Dr Cliff: In terms of if their local area doesn't have a provider that even offers it?
Host: Or just going about finding a provider who would, because I don't think our field is very good at necessarily advertising that or adopting it.
Dr Cliff: Right, and I think that the vast majority of our field is hesitant to do it. I mean, when you really look at it, this is a revolutionary technology that we are still on the tip of the spear with. And when you think of it from that perspective, things take time for people to adopt. I mean, you have this, what is it, the rate of adoption curve, where you have the early adopters you have, you know, the, the early majority, the majority, and then you have the laggards right on the tail end that just like wait til the last possible moment to adopt the technology. That's the way that I am with smartphones, right? I resisted it for years. I was a laggard with that. In my profession, I try to be on the very tip of the spear. So, you know, it's going to be difficult, I think for another couple years to find hearing care providers who are willing to use this technology, because maybe they're scared of it. Maybe they're intimidated by it. They're not comfortable with it. Whatever. They might not see utility in it. But I think that it's going to progressively get more and more. I think that you'll start seeing clinics starting to put it up on their website saying, hey, we do offer this. But for someone who's really looking to have this type of care, it's going to be a struggle to find someone who does it. And if you happen to be lucky enough to have an outstanding hearing care provider in your area who follows best practices, who's willing to adopt this technology early and go through the headache of actually administering it to figure out how it works, the nuances of it, deal with the bad wifi connections, bad cell phone connections, whatever the case may be. If you stick with it and look for those individuals, eventually they're going to start popping up because there's gonna be no other option. They're going to have to adopt at some point, or they're going to end up going away, meaning they'll go out of business because they're not offering what everybody else offers.
Host: So I wanted to take a moment and talk about insurance coverage as well. I've realized over the past ... since the new year, many insurances have switched over where they actually are starting to cover hearing aids. Do you see that happening in your area? Do you see hearing health changing for consumers in that way?
Dr Cliff: Boy, insurance, that's a tricky topic. What I would say is this, from an insurance perspective, insurance companies, they want to attract new members to their insurance plans. They know that, you know, hearing loss is a major, major issue for at least in the United States. Definitely worldwide. I don't know how insurance works in other countries necessarily, if they don't have, you know, universal health care and whatever the case may be. But in the United States, I mean, we have a lot of these insurance companies going the third party managed care route where they're basically contracting with one of these companies. You've got True Hearing. You've got Amplifon, you've got Epic, you've got, you know, a couple of these other, you know, managed care companies. They kind of farm out the insurance side of it. And a lot of times, and even outside of the managed care, you have the, where they actually insure. So like Blue Cross Blue Shield, you know, they provide insurance to their members for hearing aid coverage to a varying degree. But at the end of the day, what it comes down to is that doesn't necessarily guarantee you the highest level of care possible. Uh ... Case in point is, is that when we have someone come into our clinic, if their insurance dictates a certain level of care that they receive, or they're not going to pay for this, they're not going to pay for that. They only pay for this level of technology or whatever the case may be with that. It doesn't ensure that someone is going to receive a high level of care. Because if a clinic can't be compensated in accordance with what they need to make to keep their clinic open, it's very tough for them to even accept those types of insurances. And then if they do, what they do is they cut the quality of care in order to limit the amount of time that they have to work with the patient. So the patient at the end of the day, the member of that insurance network, loses in that scenario. Now I also am okay with looking at it from the other direction though. I mean, for certain people who have accessibility issues, meaning financial issues to where they cannot purchase and acquire hearing treatment from a local hearing care provider at a reasonable cost, then if their insurance plan allows them to have better affordability, that is a good thing, as long as you understand what you're potentially giving up to receive that treatment.
