Economic impact of hearing loss in France and developed countries

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 6 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, 7 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 8 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.