The trend in hearing aid adoption following provision policy changes in South Korea

This study used national insurance claims data to assess the effect of changes in the hearing aid delivery system on annual trends in the number of newly registered hearing impaired people and the number of hearing aid subsidies paid. It found that the annual number of newly registered hearing-impaired people increased slightly and then declined during periods of insufficient hearing aid subsidy (from 2004 to 2014) and increased dramatically in response to a significant increase in hearing aid subsidy (from 2015). . In addition, the proportion of newly registered hearing impaired people receiving hearing aid subsidies increased to 85.3% in response to the large increase in the hearing aid subsidy in 2015.

To our knowledge, this is the first formal study to assess hearing aid adoption behavior using a national population database. The results show that a realistic policy of providing hearing aids can facilitate rehabilitation behavior in people with hearing impairment.

Hearing loss is the most common chronic condition in older people. The number of people with hearing loss worldwide is expected to reach 2.45 billion by 2050, a 56.1% increase from 201911. Untreated hearing loss and inadequate hearing rehabilitation reduce quality of life in many ways, especially cognitive function11, and recognition of the social burden of hearing loss has increased. To alleviate the side effects associated with hearing loss and its consequences, the provision of a hearing aid in an audiology clinic is the standard management procedure12. Despite the high prevalence of hearing loss in old age, only a limited proportion of the population with hearing loss who could potentially benefit from a hearing aid report current hearing aid use13,14. In the United States, about three-quarters of people with hearing loss cannot afford a hearing aid8. A Korean population study showed that only 17.4% of people with bilateral moderate to profound hearing loss purchased a hearing aid, and only about 73% of these people used the hearing aid regularly14. The importance of diagnosing and managing hearing loss tends to be underestimated, especially in developing countries11.

The average cost of a pair of fitted hearing aids ranged from $2,200 to $7,000 in 2014, and Consumer Reports shows that the average price for a pair of hearing aids was $4,860 in 202115,16. The hearing aid market is controlled by a limited number of companies and the price of hearing aids is quite high and is seen as the first barrier to hearing aid adoption15,17. In other words, insurance coverage is an important driver of hearing aid adoption18. According to data on welfare provisions for the disabled, the South Korean government has been subsidizing part of the 5-year purchase cost of hearing aids since 1997. The hearing aid subsidy amount has increased from 250,000 won (about $200) to 340,000 won (about $300 ) in 2005 and then tripled to 1,130,000 won (about $1,000) at the end of 2015.

A previous large study in South Korea looked at the 10-year trend in the number of people registered with profound hearing impairment from 2006 to 201519. It showed that the trend of hearing loss showed a gradual decline from 2010 to 201519. In the present study, consistent with this report, the number of newly enrolled hearing impaired individuals decreased from 2009 to 2013 (Fig. 2A). The decline in the number of newly registered hearing impaired people can be explained by assuming that most of those motivated by the second subsidy level ($300) may well have completed registration within the first 5 years.

However, we found that the number of hearing-impaired people newly registered increased sharply from 2015, at the same time as the level of hearing aid subsidy increased. This finding suggests that hearing aid price has a large effect on hearing aid adoption in South Korea. Another interesting point is that the previous study may have underestimated the true number of people with hearing loss, as it is possible that there were many unregistered people with hearing loss before the introduction of a more substantial hearing aid subsidy19. To register as hearing impaired in Korea, three pure-tone audiometry tests and one auditory brainstem response test must be completed, and the cost of these hearing tests is approximately $250~$300. As the cost of the assessment approached the hearing aid subsidy before 2015, there was little incentive for people with hearing loss to register as hearing impaired. Furthermore, the real value of the hearing aid subsidy would have decreased continuously over the period 2004–2014 if inflation was taken into account.

The present study also examined the annual severity trend among newly registered hearing impaired persons from 2004 to 2018. The frequency of hearing impairment grades 2 and 3, indicating profound hearing loss, among newly registered hearing impaired persons gradually decreased , while the percentage of people with severe hearing loss (disability degrees 4 and 5) increased (Fig. 3). The average age of newly registered people with hearing loss increased gradually from 2004 to 2015 and increased significantly thereafter (Fig. 5), implying that many older people with hearing loss were not registered before 2015. Furthermore, the average time from disability registration to Hearing aid adoption decreased significantly (Fig. 6), suggesting that the main purpose of disability registration may usefully shift to hearing aid adoption rather than receiving other social benefits for hearing impairment.

This study showed that reducing consumer/patient costs for hearing aids by extending the hearing aid subsidy increased uptake among people with hearing loss who could benefit from a hearing aid. We found an immediate increase in hearing aid uptake after the extension of hearing aid subsidies (Fig. 4). However, there are many other types of barriers to hearing aid adoption besides the issue of price.20. In Iceland, the national health insurance system fully covers the purchase of a hearing aid every 4 years, but only 11% of people with hearing loss use hearing aids21. This low rate of hearing aid adoption may be explained by the complexity of factors in hearing aid use. Hearing aid adoption is influenced by a complex interaction between personality, perceived social value, and social stigma20,22.

Several studies have attempted to quantify the economic effects of hearing loss23. A retrospective cohort study in the United States found that the benefit of hearing aid adoption in individuals with self-reported hearing loss was identified as a reduction in the likelihood of emergency room visits and hospitalizations and a reduction in Medicare costs17. However, hearing aid use led to increased office visits and more overall health care and out-of-pocket costs17. Another study suggested that providing hearing aids ultimately adds value to the health care system and provides net savings to the Medicare program24. After 2015, people with severe to profound hearing loss could receive a hearing aid subsidy covering the cost of a single hearing aid under South Korea’s national insurance system. It will be important to monitor whether the expansion of the hearing aid delivery system reduces the loss of quality of life associated with hearing impairment in terms of access to the medical system and leads to a reduction in overall medical costs, and this information should be reflected in any future changes in hearing aid provision; Finally, hearing aid adoption does not necessarily mean regular hearing aid use14.25. Correct hearing aid fitting and testing, as well as counseling, are important in creating an appropriate and effective hearing rehabilitation environment26.

This study is powered to use national population data to investigate annual trends in the number of newly registered hearing-impaired individuals in response to changes in hearing aid provision. It successfully identified changes in hearing aid adoption by level of financial support. The study also has limitations, mainly related to the characteristics of the claims data, as it does not include physical examination data such as the condition of the tympanic membrane and exact hearing level. Also, since the National Hearing Impairment Registry only includes people with severe to profound hearing loss, the present study was unable to assess hearing aid use by people with mild to moderate hearing loss. These limitations could be overcome in the future by including additional large medical data sources.

In conclusion, the expansion of the Korean hearing aid provision system led to a dramatic increase in hearing impairment registration and hearing aid adoption, indicating that there was a large amount of unreported or untreated hearing loss before the introduction of realistic hearing aid provision.

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