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Payment Under Public and Private Insurance and Access to Cochlear Implants
Steven Garber, PhD;
M. Susan Ridgely, JD;
Melissa Bradley, BA;
Kenley W. Chin, MD
Arch Otolaryngol Head Neck Surg. 2002;128:1145-1152.
ABSTRACT
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Background Cochlear implants are expensive, yet often cost-effective. However,
among hundreds of thousands of potential US candidates, only about 3000 received
implants in 1999. To analyze whether insurance reimbursement levels may contribute
to low access rates.
Design Surveys were performed during 1999 and 2000 of physicians and audiologists
at clinics providing cochlear implant services, selected hospitals where surgery
is performed, and state Medicaid agencies. Secondary data were obtained on
Medicare payment rates and hourly incomes of otolaryngologists and audiologists.
Participants One hundred thirty-one physicians (response rate 67.9%), 111 audiologists
(74.0%), 60 hospitals (73.2%), and 44 Medicaid agencies (86.3%).
Outcome Measures Reimbursement rates for selected Current Procedural
Terminology codes and for cochlear implant systems (devices); time
required to perform services; additional time not reimbursed; and device purchase
prices.
Results Medicare and Medicaid payment rates often fail to cover costs of aural
rehabilitation. Medicare sometimes and Medicaid often fails to cover surgeon
costs. Sometimes private insurance does not cover hospitals' device costs.
Under Medicare, in 1999 hospitals lost more than $10 000 per device for
inpatient surgery and about $5000 per device for each outpatient surgery.
Device reimbursement in 2002 for outpatient surgery under Medicare is about
$3773 higher than in 1999. Medicaid device payment policies vary greatly and
fail to cover costs in at least 18 states, accounting for 44% of national
Medicaid enrollment.
Conclusions Efforts to expand access to cochlear implants may be impeded by financial
incentives. Facilitating access for Medicare and Medicaid patients could require
changes in payment policies.
INTRODUCTION
COCHLEAR IMPLANTS are an established treatment for severe to profound
sensorineural hearing loss.1 Treatment can
cost more than $40 000,2 including approximately
$20 000 for a device.3 Evidence indicates,
however, that these costs are typically outweighed by resulting benefits,
such as reduced costs of special education2 and
improved quality of life.4
It has been estimated that there are 460 000 to 740 000 severely
to profoundly hearing-impaired individuals in the United States.5 New
data reported herein suggest that approximately 3000 people received cochlear
implants in the United States during 1999. Factors limiting access to cochlear
implant technology may include (1) lack of knowledge about the performance
of the technology among primary care physicians, (2) lack of insurance or
knowledge about or interest in cochlear implants among hearing-impaired Americans,
and (3) objections to cochlear implants from representatives of the deaf community.6 We analyze another possible factor, namely, financial
incentives for professional and institutional providers stemming from payment
policies of public and private insurers.
METHODS
Data were collected through national mail surveys of physicians and
audiologists who work with cochlear implant recipients, a telephone survey
of hospitals in which cochlear implant surgeries are performed, and a telephone
and mail survey of state Medicaid agencies. Following procedures developed
in consultation with RAND's Human Subjects Protection Committee (Santa Monica,
Calif), we identified the sponsor in survey materials and respondents were
promised confidentiality and anonymity.
SURVEYS OF PHYSICIANS AND AUDIOLOGISTS
Practices or clinics that treat candidates for cochlear implant surgery
were the unit of analysis. A list of practices was developed from postings
on the Internet sites of Advanced Bionics Corporation (Sylmar, Calif), and
Cochlear Corporation (Englewood, Colo), the only companies selling cochlear
implant prosthetic systems in the United States during the study period. Because
each company wants to help candidates locate a clinic that uses its device,
we expect that their postings are comprehensive, and, therefore, we believe
our list of practices accounted for almost all cochlear implant surgeries
in the United States during the study period.
