Question: Why are private hearing aids so expensive?

Q & A 2

When I worked as an Audiologist in the UK’s National Health Service (NHS), I was often asked by my patients questions such as “Are private hearing aids any better than what you get free from the NHS?”, “Might I hear any better with a private hearing aid?”, and “Why are private hearing aids so expensive?”  I always found such questions difficult to answer because I didn’t know for sure if private hearing aids were indeed any better, I didn’t know if the private technology at the time could help a person with hearing loss hear any better and I certainly had no idea as to why NHS hearing aids are free and a pair of private devices can set you back anything up to £6,000.  Of course, I always opted for the “politician’s answer”!

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I was, however, very proud of my NHS – often working in the local hospitals, I witnessed first-hand the enormous amount of hard graft, team-work, tax-payers’ money and impressive amount of training and education that goes into running this mammoth and precious system.  A system that, despite being gargantuan in size, is actually quite fragile and teetering on collapse due to increasing demands and not enough money.  As an NHS Audiologist, I felt proud of the fact we were able to offer good digital hearing aids completely free of charge and always made sure my patients did not assume NHS hearing aids were inferior in quality just because they were free (some UK NHS patients don’t know how lucky they are!).  However, I also advised the patients who asked about private hearing aids to, by all means, see a private hearing aid audiologist, but to make sure they trial private hearing aids before they decide to buy and still stand by this advice.

I no longer work in the NHS and now work for a major hearing aid manufacturer that supplies both the public and private sectors.  I now know a lot more about the technology that goes into hearing aids and train both NHS and private Audiologists and Hearing Aid Dispensers on our latest products and software.  I am also now in a better position to answer those tricky questions posed by many an NHS patient all those years ago!

“Are private hearing aids any better than what you get free from the NHS?”

In some ways yes, but for some people it isn’t something that matters.  Private hearing aids will most often offer more advanced technology, such as direct streaming via an iPhone (“Made For Apple”), several intelligent automated features, custom In-The-Ear styles and a multi-functional app, but you might not have any need for all these things.  So, really, a private hearing aid with all the associated modern technology is only “better” if you can and will use all the extra options you are buying.  Even just 10 years ago, there was a notable difference between NHS and private hearing aids, but today this gap is closing.  Hearing aid manufacturers are now offering very similar spec in their NHS product as they do in their private product.  That said, most NHS Audiology departments do not offer the more expensive custom-made In-The-Ear or Receiver-In-The-Ear devices.

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“Might I hear any better with a private hearing aid?”

As previously mentioned, private hearing aids often come with extra smart technology, however much of this is more about convenience than actually hearing better.  For example, being able to adjust your hearing aids’ volume or noise cancellation via a smartphone app, streaming music directly to your hearing aids via an iPhone or having a tiny custom-made Invisible-In-Canal device will not necessarily contribute to hearing better, but will certainly make hearing more convenient.  How well you hear with a hearing aid is as much about its programming as it is about its technology.  The NHS routinely fit hearing aids with a Real-Ear Measurement (REM), an objective test used to fine-tune the sound of the aid to your individual ear canal and verify the aid is amplifying accurately according to your prescription.  REMs are carried out by many private hearing aid dispensers, but not routinely.

“Why are private hearing aids so expensive?”

And finally, just why are private hearing aids so incredibly expensive?!  There is one element of better technology costing more.  However, NHS hearing aids usually have a basic cost of about £50-£60 each for a standard Behind-The-Ear device, whereas private dispensers might purchase a top-spec Receiver-In-The-Ear aid for about £1500-£2000 (depending on spec, etc.).  The difference in price at this point is not just about technology, but also about the number of units purchased.  Most NHS Audiology departments in the UK fit hundreds of hearing aids every week and spend hundreds of thousands of pounds on hearing aids each year.  Compare this to an individual private hearing aid dispenser and the number of hearing aid fittings can drop to just one or two per week.  So private dispensers pay a higher cost price for premium hearing aids, so have to charge their customers more, but they also need to charge according to demand and capacity.  A private hearing aid dispenser has far less demand than an NHS department and far less capacity to see many patients.

