Thomas H. Lee, MD, interviews Charlotte Yeh, MD, the Chief Medical Officer for AARP Services, Inc.
Tom Lee: This is Tom Lee from NEJM Catalyst, and we’re talking today with my longtime friend and a great colleague, Charlotte Yeh. Charlotte Yeh is an emergency medicine physician; she’s played leadership roles both in emergency medicine and in a variety of other forms. Currently, she is Chief Medical Officer for AARP Services, Inc.
She and I recently had breakfast, and she made this one comment that got stuck in my head. At one point where we were talking frankly about our parents, as well as health care, she said that if she could change just one thing in health care, it would be to have CMS cover hearing aids — and she said it with a great deal of passion. She shared personal experiences as well as data over breakfast, and by the time we finished, I was upset about it, too, so we scheduled this conversation to see if we could whip up the rest of the country.
So, Charlotte, tell us: What is the coverage situation for hearing aids these days?
Charlotte Yeh: Thanks so much, Tom, for having me on. It turns out that Medicare, under CMS, is statutorily excluded from covering hearing aids and hearing services because back in 1965, when Medicare was passed, hearing loss was thought to be a normal consequence of aging — why would we cover anything that was normal?
We now fast forward to present day, and we’ve learned a lot about the impact of hearing on health, health outcomes, and cost of care. These days, the VA covers hearing aids because it turns out hearing loss and tinnitus are the largest disability claimed by veterans. Some of the Medicare Advantage plans, some commercial plans, some Medicaid plans do cover some form of hearing services or hearing aids, but it’s certainly not universal; it’s still an out-of-pocket expense for many.
Lee: I’m embarrassed to say, this is all news to me. I know that the answers to this are qualitatively obvious, but if you could just give us a little bit of insight: How big a problem is hearing loss? How common is it, and what do we know about its impact?
Yeh: What’s amazing to me is, we have this huge epidemic, if you will, hugely prevalent common issue of hearing loss, and yet it’s silent and nobody knows about it. It turns out, for anybody who is 60 and older, as much as 40% of the population has hearing loss that impacts their everyday life. When you get to 70 and older, it’s as much as two-thirds of people have hearing loss.
Why does this matter? We just published two studies in JAMA Otolaryngology recently, following thousands of people, a hundred thousand people, over 10 years, from the age of 50 and older who are covered by commercial and Medicare Advantage insurance, and [found that] if you have uncorrected hearing loss, there’s a 52% higher risk of dementia, 41% higher risk of depression, and 29% higher risk of falls. If you look at the cost and utilization over 10 years, that’s 46% higher health care costs, meaning someone with uncorrected hearing loss, over 10 years, costs over $22,000 more per person — 47% more hospitalization, about 2 ½ days longer per hospitalization, and 44% more readmissions.
If that doesn’t give us a business case for one thing that we could fix in health care right now, it’s attention to hearing and hearing health. And by the way, AARP recently did a study looking at hearing difficulties or perception of hearing loss by Millennials and Gen-Xers, and believe it or not, already 25% of Millennials and Gen-Xers report some degree of hearing loss.
Lee: Those are impressive data. We all understand that there are going to be confounding factors, and whether the hearing loss causes dementia would be greatly questioned, but could hearing loss drive depression? I don’t think anyone would question that. What do we know about what happens when people with hearing loss get hearing aids?
Yeh: Yes, we can say hearing loss and dementia are correlated, [along with] depression and falls. The Lancet Commission on Dementia in July of 2018 reviewed all of the literature around dementia, and they identified about 35% of dementia as potentially avoidable. The single biggest category was 9% of cases of dementia that could be avoided by attention to hearing loss. I think hypertension was about 1%, and obesity was 2%, it might be reversed, but hearing loss was way above the things we always talk about, hypertension and obesity, and there is evidence that people who do get hearing aids and hearing services do have a reduction of dementia.
There’s a randomized controlled trial going on by NIH right now, so we should have a more definitive answer. It’s thought that loneliness and isolation caused by hearing loss may be one of the driving factors of poor communication, so people in the hospital bounce back because they don’t really understand all of the communication.
I found a really interesting study back in 2017, where the researchers reviewed all the studies about physician-patient communication, which we know is so, so important in health care, and of the papers they studied, less than a quarter even mentioned hearing loss. In fact, four of the studies excluded hearing loss in their review of patient-doctor communications, and only in six was hearing loss even mentioned — talk about a silent, and yet so, so impactful [issue] in health and the cost of care.
Lee: What people really need is an experiment, a randomized trial where people are given hearing aids or not given hearing aids, and outcomes are measured. Has that been done, or is that being done now?