Initially, 231 practices were classified as eligible. Of these, 25 were
randomly chosen for pilot tests. For the main survey, a physician questionnaire
was mailed to a physician at each of the remaining 206 practices, and an audiologist
questionnaire was sent to 187 audiologists, one for each practice for which
a potential audiologist respondent was identified through a telephone call
to the practice. Both questionnaires requested information on characteristics
of practices and patients, time required to perform services identified by Current Procedural Terminology (CPT)
code, time spent on activities that are not reimbursed, and average fee-for-service
payment rates from private insurance, Medicare, and Medicaid. Each questionnaire
concluded with the open-ended question: "Is there anything else you would
like to tell us about cochlear implants?" The second of 2 mailings was followed
by intensive telephone efforts to encourage participation. Data collection
ran from August through December 1999.
SURVEY OF HOSPITALS
The hospital survey focused on numbers of surgeries performed, costs
of purchasing devices, and reimbursement rates when separate payments were
made. This information is rarely available from a single hospital department,
and a telephone survey enabled an interviewer to identify a knowledgeable
individual for each item and contact each directly. Our telephone calls to
practices identified 213 hospitals at which we were told physicians performed
cochlear implant surgery. Resources did not allow us to survey all of them.
We chose 96, oversampling hospitals in states where our information from state
Medicaid agencies was incomplete. Data collection ran from September 1999
through March 2000.
SURVEY OF STATE MEDICAID AGENCIES
The Medicaid survey focused on policies for fee-for-service enrollees.
We requested information, for children and adults separately, about coverage
policies and payment rates for physician and audiologist services and for
cochlear implant prosthetic systems (Health Care Financing Administration
Common Procedural Coding System [HCPCS] code L8614). We attempted to collect
information from all 51 Medicaid agencies through telephone calls to identify
appropriate respondents, mailings, faxes, and intensive telephone follow-up.
Data were collected from April 1999 through February 2000.
MEDICARE PAYMENT RATES
Cochlear implantation is covered nationally for Medicare patients who
meet selection guidelines.7 We focused on traditional
(fee-for-service) Medicare. Data for the period covered by the surveys were
extracted from 3 files downloaded from the Health Care Financing Administration
Internet site. The data for professional services are physician fees by CPT
code.8 For inpatient surgery, hospital payment
for the device is included in the payment for diagnosis related group 49,
and we used Medicare Provider Analysis and Review data for fiscal year 1997.9 For outpatient surgery, separate payments were made
for the device (HCPCS code L8614) according to a fee schedule.10 On
August 1, 2000, the Health Care Financing Administration, since renamed the
Centers for Medicare & Medicaid Services, implemented the outpatient prospective
payment system (OPPS), a new method for reimbursing hospitals for outpatient
services.11 We reviewed documents describing
OPPS, listing payment rates, and discussing future payment policies.
RESULTS
RESPONSE RATES AND SAMPLE CHARACTERISTICS
Data were obtained from 131 physicians and 111 audiologists. Ignoring
practices reclassified as ineligible because respondents reported that their
practices had not performed an implant in a new patient in the past 12 months
or no longer worked with patients receiving cochlear implants, the response
rates were 67.9% and 74.0% for physicians and audiologists, respectively. Table 1 provides information about the
practices and their patients receiving cochlear implants during the past 12
months. Almost 40% of the patients were covered by private fee-for-service
insurance, and about 35% by fee-for-service Medicare or Medicaid.
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Table 1. Characteristics of Practices Offering and Patients Receiving
Cochlear Implants*
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Among 82 surveyed hospitals in which cochlear implant surgery had been
performed during the past 12 months, 60 (73.2%) provided information. Of these
60 hospitals, 56 reported a total of 727 cochlear implant surgeries during
the past 12 months (median, 8.0). Of the 51 state Medicaid agencies, 44 agencies
(86.3%), accounting for 81% of national Medicaid enrollees,12 provided
data.