The other misconception about private hearing aids is that the entire cost is for the devices alone.  The cost you pay for private hearing aids may also include your consultation, hearing test, ear wax removal, ear impressions, custom-made devices, hearing aid fitting, follow-up appointment, batteries, replacement parts, reassessment, etc.  When you actually cost all of these other included products, services and clinic time, the cost of the actual hearing aids comes down significantly.  Buying a hearing aid is not the same as buying a sofa – you won’t walk out of the store with your new hearing aids and never need to visit again.  Hearing and hearing aids require on-going observation and maintenance.

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So, yes, you can get more advanced technology privately and, if you plan to use all of what’s available then it may well be worth the expenditure.  The other main difference between hearing aids from the NHS and privately is the service.  While NHS Audiologists are highly trained and well-educated, they are pressured to see as many people as possible in a very short space of time and appointment waiting lists are usually long.  Even if you don’t have to wait for an appointment for a repair, you still may have the inconvenience of having to wait at a walk-in repair clinic.  Like most other private health care, by seeing a private Audiologist you will most likely never have to wait to be seen and, when you are, you will have much more time with your clinician.

So, if you are weighing up whether to stick with NHS hearing aids or purchase privately, my advice, having worked on both sides, would be to ask yourself: do you want and will you use the latest technology, do you want a very discreet device, do you want to be seen quickly?  If these are all important to you, and of course you can afford it, then private aids may be the right option for you.  However, if your listening needs are not complex (i.e. mostly 1-2-1 conversation in quiet or watching TV), you have no desire for modern technology and don’t mind NHS waiting times and busy clinics, then stick with the fantastic UK NHS!

What Will Hearing Aids Sound Like?

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If you have, or suspect you have, a hearing loss, you might be considering trying hearing aids.  Many people are reluctant to take the first step because of concerns, reservations or even fear of what using hearing aids might involve.  Many people have concerns about how the hearing aid might look, some worry they might not manage with today’s modern technology, while others assume they won’t like the sound of hearing aids.  The latter barrier to hearing aids is most often a misconception – most people who believe they won’t like the sound of hearing aids wrongly assume that they will sound loud and some even believe a hearing aid will make them talk louder.

While these are all normal, human concerns, today’s digital hearing aids provide a more natural sound than ever before.  Modern technology has become so intelligent that hearing aids process and amplify sound using very clever electronic systems, which can carry out several automated changes at once without the hearing aid wearer having to adjust any manual controls or even being aware of the hearing aid’s sound processing changes.

The most common type of hearing loss is high-frequency (or high-pitch) – this means that the person can hear lower frequency sounds easily, even if they are very quiet.  However, as the frequency of a sound increases, the louder the sound has to be before the person can hear it.  At some frequency, which will vary from person-to-person, the sound cannot be heard at all, no matter how loud it is and no matter how much it is amplified.  The speech frequencies span from about 250Hz to 6,000Hz.  A standard hearing test will test across 250Hz-8,000Hz.  Hearing aids tend to amplify sound across 100Hz-10,000Hz, however this does vary, depending on the spec of the device and how it is fitted in the ear canal.

Most people with a high-frequency hearing loss tend to make similar complaints – speech sounds unclear or “mumbled”, even minor background noise makes it extremely difficult to understand speech, the need for people to repeat becomes more frequent, and increased volume is required to hear speech on television, usually much to the annoyance of better-hearing family members!  So if that is what a high-frequency hearing loss sounds like, what do hearing aids sounds like?

