Over on Slashdot, there’s a post that caught my eye because it is so simplistic and so wrong. It’s something I have deep personal experience with, and while not the normal fare for WUWT I thought I’d share my detailed response for the benefit of others. First, here’s the Slashdot story:
An anonymous reader writes “The price of a pair of hearing aids in the U.S. ranges from $3,000 to $8,000. To the average American household, this is equivalent to 2-3 months of income! While the price itself seems exorbitant, what is even more grotesque is its continuous pace of growth: in the last decade the price of an average Behind the Ear hearing aid has more than doubled. To the present day, price points are not receding — even though most of its digital components have become increasingly commoditized. Is this a hearing aid price bubble?”
My response: [As noted in my WUWT About page] I wear two ITC/CIC hearing aids with DSP processors built in. Let me tell you a little bit about why they are so expensive. The largest supplier of hearing aids in the USA is Starkey in Minneapolis. I’ve been to the factory, and have experienced the process from start to finish courtesy of the president of the company.
1. Because hearing aids, especially BTE (behind the ear) and ITC/CIC (completely in the canal) types use a single cell 1.5 volt battery, which can drop as low as 1.3 volts through its useful operational life, the amplifier circuits must be of extremely low power consumption and low voltage. The only chip material that works well for this is germanium, which has a diode junction forward voltage of ~ 0.3V as opposed to the ubiquitous silicon used in consumer electronics which has an ~ 0.7V forward voltage. While germanium was once very common for transistors and some early integrated circuits, it has fallen out of favor in the microelectronics hearing aid world. There are only a handful of sources and companies now that work with germanium, thus the base price is higher due to this scarcity. You can’t just take an off the shelf silicon chip/transistor and put it in these aids. Each one is custom designed in germanium. [Added: power consumption is a big issue also, aids are expected to last a few days on a single battery, if most of the power is being used to overcome the forward diode voltage, it gets lost as heat instead of being applied to amplification use.]
2. The process of properly fitting a hearing aid is labor intensive. Custom ear molds must be created from latex impressions, and these need to be fitted for comfort. A small variance or burr can mean the difference between a good fitting mold and one that is painful to wear. Additionally, if the mold doesn’t maintain a seal to the inner ear properly the hearing aid will go into oscillatory feedback. Sometimes it takes 2 or 3 attempts to get the fitting right.
3. On the more expensive aids, labor is involved in doing a spectral hearing loss analysis of the user’s hearing problem, so that the aid doesn’t over-amplify in the wrong frequencies. Just throwing in a simple linear amplifier is destructive to the remaining hearing due to the sound pressure levels involved.
4. Construction of aids is done by hand by technicians, especially with the popular ITC (in the canal) aids. At the Starkey company, a technician is assigned to create the aid from the ear mold, fit the chips and microphone/receiver and battery compartment, and connect it all with 32 gauge wire and make sure it all fits in the ear mold. This can be a real challenge, because human ear canals aren’t often straight, but bend and change diameter. Imagine a room with a hundred technicians sitting at microscopes assembling these. Each is a custom job. There’s no mass production possible and thus none of the savings from it.
5. After the aid is created, then there’s the fitting. This process is also hands on. Getting the volume and the audio spectrum match right is a challenge, and audiologists have to have chip programming systems onsite to make such adjustments withing the limits of the aid. Sometimes aids are rejected because the user isn’t comfortable with the fitting, and then the aids go back to the factory for either a new ear mold, new electronics, or both.
6. There’s a lot of loss in the hearing aid business. Patients don’t often adapt well, especially older people. There may be two or three attempts at fitting before a success or rejection. Patients only pay when the fitting is successful. If it is not, the company eats the effort and the cost of labor and materials. Imagine making PC’s by hand, sending them out to users, and then having them come back to have different cases or motherboards or drives fitted two or three times, and software adjusted until the customer is happy with it. Imagine 4 out of 10 PC’s coming back permanently after trial and error with a customer.