TIME REQUIRED AND REIMBURSEMENT FOR AUDIOLOGIST SERVICES
Table 2 reports information
about 7 candidacy testing and evaluation procedures and 2 postoperative procedures
audiologists reported performing relatively often. One preoperative procedure
(CPT 92506) and one follow-up procedure (CPT 92510) stand out as requiring relatively large amounts of time. Table 3 reports median fee-for-service
reimbursement levels for the 9 procedures in Table 2, and Table 4 expresses
reimbursement in dollar-per-hour terms. The medians give equal weight to each
practice for which an hourly reimbursement rate could be calculated, and the
weighted medians weight each hourly reimbursement rate by the number of the
practice's patients in the payer category during the past 12 months.
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Table 2. Required Audiologist Hours per Session and Numbers of Sessions
for an Average Cochlear Implant Candidate or Recipient
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Table 3. Median Payment Rates per Session for Audiologist Services
Provided to Cochlear Implant Candidates or Recipients
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Table 4. Payment Rates per Hour for Audiologist Services Provided to
Cochlear Implant Candidates or Recipients
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Regarding additional time spent by audiologists that is not reimbursed,
90 and 89 respondents reported time spent before and after surgery, respectively.
None reported zero unreimbursed time. Median and mean unreimbursed times were
3.0 and 4.6 hours, respectively, before surgery (interquartile range, 2.0-5.4)
and 5.0 and 7.1 hours, respectively, after surgery (interquartile range, 2.0-10.0).
TIME REQUIRED AND PHYSICIAN REIMBURSEMENT FOR COCHLEAR IMPLANT SURGERY
Of 6 procedures included in the physician survey, only cochlear implant
implantation (CPT 69930) was reported as being used
frequently enough to analyze reimbursement levels. Table 5 reports information about time required to perform the implant
surgery, unreimbursed time of physicians spent before and after surgery, and
distributions of reimbursement expressed alternatively per procedure, per
hour in surgery, and per total hour.
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Table 5. Physician Time Required and Payment Rates for Cochlear Implant
Surgery (CPT 69930) for an Average Patient*
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HOSPITAL PURCHASE COSTS AND REIMBURSEMENT FOR COCHLEAR IMPLANT PROSTHETIC
SYSTEMS
Table 6 summarizes prices
paid by hospitals during the past 12 months to purchase cochlear implant systems
and reimbursement amounts from private insurers when hospitals were reimbursed
separately for devices. Among the 27 hospitals that reported both average
purchase prices and average private reimbursement rates, 15 reported purchase
prices exceeding reimbursement and 6 reported the opposite. The median and
mean differences between purchase price and reimbursement were $2000 and almost
$3700 per device, respectively.
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Table 6. Purchase Prices Paid by Hospitals and Private Payment Rates
to Hospitals for Cochlear Implant Prosthesis Systems
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Medicare payment rates for calendar year 1999 ranged from $14 086.90
to $14 791.63 per device for outpatient surgery. National average reimbursement
per short-stay discharge under diagnosis related group 49 was $8982.58 during
fiscal year 1997.
Under Medicare's OPPS, outpatient services related to cochlear implant
surgery are assigned to ambulatory payment classification group 259 ("Level
VI ENT [Ear, Nose, and Throat] Procedures") with a payment rate for 2002 of
$19 279.89, of which $16 243.65 is intended to cover or "offset"
part of hospitals' costs of purchasing cochlear im plant systems.13 In addition, cochlear implant systems (and many other
innovative devices, drugs, and biologicals) are eligible for "transitional
pass-through" payments. These payments will cease for cochlear implants after
December 31, 2002.14 The potential transitional pass-through payment for a cochlear implant
system is calculated as a hospital's charge for a system multiplied by its
cost-to-charge ratio minus the portion of the ambulatory payment classification
rate intended to cover (some of) the costs of acquiring systems.11, 15 Actual transitional pass-through payments for 2002 are
substantially less than potential payments, however, because of a legislative
requirement that in 2002 total transitional pass-through payments may not
exceed 2.5% of total Medicare payments under OPPS.16 For
2002, potential payments were reduced by 63.6% to conform to this requirement.13 For 2002, ambulatory payment classification group
payment rates were constructed to incorporate 75% of estimated pass-through
device costs.13 Thus, actual transitional pass-through
payments in 2002 will average roughly $1970 per cochlear implant system, and
total reimbursement for the device will be roughly $18 213, about $3773
more than the midpoint of the range of fee schedule payment rates for 1999
($14 440).
