your hearing aid provider to see if that’s a good idea for you.
  • Accept Your Hearing Aids: Some estimates suggest that when people buy their first hearing aid, they have waited about 7 years from the time they really needed one. Research also tells us only 20% of people who could benefit from hearing aids use hearing aids.

    One of the biggest reasons for these disturbing figures is denial, not just the cost of hearing aids. Hearing aids aren’t yet as “fashionable” as glasses, but they are getting there. A very similar situation emerged with glasses, many years ago, before they became a fashion statement. Almost everyone has heard Dorothy Parker’s famous quote: “Men don’t make passes as women who wear glasses”. That might have been true when Dorothy said it, but it’s certainly not true any more.

    Hearing aids are finally becoming more acceptable … even fashionable. Cell phones and personal music players are ubiquitous. Headsets, ear inserts, hands free sets, and even Bluetooth wireless connections to things that look like hearing aids are adorning even the youngest and “coolest” of consumers. Rock stars routinely wear “hearing aids” with wireless connectivity while on stage. Some rock stars also need real hearing aids, after being in all that noise, too.

    Hearing aid manufacturers are recognizing that hearing aids can be “cool” and don’t have to look like bland “flesh” colored appliances. These things will make it much more acceptable, even desirable, to wear hearing aids.

    SHHH is only a little over 25 years old, but as the premier organization for people with hearing loss, it’s already starting to help people actually accept and take charge of their hearing loss. That’s going to help broaden the market.

    As people accept and buy hearing aids in larger numbers, and as the technology stabilizes, the price will eventually come down. We’re already starting to see some low cost digital hearing aids becoming available.

If you demand the absolute best product you can get, it’s going to cost you more than the run-of-the-mill product. That’s true of everything, not just hearing aids.

One of the reasons that we have made so much progress in hearing aid technology over the last 20 years is because people who buy hearing aids have been willing to pay for that technology. It’s painful to pay that much, but there’s some comfort that the money is helping the industry make better hearing aids. I’m certainly happy that I’m able to buy a much better hearing aid today, than I was able to buy 20 years ago.

The most important thing we, as consumers, can do to help reduce the price of hearing aids is to broaden the market for them. If we can help make wearing a hearing aid as acceptable (even as fashionable) as wearing glasses, more will be sold, and prices will come down. So, wear your hearing aid with confidence, stop hiding them as if they were something to be ashamed of. You can help others see that hearing aids are not something to avoid.

If you’ve gotten this far and still want more about the cost of hearing aids, then check out the January-February issue of SHHH’s Hearing Loss magazine. That issue has several excellent articles by various hearing loss professionals. If you’re already an SHHH member, you’ve already got that issue. If you’re not an SHHH member, then go to and ask if they’ve still got a back issue when you join.


Steve Barber has gradually lost most of his hearing over the last 25 years. He’s retired from IBM and currently working as a software tester for SAS Inc.

Steve has been a volunteer/leader in Self Help for Hard of Hearing People for 14 years and he served as the chairperson for the North Carolina Council for Deaf and Hard of Hearing people during 4 of his 10-year tenure with that council.

He built and maintains the NCSHHH web site at and the Beyond-Hearing web site at

Hearing Aids: Reasonable Expectations for the Consumer

Rose L. Allen, Ph.D., CCC-SLP/A, Assistant Professor of Audiology, East Carolina University, Dept. of Communication Sciences & Disorders

Editor’s Note: This article was the winning submission for the Audiology Online ( contest sponsored by Rayovac Ultra Pro Line, for the best new article written for consumers and patients, titled "Hearing Aids: Reasonable Expectations for the Consumer." We offer Dr. Allen our congratulations for her excellent work, and we invite the readers to download (in it’s entirety) and distribute this article to their patients for educational purposes. ---Editor

Since you are considering the purchase of hearing aids, it’s important for you to establish reasonable expectations from these highly sophisticated, miniature devices. Acquiring hearing aids is not merely a simple act of going to a store and purchasing a product.

Rather, it is a complex process - one that evolves over time and begins with the hearing-impaired individual accepting the realization that hearing impairment has detrimental effects on interpersonal relationships and safety. The hearing impaired person’s motivation to hear well is the single most important factor in determining the success of the hearing aid fitting. It is important to realize that you will not experience the exact same benefits from your hearing aids as your neighbor does. This individuality is a critical component, and I want to emphasize that your expectations should be based on you, your type and degree of hearing loss, your past experiences, and the improvements you personally receive from amplification.

The title of this article implies there are "reasonable expectations" for the consumer. Therefore, there must also be "unreasonable expectations". For the most part, there is only one totally unreasonable expectation - do not expect normal or perfect hearing.

It is my hope that this point-by-point tutorial will help guide you in establishing realistic and reasonable expectations from hearing aids, from the professionals you interact with, through the process of acquiring hearing aids, using them effectively, maintaining them, and living the fullest life possible.

1. Expect others to notice your hearing loss before you do! A common complaint of hearing-impaired individuals is that other people mumble - and if they would just speak up, it would be easier to hear them! This is placing the "blame" externally, rather than accepting the reality that your ears are not as good as they used to be. Realize that it is your hearing. Take that step to have your hearing tested before you blast your loving spouse out of the den with the blaring sound of the TV set. Seek the advice of your local audiologist or hearing instrument specialist (HIS), who you will find listed in the yellow pages under "audiologists" or "hearing aids". Of course, another option is to go to the Healthy Hearing website (, and if you enter your city and state, or just your zip code, a list of professionals will be created for you.

2. Expect your audiologist/hearing instrument specialist to be knowledgeable, courteous, and accommodating. Your audiologist/HIS will take a thorough case history. He/She is searching for information about your hearing loss, it’s probable cause, and whether your offspring may be affected. It is important to establish the presence of any medical condition associated with your hearing loss as this will trigger a medical referral. Comprehensive hearing and hearing aid evaluations will be conducted. These evaluations will provide information about the degree and nature of your hearing loss, as well as your ability to process and discriminate the fine sounds of speech. Comfortable listening levels will be defined, as well as a determination about how well you tolerate loud, intense speech and other sounds. These findings are very important as they allow the professional to pre-set some of the characteristics of the hearing aid’s circuitry. You will have time to talk with the audiologist/HIS about the differing styles of hearing aids (in-the-ear, in-the-canal, completely-in-the-canal, behind-the-ear), the advantages and disadvantages of each style, and maintenance issues and costs involved. Approximately 80% of all hearing aids sold fit in the ear1. After you and your hearing professional determine the best style of hearing aid for your needs, an ear impression will be obtained. The ear impression is a plastic cast of your ear which reveals the exact shape of your ear, so the laboratory can place circuitry in a hearing aid shell that will fit your ear(s) only.

