Should Time Spent with an Audiologist 3 hrs and 5 min over 6 -7 weeks Cost you $3000?

Hearing Aids Direct follows "Model 2"


In all 3 Models the audiologist/specialist is always paid for their time and the service they offer for that time. No one is putting them out of business by empowering the consumer to purchase their hearing aids somewhere else and returning to them for service. 

"Model 2 does not actually alter the traditional clinic process of Model 1, other than to redirect the source of purchase. The time in clinic remains unchanged (minus 20 minutes for administration picked up on the online distributor’s end). And clinicians can and should be remunerated for their professional time spent in the fitting process."

This article we found breaks down what one audiologist thinks is the ideal time spent with a patient through the entire process. So when they quote you a "bundled" price its usually just a big number regardless of what time they'll actually spend with your particular case, clouded by sales tactics like free batteries, or scaring you with the idea that you'll need unlimited office visits, to keep you from buying your hearing aid somewhere and just asking them to do the service part of the business. 

Developing a Viable Best Practice Model for Online and OTC Hearing Aid Distribution

Ryan Kalef, Canadian Audiologist and Intrepid Reporter
Ryan Kalef, Canadian Audiologist, Intrepid Reporter, Worthy Competitor

Hearing Economics  welcomes back Ryan Kalef as Guest Editor for the next few weeks.  His previous posts have given readers the Canadian perspective with An Earful From CanadaCall of the Wild, and Different Views on Selling.  Today he jumps in the bare-knuckled Price ring, joining the Pricing Series to the effort started last week by Terry Ross to find rational and professional means of competing against new challengers.


The burgeoning question on my mind lately is this:

Can Internet sales of hearing aids executed to achieve lower prices for the consumer/patient/client, be a sustainable business model and follow best practice principles? 

Best Practice OTC Hearing Aid Distribution Model: Could it Work?


I do see the potential and, theoretically, I think there is a model that could work. But is it a more economical system? Instead of joining the critics who fight over average follow-up rates, time value, and the value of expertise, I decided to explore the structure that would actually satisfy my criteria for operating such a practice.

  • First, the model needs to meet best practice hearing healthcare standards.
  • Second, it needs to offer lower prices to the consumer/patient/client.
  • Third, it needs to be a viable, sustainable business model.


Model 1:  Best Practices for Ideal Patients in Current Dispensing Settings


As an Audiologist first and business person second, my modeling effort is in stark opposition to the business minds working from the business idea outward and bashing the world of hearing health care in the process.  I’ll explore and develop the model through step-by-step examples, much like writing a computer program (or body building).  The model is best started with the simplest case — one with no problems.  I’ll start with my ideal clinical patient, whom we will name Mr. Ideal.

Mr. Ideal is an active, well-educated 70-year-old patient who lives an active and social lifestyle. His dexterity is excellent, he does not wear glasses as his vision does not require it, and he describes himself as tech savvy. Mr. Ideal has noticed a gradual decline in his hearing ability, particularly in group situations over the past 5 years, and is now motivated to correct his problem through the use of hearing aids. And, oh yes, he does not have a wax problem, and he has a “standard” mild to moderate sloping bilateral sensory-neural hearing loss (SNHL).

In the clinic Mr. Ideal’s best practice process goes as follows:

  1. A complete assessment.  Time length is 1 hour because he is Mr. Ideal.
    • case/medical history ( I had to learn those qualities about Mr. Ideal from somewhere)
    • otoscopy ( to ensure the ears are, in fact, healthy)
    • tympanometry (verifying again the health of the middle ear)
    • air conduction (AC) pure-tone assessment
    • bone conduction (BC) pure-tone assessment
    • Word Recognition Score (WRS)
    • Speech Reception Thresholds  (SRT)
    • speech assessments, perhaps including a quick Speech in Noise Test (quick SIN) to look at speech in noise performance
    • review findings and agree on a treatment plan
      • affirm with Mr. Ideal the nature of his hearing loss
      • complete hearing aid candidacy review with Mr. Ideal
      • confirm that Mr. Ideal agrees with the recommendation for bilateral open-fit hearing aids, with the option for Bluetooth technology
      • measurements for tubing length and dome size are made
      • color selected
  2. The appropriate paperwork is filled in and the order is made to the HA manufacturer.  Time required:  10 minutes.
  3. Upon receipt of the hearing aids, correct paper work is filed and double-checked to be sure hearing aids are accurate and electro-acoustic performance is to specification.  Time:  10 minutes.
  4. Mr. Ideal returns to the clinic for his fitting appointment.  Time length is 1 hour because he is Mr. Ideal.
    • He is counseled as to expectations and adaptation with his new hearig aids and he fully understands on all fronts.
    • Hearing aids are programmed to target in the manufacturer’s software.
    • The output of the hearing aids is verified to target using real-ear measures (objective verification).
    • Mr. Ideal is very pleased in the clinic with his target fitting and no other adjustments are required.
    • Insertion and removal of the battery is reviewed and Mr. Ideal gets it on his first try.
    • Insertion and removal of his hearing aids are reviewed and Mr. Ideal is able to demonstrate insertion ability after a few short moments of practice.
    • He is very pleased and is on his way.
  5. Mr. Ideal returns for his first scheduled follow-up after two weeks.  Time required is 30 minutes because he is Mr. Ideal.
    • He reports no difficulty changing the battery.
    • He happily wears his hearing aids 8 hours a day.
    • A listening questionnaire (COSI) is filled to step two.
    • Basic maintenance and care of the hearing aids are reviewed (changing domes, wax guards etc…) and he demonstrates no difficulty performing these himself.
  6. Mr. Ideal returns for follow-up one month later.  Time required:  15 minutes.  
    • He reports no concerns.
    • He is performing maintenance correctly, as confirmed by observation and a clean and check of the hearing aids.
    • COSI is completed.
    • Mr. Ideal accepts the hearing aids formally and is advised to return for 6-month follow-ups and/or on an as needed basis.