Medicaid policies for reimbursing hospitals for the prosthetic system
vary widely in form, specificity, and generosity (Table 7). Respondents in several states emphasized inpatient surgery,
and the categories in the first column of the table reflect that emphasis.
In cases where states reported different policies for outpatient surgery,
these are noted as comments. Only 9 of the 60 hospitals that provided data
reported levels of device reimbursement from Medicaid, with a median of $13 800.
Moreover, 29 hospitals reported that in past 12 months they had not billed
Medicaid for a cochlear implant device, had not received a separate payment
from Medicaid for a cochlear implant device, or both.
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Table 7. Types and Prevalence of Medicaid Reimbursement Policies Regarding
the Prosthesis System*
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COMMENT
If we assume that 14 annual surgeries per practice as reported by physicians
(Table 1) applies to the 193 practices
considered eligible for the main survey and to the 25 practices used for pilot
testing, the total number of cochlear implant procedures performed in the
United States in 1999 was approximately 3050. Are financial incentives a contributor
to limited access?
Because we cannot observe responses to financial incentives, we analyze
incentives quantitatively and draw inferences about potential behavioral responses.
For audiologist and physician services, costs of serving patients receiving
cochlear implants include professionals' time required and expenses for other
required resources such as office staff, office space, insurance, and equipment.
Substantially increasing access to cochlear implant services would almost
certainly involve significant costs in addition to professionals' time.
HOURLY INCOMES OF AUDIOLOGISTS AND OTOLARYNGOLOGISTS
Data on hourly incomes of audiologists from the 1999 Omnibus Survey
of the American Speech-Language-Hearing Association (Rockville, Md) were provided
in October 1999 by Jeannette Janota, PhD, of that organization. Median salaries
in 1999 for audiologists with Certificates of Clinical Competence in Audiology
were $20.00 (n = 142) and $23.18 (n = 160) per hour for audiologists working
26 or more and 25 or fewer hours per week, respectively. Hourly incomes of
otolaryngologists are gauged from American Medical Association Socioeconomic
Monitoring System data. Median figures for hours per week in professional
activities, weeks worked, annual incomes, and annual professional expenses
of self-employed otolaryngologists17 suggest
net and gross hourly incomes of approximately $93 and $207, respectively.
The ratio of median professional expenses to net income is 1.2, and excluding
nonphysician payroll expenses, the ratio is about 0.85.17
FINANCIAL INCENTIVES FOR AUDIOLOGIST SERVICES
Suppose that practice costs associated with audiology services add 100%
to audiologist salaries (ie, about halfway between the ratios for otolaryngologists
alternatively including and excluding nonphysician payroll expenses). Then,
total cost per hour for audiology services would be $40 to $46. The median
hourly reimbursement rates reported in Table 4, none of which factors in audiologist time that is not reimbursed,
are typically more than $46 for private payers. However, they are near or
less than $40 per hour for some procedures for Medicare and Medicaid. Notably,
these include the 2 procedures—CPT 92506 and
92510—that require relatively large amounts of time per session and
numbers of sessions (Table 2).
Reimbursement for aural rehabilitation is likely to be particularly important,
because several sessions are required.
In addition, reimbursement rates for aural rehabilitation reported by
some Medicaid agencies are much lower than the medians in Table 3. For example, 7 agencies reported a rate of $20 or less
per session for children. If financial incentives for audiologists to serve
cochlear implant recipients impede access, a leading factor is likely to be
payment levels for aural rehabilitation after surgery in public insurance
programs, especially in some states under Medicaid.