3. Expect differing opinions. If you choose to seek the advice of two or more audiologists/HISs, you may get differing opinions about the "best aid" for you. Everyone in the hearing aid industry acknowledges the fact that there is not a single "best" hearing aid. Rather, there are many excellent hearing aid brands available, and there are many different types of circuitry that may benefit you. Your audiologist/HIS uses the case history information and the evaluation results to make the best recommendation for you and your lifestyle. Expect a recommendation to purchase two hearing aids if both of your ears are hearing impaired and are "aidable." There are many benefits to binaural (two ear) hearing, including being better able to understand speech in noise, and being better able to localize sound. Your audiologist/HIS will explain the advantages of a binaural fitting versus a monaural fitting in more detail2. Nonetheless, it is very important to understand that if you have two ears with hearing loss, and you only wear a hearing aid on one ear, you will still have significant hearing problems, even under the best of circumstances. A reasonably good analogy is to consider wearing a single eye glass (monocle) for a two-eye vision problem, such as being near-sighted or far-sighted – it simply will not work well for very long!

4. Expect your audiologist/HIS to assess your hearing difficulties in several environments and define individual goals for you. Although there are many self-assessment scales available, a popular one is the Abbreviated Profile of Hearing Aid Benefit (APHAB) developed by Cox and Alexander3. It may be administered to you prior to and following the hearing aid fitting to identify the benefits you receive from the hearing aids and to measure the reduction of any disabling effects of your hearing loss. The COSI (pronounced "cozy") is the Client Oriented Scale of Improvement which was developed by Dr. Dillon and colleagues at the National Acoustics Laboratory in Australia 4. As you will remember from my earlier comments, I emphasized that benefits from hearing aids are highly individualized. The COSI allows the audiologist/HIS to determine, based on your input, five major goals or changes you want to occur as a result of wearing hearing aids. These goals may include hearing your spouse better in the car, hearing your friends better on the phone, or any others that relate to you and your hearing difficulties. These assessments are not like the hearing evaluation given by the audiologist/HIS. These are tools that allow us to measure your self-perception of how your hearing loss affects your activities of daily living and how amplification can improve your quality of life.

5. Expect to be offered a 30 day trial period. Although not always required by law, many audiologists/HISs offer a trial or rental period of 30 days for you to adapt to amplification. You may be asked to pay a non-returnable fee during this time. Ask about this trial period, and if not offered, seek a second opinion. Use this 30 day period to test the hearing aids in the environments that are typical of your lifestyle - not only at home, but also at your friends’ and relatives’ homes, your favorite restaurant, shopping center, grocery store, or place of worship.

6. Expect a referral to a physician to rule out any medical condition that may contribute to your hearing loss. All hearing aids are medical devices and, as such, are governed by regulations of the Food and Drug Administration (FDA). The FDA requires that all users of hearing aids be examined by a physician, preferably one who specializes in diseases of the ear. If you are over the age of 18 years, you may be given the opportunity to sign a medical evaluation waiver that will allow the audiologist/HIS to proceed with your hearing aid fitting. It is in your best interest to be evaluated by a physician prior to the hearing aid fitting, but particularly so if you have a history of ear problems or hearing loss of unknown origin.

7. Expect the hearing aids to cost more than you think they should. There are three categories of hearing aid technology - analog, digitally programmable, and digital. Analog technology has been around for many years. Aids utilizing this technology are also called "conventional" hearing aids and they are the least expensive. According to the most recent dispenser survey published in the Hearing Review in June of 2001, the average price of a hearing aid with analog technology will cost approximately $900 to $1500 per aid, depending on the size of the aid - the smaller the aid, the larger the price1. Digital hearing aids use digital signal processing - the newest form of technology on the market. Digital hearing aids are indeed complete computers, similar to the PC on your desktop, but they are the size of a pencil eraser! These aids cost approximately $2500 per aid, similar to your PC. Digitally programmable hearing aids will probably cost somewhere between the conventional price and the digital price. You may benefit from any of the three types of technology. Speak with your audiologist/HIS about the types of circuitry and which would be best for you. Importantly, in 2002, some basic digital hearing aids are available at a lower price than in previous years. Many of the manufacturers have switched the focus of their product lines to completely digital offerings, as digital products are more efficient and have broader application. Consequently, as the demand and sales have increased, the price has gone down a little. The bottom line is that there are many more digital hearing aids on the market in 2002 than there was in 1999, and the prices vary tremendously, as do the products.

8. Expect an initial orientation session with your audiologist/HIS in which you will learn how to handle and care for your new aids. You should invite your spouse or significant other to attend this first critical session in getting oriented to your new aids. During this session, you will be taught how to operate the hearing aids, how to clean them, and how to change the batteries. You will receive written information about your aids - a booklet called a ‘User Instructional Brochure’ which is a requirement of the FDA. Please note, batteries are particularly important. Please be sure to store them and use them exactly as your hearing healthcare professional advises. Please be sure to keep all batteries way from pets and children. It may be difficult for you to remember all the things the audiologist/HIS tells you during this first session, so don’t leave the office without your instructional brochure! It will be very valuable to you, particularly during the first weeks of owning your new hearing aids.

9. Expect a period of adjustment. Remember the 30-day trial or rental period mentioned earlier (see point 5 above)? Once you get your new hearing aids, expect an adjustment period of several days to many weeks to get used to the daily care and maintenance of the hearing aids.

You’ll need time to learn how to; insert and remove the hearing aids from your ears, learn to adjust the volume control (some hearing aids have volume controls, other are automatic), learn how to clean them, learn how to open and close the battery door, learn to change the battery, get accustomed to placing the hearing aids in a dry-aid kit for the times when they are not in your ears. As you can see, there is a lot to learn, and people learn at different speeds. I recommend that you go slowly, learn one thing at a time, practice, and stay in contact with your hearing healthcare professional.

Many times, a spouse (or significant other) is very useful in helping you adjust to the new responsibilities of ownership of hearing aids. The largest adjustment you will go through is, of course, listening with your new hearing aids. You will hear sounds that you have not heard for a long, long time. Some of these will be "good sounds", like the songs of the birds or high-pitched voices of children. Other sounds, the "obnoxious ones", are sounds we need to hear for our safety and/or general knowledge of what is happening around us. These are sounds like the refrigerator or air conditioning units humming and buzzing, the sound of our footsteps, or a "knock" in the sound of the car engine. Research in this area has shown that this adaptation or adjustment period may last a few months. It takes time for the brain to re-learn all these sounds. Be patient!

