Economic impact of hearing loss in France and developed countries
Résumé
Hearing loss in France affects about 10% of the population, namely over 6 million people have
to face hearing difficulties in daily life. Older adults (over 50 years old) are the most concerned
– one third of this population – as hearing loss arises during the course of life (for 88% of
French people), through a natural and progressive phenomenon (presbycusis) or after
exposure to noise. In Europe, Japan and the United States, prevalence rates are comparable
to those in France. The WHO estimates this burden of illness to currently concern more than
5% of the global population, representing 360 billion people. Nowadays, hearing loss is
considered as a major public health issue in the scientific literature and by international health
agencies.
Not only is hearing loss apparent through direct functional limitations (understanding and
communication difficulties), but hearing impairment is also associated with a higher frequency
of mental disorders, cognitive decline, falls and even mortality, independently of ageing
effects. Hearing loss could precipitate the elderly into dependency. Hearing aids (‘medical
devices for individual use’) compensate, to a certain extent, for hearing impairment and,
furthermore, ensure some individual rehabilitation: in 2015, more than 2 million French people
owned hearing aids out of 3 million eligible people. This technical solution should be further
encouraged, since 1 million French people declare a need for hearing aids but don’t get them.
As a result, improving access to hearing aids represents a decisive issue, not only in terms of
financial accessibility and fairness, but also in terms of efficiency: hearing aid equipment is
presumed to reduce the significant implications of hearing loss on health state and healthcare
expenditure and, thus, improve the patient’s quality of life. Yet, the hearing aid sector in France
has been long characterized by a wait-and-see public policy: the regulatory rules have been
frozen for several decades, due to a lack of reliable information on the expected added value
of hearing aids (in economic terms of utility). This lack of information and stalled regulations
have resulted in several recent reports, released by the Court of Accounts (Cour des comptes)
and the General Inspectorate for Social Affairs (Inspection générale des affaires sociales),
which both underline the urgent need to re-examine the access rules to hearing aids and to
provide, at the same time an economic assessment of this equipment.
The main obstacle to hearing aid access in France (financial barrier) concerns current financing
rules, and particularly the public trade-offs that have led hearing aids to be classified in the
‘low risk’ category and practically excluded from socialised health care. This classification
implicitly indicates that the hearing aid is a luxury product whose medical added-value is very
low: in comparison to the trade-offs for drug classification, the hearing aid medical addedvalue
ranges between ‘low’ and ‘insufficient’, since its observed reimbursement rate is under
15%. Yet, wide access to hearing aids (2/3 in terms of ‘real access’ of the eligible population)
shows clearly that demand elasticity is low: they are a necessary item. In general, the public
choice of coinsurance depends on the combination of ‘low risk’ and ‘commitment’. There is
only partial reimbursement in relation to ‘low risk’, or even totally exclusion from the social
health care basket when it does not depend on the collective responsibility and implies an
individual judgement on the trade-off consumption-price (in order to avoid over-consumption
or, in economics, the ‘moral hazard’ risk). Yet, not only is access significant despite the out-ofpocket
payment, but moreover its health consequences as well as its economic impact are
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likely to be major. The cost to society of hearing aid renunciation, in terms of quality of life,
expenditure and social inequalities is in total opposition to the objectives assigned to the
French health system.
Hearing loss: outline data
Disabling hearing loss prevalence is estimated today to range between 8.6% and 11.2% of the
overall French population. The analysis of hearing aid access shows that 30% to 35% of hearing
impaired people are equipped, namely 2 million out of 6 million people. This gap is reduced
when considering people being equipped and people eligible for hearing aids: whatever the
expert assessments, survey data or empirical statements (monographs by country), only half
of hearing impaired people would be eligible for hearing aids, thus 3 million people in France.
Thus, 65% of eligible French people are hearing aid owners whereas 35% of them remain
unequipped.
