New problems in the scope-of-practice controversy [Ear, Nose & Throat Journal]

Patient safety and quality of care are primary concerns for physicians and all responsible allied health professionals. However, disagreements between otolaryngology and other health organizations (such as the American Speech-Language Hearing Association) have occurred. Most professional audiologists and speech-language pathologists recognize and agree that medical diagnosis is not within their scope of practice and that diagnosis requires a physician. Nevertheless, bills appear frequently in state legislatures that contain language such as "diagnosis" within the scope of practice of audiologists and speech pathologists. Similar scope-of-practice concerns have arisen around the endoscopic diagnosis of voice and swallowing disorders.

In general, the discussions and debates have been vigorous but civil, and relationships between most otolaryngologists and most speech pathologists remain good, as do relations between our professional organizations for the most part, despite some disagreements over scope of practice.

A recent related development has introduced a potential patient risk about which physicians and audiologists are united in steadfast agreement. In many jurisdictions, hearing aids cannot be sold without a purchaser either having a medical evaluation and hearing health diagnosis, or signing a waiver declining medical consultation. This process was intended to protect the general public from inappropriate hearing aid sales and to prevent delayed diagnosis of serious conditions. Recently, however, the process has been undermined and bypassed by UnitedHealth Group (UHG), the company that offers health insurance and other services through United Healthcare (UHC).

By revenue, UHC is the largest health insurer in the United States. On October 3, 2011, UHC announced that it will provide its clients and the general public with online hearing testing and, on the basis of those hearing tests, will permit the purchase of hearing aids through the Internet, operating through hi HealthInnovations (HHI), a subsidiary company of UHG. HHI has contracted IntriCon Corporation (Arden Hills, Minn.) to manufacture its hearing aids.

Most reputable hearing aid manufacturers have a public policy against the sale of their hearing aids online. Therefore, the HHI model is in conflict with the standard of practice within the hearing aid industry. This is no small issue. Even if this policy involved only UHG/UHC's clients and not the general public, the impact would be substantial. UHG/UHC clearly has established an aggressive strategy targeting the elderly population. Also on October 3,2011, UHC introduced a new Medicare plan and began marketing actively to the elderly. The company has the financial and organizational ability to reach a great many people. However, the decision to offer online diagnosis, treatment, and hearing aid distribution for hearing-impaired patients has raised major concerns among otolaryngologists and audiologists.

On October 31, 2011, the Academy of Doctors of Audiology and the American Academy of Audiology sent a joint letter to UHC expressing their concerns.1 Otolaryngologists share those concerns. An online evaluation is no substitute for a thorough examination by an otolaryngologist with comprehensive audiometry performed by a certified audiologist, followed by appropriate testing leading to an accurate diagnosis of hearing impairment. It will not be surprising if the online testing and hearing aid dispensing process leads to delayed diagnosis of serious and potentially treatable conditions.

At present» it is not clear whether UHG/UHC will be liable for missed or incorrect diagnoses or whether, in its role as an insurance company, it will have legislative immunity (under the Employee Retirement Income Security Act [ERISA]). One might argue that such protection would not be appropriate since the insurance company is clearly venturing into the practice of medicine with this initiative. However, one might make the same argument about insurance company "medical directors" who determine what studies and operations our patients may or may not have (the practice of medicine, it seems to me); and yet the insurance companies generally enjoy protection from the consequences of their actions, when similar actions by individual practitioners could result in malpractice suits.

This new approach by UHG/UHC is a matter for serious investigation in and of itself, but if it is allowed to stand and marks the beginning of a new trend in the delivery of hearing health and/or geriatric care, it is even more disturbing. Otolaryngologists should follow this matter closely and be alert to help patients who have been treated suboptimally through the HHI process.

Reference

1. The Academy of Doctors of Audiology. The Academy of Doctors of Audiology warns consumers against obtaining hearing aids without proper diagnosis, treatment and counseling, www. audiologyonline.com/news/pf_news_detail.asp?news_id=4962. November 22,2011. Accessed January 23,2012.

Robert T. Sataloff, MD1 DMA, FACS

Editor-in-Chief

Ear, Nose & Throat Journal