10. Expect your voice to sound different. For many reasons, your voice will sound strange to you at first - like being in a barrel. This is a normal early perception and it is often called the ‘occlusion effect’. If you don’t adjust to this after a few days, discuss this with your audiologist/HIS. Many times, this feeling can be alleviated through changing the vent size in your hearing aids or changing the amount of amplification you are getting for low-pitched tones. Your audiologist/HIS deals with this issue regularly, and they will be able to solve this with you, over a short period of time.

11. Expect a good, comfortable fit. Initially, it will take a while to get used to having the hearing aids in your ears. You may experience a little soreness or irritation at first, but after a few days or a week or so, you should be able to wear the aids for several hours per day without any pain or discomfort. I always find it reassuring when patients tell me they often forget that they are wearing their aids. Remember - even though the audiologist/HIS will make your ear impressions so your hearing aids will be custom fit, many things can happen in the manufacturing process and any discomfort should be reported to your audiologist/HIS immediately. If your aids are not comfortable, you will not get the maximum benefit from them, and you should not wear them. Report all discomfort or irritations to your hearing healthcare professional, and do not wear the hearing aids until he/she advises you as to how to best address the problem.

12. Expect multiple follow-up appointments. The greatest advantage of digital hearing aid technology is the flexibility in programming the sound quality, as well as many other electro-acoustic characteristics of your hearing aids. These hearing aids are highly sophisticated instruments with many features. The computer software that is used to program your hearing aids allows the audiologist/HIS to make a multitude of adjustments while the aids are in your ears. You can actually hear many of the changes as the audiologist/HIS is adjusting different features or characteristics. Other features will only be noticeable in other environments. So, be sure to tell your audiologist/HIS as much as you can about your listening experiences in many environments. If you are a new user, you may get an initial setting of about two-thirds of the amplification that will be ideal for you. As you get used to your aids, the audiologist/HIS will increase the amount amplification over several visits. This will help in your adjustment period and lessen the chances of rejection due to over-amplification.

13. Expect your audiologist/HIS to evaluate the benefits provided by your hearing aids. This is normally done in at least two ways. First, electronic measurements of "real ear" performance give the audiologist/HIS an idea of how the aids are functioning when the hearing aids are in your ears. Your audiologist/HIS may make measurements in which a small microphone is placed in your ear to measure what is happening in your ear canal with and without the hearing aids in place. This is an objective measure and a starting point for successive changes in the performance of your aids. Secondly, the APHAB, COSI, or other assessment scales may be repeated so the audiologist/HIS can help you evaluate pre- and post-fitting hearing difficulties. These two evaluation methods are important in establishing the benefits you personally receive from amplification. If there are no significant changes in these measures, your audiologist/HIS will need to make additional changes in your hearing aid fitting.

14. Expect to be able to hear well, but not perfectly, in quiet one-to-one situations and most small group settings. In order for you to hear well, we must make sound audible, then comfortably loud. Your hearing aids will amplify sound so speech will become comfortably loud. You should be able to hear most of what is said without having to watch a person’s lips all the time. However, even people with normal hearing watch the person speaking in order to gain more information! Even when wearing the hearing aids, you should combine your vision and your hearing to maximize your benefits from the hearing aids. When sound is comfortably loud, it will be easier for you to listen and the stress of straining to hear rapidly diminishes. Therefore, listening in social situations becomes pleasurable again. If everyday sounds are uncomfortably loud, report this to your audiologist/HIS immediately.

15. Expect an optimal "distance for hearing". The best distance for hearing with your aids will be dependent on the type of microphones in your hearing aids, and other factors. The hearing aids may be directional or omni-directional. Find out from your audiologist/HIS which type of microphones you have, and the effective listening range or effective "distance for hearing". People within this distance will be the most audible to you. Once you increase the distance from the source you want to listen to, it will get increasingly difficult to hear - just like without the hearing aids.

16. Expect to have difficulty hearing in noisy situations. You may say that you can hear fine in quiet and that the noisy situations are the ones in which you need the most help. This is a common statement made by individuals who have presbycusis (hearing loss due to aging), noise-induced hearing loss, or any hearing loss where the
high-pitched tones are affected the most. Eventually though, as your hearing loss progresses, your ability to hear in quiet settings is also affected. Background noise is a nuisance for everyone, even normal hearing individuals. As sophisticated as today’s technology is, hearing aids still cannot eliminate background noise for you. Some of the more sophisticated digital circuitry can effectively reduce (although not eliminate) background noise. If you are in a lot of noisy environments, it is important to discuss this with your audiologist/HIS when discussing your case history and setting your goals for improvement.

17. Your hearing aids may squeal (also called "whistle," or "feedback") under some circumstances. If a hearing aid is somewhat functioning and has a good battery in it, this squeal (acoustic feedback) will occur when the hearing aid is cupped in the hand. Most users find that this helps determine the status of the battery and it is a good sign! However, you should be able to wear your hearing aids at a comfortable loudness level and not experience this squeal. If you do not have a volume control on your aids, they will squeal when you place them in your ears - until you get them placed comfortably. Sometimes, your aids will squeal if you press the phone too tightly to your ear. Report these events to your audiologist/HIS and determine what is normal, what is abnormal, and what can be done to reduce unnecessary acoustic feedback.

18. Expect repairs. You should realize that hearing aids are incredibly sophisticated devices being inserted in the ear canal where moisture and cerumen (ear wax) is waiting to attack any foreign object! Hearing aids are also prone to being dropped if our fine motor dexterity is a little compromised. Microscopic solder joints that connect the tiny wires of the microphone and receiver to the computer chip in the hearing aid can be jarred loose. All repairs cannot be avoided, but the majority of repairs can be avoided with regular and careful maintenance! Being careful and establishing and maintaining a good preventive maintenance schedule, at home and at your audiologist’s/HIS’s office, can significantly reduce the number of repairs on hearing aids. Your aids will probably come with a standard one year warranty, and after that, you can purchase hearing aid insurance from a number of companies. Talk to your audiologist/HIS about additional warranty options when you purchase the aids.

19. Expect to buy batteries. Hearing aid batteries will probably last a week or two in the hearing aid. Hearing aid battery service life varies based on the hearing aid circuit and the quality and type of battery and is also dependent on environmental conditions (temperature, humidity etc.). Some people ask why hearing aid batteries don’t last as long as watch batteries. The answer is the hearing aid battery accomplishes a great deal more work and requires much more electrical energy than does a watch battery. The information you receive during the hearing aid orientation session will define a reasonable length of time for your batteries. When your hearing aids are new, you might want to keep a calendar indicating the days you change batteries. Report any significant changes in battery usage to your audiologist/HIS. Many professional offices offer battery promotions or special programs for their patients. Ask your hearing healthcare professional about this.