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I’m lucky to have normal hearing myself, so can’t speak from personal experience, but I have fitted hundreds, if not thousands, of hearing aids, so I can tell you about how my patients report their experiences of wearing hearing aids.  Many people report the hearing aids’ sound to be “tinny” – some patients do not take to this quality initially and prefer less volume in the high frequencies that causes this effect.  However, many patients understand that this is normal – if s/he has had a high-frequency hearing loss for many many years, the brain is inevitably going to sense a “tinny” sound when the hearing aids are amplifying high-pitch sounds so that they can be perceived by the brain.  Patients also report speech as sounding “sharp”, “crisp” or “clear” and they become more aware of quieter surrounding sounds, such as rustling paper, air conditioning or a ticking clock.  Many patients note they can hear their own voice more (which people may or may not like!), however, sometimes this can be remedied by trying a different fitting in the ear canal.  Because new hearing aid users can hear their own voice louder, they worry that they are talking louder – reassuringly, it is actually the opposite.  Hearing loss can cause a person to talk louder because they cannot hear their own voice properly.  However, because hearing aids amplify sound, the hearing aid wearer can hear his/her own voice more clearly and at a normal level.  Most people with hearing loss who routinely raised their voice when talking prior to using hearing aids notably lower their voice as soon as their hearing aids are in their ears.  Some patients perceive the new sound as being loud – such patients have usually put off getting hearing aids until their hearing loss has become more severe.  As the brain becomes accustomed to being deprived of sound, adapting to amplification can be more of a challenge.

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Overall, and most commonly, new hearing aid users report that the sound of their hearing aids is just different.  Often people find it difficult to explain how the sound is different, but once they become aware of how much clearer speech is, how much easier it is to communicate with people, how their aids may allow them to bring previously lost pleasures back into their life, such as music, and how general listening requires less effort, they stop worrying about the sound of their aids and instead start anticipating how hearing aids may positively impact their quality of life.

A Review of Tinnitus Treatments

A Review of Tinnitus TreatmentsTreatments used in the management of tinnitus are aimed either at reducing the intensity of the tinnitus directly or at relieving the annoyance and distress caused by tinnitus (Han et al., 2009). Audiologists are generally concerned with the latter and management of tinnitus in clinic typically involves a combination of strategies: (1) habituation of perception, which aims to alleviate the intrusiveness of the tinnitus signal and (2) habituation of reaction, a psychological approach, which aims to adjust any negative and irrational reactions to tinnitus (Hobson et al., 2012).

1. Habituation of Perception

Sound Therapy or Sound Enrichment

Table-top or body-worn in-ear sound generators can present broadband noise, such as white or pink noise, or relaxing environmental sounds, such as rain or waves, which are intended to be relaxing and to alleviate the intrusiveness of the tinnitus signal. The main principle of sound-enrichment is that the therapeutic sound should be perceived as less disturbing than the tinnitus sound (Langguth et al, 2013).

Tinnitus Retraining Therapy

Tinnitus Retraining Therapy, or TRT, is a combination treatment of both counselling and sound therapy that was developed by Pawel Jastreboff and Jonathan Hazell in the 1980s. TRT is based on the neurophysiological model of tinnitus and its implementation is based on the plasticity of the brain and its natural tendency to eliminate (habituate) reactions to unimportant stimuli (Jastreboff & Hazell, 2004). Put simply, sound therapy induces habituation by reducing the strength of the tinnitus signal, while counselling aims to encourage the patient to reclassify their tinnitus into a neutral category to further facilitate habituation.

Hearing Aids

Hearing aids are cited to offer relief from tinnitus in some patients who have hearing loss (Andersson et al., 2011) and are widely used in Audiology clinics. Amplification compensates for the absence of auditory input in the frequency range of the hearing deficit. However, the 2013 literature review by Langguth et al. cite research that observes the limitation of hearing aids in the high-frequency range and the issue of dead regions in the cochlea. Research suggests that hearing aids may only provide benefit to tinnitus patients whose tinnitus is of a frequency that is within the amplification capabilities of a hearing aid and this is often less than 6kHz. However, hearing aids often help to enhance speech and environmental sounds, thereby drawing attention away from tinnitus (Han et al, 2009).

2. Habituation of Reaction

Counselling and Education

Patient counselling and education should form the foundation of all tinnitus treatments and can incorporate the provision of information, which should aim to explain and demystify the condition and correct any false beliefs, as well as empower and encourage patients to cope with the emotional consequences of tinnitus (Langguth et al., 2013).