There are two main reasons which can explain this renunciation: a low public and private
coverage (provision), and a lack of information. Indeed, the average price for one hearing aid
comes to 1,535 euros, and 3,070 euros for binaural equipment. But this expense is poorly
covered by the National Health Insurance (8%) and poorly reinsured by complementary health
insurances (30%), leaving a high out-of-pocket payment for the adult insured (62%), namely
950 euros per apparatus. The price for hearing aid equipment comprises both the device and
the hearing aid professional’s counselling and follow-up services.
For the hearing aid owners, the equipment has an average duration of 5 to 6 years, during
which a qualified check-up is ensured by the hearing aid professional. The quality of the
equipment as well as the quality of the follow-up should influence hearing aid efficiency, user
satisfaction and beneficial compliance. This hypothesis seems to be confirmed throughout
international comparisons: in countries where the access rate to hearing aids is higher, the
social coverage is better for downmarket or middle market equipment. However, these
countries don’t necessarily have greater rates of real HAs users (i.e. rates considering effective
eligible people for hearing aids and effective wearing of hearing aids). Taken thus, France
would present a real rate of use close to those of the United Kingdom, Germany and Norway
and starting from very different situations in terms of financial access to equipment. If there
is room for improvement in France regarding the need for hearing aid equipment – due to
financial impediment - there is also room for growth in countries where hearing aids are
(almost) freely delivered but where the compliance isn’t sufficiently performant. A review of
financial rules relating to hearing aids has to consider the compliance factors determining the
effective use of equipment and, thus, the level of satisfaction for hearing aid users.
As concerns the payment schemes for hearing aid professionals, an economic analysis is
necessary, taking into account their incentive properties. In order to regulate the hearing aid
sector and to design an incentive payment for hearing aids, a trade-off is necessary between
the objectives of expenditure control, health care quality and freedom of choice, in a
hypothetic framework assuming a higher coverage of hearing aids. There are many tools
allowing us to realise the optimal trade-off for public financing, but a cautious approach is
required regarding the issue of a possible decoupling of the device and the service. This
decoupling model brings up adverse effects which are similar to those of ‘cost-plus’ payment,
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leading to increasing prices and putting patients’ compliance at stake, i.e. affecting the
therapeutic efficiency of hearing aids for some of them. At the same time that recourse to
prospective payment systems is increasingly implemented for pricing in health systems, and
as growing attention is paid to patients’ empowerment, this concept of divisibility
device/service falls within a backwards economic approach in terms of optimal incentives.
International comparisons highlight the impact of coverage and health care organisation on
hearing aid access, equipment renewal and patients’ compliance. They show also that French
prices for one hearing aid are very similar to those of other European countries.
Health and economic consequences of hearing loss: impact study
International medical scientific literature as well as French survey data are profuse on the
burden of illness topics and these start to provide evidence-based studies on the causal
alleged connection between hearing loss and health state degradation. Disabling hearing loss
(or moderate to total auditive functional limitations), by reducing the person’s communication
capacities, rebounds significantly onto the whole dimensions of health state (mobility,
autonomy, daily activities, pain/discomfort, anxiety/depression) through a succession of chain
reactions, the main ones being social isolation, cognitive decline, suffering at work, mental
troubles and falls. Hearing loss represents a major impairment which, by affecting more than
six million (often older) French people, not only has deleterious effects on quality of life but
also leads to additional health and social care expenditure for society as a whole.
The scientific literature unambiguously reports the negative waterfall effects of hearing loss,
but also shows the beneficial effects of hearing aid wearing: reduced mortality risk; improved
psycho-social health state; and a normalising effect on cognitive decline risk. Publications also
point out that this favourable impact on mental health is appreciable starting from the first 3
months of equipment. In the same perspective, some studies show the reliability and the
efficiency of earlier screening for people at the end of their working lives, screening those who
are old enough to justify secondary prevention, but who are still young enough to benefit from
it since their hearing loss level is moderate to severe. Earlier screening appears to be a very
efficient strategy regarding cost and quality of life. It should be implemented over the course
of medical consultations, in the form of two short questions without additional costs to general
practice.