20. There are two ‘NEVERs’ with batteries. NEVER keep batteries with your medicines, as you might accidentally ingest one. NEVER allow young children to handle batteries, as they might ingest them. All hearing aid batteries are toxic if swallowed. Keep them in a safe place and be sure to recycle your batteries properly.

21. Expect to purchase new hearing aids every 5 years. This may come as a surprise, particularly if you just purchased a set of digital hearing aids! However, hearing aid technology changes rapidly, just like computers, and new technology may benefit you greatly. Some people may keep the same pair of hearing aids for 10 to 12 years, particularly if their hearing loss remains stable over time and if they do a great job with maintenance, but the average life expectancy is about five years.

22. Most importantly, expect to enjoy the sounds of life again! Your hearing aids are a key ingredient to staying active and improving the quality of your life. You will once again enjoy social events, leisure activities, and conversations with your family, friends, and co-workers. Your hearing aids will also help you hear sounds to keep you safe and well.

1. Strom, K. E. (2001). The HR 2000 dispenser survey. The Hearing Review, 7 (6), 20-42.

2. Staab, W. J. (2000). Hearing aid selection: An overview. In Sandlin, R. E. (Ed.), Textbook of Hearing Aid Amplification: Technical and Clinical Considerations (pp 63-64). San Diego, CA: Singular Thomson Learning Publishing Group.

3. Cox, R. M. and Alexander, G. C. (1995). The abbreviated profile of hearing aid benefit. Ear & Hearing, 16 (2), 176 - 186.

4. Dillon, H., James, A. and Ginis, J. (1997). Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. Journal of the American Academy of Audiology, 8 (1), 27-43.

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Assistive Devices: Inexpensive and Alternative Ways to Address Hearing Loss

Nancy L. Aarts Ph.D., University of South Alabama

I. Introduction & Overview:
Assistive devices for individuals with hearing impairment fall into two main categories. Assistive Listening Devices (ALD) are products that address problems associated with listening in noise, at a distance, and in high reverberation. Alerting Devices (AD), are products that alert one to the presence of sound in the environment. Assistive devices may be used to improve communication in interpersonal and small and large group settings, on the telephone, while enjoying television programs, or to notify an individual of an important signal in their environment such as the telephone, doorbell, or a safety alarm.

When audiologists and other hearing professionals address the communication needs of people with hearing loss, assistive devices "fill in the gaps," they pick up where traditional ear-level amplification leaves off.

Traditional hearing aids have a relatively small "effective area" within which they work maximally, due to microphone size and microphone location. In other words, if two people are engaged in a conversation at a party, and if they move a few feet apart, the distance between the hearing aid microphone and the person speaking can increase dramatically, decreasing the signal-to-noise ratio while introducing significant ambient noise into the conversation. Typically, hearing aids provide acoustic signals only (FM and DAI systems used in tandem with hearing aids do indeed vary from the "traditional" limitations and are addressed below), which are subject to reverberation, signal-to-noise issues, background noise and other sources of degradation.

Assistive devices typically pick up signals closer to the sound source, that is, the microphone is placed in close proximity to the sound source. This is accomplished using a variety of methods including various and multiple microphones, induction pick-up systems, and direct connection. Assistive devices can transmit high quality auditory signals across significant distances, such as when an FM or infra-red system is used in a theater or lecture hall. Assistive devices can deliver the signal of interest to the end-user in several ways to assure a high quality sound. Options include various headphones and acoustic couplers, direct audio input or neckloop coupling to a personal hearing aid, vibrotactile signal, or the signal can be visually coded as in captioning.

There are times when assistive devices offer a more appropriate and more efficient solution to communication problems than do hearing aids. Depending on an individual’s communication demands and financial constraints, ear-level amplification may not be the best solution. For example, a telephone amplifier and/or knowledge about how to access closed captioning on a home television set may yield a greater return on investment in a particular situation than would ear level amplification.

Recent studies examined how often audiologists provide information to patients about assistive devices. Prendergast and Kelly (2002) surveyed audiologists to determine the type and amount of audiologic rehabilitation techniques they employed. Results showed that 100% of the 120 respondents reported recognizing the benefit of providing more information about ALDs to their patients, while 78% of the respondents reported they provided information about ALDs to their patients most of the time.

A different perception of how often audiologists provide information about assistive technologies was provided by a survey of consumers. Stika, Ross, and Cuevas (2002) analyzed surveys from 651 members of Self-Help for Hard of Hearing People, Inc (SHHH). The respondents indicated they were hearing aid users who received services from audiologists. Whereas 48% of respondents reported their audiologist made certain they understood their t-switch, only 34% of respondents stated their audiologist informed them about other assistive technologies.

The discrepancy between the survey of audiologists and consumers regarding how often assistive device information is provided could be a matter of perception, recall, or miscommunication. However, it may also serve to alert audiologists and other hearing health care professionals that consumers of our services are not recalling or retaining information about ALDs and ADs, and perhaps we need to transmit the message more consistently, and with greater emphasis.

Despite the benefit of assistive listening devices (ALD) and alerting devices (AD), some audiologists and hearing professionals are not able to provide adequate sample space for assistive technologies "in-house" due to cost, space, display, or inventory concerns. Others may not have the same expertise and comfort level with assistive devices as they have with hearing aids, and therefore they may elect to not offer these devices in the office.

II. Inexpensive Options:

A. The Benefits Of T-Coils

There are multiple benefits to flexible, adaptable (larger) hearing aids. T-coils can be built into behind-the-ear (BTE) and in-the-ear (ITE) hearing aids, but very few in-the-canal (ITC) and completely-in-the-canal (CIC) models contain t-coils, a pre-amplifier, and a mic/t-coil switch (Marshall, 2002). Despite the benefits of t-coils, less than 40% of hearing aids sold in the U.S.A. include t-coils (Ross, 2002). This is perhaps due in part to user preference for small, seemingly hard-to-see hearing aids.

My personal experience indicates that more often than not, when faced with the options and alternatives, most people choose t-coils. I generally provide patients with specific advantages and disadvantages of various styles of hearing aids, including a discussion regarding t-coils. Most patients conclude the functional benefits of a BTE or ITE style with a t-coil outweigh the cosmetic advantages of an ITC or CIC style hearing aid.