7. Early hearing aids weren’t anything but simple amplifiers. Even until the mid 90’s there was very little spectral customization. Now many aids are getting features like frequency equalizers and DSP noise reductions that we take for granted in even the cheapest silicon based consumer electronics. Hence, price has increased with complexity, but there’s still the high cost of custom special chips, and lots of labor.
So for those who think mass production techniques used on iPods would work just fine for making a delicately balanced instrument that must fit in your ear, please think again. As a hearing aid user since 1969, do I think the price tag of the special hearing aids today are worth the price compared to the simple linear amplifiers I used to have to deal with? Absolutely.
For more on hearing loss, see the Starkey Hearing Foundation, which I support.
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My younger brother wears a pair of open ear BTE hearing aids due to high frequency hearing loss and his new pair only cost 3500 which while expensive was less than half the cost of his much less sophisticated pair we bought in the late 90s though they were the molded ear insert style BTEs. So from our perspective the costs have come down especially when you consider inflation. The reason is that the newer electronics can be standardized to a degree and some open ear models only require the programming phase which further reduces costs.
As one who is also afflicted with severe hearing loss, I’d like to say thanks for posting this interesting explanation of hearing aids.
Should we also complain that the price of cell phones keeps rising out of control? Or should we marvel at the amount of tech and functionality the can now pack into such a small device.
Some people choose to see the worst in things. Sad.
Reminds me of a reporter who went to China to cover labor issues. She priced out what a typical American would eat by going to a local Wal Mart (yes, they have them in China.) She then compared the $2 dollars a day the workers were earning to the totals of what it would cost for an American diet bought at a store for expats. Her conclusion was that the factories in China were paying below a living wage and therefore were exploiting the workers.
The reality is that these workers represent China’s new middle class. Yes, at $2 dollars a day, they can save $1 dollar a day, with 50% disposable income they can buy a TV in a few months, a washing machine, moped, cell phones etc.
One of the issues that so often leagues any advanced field is a number of people who are knowledgeable in an unrelated field believing that their knowledge makes them equally knowledgeable in every other field and commenting based on that assumption. Equally those who have a little knowledge assuming that they are now experts.
Amongst my many official hats (mediator, software developer, electrician etc etc) I occasionally take part in overseas outreach programmes, ostensibly evangelical outreach, but there isn’t any preaching involved as we go for more practical reasons. Last time I was helping rebuild someone’s fence and roof in Romania. Every time I’ve been out I’ve faced two issues on returning: I find that I’m personally very pissed off at people in the west who act as if their tiny little probems are the end of the world (and I include AGW in this bracket as it’s very definitely a Rich Westerner Problem); and I find no end of people explaining that the five or ten minutes they spent watching a video about orphans in china is exactly the same as the week I spent labouring for some poor sod in the middle of Icephalia, Frozenia (yes it’s made up before you ask) who couldnt even afford the cement we were using to repair his home.
It’s a cliché that a little knowledge is a dangerous thing. It’s also a frustrating thing, especially when people argue from their ignorance and thaat little bit of knowledge to make a political point.
I suspect that the Audicus guys are cutting costs by skipping steps 2 through 7. Maybe you should take them up on their offer since you certainly seem to be knowledgeable about what hearing aids you want!
http://www.audicus.com/affordable/
I’m curious what the recurring costs are in the ongoing use of hearing aids?
Very informative, thanks, Anthony!
As my hearing function is diminishing due to age ( early 70s) and not wearing ear protectors while operating chainsaws, working on racing two-stroke motorcycles fitted with the usual expansion-box exhaust systems, etc, I found the article very useful and informative.
And yes, some people have a glass-half-empty mentality.
Competition makes products cheaper by lowering the worker costs?
The same people that are going to buy the products?
“The reality is that these workers represent China’s new middle class. Yes, at $2 dollars a day, they can save $1 dollar a day, with 50% disposable income they can buy a TV in a few months, a washing machine, moped, cell phones etc.”