Starting from this literature and the survey data, two scenarios for economic assessment of
hearing loss are proposed. The first one gives rough estimates for intangible costs related to
quality of life degradation in France. The aim is to assess the monetary value of lost healthy
years by valuing them in terms of the implicit price of human life. Based on realistic
assumptions, this estimation draws an image of saved costs thanks to hearing aid equipment
or compliance, as well as the economic burden of hearing loss related to its prevalence:
without equipment, this burden would amount to 23.4 billion euros. The real rate of
equipment (effective access and effective use of hearing aids) reduces this burden by 30%,
whereas the target equipment rate (i.e. 50% of hearing impaired people related to actual
compliance) would lighten the burden by 40%.
The second scenario relies on several assumptions in order to estimate, on the one hand,
medical costs related to hearing loss without equipment and, on the other hand, average
scores of lost utility related to quality of life. Both dimensions are graduated according to
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French hearing loss prevalence rates by age groups and by severity levels, then they are
connected with the rate of eligible people for hearing aids but who are not being equipped.
For this specific population, we assume that a gain should be expected in quality of life and in
cost savings, if equipment were delivered for 6 years. Assessing these values allows us to
roughly estimate a range for the incremental cost-utility ratio, expressing the cost to pay in
order to gain one additional healthy year for the period. Yet, through this simple simulation,
the target strategy (i.e. equipment for eligible population not accessing hearing aids) would
be dominant, even taking into account the compliance rate that reduces quality of life gains
and costs savings: the overall cost of this additional equipment would be 1.5 billion euros, with
48,000 QALYs gained and with cost savings worth 1.7 billion euros, namely a ICER of - 830
euros/QALY. In other words, the target strategy of ‘all eligible people are equipped’ saves costs
and provides an increased quality of life, and is thus the dominant strategy. This entire case
study, which relies on acceptable assumptions, underlines the requirement for a substantial
economic assessment that would corroborate these results, that is the highly efficient target
strategy that ‘all eligible hearing impaired people are equipped’, since the annual overall
expenditure of the hearing aid sector comes close to 1 billion euros. However, it remains to
solve the touchy question of hearing aid financing likely to support access to them, and
especially the question of the relative financial contributions of payers, as seen in the first
section of the report. Moreover, if the National Health Insurance could greatly increase its
financial role in hearing aid reimbursement, we would anticipate a bounce effect for people
being equipped but having postponed hearing aid renewing. This effect would inevitably
increase the budget impact of hearing aid access. That’s why an overall scenario has to be set
up, through prospective cost-efficiency assessments, by collecting useful data in sequential or
regular surveys based on the working and older population, in order to infer the differential
cost-utility ratio between strategies. This overall scenario would be completed by estimating
the budget impact of hearing aid equipment depending on several coverage scenarios from
the National Health Insurance’s point of view.
Coming out of this overview, the health policy for secondary prevention, that could consist of
screening and equipping hearing impaired people with hearing aids, is non-existent regarding
public reimbursement. National Health Insurance, by covering only 8% of hearing aid price for
adults, has almost excluded hearing loss from its management policy for health risk, leaving
the out-of-pocket payment to complementary insurance bodies and above all to patients. In
fine, families, close relatives and the whole society bears the costs of this impairment, as well
as for the loss of autonomy since one third of the eligible population for hearing aids don’t get
to them. Moreover, inequalities relating to the rights of those insured with complementary
health bodies, their revenue and ability to pay for equipment contribute to maintain these
social inequalities in health, by the renouncement effect. These statements would impose the
need for an urgent examination of the regulatory rules for the hearing aid sector in France, at
a moment where ageing, and listening to amplified music among the young risks contributing
to aggravated hearing loss prevalence in France.
Origine : Fichiers produits par l'(les) auteur(s)
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