The key points relating to hearing aid selection, t-coils, and assistive devices, which I address with my patients and their families are noted below.
  1. How t-coils and direct audio input (DAI) are used to couple ALDs to hearing aids via neck loops, small area and room loops.
  2. How and why a t-coil can improve speech understanding with wired, mobile and cell telephones.
  3. How t–coils (and DAI) are generally available in larger hearing aid styles.
  4. The availability of ALDs in the community due to the Americans With Disabilities Act (ADA).
  5. The benefits of ALDs in situations where hearing aids may not help. For example, in a movie theater or a worship service.
  6. I also demonstrate (by wearing) a BTE aid with a clear ear mold in one ear and an ITC in the other ear to demonstrate their appearance when in use.
Providing the above information about t-coils and demonstrating the appearance of different types of hearing aids requires a few minutes of time during the initial discussion, but reduces frustrations and potential remake time later.

B. Order an appropriate t-coil.

An appropriate t-coil must be oriented in the hearing aid in a way that maximizes signal strength. It must be of sufficient strength to provide an audible signal, and lastly, it needs to be activated in a way suitable to the hearing aid user.

Proper orientation is dependent on how the t-coil will be used. The t-coil should be horizontal for telephone use and vertical when a neck or floor loop is used. A diagonal orientation compromises the usefulness of the t-coil in all uses situations. An alternative to diagonal orientation would be to orient the t-coil to the loop and have the user move the receiver to a position that generates the best signal while talking on the phone (Ross, 2002).

The audiologist can specify the orientation when ordering custom products by drawing a line on the earmold impression while it is in the ear to indicate horizontal to the manufacturer. For BTE products, the audiologist should contact the manufacturer to determine each models’ t-coil orientation.

The strength of the t-coil pick-up is dependent on the size of the metal rod around which wire is coiled and on the presence of an amplifier for the t-coil. The larger the rod the more turns of wire, and the more powerful the t-coil (Ross, 2002). The size of the rod may be reduced when a pre-amplifier is available. Some manufacturers offer t-coils that include an integrated amplifier while other manufacturers will require that the audiologist order a pre-amplifier along with the t-coil. Regardless of the way in which the amplifier is added, the audiologist should ensure that an amplifier is included with the t-coil to maximize induction strength.

T-coils can be activated by the common Microphone/Telephone/Off (MTO) switch or a Microphone/Mic+T-coil (M/MT) switch, or, in some BTE models, a switch that offers both M/T/O and M/MT/O options. This type of switch can be difficult to operate for individuals with reduced dexterity. A newer t-coil control option is the "touchless" t-coil. This system automatically switches from the microphone to the t-coil when it "senses" the magnetic energy of the telephone and switches back to the mic when the magnetic field is no longer apparent (Marshall, 2002). This type of system makes t-coil activation much easier for the hearing aid user, and in particular, for those with limited or reduced dexterity.

C. Confirm the t-coil is working properly.

Real-ear probe-microphone measures (REM) are often used to fit, verify, and adjust hearing aids. The purpose of REM is to ensure the hearing aid output is appropriate. It makes sense to fit, verify and adjust the hearing aid output when the t-coil is active. Additionally, REM can indicate the placement of the telephone near the ear that results in the greatest signal strength and whether or not the volume control wheel (VCW) setting needs to be increased in order to maintain appropriate signal strength in the t-coil mode. See Mueller (1992), and Grimes and Mueller (1991a, 1991b) for specific directions on how to obtain REM with an active t-coil.

D. Teach patients how to use the t-coil.
Adults have reported they received inadequate training on how to use their t-coils when fit with hearing aids (Stika et al., 2002). Education at the time of fitting should include determining the telephone receiver position and VCW setting that produces the greatest signal strength (see above), verification that the patient can manipulate the control switch or remote control, and can recognize when the aid is on "M" versus "T".

Additionally, if the patient has access to a neck loop or small area or room loop in their home or community (see below), he or she should be reminded that the signal of interest can be accessed just by activating the t-coil and adjusting the VCW if necessary.

The patient should be notified of the availability of a directional array microphone ( that can be used with hearing aids that have a t-coil. I also recommend that the patient be given information about the "Let’s Loop America" initiative, a public awareness program designed to bring loop systems to more hearing aid users (Myers, 2002).

E. Provide Tips On How To Improve Telephone Communication

Hearing impaired people using wireless phones can often switch from the traditional audible ring option, to the vibrating option. When hearing impaired listeners are having difficulty due to ambient noise levels present while using their phone, they can cover the phone mouthpiece while listening. This simple act reduces the level of background noise picked up by the handset mouthpiece which is also directed to the listener’s ear. Simple and inexpensive ways to increase the intensity of the acoustic signal include a strap-on portable amplifier (for wired, wireless and cellular phones) or an in-line tabletop amplifier (for wired phones) both of which are available from Ameriphone and NFSS. The HATIS cellular phone amplifier (CPA) is available from Life With Ease. Similarly, the telephone’s electromagnetic signal can be amplified with an inductive coupler such as the Oticon TE-80 induction adapter available from Earlink or the Phonear PE 850 available from HARC. Table 1 (below) provides contact information for these and other companies.

F. Encourage Use Of Closed Captioning At Home
If your television has a screen larger than 13 inches and was manufactured after 1993, it will have closed captioning capability. Many people are unaware of closed captioning, its potential benefits, and how to access it. Consider instructing patients in how to access the captioning function via the menu button on their television’s remote control. Some models allow the user to select the size of the captioning text and whether or not the text appears in a box.

G. Educate Patients About The Americans With Disabilities Act (ADA):
The ADA (Public Law 101-336) is landmark civil rights legislation. The ADA went into effect in January 1992 and it provides a comprehensive national mandate for the elimination and prevention of discrimination against individuals with disabilities. Because of the ADA, businesses and employers must take steps to ensure that disabled people, including those with communication disabilities, have access to all goods, services and facilities available to non-disabled people. Additionally, the ADA prohibits discrimination on the basis of disability by private entities and ensures that individuals with disabilities have access to public accommodations, employment opportunities, transportation and telecommunications (U.S. Equal Employment Opportunity Commission, 1992).

All individuals with hearing-impairment, regardless of their age, are affected by the ADA. It is the responsibility of public access facilities, employers, and telecommunication providers to comply with the ADA, but it is the responsibility of the consumer to demand compliance.

However, some consumers -- such as those with hearing loss -- may be unaware of the benefits of the ADA. Therefore, audiologists are the most logical professionals to educate consumers with hearing-impairment about the ADA and the rights of the hearing-impaired. Following are some ways in which audiologists can help their patients learn about and take advantage of the ADA.