That reporter needs to watch “Free to choose” by Milton Friedman. Let her be informed on how Miltons mother “was exploited” by the US when his family immigrated (to the US). Let her see how his mother managed to build a new life and prosper.
Interesting, thanks Anthony.
Makes you think what today’s computers would cost if mass production was not available, or even if we had computers at all due to high cost.
Interesting stuff. As an English reader, perhaps someone could tell me if the poor in the USA can receive any help in getting these sophisticated, but clearly very pricey, modern aids?
Australia Hears ( http://www.australiahears.com.au ) has developed a new technology hearing aid, based on research from the ‘Bionic Ear’ project. I purchased two BTE units, which I can program myself, for less than $1000USD each. The hearing aids, and accessories including the hardware/software programming interface, can be purchased on line at the above address.
|I also suffer from high frequency hearing loss, due in part to following the drum, and have open ear BTE aids. Besides completely transforming my life, Over the years I have noticed that while manufacturers list price goes up, actual consumers price has gone down. Prices half that of the manufacturer’s price are not uncommon thanks to competition in the market place.
Thank you for shining a light on a little commented upon area of modern living, Anthony, which more and more of the disco and Walkman generation are going to be experiencing over the coming years. I’ve also worn aids for 20 years now and have experienced the move from analogue to digital technology. All of the points you make are, in my experience, very true and especially the role played by a good audiologist and and well fitting molds. The last aids I purchased (in 2010 at a cost of over $9,000 here in the UK) were only chosen after my audiologist had made up 3 other sets of molds for both BTE and complete ITC models of 3 different brands, and tailored the sound profile to my exact hearing loss (very severe ski slope). The sound characteristics and performance of all 4 aids differed hugely and in fact by far more than I could ever detect in comparing HIFI systems when I had normal hearing. In the end I chose to stay with my existing brand (Widex) for the familiar, smooth, natural sound they produced.
My advice would be to choose a good audiologist (from recommendation) who is non-aligned to any one manufacturer (becoming more difficult) and work closely with them.
Yes, modern aids are incredibly expensive but they enabled me to continue working in very demanding roles for at least another 10 years beyond the point where I would have had to give up without them
In response to Extremist’s question as to the nature of recurring costs, in my experience (with declining hearing) I have to have at least an annual visit to my audiologist to retest my hearing and re-calibrate the aids.
Small technical error in your otherwise excellent description of the technology behind these devices. It is the bias voltage (at which conduction starts in a diode) that you are referring to , not the breakdown voltage, which is the point at which the diode stops blocking the reverse current and ceases to be a rectifier. This usually measured in hundreds of volts not tenths of volts.
Thanks, Anthony, for an interesting reflection on a topic not often mentioned anywhere. My own hearing was wrecked in an attack thirteen years ago, and from being my most acute sense by a margin has become only a distressing source of pain, so I have been through the surprisingly complex process of trying to tune aid to ear myself – sadly, with little useful effect in my case.
As soon as you mentioned that aids are built with germanium chips, a lot fell into place – I’d wondered how they packed so much crunch into so little space, but your mention of germanium made it instantly obvious – the cost likewise. You’d think that, with all the little electronic doodads running on silver cells, there would have been a bit more R’n’D on “geraniums” than has been evident. Maybe someone will wake up sometime soon and make them more widespread and cheaper.
Looking at those prices also made me very grateful for our (UK) National Health Service and its “free at the point of use” ethos. Meanwhile, having found that current aids serve me poorly, I’ll put on my radio amateur hat for a second and say “Thank God for Morse code”! – my delicate, shell-like tabs will have to get a LOT worse before I can’t distinguish between “tone present” and “tone absent”. It’s strange, but true, that I can often understand someone sending Morse from thousands of miles away better than a person talking in the same room! Medical techs, please keep those germanium chips coming.