FINANCIAL INCENTIVES TO PERFORM COCHLEAR IMPLANT SURGERY
The 25th percentile of private reimbursement for surgery per total hour
of $250 (Table 5) exceeds our
estimate of average gross hourly earnings ($207). For Medicare, median reimbursement
per total hour is $192, and the 25th percentile value is $144 (Table 5). The former figure is not much less than that for average
gross hourly income for self-employed otolaryngologists ($207), and the latter
is closer to the figure for average net hourly income ($93). Thus, for surgeons
who spend about the average time per Medicare patient and whose hourly gross
incomes are near $200 per hour, Medicare reimbursement may cover their costs
of surgery.
The median reimbursement for CPT 69930 per
total hour for Medicaid is $156 (Table 5), about halfway between the figures for gross and net hourly incomes.
The 25th percentile value for hourly reimbursement is $100, which is close
to the figure for average net hourly incomes. Thus, for many surgeons, reimbursement
may contribute to financial disincentives to serving Medicaid patients. In
addition, one Medicaid agency reported a reimbursement rate for CPT 69930 of only about $600, and 11 agencies reported rates of less
than $1000. Moreover, 3 Medicaid agencies reported that CPT 69930 is not covered for children, and 11 agencies reported that
it is not covered for adults. We infer that in several states Medicaid payment
rates fail to cover costs for many, but not all, surgeons, and that in some
of these states Medicaid policies amount to a financial disincentive to perform
cochlear implant surgery for most, and perhaps almost all, physicians.
FINANCIAL INCENTIVES FOR HOSPITAL SERVICES
Data from the hospital survey suggest that even private insurance can
fail to cover device costs; 15 of 27 hospitals reported higher average purchase
prices than average private reimbursement levels.
Regarding outpatient surgery under Medicare, the midpoint of the range
of 1999 reimbursement rates for a device ($14 440) was about $6400 and
$5300 less than the median and mean reported purchase prices, respectively
(Table 6). The 2002 payment rates
under OPPS are about $3773 higher than that midpoint, with a little more than
half of that difference attributable to transitional pass-through payments
that will expire at the end of 2002. Regarding inpatient surgery, the average
Medicare reimbursement per hospital discharge ($8982.58) in 1997 was less
than half of both the median and mean purchase prices (Table 6). Thus, Medicare diagnosis related group payment levels
often confronted hospitals with financial losses of more than $10 000
for each inpatient cochlear implant surgery.
Information in Table 7 indicates
that in at least 18 states Medicaid payment policies usually or often failed
to cover hospitals' costs of purchasing cochlear implant devices; these 18
states account for 44% of national Medicaid enrollment.12 In
contrast, Table 7 also indicates
that Medicaid payments usually or often covered costs in at least 8 other
states; however, these states account for only 8% of national Medicaid enrollment.12 For the other 25 jurisdictions, survey information
is not specific enough to draw either inference.
SACRIFICES REQUIRED TO EXPAND ACCESS THROUGH MEDICARE AND MEDICAID
Suppose that many additional publicly insured candidates for cochlear
implant surgery had been referred to otolaryngologists in 1999. Might lack
of sufficient reimbursement have impeded many of them from being served? Consider
some "back-of-the-envelope" calculations.
About 1100 Medicare and Medicaid fee-for-service enrollees received
cochlear implants in 1999 (Table 1).
Approximately 30% of the estimated 460 000 to 740 000 severely to
profoundly hearing-impaired individuals in the United States have only public
health insurance.5 Increasing implantation
rates 10-fold for Medicare and Medicaid enrollees would involve 11 000
implants per year or 5% to 8% of the publicly insured, severely to profoundly
hearing-impaired, an unknown fraction of whom are clinically appropriate and
potentially enthusiastic candidates for cochlear implant surgery.