1. Display access symbols.

Display the symbol that represents international access for the hearing impaired on your office door, in advertisements, on letterhead, and on mailings. Or, make a flier to instruct patients about this and other relevant symbols about the availability of assistive devices. These symbols are available on the websites and
2. Provide a list of public access facilities in your community that have assistive devices and encourage ALD use.
Generate a list of theaters and other public venues in your community that are ADA compliant and have assistive devices for the hearing impaired. If time is a concern, you could consider contacting other individuals or organizations and ask them to help you with this task. For instance, you may ask an area SHHH or AG Bell group, or local middle or high school students, who are required to obtain volunteer hours, and suggest they take on this task as a community improvement effort. This list could be put in the form of a flier or brochure that is kept in your lobby, given to patients an initial during appointment, mailed to patients with a monthly bill or used as a column in your quarterly newsletter.

3. Educate Patients About Specific Assistive Listening And Alerting Device Options
There are a number of things that can be done to educate patients about specific devices. First, obtain catalogs from assistive device providers and put the catalogs in your waiting room alongside the magazines (see Table 1). Second, create a notebook of fliers that display photos, descriptions, and purchase information about various devices, and keep this notebook in your waiting room. Third, mail one of these fliers with monthly invoices or post them in your patient care areas. Fourth, develop of list of local providers and distributors in your area who offer reasonable policies for individual purchases, including inventory and price information, and return and repair policies. Fifth, show a looped videotape of assistive devices in your waiting room such as Cindy Compton’s video, "Doorways to Independence." Sixth, for patients who have access to the Internet, compile a list of websites about the ADA and assistive technologies. See Table 2 for a short list of such websites. Make this flier available in the waiting room or put the information in your quarterly newsletter. Seventh, volunteer to give presentations to local SHHH or AG Bell support group meetings, worship groups, senior centers, local professional groups, or adult retirement communities. Presentation topics could include the ADA, local ADA compliance and self-advocacy regarding ADA compliance, t-coil use, the "Let’s Loop America" initiative, and demonstrations of specific assistive device technologies.

Table 1.
Assistive listening and alerting device sources available on the Internet.

Ameriphone, Inc. (800 874 3005)

Audio Enhancement (800 383 9362)

Beyond Hearing Aids

Global Assistive Devices (888 778 4237)

HARC Mercantile/HAC Group (800 445 9968)

Hearing Aid Telephone Interconnect Systems (HATIS)

Hearing Resources On-Line Store

Life With Ease (800 966 5119)

NFSS (888 589 6671)

Phonic Ear, Inc (800 227 0735)

Plantronics (408 426 5858)

Siemens (800-766-4500)

Silent Call Corporation (800.572.5227)

Sonic Alert, Inc (248 656 3110)

Ultratec, Inc (800 482 2424)

Williams Sound Corp (800 843 3544)

Weitbrecht Communications Inc (WCI) (800 233 9130)

Table 2. Assistive device information available on the Internet.

Funding Assistive Technology For Persons With Disabilities: The Availability Of Assistive Technology Through Medicaid, Public School Special Education Programs, And State Vocational Rehabilitation Agencies

Gallaudet’s Assistive Devices Center web page

International Hearing Dog, Inc

Let’s Loop America

National Institute on Deafness and Other Communication Disorders (NIDCD) captioning information

Ross, M. (2002, January/February). Telecoil and telephones: The most commonly misunderstood "assistive listening device". Hearing Loss.

Grimes, A. M., & Mueller, H.G. (1991a). Using probe-microphone measures to assess telecoils and ALDs Part I: Assessment of telecoil performance. The Hearing Journal, 44, 16-18.

Grimes, A. M., & Mueller, H.G. (1991b). Using probe-microphone measures to assess telecoils and ALDs Part II: Assessment of ALDs, telephones, and telephone amplifiers. The Hearing Journal, 44, 16-18.

Marshal, B. (2002). Advances in technology offer promise of an expanding role for telecoils. The Hearing Journal, 55, 40-41.

Mueller, H. G. (1992). Assessment of telecoils and assistive listening devices. In H.G. Mueller, D. B. Hawkins, & J.L. Northern (Eds.) Probe microphone measurements: Hearing aid selection and assessment (pp. 227-249). San Diego: Singular.

Myers, D.G. (2002, Sept). The coming audiocoil revolution. The Hearing Review, 28-31.
Prendergast, G.S., & Kelley, L.A. (2002). Aural rehab services: Survey reports who offers which ones and how often. The Hearing Journal, 55, 30-35.

Ross, M. (2002, Sept). Telecoils: The powerful assistive listening device. The Hearing Review, 22-26, 57.

Stika, C.J., Ross, M., & Cuevas, C. (2002, May/June). Hearing aid services and satisfaction: The consumer viewpoint. Hearing Loss, 25-31.

U.S. Department of Justice. (2002). Enforcing the ADA: Looking back on a decade of progress. Washington, DC: U.S. Government Printing Office.

U.S. Equal Employment Opportunity Commission. (1992). The Americans With Disabilities Act questions and answers. Washington, DC: U.S. Government Printing Office.

the Societal Costs of Hearing Loss and Issues in Third Party Reimbursement

The purpose of this paper is to provide policy makers, government officials, third party payers and consumers a brief overview of hearing health challenges in the United States and highlight the hearing healthcare field’s position on reimbursement for hearing services and devices.

The following organizations endorse the recommendations in this paper and can provide additional information:

Alexander Graham Bell
Association for the Deaf and Hard of Hearing
Contact Person: Michele Duchin
Tel: 202-337-5220
Web Site:

American Academy of Audiology
Contact Person: Jodi Chappell, Director of Health Care Policy
Tel: 703-790-8466
Web Site:

American Speech Language Hearing Association
Contact Person: Jim Potter, Director of Government Relations and Public Policy
Tel: 301-897-5700
Web Site:

Deafness Research Foundation
Contact Person: Susan Greco, Executive Director
Tel: 202-289-5850
Web Site: and

Hearing Industries Association
Contact Person: Carole Rogin, Executive Director
Tel: 703-684-5744
Web Site:

International Hearing Society
Contact Person: Robin Clowers, Executive Director
Tel: 734-522-7200
Web Site:

Self Help for the Hard of Hearing People
Contact Person: Brenda Battat, Director of Public Policy and State Development
Tel: 301-657-2248 (Voice) 2249 (TTY)
Web Site:

"Among the five senses, people depend on vision and hearing to provide the primary cues for conducting the basic activities of daily life. At the most basic level, vision and hearing permit people to navigate and to stay oriented within their environment. These senses provide the portals for language, whether spoken, signed, or read. They are critical to most work and recreation and allow people to interact more fully. For these reasons, vision and hearing are defining elements of the quality of life. Either, or both, of these senses may be diminished or lost because of heredity, aging, injury, or disease. Such loss may occur gradually, over the course of a lifetime, or traumatically in an instant. Conditions of vision or hearing loss that are linked with chronic and disabling diseases pose additional challenges for patients and their families. From the public health perspective, the prevention of either the initial impairment or additional impairment from these environmentally orienting and socially connecting senses requires significant resources. Prevention of vision or hearing loss or their resulting disabling conditions through the development of improved disease prevention, detection, or treatment methods or more effective rehabilitative strategies must remain a priority."
Healthy People 2010
National Institutes of Health

There are over 28 million Americans with hearing loss, 10 % of the US population.1 Deafness or hearing impairment may be caused by genetic factors, noise, trauma, certain drugs or medications, as well as viral or bacterial infections.2 According to AARP, hearing loss is the third most prevalent chronic health condition facing seniors.3 There is, in fact, a high correlation between aging and hearing loss, and one out of three older Americans has this condition. Over the next 15 years, 78 million people will move into the 50+ age bracket and the incidence of hearing loss will indeed escalate well beyond the current 1 in 10 affected persons.4 The result of this demographic shift will place greater demands on all age-related health care issues, particularly on hearing health care.

