The Economic Complications of Cochlear Implant Candidacy and Disparity

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The Economic Complications of Cochlear Implant Candidacy

Cochlear implants have been known to significantly help those with hearing loss, especially children with severe hearing impairments. Unfortunately, the guidelines that suggest a patient may be a proper candidate for a cochlear implant does not always align with the guidelines of insurance policies. Though a hearing health professional may deem you a classic CI candidate, certain plans such as Medicare Part B are more likely to leave patients disappointed as their health insurance concludes that they should continue using hearing aids unless they can pay out of pocket. This disparity is a common scenario many CI providers and their patients find themselves in, as doctors struggle to advise patients who could benefit greatly from a cochlear implant but do not meet Medicare’s guidelines. Now, a 2019 review is advocating for change in how Medicare beneficiaries can gain access to cochlear implants.

Medicare’s Restrictive Criteria

Lead by Dr. Sarah Sydlowski, PhD, AuD, the audiology director of the Hearing Implant Program at the Cleveland Clinic, a review of the clinic’s academic medical center’s CI program had found that although the majority of those who went for cochlear implant evaluations were Medicare beneficiaries, they demonstrated the lowest rate of CI candidacy. “In other words,” Dr. Sydlowski explains, “although Medicare beneficiaries in this sample were the largest group perceiving enough difficulty to be evaluated for a CI, they were the least likely to have access to one, mostly due to Medicare’s restrictive criteria.”

In 2005, the Center for Medicare and Medicaid Services (CMS) had revised its National Coverage Determination (NCD), guidelines that remain in effect today. Similar to commercial payers though, Medicare Advantage plans may determine how benefits are distributed, prompting more cases to be approved under less strict guidelines.

Advocating For Change

According to the World Health Organization (WHO), nearly 60 million people have enrolled Medicare beneficiaries, with estimates ranging up to 20 million with disabling hearing loss. Dr. Sydlowski had found that “Given that Medicare covers 3,600 CIs per year and approximately 10 percent of CI candidates have a CI, we could reasonably expect that at least 36,000 Medicare beneficiaries could benefit from CI per year using conservative candidacy criteria,” showing the benefits that expanded candidacy could mean for those 20 million with hearing loss.

Expansion for candidacy has been widely advocated by hearing health professionals and CI providers for some time, though this comes at an increased cost. The economics of cochlear implants and Medicare is complicated, as CMS must keep its budget under control and health care administrators struggle to maintain profitable margins. “It is critically important to recognize that increased access to CI for Medicare beneficiaries will come not only from expanded candidacy criteria but also from reimbursement commensurate with the cost of providing the service and realigning service delivery to maximize efficiency.” Dr.Sydlowski explains, “While expanding candidacy is justifiable from a comparative clinical effectiveness standpoint and providing best possible outcomes is ethically and morally defensible, advocacy for CMS coverage of CI cannot only focus on clinical criteria but must also demand commensurate reimbursement to ensure that providing the technology is viable for clinicians.”

Though the economics of CIs can be complex, Dr.Sydlowski’s 2019 review has highlighted the importance of advocating for change. “Advocacy efforts must not exclude consideration of appropriate reimbursement for CI services, otherwise access will continue to be unnecessarily limited.”

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