Findings from our surveys indicate that an additional 10 000 cochlear
implants per year would require an additional 180 000 hours per year
from audiologists just for aural rehabilitation and unreimbursed activity,
or 340 hours per year for each audiologist currently working with patients
receiving cochlear implants. Similarly, an additional 70 000 hours per
year would be required from physicians for surgery and unreimbursed time,
or 200 hours per year for each of approximately 350 physicians who currently
perform cochlear implant surgery. Given the financial disincentives discussed
already, additional time requirements of these magnitudes would involve considerable
financial sacrifice by many audiologists and physicians.
Under Medicare, in 1999 hospitals lost about $6000 per outpatient surgery
and more than $10 000 per inpatient surgery, respectively, on the device.
Under Medicaid, the extent of any losses varies considerably, with potential
losses in many states ranging from approximately $5000 to $20 000 per
device. It seems conservative, then, to assume that on average hospitals would
have lost $5000 for each of the hypothetical 10 000 additional publicly
insured patients who would have received implants in 1999. This implies an
additional loss in 1999 of $50 million or about $250 000 for each hospital
that provided access to cochlear implant surgery.
As 5 physicians suggested in response to the open-ended question, professional
(and institutional) providers may be willing to serve some patients receiving
cochlear implants despite financial sacrifices. Motivations include professional
responsibility, personal satisfaction from making profound differences to
people's lives, a desire to be at the professional cutting edge, and the possibility
of generating publicity. However, current rates of access may largely satisfy
motives for providing unprofitable services, and therefore such motives may
not suffice to support substantial expansion of access under current financial
arrangements.
CAVEATS
We shall discuss herein some qualifications and comment on some factors
and issues not already addressed.
First, consider potential survey response biases. Directions of any
biases in the audiologist and physician surveys are difficult to gauge. Providers
facing relatively low reimbursement rates may be underrepresented in our samples
if, as a result, they serve fewer cochlear implant recipients and are thus
less motivated to respond. Alternatively, providers facing relatively low
rates may be more concerned about payment issues and thus more motivated to
respond. Participation by hospitals is unlikely to be related to the key items
in our survey, because cochlear implants generally represent tiny fractions
of purchasing activity or revenues for hospitals. Finally, we expect that
participation by Medicaid agencies is determined almost entirely by agency
policies or attitudes of individuals regarding cooperation with research studies
and by time availability.
Second, financial incentives depend on costs and revenues totaled over
all services, but our analyses for professionals focused on selected services.
Nonetheless, our conclusions appear valid, because we focused on key services,
and additional data suggest that payments for other services rarely, if ever,
make up for the losses we have analyzed. For audiologists, we emphasized aural
rehabilitation (CPT 92510). While per-hour payment
is higher for some other services (Table
4), the other service standing out as requiring considerable time
is CPT 92506 (Table 2), which involves even lower per-hour payment (Table 4). Moreover, our analysis of audiologist incentives ignored
their unreimbursed time. For physicians, we emphasized reimbursement for surgery
(CPT 69930). Relatively few physicians reported using
other codes to bill for their time, and payment levels for other codes are
relatively low. Under Medicaid, for example, medians for these other payments
were all less than $100, and only one was more than $60.
Third, our analysis for hospitals considered only purchase prices and
reimbursement rates for devices. It seems implausible, however, that hospital
costs other than device costs are often, if ever, reimbursed sufficiently
to compensate for losses on the devices, which often amount to $5000 or more.
Fourth, we have not addressed various issues of interest. For example,
we did not investigate in detail differences in outpatient and inpatient reimbursement
policies under Medicaid, nor how differences in payment policies may affect
whether surgery is performed on an inpatient or outpatient basis. We have
also not investigated how payment rates vary with the organizational forms
of payers (health maintenance organization, preferred provider organization,
etc). Nor did we collect information concerning retrospective payment denials;
our surveys requested average payment rates when services were reimbursed,
and thus our analysis does not account for potential effects of payment denials
on financial incentives. We also have not surveyed speech therapists or analyzed
payment rates for speech therapy (CPT 92507). Although CPT 92507 was included in the audiologist survey, only
16, 10, and 8 audiologists reported sufficient information to calculate hourly
payment rates for private payers, Medicare, and Medicaid, respectively.
