20 CRF Parts 404 and 416
(Regulation Nos. 4 and 16)
RIN 0960-AG20
Revised Medical Criteria for Evaluating Hearing Impairments and Disturbance of Labyrinthin-Vestibular Function
Advance Notice of Proposed Rulemaking
Self Help for Hard of Hearing People (SHHH) appreciates the opportunity to comment on the current SSA criteria used to evaluate people with hearing loss.
SHHH, based in Bethesda, Maryland, is the largest consumer organization for people with hearing loss in the United States. With thirteen state organizations and 250 chapters, SHHH's mission is to open the world of communication for people with hearing loss through education, advocacy, and support.
SHHH has hosted annual research symposiums related to hearing science since 1994, and has had extensive communication and experience with thousands of people with varying hearing loss conditions that inform our comments.
Speech discrimination tests. For adults it is important that testing be done in realistic, lifelike situations. Testing performed in a clinical setting may not be a reliable predictor of functioning in the “real” world of work. Testing should be designed to match the communication demands of the job such as hearing in meetings, a busy office, or on a noisy factory floor.
Speech may not be the only communication demand on the job. Other critical listening situations could be the ability to localize sound, be alert to emergency warnings, communicate over an intercom, and comfort level using different kinds of telephones to ensure safety and ability to perform the job.
Specific guidance needs to be provided about speech discrimination tests, which vary greatly in how well they evaluate a person's ability to discriminate speech. There is a need for speech discrimination tests that have better predictive value in gauging the person's ability to understand speech in various situations.
Many variables can affect the ability of speech discrimination tests to assess widespread functional impairment including: whether the speech used in the test is low-pitched or high-pitched; whether the test is recorded or spoken live by the audiologist; whether two-syllable words are used rather than monosyllabic words; whether the tests use words or nonsense syllables; whether the words are spoken in noise or with an absence of background noise. There is need for closer guidance on which speech discrimination tests to use and how they should be administered.
Specified Hearing Thresholds Levels. The specified levels currently ignore the presence of hearing loss over 2000 hertz for adults and over 3000 hertz for children, but hearing loss over these frequencies has a significant impact on speech discrimination. The 1990 Mueller and Killion "Count-the-Dots audiogram form for calculation of the Articulation Index" indicates that 35% of speech cues occur over 2000 hertz and 24% over 3000 hertz. The current SSA criteria for adults from 500 hertz to 2000 hertz only evaluate the person's ability to hear a mere 55% of the speech cues. We recommend expanding the hearing threshold levels for both adults and children to be more representative of the person's disability across the spectrum of speech frequencies.
Other considerations not noted in current criteria. Some people with hearing loss will have much greater difficulty functioning if they have other medical conditions affecting their ability to compensate for the hearing loss, but these medical conditions may not rise to the level of disability by themselves. For example, visual acuity and certain cognitive processes are needed for speech reading. People with hearing loss who are also impaired in these capabilities could be significantly more impaired in their ability to understand communication than someone who performs more poorly than they do on hearing tests but who has the capacity to speech read. Cognitive impairment can also disrupt a person's ability to quickly and fluidly utilize multiple environmental cues to deduce what is being communicated. Thus a person with hearing loss and additional impairments may be able to score over 40% on a carefully administered speech discrimination test, but the person could be extremely disabled in responding flexibly to the communication challenges of everyday life.
We are additionally concerned that many people with severe hearing loss may be unable to support themselves financially due to the impact of their hearing loss, but they could still be deemed ineligible for benefits due to the eligibility criteria being too restrictive. A person’s audiological status does not necessarily predict their level of functioning. Hearing loss can be an extremely challenging disability on many levels but inner and outer resources may not be available to help the person compensate successfully for the hearing loss. If a person does not meet the pure tone average or the initial speech discrimination criterion, the person may still be profoundly disabled and should be evaluated further, especially if there has been a sustained inability to maintain substantial gainful employment.
Currently it does not appear that physicians and audiologists are allowed to consider additional factors for determining that a person is disabled. The current requirements pertaining to pure tone averages for adults and children need to be made less restrictive partly to accommodate people with multiple impairments or weaknesses which do not meet the eligibility criteria for a single disability. Alternatively, we ask that the SSA allow the use of other supporting evidence to determine disability due to hearing loss.
The challenge for people with hearing loss is finding access to the appropriate technology that would enable them to stay on the job and work productively. Anecdotally we know that many people with hearing loss retire early who could remain gainfully employed if they had access to hearing aids, cochlear implants and other assistive technology that could benefit their performance in the workplace. Few commercial insurance plans cover hearing aids, Medicare explicitly has an exemption for hearing aids, Medicaid covers basic hearing aids for children in most states but due to budget shortfalls, Medicaid is cutting many programs, including those related to hearing health
Hearing loss can have significant negative effects on all areas of an individual’s life. Criteria for determining eligibility for an individual with hearing loss needs to be expanded to take into consideration challenges beyond the results of a hearing test in a sound-proof booth.
Thank you for the opportunity to comment on this proceeding.
Sincerely,
Brenda Battat
Associate Executive Director
Self Help for Hard of Hearing People www.hearingloss.org
13 June, 2005
