Data shows more than half a million adults in Colorado had evidence of hearing loss between 2015 and 2022, and yet the vast majority of patients did not get a hearing aid or cochlear implant to help improve their hearing, according to ongoing research led by University of Colorado Department of Medicine faculty member Liza Creel, PhD. The findings suggest there are barriers to accessing hearing health care — and the type of insurance a person has may be a key factor.
Creel, an associate professor in the Division of Health Care Policy and Research and director of the Economic Analysis Core in the Adult and Child Center for Outcomes Research and Delivery Science, is spearheading a research project that aims to improve hearing health care equity using data from the Colorado All Payer Claims Database, a comprehensive source of health care claims data that represents the majority of people who are covered by insurance in the state. It includes data from commercial payers, Medicare (a federal health insurance program primarily for people ages 65 and older), and Medicaid (which is also called Health First Colorado and is primarily for people with lower incomes).
“Our main questions are related to understanding the prevalence of hearing loss in Colorado and to examine disparities in access to hearing health care, specifically hearing aids and cochlear implants,” she says. “To our knowledge, this is the first study to use this type of statewide dataset to answer these questions.”
As part of the research project, which is partially supported by the company Cochlear Americas, Creel and her colleagues are investigating how factors like a person’s insurance coverage, location, and age may impact their ability to access hearing health care and interventions like high-quality hearing aids.
“We know that hearing loss or difficulty hearing is associated with a lower quality of life. We also know there are effective interventions, should a person want them, that can support people and improve their quality of life as they experience hearing loss and as they age — but accessing those services can be challenging and expensive,” she says. “We want our research to generate strong, reliable, and valid data that helps inform decisions among policy makers and providers so that more people have access to care.”
After receiving data from the claims database for the years 2015 to 2022, Creel and her research team assessed the prevalence of hearing loss among adults in Colorado. They found that over the seven years, 586,997 individuals had evidence of hearing loss. The overall prevalence of hearing loss was approximately 8% among Coloradans, and it remained relatively stable across the years.
A slight majority of those with hearing loss were female (52%) and most were white (62%), which Creel said were not surprising findings. She was also unsurprised to see that approximately 65% of individuals with hearing loss were aged 60 or older.
“We see an increase in hearing loss diagnosis at age 65. I believe that is probably related to both the age-related nature of hearing loss and the fact that people gain access to covered services under Medicare at age 65,” Creel says.
However, the data also showed that among those who had hearing loss, over 90% had no evidence of getting a hearing aid or cochlear implant. This may be due to limited coverage of these services or other access-related issues, she explains.
“None of our findings so far are all that surprising given what we know about the population of people who are affected by hearing loss, but they validate the age-related prevalence trends we’ve seen and the role of insurance in facilitating access to care,” she says.
Among those covered by Health First Colorado, the state’s Medicaid program, there is not much evidence of cochlear implants among adults because it is largely not a covered benefit, Creel says. The data did show there was a slight increase in Medicaid coverage among those with hearing loss, with 26% in 2015 compared to 29% in 2022.
Much of Creel’s analysis so far has focused on Medicare, given that the incidence of hearing loss increases as people age. Although research shows that nearly half of all Medicare beneficiaries report difficulty hearing, Medicare generally does not cover hearing aids or exams for fitting hearing aids. However, some Medicare Advantage Plans — a type of Medicare plan — offer additional benefits like hearing aid coverage.
“It’s still a work in progress, but our most salient findings so far appear to be around the important role of Medicare Advantage in facilitating access to care for older adults, because hearing aid coverage is an added benefit that many other plans don’t have,” she says. “The data suggest that Medicare Advantage appears to be helping improve uptake of intervention.”
Among those who are eligible for Medicare, they typically have to decide between a traditional Medicare fee-for-service plan or a Medicare Advantage plan, Creel notes. The data shows there has been an increase in the number of people selecting Medicare Advantage plans, given that 16% of people with hearing loss had a Medicare Advantage plan in 2015 compared to 27% in 2022.
“Market penetration of Medicare Advantage plans has been increasing overall but even more so in rural communities, so I think some of our additional work will focus on examining the intersection of a person’s coverage type with their location and age,” Creel says. “We also intend to do more investigating on the role of the Medicare fee-for-service plans and the Medicare Advantage plans in facilitating access to a hearing loss diagnosis and access to interventions.”
In addition to comparing insurance plans, Creel and her team will compare the accessibility of hearing health care between rural and urban communities in Colorado. They also want to look at the availability of physicians, audiologists, and audiology services in local communities, as having access to these providers is key to getting hearing health care.
“We are using a database maintained by the Colorado Department of Public Health and Environment to collect information on provider availability across the state,” she says. “We know there are hearing health care deserts in some areas, and we hope to identify if and where those exist in Colorado.”
The team’s analysis will not be limited to adults. By this fall, Creel and her colleagues plan to start analyzing state pediatric population data to further reveal the accessibility barriers that adolescents may face and how that can change in adulthood.
“Access to hearing health care and identification of hearing loss is very different in a pediatric population, where we have both newborn screening and school-based screening for hearing loss,” Creel says. “We also have different coverage of care for our pediatric population, so we want to analyze that population separately from the adults. Turning 18 shouldn’t change whether you can access health care, but that’s the case for some people today.”
Ultimately, Creel’s hope is that this research will help policymakers, health insurance payers, health care providers, and patients make more informed decisions by identifying the structural barriers that limit people’s access to hearing health care.
“We know that we have structural barriers to access hearing health care that are driven by health insurance plans and geographic factors. People shouldn’t have to move to get access to care, and the cost of care should not prevent people from being able to access the support they need,” she says. “We want to understand the best circumstances under which people can access hearing health care interventions. That’s the point of this work — to inform policy and practice change.”