According to a major study recently published in the Journal of the American Medical Association, hearing aids provide a significant benefit to individuals with hearing loss.5 Hearing devices are the treatment of choice for more than 80% of hearing losses. Unfortunately, less than 20% of the estimated 28 million Americans that could benefit from hearing devices currently own them and less than 20% of physicians include any kind of hearing screening in regular physician examinations, exacerbating the challenge of identification and treatment.6 Furthermore, several recent studies have substantiated negative psychological and emotional changes with untreated hearing losses that are reversible with hearing devices.7

Although not the sole cause of underutilization, a lack of payment assistance for hearing devices is a major factor in the low rate of ownership and use. While the Veteran’s Administration provided over 237,000 hearing devices to hearing impaired veterans in 2001,8 and local, state and federal governments purchase a range of assistive listening devices for schools and other public accommodations, there is little or no coverage for individuals accessing hearing health services or hearing devices through private health insurance and Medicare. The hearing health care delivery system in the United States has many interrelated issues that make access confusing, difficult and expensive. Medical economics, quality of care, social impact, patient access, follow-up care, provider training and qualifications are all part of this puzzle. The system is further complicated by a matrix of national, state, and local rules and regulations.

The Economic and Societal Costs of Hearing Impairment
Infants and Children – Million Dollar Babies
The most critical period for the development of language is during the first 3 years of life, as this is the period when the brain is developing. The skills associated with the effective acquisition of language depend on exposure to, and manipulation of, these communication tools. Early identification of deafness or hearing loss is critical in preventing or ameliorating language delay or disorder in children who are deaf or hard of hearing and allows for appropriate intervention or rehabilitation.. Early identification and intervention have lifelong implications for language development.9

The standard estimate of congenital hearing loss (1 in 1,000 live births) appears to underestimate actual congenital hearing loss as reported in data from States with universal newborn screening programs. Estimates based on recent data place this number at 2 to 3 per 1,000 live births. These data do not include children who are born with normal hearing and have late-onset or progressive hearing loss. Hearing loss often is sufficient to prevent the spontaneous development of spoken language. More than 50 percent of childhood hearing impairments are believed to be of genetic origin. Earliest possible identification of infant hearing loss has been widely endorsed as critical for the developing child. Minimal hearing loss also is an important factor in school success and psychosocial development.10

Early identification of hearing loss and treatment in newborns has a dramatic and positive impact on speech development, language development, and learning. Even a six-month delay in treatment of newborns can make the difference between a special education and a mainstream education. According to a 1993 study by the Marion Downs Center, children who do not require special education save a school system as much as $348,000 during a 12-year education.11 The lifetime costs of profound hearing loss, according to the Downs study, can total as much as $1 million.12

Long-term studies indicate that delays in treatment result in the inability of children with hearing loss to reach the academic level of their peers. This also has psychosocial consequences, although the true social cost of low peer group acceptance is undetermined. For newborns, the argument is so compelling that mandated infant screening has been implemented or introduced into legislatures in 37 states. This infant screening seemed to be a "justifiable decision" for policy and decision makers. However, early identification must be partnered with amplification, aural rehabilitation, speech therapy and other treatments.

Adults – Productivity and Effects on Lifestyle

Approximately 10 million persons in the United States have permanent, irreversible hearing loss due to noise or trauma.13 Additionally, 30 million people are estimated to be exposed to injurious levels of noise each day. Noise-induced hearing loss (NIHL) is the most common occupational disease and the second most self-reported occupational illness or injury.14 In industry-specific studies, 44 percent of carpenters and 48 percent of plumbers reported they had a perceived hearing loss.15 Ninety percent of coal miners are estimated to have a hearing loss by age 52 years,16 and 70 percent of male miners will experience a hearing loss by age 60 years. 17

Data indicate that people are losing hearing earlier in life and that men are more frequently affected in the 35- to 60-year-old age group.18 Noise-induced hearing loss can be the result of a traumatic sudden level of impulse noise, such as an explosion, that can leave an individual immediately and permanently deafened; the result of continuing exposure to high levels of sound in the workplace or in recreational settings; the consequence of years of noise exposure causing subtle, progressive damage; or exacerbated due to individual vulnerability to noise. Noise-induced hearing loss is related to noise level, proximity to the harmful sound, duration of exposure, and individual susceptibility. Many of these causes can be controlled by prevention. Prevention of noise-induced hearing loss is imperative for people both on and off the job.

While there exists a strong correlation between aging and hearing problems, half of the 28 million Americans with hearing problems are under the age of fifty and are active in the work force. Noise exposure, aging and genetic predisposition place this group at risk. According to the Project Hope Study, those with a severe hearing loss still in the workplace are expected to earn only 50-70 percent of their non-hearing impaired peers and lose between $220,000 and $440,000 in earnings over their working life.19 Unfortunately, these costs only cover earning potential and neglect intangible losses, such as the social isolation and psychological stress imposed by hearing impairment.

Older people also are a major concern in terms of hearing health disparity. Presbycusis, the loss of hearing associated with aging, affects about 30 percent of adults who are aged 65 years and older.20 About half of the population over age 75 years has a significant hearing loss.21 As the population ages with greater longevity, these numbers are increasing. Only about one-fourth of those who could benefit from a hearing aid actually use one.22 More than 8 percent of the population aged 70 years and older report both hearing and vision impairment. 23

Hearing loss adversely affects quality of life according to a 1998 study by the National Council on the Aging (NCOA). The study, which surveyed 2069 individuals with hearing loss and 1710 of their family members, revealed that hearing device users are likely to report better physical, emotional, mental and social well-being than those who do not use hearing aids.24 Conversely, those that do not take advantage of treatment and amplification are likely to place unnecessary additional cost on both private insurance and Medicare.