Cognitive Behavioural Therapy

Cognitive-Behavioural Therapy, or CBT, aims to reduce the tinnitus-related disability by modifying dysfunctional cognitive, emotional and behavioural responses to tinnitus (Langguth et al, 2013). The main components of CBT include relaxation training, mindfulness training, psychoeducation, imagery training and attention-control techniques.

Relaxation Therapy

Research demonstrates an association between tinnitus and psychological disorders, with some studies reporting a high prevalence of tinnitus in patients with psychiatric illness, depressive disorder and anxiety when compared with the general population (Milerová et al, 2013). Relaxation therapy has long been judged to play an important part of a multi-strategy tinnitus in the psychological treatment of tinnitus, but appears to offer little benefit to tinnitus on its own (Baguley et al., 2013a).

Self-Help

In a health service that always faces the challenge of time restraints and long waiting lists, self-help interventions are becoming more frequently used in the clinical setting. CBT has been researched historically mainly in the face-to-face setting, but more recent literature has investigated the efficacy of self-help tinnitus treatments. A systematic review by Nyenhuis et al. (2013) concluded that self-help interventions are effective in the reduction of tinnitus distress and depressiveness in tinnitus patients, however, it is not known with any certainty as yet, how this efficacy compares with face-to-face treatments. Therefore, self-help CBT treatments are recommended in the healthcare setting to support tinnitus patients who are unable or unwilling to attend face-to-face counselling, which still remains the preferred method of administering CBT.

Discussion

Tinnitus is difficult to assess and research. It is therefore a challenge to treat successfully. Research using human subjects, particularly trials, is scarce and the use of multi-disciplinary treatment approaches or combination rehabilitation strategies complicate the process of drawing scientific conclusions on the efficacy and value of each intervention (Baguley et al, 2013b). However, animal research and neuroimaging techniques have improved understanding of the pathophysiological mechanisms of the different types of tinnitus (Langguth et al., 2013). Despite the lack of research on tinnitus that is truly isolated from other influencing factors, a multidisciplinary approach that includes all of the treatment strategies discussed above remains the preferred treatment strategy for tinnitus. Indeed, while the benefits of such treatments may be small in most cases, and the perception of tinnitus is not eradicated, they do appear to have a significant and positive effect on quality of life (Baguley et al, 2013b).

References

Andersson, G., Keshishi, A. & Baguley, D. 2011. Benefit from hearing aids in users with and without tinnitus. Audiol Med. 9. pp73-78.

Baguley, D., Andersson, G., McFerran, D. & McKenna, L. 2013a. Tinnitus: A Multidisciplinary Approach. Wiley-Blackwell, UK.

Baguley, D.M., McFerran, D. & Hall, D. 2013b. Tinnitus. The Lancet. 382, pp1600-1607.

Han, B.I., Lee, H.W., Kim, T.Y., Lim, J.S. & Shin, K.S. 2009. Tinnitus: Characteristics, Causes Mechanisms, and Treatments. Journal of Clinical Neurology. 5, pp11-19.

Hobson, J., Chisholm, E. & El Refaie, A. 2012. Sound therapy (masking) in the management of tinnitus in adults (Review). The Cochrane Database of Systematic Reviews. Issue 11. Art. No.: CD006371. DOI: 10.1002/14651858.CD006371.pub3.

Jastreboff, P.J. & Hazell, J.W. 2004. Tinnitus Retraining Therapy. Cambridge University Press, New York.

Langguth, B., Kreuzer, P.M., Kleinjung, T. & De Ridder, D. 2013. Tinnitus: Causes and Clinical Management. Lancet Neurology. 12, pp920-930.

Milerová, J., Anders, M., Dvořák, T., Sand, P.G., Kniger, S. & Langguth, B. 2013. The influence of psychological factors on tinnitus severity. General Hospital Psychiatry. 35, pp412-416.

Nyenhuis, N., Golm, D. & Kröner-Herwig, B. 2013.  A Systematic Review and Meta-Analysis on the Efficacy of Self-Help Interventions in Tinnitus, Cognitive Behaviour Therapy, 42:2, pp159-169.