Host: In the facility I work at, it's the Center for Sight and Hearing. It is a nonprofit. And we end up working with a lot of these third party groups, the ones you mentioned, like True Hearing, some of the other ones as well. And you're right, they, for listeners who aren't familiar with it, as Dr. Cliff mentioned, they will pretty much dictate what hearing aids can be sold for, how many follow-up visits you get and what can be charged maximum for those follow-up visits. So it can put a strain on providers and, or just the facility with having some of those regulations. Now, that being said with my experience in this area, it has been fantastic because there is a big issue with accessibility and finances where not everyone is able to afford the devices that might be appropriate for them, with their lifestyle, and being at a non-profit, we're always trying to do everything we can with grants to get people appropriate hearing devices, but it has been really good with those third party groups. And then also just with other insurances, like Blue Cross, actually covering devices a lot more.
Dr Cliff: You know, I think any care is better than no care for sure, right? It's just, people have to understand really what they're getting into with it. I mean, if you think, oh hey, I've got insurance benefit through my insurance company. And I want those newest, latest, and greatest devices at the highest technology level possible. I want all best practices to be followed. And then you go into that hearing care provider and they're like, ah, yeah, you're not getting that. Then it's like, that can be a let down in and of itself. Right, so it's just, you just have to educate yourself and understand what you're signing up for, with whatever insurance you're going with. And if that insurance plan limits you and you don't want to be limited, then it's not right for you. But if you're someone who like you mentioned, I mean, a lot of individuals have an affordability issue when it comes to hearing devices and hearing treatment. And for those individuals, if that insurance coverage is the difference between them acquiring treatment or not acquiring treatment, it is absolutely a good thing.
Dr Cliff: Yeah, I do think they meet a need. I mean, first of all, is just someone who wants a set of like your buds that work and work well. I mean, even without hearing loss, fantastic worth the purchase, right. But then of course, we look at it through the lens of an individual who may actually have a mild, maybe moderate level of hearing loss with a device like that. And I think that they have utility for those individuals, whether it's someone who just wants a little bit of a boost, you know, to hear a little bit better, to have that multi-functionality of being able to stream audio and kind of blend that with their surrounding environment, so they can hear someone better at a noisy restaurant or just in normal conversation, but they're not quite ready to go that hearing aid route. I think that that serves as a nice little stepping stone or even a treatment that they can use for, you know, a prolonged period of time until they're ready to take that next step, if they ever even need to take that next step. Now, you know, in my reviews, I try to be as objective as possible with these things. I like to let people make their own determinations of whether or not something is right for them. I try to objectively measure these things, so it removes a little bit of my own opinion from it. And sometimes things come out, you know, better than others. And, you know, I think that, you know, I receive criticism a lot of times because if I ever say anything negative about something that somebody likes, there's always going to be people that kind of to jump on me, but I'm okay with that because I verify and validate everything. And I'm comfortable with where I stand with a lot of the tech that I review.
Host: What I was most impressed about in the video, what you had done is you would actually performed acoustical measures on the devices and the Nuheara IQbuds MAX, they actually do have programming in them similar to what hearing aids will use. Basically they are prescriptive algorithms that look at your hearing loss and give you a specific amount of volume to correct for your hearing loss as accurately as possible. And I think in your video, you showed that for the mild and moderate hearing losses, it was actually pretty accurate across the spectrum, more so than I would have expected.
Dr Cliff: Yeah. It's been their best yet. And I haven't found another product on the market. I mean, the Bose Hearphones did a pretty good job, but that was after self customization, with the help of real ear verification. But you're right. I mean, I think that, you know, being able to take a hearing test inside of a device, and when I say hearing tests, I mean a threshold check in order to determine an NAL-NL2 hearing loss prescriptive target, which is what you're talking about, for the listeners. And then actually measuring to see how close the devices are at giving amplification and very specific frequency ranges, based on an individual's hearing loss. The IQbuds did a really good job of that inside of my ear canals, which is another variable, right? Because everybody's ears are different. So even though it matched up nice for mine, it might not necessarily be as clean for somebody else. But to be honest with you, from a positive standpoint, I was really impressed with the IQbuds when it came to that side of it.
Host: Yeah and something I see stemming from this is a lot of confusion from the consumer. They are constantly hit with advertisements about these devices that function as quasi hearing aids, but there are also hearing care professionals with medically-researched devices. So for someone who might have that question, looking at the difference between these two, how would you describe it and how do you help them understand that difference?