Hi Anthony
As someone recently diagnosed with loss of higher-frequency hearing, I must admit to being horrified by the NZ$5000 (about US$4200) price-tag on the recommended OTE hearing aids. Your post explains a lot
But I’ll ask the question of the consumer though – since I am not yet up to speed on these issues – I was offered 2 types – the more expensive OTE has the actual “speaker” inside the ear on the end of a wire. The other OTE had the speaker in the hearing-aid, and a “speaker tube” taking sound into the ear.
Both models had full spectral control via blue-tooth technology
The more expensive in-the-ear-speaker was highly recommended (and NZ$1000 more expensive as well) – but what are your thoughts?
Andy
Anthony: thanks for the interesting thread – without personal knowledge it’s easy to overlook that hearing aids are actually fine-tuned, precision, instruments.
And to Archonix: yes, there is of course a risk that those knowledgeable in unrelated fields assume their knowledge extends to every topic under debate – but what is wrong with that, in this type of debating forum? It makes one think through the merits of any suggestions in these threads, and occasionally realise that someone seemingly in a different discipline has just had a shining new insight (Albert Einstein just started off as a clerk in Bern patent office, after all)!
Anthony said: “Construction of aids is done by hand by technicians, especially with the popular ITC (in the canal) aids. ”
The telly show How It’s Made has shown how fiddly and intricate making hearing aids can be.
How It’s Made – Hearing Aids
This particular bubble has been around for a long time. It’s not the germanium in the DSP, it’s just an ordinary cartel arrangement between the few HA manufacturers.
I trained as an audiologist back in the late ’70s, and my mentor explained the monopoly to me. (I didn’t take up the career but moved into related research.) At that time the typical BTE aid was built with discrete silicon FETs. It cost around $500 to the patient but could have sold for $50 with a reasonable profit.
I still have reasonably good hearing, but I also recognize that I’ve had adequate noise exposure to reduce my hearing even more than age would indicate as I get older. I expect to need aids at some point.
The anonymous “slashdot” reader is one of those who believes that someone else should pay for their “stuff”. They “need” it, so shouldn’t be required to pay themselves. They expect that government with its’ big pile of money will pay, giving zero thought to where that money comes from. Typical human nature. Especially in the US.
Thanks for posting this Anthony. I had no idea. I always took my excellent hearing for granted until a number of years ago when bad ear infections twice resulted in a perforated eardrum. The second time my hearing loss in the affected ear was >90%. It took 6 weeks before the residual ‘gunk’ even started to clear and more than 8 months for hearing to return to near normal, which thankfully it did. I was shocked how much I missed ‘stereo hearing’, and by interference when listening to music (I couldn’t enjoy it for months).
Verbal communication has become less and less formal and more and more casual. This is a good thing in many ways, but ‘more casual’ has also enabled ‘sloppy’ and ‘indistinct’. I know many people with reduced hearing and without meaning to sound patronising I now try to be concious of ensuring I speak clearly and, for example, facing them when I speak – my brief experience taught me how much visual clues help.
Thanks for this. Nice to know one is not alone. I am totally deaf in my left ear with severe high frequency loss in my right ear. I wear just the one BTE model with no frequency control, just volume. I am unable to source sounds such that if anyone calls me from my deaf side I invariably look the wrong way. Sometimes people think I am being rude. Conversations in a crowded environment are virtually impossible. Be nice if something can be done about tinitus.
I wear an artificial leg. My first one in 1965 cost $350 which translates into $2,500 in current dollars. My most recent model ran in the neighborhood of $25,000, ten times the original cost in constant dollars. In that case, although fabricating the limbs is now actually less labor intensive than before, thanks to synthetic materials and bolt-on components, the increased cost is attributable (at least in theory) to the vast amount of R&D effort and expense that has gone into developing the improved components.
These days, there appears to be lots of money to be made manufacturing high tech components for artificial limbs. Until there was serious money to be made, those components did not get developed. I suspect the “prime movers” in that money supply were the U.S. Military and Medicare. Has the result been worth a price multiple of ten? It certainly has been for me. I doubt I’d still be on my feet (one natural and one purchased) without the series of breakthrough improvements that have occurred in prosthetic technology.