Yeh: The randomized controlled trial is going on right now, but there is a lot of other evidence that the use of hearing aids, or hearing, does mitigate against dementia, falls, and depression. We found in some of our studies of our Medicare supplemental population that hearing loss was a larger impact on quality of life than diabetes, heart disease, arthritis, any of the other common clinical conditions. Helen Keller, who was both blind and deaf said, “Blindness separates people from things, but hearing loss separates people from people.”
Lee: When we had breakfast, you shared with me your own very sweet story about the impact of hearing aids for your father. Do you mind sharing that with our listeners?
Yeh: Sure. My father, like a typical older man, for years was having progressive hearing loss and absolutely refused to have hearing aids, or even have his hearing tested. I was watching him at family get-togethers, and he was becoming more withdrawn, he was sitting in the corner, he started having a shuffling gait, very tentative, and honest to goodness, I was starting to think, “My father’s having early signs of dementia.”
At one point, my mother got locked out of the house and he couldn’t hear the doorbell, and so she waited 30 minutes out in the cold waiting for him, so he finally went and got hearing aids.
About 2 months later, we were at a family gathering, I walk down to breakfast, and there was my father sitting in the middle of the breakfast table, regaling people with stories of families and childhood. My mother’s punching him playfully in the arm saying, “You’re talking too much. You’re talking too much.” And he got up off the table and he walked with a bold stride. He was the father I remembered who loved engaging with people, who just had a much more powerful walk, and I went, “Oh my God” — even I didn’t recognize it was simply that he couldn’t hear.
He admitted later on, “You have no idea how profoundly lonely and isolated you become when you can’t hear and you can’t connect.” Nobody talks about that.
Lee: That is priceless. I hope you don’t mind educating a doctor like me, who doesn’t even know what hearing aids cost these days. How expensive are they?
Yeh: In the traditional model, which is what we’ve had for decades, hearing aids are bundled in with hearing services combined, and the pricing can be anywhere from $2,000 to $4,000 per hearing aid, per ear — which really is priced out of most people’s range. But recently, over-the-counter hearing aid legislation was passed, which the FDA has until next year to produce regulations for, and it means for people with early and mild to moderate hearing loss, getting some kind of hearing device could cost in the few hundred of dollars, rather than the thousands of dollars.
I want to make note that just getting a hearing aid isn’t going to solve the hearing problem for everyone. If it’s early on and mild, that’s great, but the longer you go without hearing well, your brain starts to lose that cognitive function, so even when you get a hearing aid, you may no longer be able to convert that sound into speech. If you don’t use the brain, you lose it.
Secondly, if you move into an apartment next to a train station, you [might say], “I can’t sleep.” But about a month later you say, “What train station?” You’re going to have to retrain and have your brain understand which sounds to pay attention to.
I do think we are coming at a convergence now: (1) we’re recognizing the huge prevalence and impact of hearing loss over time; (2) with technology — the technology is awesome, it can connect with your smartphone, you can adjust it yourself, for those who want it, you can get an audiologist to help you with adapting and getting the right hearing aid for your particular lifestyle; and (3) the cost hopefully will be coming down over the next few years and people’s plans will begin to start to cover hearing services more.
Lee: You’ve made the case well. What would it take for coverage to change? How do we go about making your dream come true?
Yeh: Obviously, it’s not something I can do as one person, but if I had my dreams, we would figure out how to address hearing loss, whether it’s through CMS coverage, whether through commercial and Medicaid plans, and address the stigma. I think it’s fascinating, no one wants hearing aids because they think it’s going to make them old, most people wait 7 to 10 years of hearing loss before they get hearing aids, and only 20 to 30% ever get one.
It’s not just the affordability, but it’s also reversing that image that you’re old with hearing aids. I like to tell people, you’re old without hearing aids; hearing allows you to engage back with society, so I would love to see hearing aids be covered, be accepted, everyone’s got things in their ears.
Starting right now, every clinical provider, clinician, or every health system could do these three things to make a difference:
- You should be screening your patients for hearing loss right off the bat, especially if they’re 60 and older.
- While you’re on the clinical floors, or if you’re doing care coordination, or you’re talking to a patient, for several hundred dollars you can get a handheld amplifier so that you can improve communication with your patient. In fact, there’s a study coming out of Johns Hopkins that by using handheld amplifiers, not only did the individuals with hearing impairment have better communication, but normal hearing people had better communication, too, and the nurses loved it because it reduced their workflow. What could be better?
- Every health system or provider group could check the hearing of their own employees. I told you how prevalent it is; we know that we want to keep our workers in the workforce as long as possible, so we should be checking their hearing, as well. People with uncorrected hearing loss tend to leave their jobs earlier, and they tend to have poorer job performance because they can’t communicate.
Lee: Charlotte, this was fantastic. I’m embarrassed to say how much I learned. This is a great obsession that you have, and I hope that we can change the one thing that you want to change, and then we’ll come back to you and ask about what’s the next thing you want to change, but that’ll be another day. Thanks again, so much.
Yeh: Thanks so much, Tom.