The Solution – National System Support for Early Identification, Patient Participation & Professional Treatment
The Hearing Health Community Believes That The Following Actions Will Contribute To A Successful National Hearing Health Policy:
  • Expand Universal Infant Hearing Screening to all States
  • Increase Educational Focus on School Hearing Testing Programs
  • Extend OSHA Guidelines for Work Place Hearing Testing and Monitoring to incorporate treatment
  • Enhance Medical school curriculum and continuing education for family physicians that increases the inclusion of hearing screening as part of Routine Physical Exams particularly for infants, school age children, adults over the age of fifty, and those in high risk groups from occupation or genetics.
  • Broaden public education about the symptoms of untreated hearing loss and the appropriate steps to treat hearing problems. The National Institute On Deafness and Other Communication Disorder’s mission and organization are well-suited to lead this national effort.
The Hearing Health Community Recommends The Development Of A National Hearing Healthcare Reimbursement Policy That Embraces The Following Key Principles:
Provider Choice The ingredients of successful adaptation to hearing aids are not only excellent technology, but also provider service. Closed provider networks have been shown to limit access, increase waiting times, limit innovation and generally negatively impact quality of service. In the case of hearing aids and implants, quality of care and follow-up treatment plays a critical role in outcome. Patients should be allowed to select their hearing healthcare providers and those providers should be qualified through state licensure.

Patient Participation in Treatment OptionsTechnology, science and medicine are making rapid advances and patients should have access to the full range of these advances. Whether they are rich or poor, belong to a Medicaid or commercial plan, people should have the right to participate in the selection of their hearing devices. Any reimbursement system should allow the patient to choose to upgrade the type of instrument and/or technology they desire if it is recommended by the hearing healthcare professional and the individual pays the difference.

Quality ComponentHearing healthcare providers have the responsibility to deliver quality hearing care. Providers should follow professional practice guidelines, adhere to well-developed standards of care and demonstrate patient benefits with acceptable, appropriate outcome measures. Hearing device manufacturers must be able to demonstrate the efficacy of their devices with independent clinical studies substantiating patient benefits.

Medically Effective Treatment Fiscally responsible, medically effective treatment is one of the goals of health care in the United States. Hearing health care is no exception. Price transparency, reimbursement levels, initial & renewal eligibility procedures, and patient co-pay must be established within the context of budget boundaries. Regardless of the level of reimbursement, patients deserve the highest quality of hearing healthcare and qualified providers and hearing device manufacturers strive to ensure that the value of hearing healthcare is recognized and understood by patients, insurers, the government, and other healthcare providers.

In a plethora of studies, it has been proved that the use of hearing aids and implantable devices by Americans with hearing loss improves quality of life and reduces societal costs of caring for those with hearing loss. Indeed, in the case of infants and children, the early diagnosis and treatment of hearing loss can substantially improve development and academic achievement. The treatment of hearing loss provides for a return on the investment many times the cost of the treatment and improves the quality of life for millions of Americans. It is incumbent on policymakers, both in the public and private sectors, to acknowledge the benefit that hearing devices provide and develop programs that allow those in need of treatment to access these technologies as part of a wider healthcare policy agenda.

  1. National Institute on Deafness and Other Communication Disorders (NIDCD). National Strategic Research Plan: Hearing and Hearing Impairment. Bethesda, MD: HHS, NIH, 1996.
  2. National Institutes of Health, Healthy People 2010 Program, Volume 28.
  4. U.S. Census Bureau
  5. Larson, PhD, Vernon et. al., Efficacy of 3 Commonly Used Hearing Aid Circuits, Journal of the American Medical Association, October 11, 2000, Vol. 284, No. 14.
  6. Kochkin PhD, Sergei & Rogin MA, Carole, Quantifying the Obvious: The Impact of Hearing Instruments on Quality of Life, The Hearing Review, Page 10.
  7. Ibid, Page 18.
  8. Hearing Industries Association, 2001 Industry Statistical Program.
  9. National Institutes for Health, Healthy People 2010.
  10. Ibid.
  11. Downs, MP, Universal Newborn Hearing Screening: The Colorado Study, International Journal of Pediatric Otorhinolaryngology, 1995, page 32.
  12. Ibid.
  13. NIDCD. Fact Sheet on Noise-Induced Hearing Loss. Washington, DC: HHS, 1998.
  14. National Institute for Occupational Safety and Health (NIOSH). Fact Sheet: Work-Related Hearing Loss. Washington, DC: HHS, 1999.
  15. Lusk, S.L.; Kerr, M.J.; and Kauffman, S.A. Use of hearing protection and perceptions of noise exposure and hearing loss among construction workers. American Industrial Hygiene Association Journal 59:566-570, 1998.
  16. Franks, J.R. Analysis of Audiograms for a Large Cohort of Noise-Exposed Miners. Cincinnati, OH: HHS, Centers for Disease Control and Prevention, NIOSH, Division of Biomedical and Behavioral Science, 1996.
  17. Mine Safety and Health Administration. Health Standards for Occupational Noise Exposure in Coal, Metal, and Nonmetal Mines: Proposed Rule. Federal Register 61:243:66347-66397, December 17, 1996.
  18. Wallhagen, M.I.; Strawbridge, W.J.; Cohen, R.D.; et al. An Increasing prevalence of hearing impairment and associated risk factors over three decades of the Alameda County Study. American Journal of Public Health 87(3):440-442, 1997.
  19. Mohr, Feldman, Dunbar, The Societal Costs of Severe to Profound Hearing Loss in the United States, Project Hope Policy Analysis Brief, April, 2000, Volume 2, No. 1.
  20. Gates, G.A.; Cooper, Jr., J.C.; Kannel, W.B.; et al. Hearing in the elderly: The Framingham Cohort, 1983-1985. Part I. Basic audiometric test results. Ear and Hearing 11(4):247-256, 1990.
  21. Cruickshanks, K.J.; Wiley, T.L.; Tweed, T.S.; et al. Prevalence of hearing loss in older adults in Beaver Dam, Wisconsin: The Epidemiology of Hearing Loss Study. American Journal of Epidemiology 148(9):879-886, 1998.
  22. Popelka, M.M.; Cruickshanks, K.J.; Wiley, T.L.; et al. Low prevalence of hearing aid use among older adults with hearing loss: The Epidemiology of Hearing Loss Study. Journal of the American Geriatrics Society 46(9):1075-1078, 1998.
  23. Klein, R.; Cruickshanks, K.F.; Klein, B.E.K.; et al. Is age-related maculopathy related to hearing loss? Archives of Ophthalmology 116(3):360-365, 1998.
  24. See Kochkin & Rogin, page 13.