Thus ends the fitting and follow up process for Mr. Ideal, fit within best practice principles.  Total time for his fitting process is 3 hrs and 5 min over 6 -7 weeks. Additional time for follow ups down the road is not included because he is Mr. Ideal and will return happily in 5 years time ready to purchase new HAs.

With the groundwork for Mr. Ideal  laid, the next step is to substitute a mode that integrates an Internet/over-the-counter sale of the hearing aids themselves without precluding best practice.  Hold that thought till the next post, when Mr. Ideal meets his hearing aid online in Model 2.

Model 2:  Internet/OTC Hearing Aid Purchase with In-Office Programming


Now that the groundwork for Mr. Ideal has been laid, let’s substitute a mode that would integrate an internet/over-the-counter sale of the hearing aids themselves without precluding best practice.  Readers are referred to the previous post or the footnotes below to review steps that are similar or identical in Models 1,  2 and 3.

  1. Mr. Ideal still requires a Hearing Test identical to that in Step 1, case/medical history, otoscopy, tympanometry, air conduction, bone conduction, Word Recognition Score, Speech Reception Thresholds, speech assessments, review/affirmation of treatment plan and hearing aid candidacy, confirm amplification recommendation, tube and dome measurements,  color selected. Time length remains 1 hour.
  2. Mr. Ideal purchases the recommended hearing aids from an online or over-the-counter source. It arrives at factory settings, unprogrammed for Mr. Ideal.
  3.  Steps 4 through 6 are repeated in the clinic Counseled as to expectations and adaptation;  hearing aids programmed to target in the manufacturer’s software; output verified to target using real-ear measures; battery and hearing aid manipulation instruction and practice;  follow-up at 2 weeks and again at one month; COSI completed.Time length is 1 hour, 45 minutes.

Model 3:  Internet/OTC Purchase of Programmed Aids


  1. Mr. Ideal still requires a Hearing Test identical to that in step one. Time required is 1 hour.
  2. A real-ear-to-coupler difference (RECD) measurement is taken in clinic so programming can be verified to target in a test box. Time required is 10 minutes.
  3. Mr. Ideal purchases the recommended hearing aids from the online/over-the-counter source while submitting the Hearing Test and RECD.
  4. The online source programs the hearing aids and verifies them to target in a test box using the given RECD and Hearing test. The appropriate length tubing and domes are provided.  The hearing aids are sent to Mr. Ideal.
  5.  Mr. Ideal returns to the clinic to review insertion and removal, battery changing.  Time required is 15 minutes.
  6. Steps 5 and 6 are repeated (2 week and 1 month follow-up).  Time required:  45 minutes.


Professional Time for Each Model


Both Models 2 and 3 appear to be viable ways to incorporate online/over-the-counter dispensing into a best practice model for Mr. Ideal, although there would be some logistical kinks to work out.

Model 2 does not actually alter the traditional clinic process of Model 1, other than to redirect the source of purchase. The time in clinic remains unchanged (minus 20 minutes for administration picked up on the online distributor’s end). And clinicians can and should be remunerated for their professional time spent in the fitting process.

Model #3 removes the programming and REM from the clinician’s hands, although the extra 10-minute test is added for the RECD.  That work is passed to the online dispensary, which must have trained individuals available to perform the programming and verification tasks in the test box.  In Table 1 below, I have assigned 1 hour for work required on the online dispensary’s end. All other time remains the same.

Table 1. Hours Required per Model


Hours in Clinic Hours for Online Dispensary Total  Hours
#1: Clinic Model




#2: Online, unprogrammed




#3: Online, programmed




Model #3 may reduce Mr. Ideal’s costs if the online dispensary can actually provide the hearing aids, programming and verification service at a lower rate than the clinician. And again theoretically the clinician can be remunerated for their time.


Ryan Kalef is a clinical audiologist and clinic manager with Hearing Life Canada.  He holds an Msc in Audiology degree from UBC as well as a Bsc in Integrated Sciences (Physics and Psychology) also from UBC.  He  recently was  the conference co-chair for the 2012 BCASLPA conference in Richmond, BC and is the private practice audiology representative for BCASLPA. Ryan enjoys the active lifestyle Vancouver has to offer including the many scenic hikes, golf courses, and ski hills in the surrounding area. And, oh yes, a healthy interest in economics.  

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