Dr Cliff: It depends on what they want. I mean, sometimes for a certain individual, the direct-to-consumer consumer electronic is what they're looking for. It just depends on what it is that they are prioritizing. In other cases, if they tell me that the things that they want are not a capability of these products that cost a couple hundred bucks, then they have to consider the other option, the more expensive option, because they will give them those other things that they're looking for. Then I'll try to come up with a for instance for you here. So if you are someone with a high frequency, sensory neural hearing loss, so you got good low frequency, decent mid frequency, but bad high-frequency hearing in terms of the pitches that you can hear. If you take a device that completely blocks off your ear canal, and then you want to try to amplify those high frequencies that you're missing, you're going to create what we call is the occlusion effect. So because your low frequency hearing is really good, when you talk, your voice bone conducts through your jaw and vibrates inside of your ear canal and will vibrate your eardrum, and your own voice will be excessively boomy and loud to yourself, almost intolerable to where you can't talk to anybody. However, with like a hearing aid, a traditional hearing aid, you would open fit that type of a hearing loss. So you'd amplify the high frequencies appropriately. You would blend it with the natural low frequencies that are coming through this open dome that's inside of your ear canal, and it blends inside of your ear canal. So, you know other people's voices sound more natural to you. Your voice sounds more natural to yourself, and it kind of seamlessly integrates with you. And that's just something that you can't get when you use a device that completely blocks off your ear canal. So if you're an individual who does not mind the occlusion effect, if you're an individual who has low frequency hearing loss as well, then it creates a situation where maybe the direct-to-consumer consumer electronic would work for you just as well as a hearing aid. But at the end of the day, until you actually go in and you identify the specifics and you do verification measures on both of those with an individual patient, you're not gonna know which one's the ideal.
Host: What in any of these devices do you think is being done differently? So for example, with Hearables and over the counter devices, other personal sound amplification devices, is there anything that you are seeing in them that you wished you'd see in the hearing aid realm as well? The medically-researched hearing aid world.
Dr Cliff: Boy, you know, they're starting to blend so much. I mean, the things that you see with these Hearable companies and the things that you see with hearing aids, it's almost like they're speaking to the exact same person and all the features are speaking to the exact same person. The one thing that you could take a look at is that in the Hearable community, there's a lotta talk of this active noise cancellation, which is not necessarily something that you hear in the hearing aid world. And the reason you don't is because of the difference of how those devices are coupled to an ear. Again, this comes down to, if you completely close off an ear canal, you can use something like active noise cancellation to cancel out additional noise that's coming in through the earbud. if you're gonna open fit a hearing aid, you can't close off the entire ear canal and perform active noise cancellation. So if we're gonna compare, you know, apples to apples from an active noise cancellation standpoint, you can't do active noise cancellation in a hearing aid, but you can inside of a Hearable, but then again, you're giving up the other aspects that you could get with a hearing aid in terms of being able to have an open fit that you can't have with a Hearable. So, you know, it's very hard to kind of look at each one and separate out the things that are different because they're different because they need to be, because of the form factor and how they actually set things up. The other thing I would say, though, that is slightly different here is, that the stigma potentially associated with each one. So the Hearable community has done a good job of making these devices. Hey, there like an earbud, you know, but you can also do this hearing loss function, right? This amplification for a hearing loss. Whereas the hearing aid industry is we're putting hearing loss first and then whatever form that we can get on top of that is just as a bonus, right? So they're just approaching it from different directions.