Fifth, we have not analyzed potential sources of funding to augment
insurance payments such as state programs other than Medicaid, private donations,
and foundation grants to cochlear implant programs.
Sixth, our ability to draw inferences is limited by the nature of available
information concerning earnings and practice costs of audiologists and physicians.
For example, we do not know whether the average incomes of audiologists and
otolaryngologists who work with cochlear implant recipients differ substantially
from the average incomes of all Certificate of Clinical Competence in Audiology
audiologists and self-employed otolaryngologists, respectively.
Seventh, the time and device costs used in analyzing potential financial
burdens of expanding Medicare and Medicaid access may be somewhat high. Major
increases in cochlear implant production might reduce unit production costs
and device prices because of economies of scale and learning in production.
Moreover, one third of our sample physicians reported that their practices
had implanted 5 or fewer cochlear implants in the past 12 months; additional
experience with patients receiving cochlear implants might decrease audiologist
and physician time costs per patient (and improve patient outcomes).18
Regarding the scope of our analysis, we have analyzed financial incentives
only under fee-for-service insurance. Capitated public insurance arrangements,
such as Medicare + Choice (Part C) plans and Medicaid full-risk plans, are
becoming more widespread. However, in 1998 shares of revenues of otolaryngologists
from capitated contracts were low (mean, 7.6%; median, 0%; 75th percentile,
5.0%).17 We also have not analyzed exclusion
of cochlear implants in private health insurance contracts, which existed,
but was not common, during the early 1990s,19 or
the stringency of medical-necessity criteria and preauthorization procedures.
CONCLUSIONS
A troubling picture emerges from this analysis. Insurance payment levels
that do not cover the costs of physicians, audiologists, and hospitals could
be an important factor limiting access to cochlear implants, and gaps between
payment levels and costs are particularly striking for Medicaid and Medicare.
This is of substantial concern because many potential candidates for cochlear
implants are insured only through these programs.
Many factors other than insurance-based, financial disincentives are
likely to limit access to cochlear implants, and to increase access substantially,
various potential barriers would need to be addressed. Our data point to specific
elements of financial incentives that seem particularly important. For patients
to benefit from cochlear implants, audiologists, physicians, and hospitals
must all be willing to provide services; the access chain is only as strong
as its weakest link. While hospital reimbursement appears to be the weakest
link in most cases, in some instances hospitals may be willing to allow more
cochlear implant surgeries than physicians want to perform.
To hope that providers will serve candidates for cochlear implant surgery
despite financial sacrifices may not suffice to achieve socially desirable
rates of access. A key message for policymakers is that facilitating access
to cochlear implants for qualified candidates enrolled in Medicare and Medicaid
could require changes in payment policies at both the federal and state levels.
Expanding access to cochlear implants for qualified candidates poses complex
challenges to providers and manufacturers of cochlear implant systems as well
as to policymakers.
AUTHOR INFORMATION
Accepted for publication March 21, 2002.
This study was supported by Advanced Bionics Corporation, a manufacturer
of cochlear implant prosthetic systems.
The research was conducted independently, and RAND retains all rights
to publish data, interpretations, and conclusions.
We thank Mary Lou Gilbert, JD, and Meg Bernhardt, MS, for research assistance,
and Jay Bhattacharya, MD, PhD, for helpful comments on a previous draft.
Corresponding author: Steven Garber, PhD, RAND, 1700 Main St, Santa
Monica, CA 90407 (e-mail: Steven_Garber{at}rand.org).
From RAND Health, Santa Monica, Calif (Dr Garber and Mss Ridgely and
Bradley); and Division of Head and Neck Surgery and RWJ Clinical Scholars
Program, University of California, Los Angeles (Dr Chin).
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