Host: And for our listeners, I wanted to just talk about it a little bit more, 'cause you mentioned active noise cancellation. And I think everyone who has ever heard of a hearing aid understands that they do offer different forms of noise reduction. So there is a difference between the two. The open fit hearing aids that like Dr. Cliff is describing, Those will have noise reduction features and algorithms inside of them. Unfortunately by the nature of it, where you leave your ear canal opened, you are not getting a traditional benefit from a signal to noise ratio. What the studies show is that the hearing aids are basically making the volume softer so it's more comfortable for you. So then the cognitive load isn't as much. And just in general, any fatigue from all that background noise isn't as fatiguing. Now active noise cancellation isn't necessarily new, but it's new to hearing tech, it's been around in headphones for awhile, it's certainly been around in live sound, but that requires actually measuring what signal is coming into the device and then playing that same signal with what's called the polarity flip. So basically it cancels out with the noise that's happening in the world. And you'll see that in like Bose headphones. And we're starting to see it now in these more Hearable devices. So there is a difference between the two, the noise reduction in hearing aids, again, I have personally never read anything that shows it improves the signal to noise ratio. Only the directional microphones that hearing aids offer will do that.
Dr Cliff: That is definitely in line with everything that I've read on that topic and everything that I personally see when working this with this stuff on a day in day out basis. I think people have to recognize that the reason that active noise cancellation works so that, that polarity, you know, phase in version that you're talking about, the polarity flip rather is that you're using it with direct audio input. I mean, you have a music let's say coming from your smart device into the headphones or the earbuds, right? And it's easy to cancel out everything that's not that, but if you're trying to separate speech from a human that's talking to you right in front of you, you can't use active noise cancellation even in these headsets, in these earbuds that are out there. It's only to improve the sound quality and the reduce background noise for this streamed in audio. And you could make the argument that the headsets in and of themselves, or even with passive noise reduction, do a good job. It's just the icing on the cake is the active noise cancellation, but you're not going to get, you know, active noise cancellation, at least with the tech that we have currently, with spoken, you know, speech from a person who's standing in front of you, that's not being directly audio input into your hearing devices.
Host: I think in my experience with some of these, the nicest thing is when you do have good acoustic coupling, where basically you do seal up the ear canal, the benefits for sound quality for music are vastly improved. Whereas when you're fit with an open device, you really don't get much amplification below around 1000 Hertz or so. By having it completely occlude your ear canal, it does offer big improvement in that sense. Now the other side of that coin is the comfort. Then you're gonna have to walk around with a device that is completely plugging up your ear and then having to re-amplify for basically that loss that it's creating, which can be less natural. But that's definitely been one of the main benefits I've seen in them, from a person who doesn't have a hearing loss though.
Dr Cliff: Yeah. I mean, it's everyone's trying to serve both masters at one time. They're trying to get the best streaming audio quality, but then they're also trying to get the best speech understanding, you know, and quality of amplification from a person's voice. And what people don't understand is you cannot currently have both. The thing that bothers the heck out of me, and I'm gonna go on a little bit of a rant here for you, is when people like they review these hearing devices and they say, oh my gosh, the Bluetooth quality on these is so awesome through these hearing aids. They're just, they're amazing. They're just like any of these other like headphones that are out there, these consumer headphones that are out there. And I'm sorry, but they're not. They only are if you completely block off the entire ear canal and you use a really nice, you know, power receiver that can really drive the low frequencies for you, but at the end of the day, you lose all of that benefit. Like you said, below 1000 Hertz, you know, more or less, if you open up the ear canal, and the vast majority of individuals need to have some kind of venting or open nature of their ear canal, which drops off the low frequency amplification. So anytime that I'm watching a review on a hearing aid and they say, oh man, the streaming quality for music on these devices are so great. I immediately almost discredit everything else that they say in their review.
Host: Yep, very true. So as an audiologist, I know you see lots of patients, you deal with lots of technology and different forms of care as we've been talking about with like telehealth, is there one of those that you've seen patients benefiting from most?
Dr Cliff: You know, I just think that this whole creation of Bluetooth technology has really ramped up the improvement for individuals from a hearing perspective. I think a lot of people think of it as a nice to have. Oh yeah. If you get Bluetooth, that's great. I'm really just interested in hearing people, you know, better, but really at the end of the day, I don't think people realize how much they struggle from a multimedia perspective, whether it's on the phone, whether it's, they have Zoom calls now, whether it's, they can't hear the TV, all of these other things. I mean, Bluetooth is really what allows that to happen. And I think, you know, here in the next year or two, when we have, you know, this new Bluetooth protocol that's gonna be coming out, I think that's really going to improve things even further. It would be nice to be able to, and I know there's going to be people who destroy me for this, but I think it's going to be nice to get rid of this necessity of a telecoil inside of hearing aids. And it's not that I don't love telecoils. I absolutely love telecoils, and I encourage them every opportunity that I get. The problem with telecoils is that public facilities need to incur a massive expense usually to install a hearing loop inside of their public facility. And what that results in is that you've got this awesome telecoil inside of your hearing aids, but you have almost nowhere that you can use it. And you have to literally take on this social movement campaign in your area to get individuals with hearing loss, to essentially lobby these companies that you would go to like churches or movie theaters, or any performing arts centers, whatever the case may be, to have a hearing loop installed, where for a fraction of the cost, you would be able to have these public facilities be able to use this newer version of Bluetooth to tap into the hearing aids directly, hopefully making the telecoil obsolete and getting the exact same or better ability to hear than a telecoil will give you currently.
Host: Right, for everyone then who has a hearing aid, not just those who have them with telecoils, 'cause I believe now with the extra space requirements of the telecoil, many of the smaller devices that people tend to lean towards, they don't have that option anyway. So it's like this a little bit of a battle from companies don't wanna loop or put a telecoil-enabled system into their facilities because of the cost of it. And then also people I don't see many of them opting for telecoils now. So it's almost like this chicken or the egg where both of them don't work. So I think you're absolutely right. If we did have a better Bluetooth signal that would stream further with less latency at a better bandwidth and better sound quality, it would definitely solve both of those problems. And it's just the way things are going now, everything is going to wireless communication for sure.
Dr Cliff: What we're looking for is the result, right? I know there's a lot of telecoil advocates out there, but the reason that they're telecoil advocates is because they want the result of the better hearing in these large public facilities. So we need to look at what's going to actually achieve that. And what's going to achieve that at the lowest cost? Because if the cost is still prohibitive, that's a problem. And so we need to identify a technology that can reduce down the cost for these public facilities to actually incorporate this with their venue.
Host: Before we wrap things up here, Dr. Cliff, is there anything else that you wanted to share with us or add to our discussion here?
Dr Cliff: You know, I just think that from a technology standpoint, the way that things are going, it's really an exciting time for everybody. I mean, whether you have a hearing loss, whether you don't have a hearing loss, but you're just, you know, an audiophile or someone who likes audio of things and likes being able to, you know, whether it's directly stream that audio into your ears or amplify speech of individuals even more, even if you don't have a hearing loss, this happens to be a really pivotal time for us right now. And the things that are happening right now from a technology perspective is just going to be built upon here in the future. So a lot of this stuff that we talked about today, a year from now is going to be different. It's going to be better than everything right now. So, and I've told you this before, Steve, but right now we are in the least technologically advanced state that we will ever be, right. So next week will be a more technologically advanced time period in our lives than we are right now. And it's going to continue on that trajectory. And the cool thing is, is that the cycle at which we're functioning at is accelerating. So, you know, over the last five years, we progressed to this point. Over the next one year, we're gonna progress what we did in that last five years plus, right? I mean, and it's just gonna keep accelerating on this exponential route. And that's a really exciting thing. So if you're not paying attention and tapped into, you know, your podcast, my YouTube channel, a ton of other, you know, podcasts and YouTube channels out there, you need to start paying attention to what's going on, because there's a lotta stuff coming down the pipeline that you as a consumer need to be aware of.
Host: Completely agree. Well, thank you so much for your time and thank you for sharing all that information. I'm sure our listeners will get a significant benefit from that. And if you'd like to check out more of what Dr. Cliff has to say, you can check him out at Dr. Cliff, AuD. He has a YouTube channel. Cliff, thank you so much for giving us your time. It's been a pleasure.
Dr Cliff: Thanks Steve. Thanks for having me.
Host: And thank you everyone for tuning in, this is the Hearing Tracker podcast.
