A note about hearing technology

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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139 thoughts on “A note about hearing technology

  1. 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.

  2. As one who is also afflicted with severe hearing loss, I’d like to say thanks for posting this interesting explanation of hearing aids.

  3. 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.

  4. 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.

  5. 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?

  6. 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.

  7. Competition makes products cheaper by lowering the worker costs?
    The same people that are going to buy the products?

  8. “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.

  9. 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.

  10. 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?

  11. 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.

  12. |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.

  13. 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

  14. 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.

  15. 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.

  16. 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

  17. 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)!

  18. 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.

  19. 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.

  20. 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.

  21. 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.

  22. 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.

  23. “The only chip material that works well for this is germanium, which has a diode junction breakdown voltage of ~ 0.3V as opposed to the ubiquitous silicon used in consumer electronics which has an ~ 0.7V breakdown voltage.”

    Not the breakdown voltage, but the forward voltage: the voltage across the p-n junction when it is forward biased and conducting normally. Breakdown voltage relates to conduction under reverse bias, for example avalanche breakdown, which is much higher than a fraction of a volt (apart from low voltage Zener diodes, normally designed to be tens, hundreds or even thousands of volts).

    Germanium is really useful for low voltage circuits and I have used germanium junctions myself. However, there are silicon audio circuits that work very well off 1.3 – 1.5V: I have a Panasonic compact cassette player that has everything, motor, control and amplifier, working off a single 1.5V AA battery. Perhaps this is mainly analog circuitry, but CMOS and switched capacitor systems working at 1V supply voltage (and below) have been around for over 10 years, and silicon on insulator digital circuits can work with supply voltages in the 0.6V range, which is very useful for RFID applications (which are very high volume, low cost).

    REPLY: You are correct, I meant forward voltage, but wrote the post late at night. My bad. When I asked about the technology two years ago, they told me they were using germanium because they couldn’t get the battery life they needed with silicon – Anthony

  24. I don’t think most people realize how much better the new digital hearing aids are compared to the older analog types. My father and grandfather really struggled with their hearing aids, (which weren’t cheap) My sister and I deeply appreciate how much well these DSP hearing aids compensate for our hearing loss. As long as we have a competitive, free market in devices and services we will have a market price. If I don’t like the service I go to a different hearing-aid guy. If I don’t like the hearing-aid I get a different brand. Also, if you want a cheap hearing-aid, and a pretty good one too (compared to Grandpa’s) you can buy one out of a hunting catalog for around $100. Free markets have driven the dramatic improvements in hearing-aids and they keep the prices competitive. If the government managed development, sales, service… made sure everyone was treated fairly. It would be a mess.

  25. My first set of ITCs cost $4,200 (USD) and had 4 adjustable frequency ranges. Five years later, i bought an 8 range pair, more power, and two receivers, for $3,400 (USD).

    More features, less money, but still expensive.

    OH! And when ya’ll are talking to us’ns with hearing aids, remember that they are just that – aids. They don’t restore perfect hearing and their programs sometimes are amplifying the heck out of the fan or dishwasher in the background while you’re talking right in front. The programs aren’t perfect. We still have to have things repeated to us in some situations.

  26. Why is no one using lithium electrochemistry to provide a 3 volt supply and circumvent the low bias voltage circuit requirement?

  27. There are cheaper alternatives. Last January I bought 2 behind the ear hearing aids online for a little more than $300 USD. They are not fancy. They are not hand fitted. They only have 2 frequency ranges which you set manually, but they have vastly improved my hearing.

    Within a month of purchasing them, I forgot them in my white-shirt pocket, and didn’t remember them until the laundry was half way through the wash cycle ~ very hot water & 2 cups of bleach with detergent. . .After drying overnight, the hearing aids survived fully functional, which looking online appears to be extremely rare for higher prices hearing aids to function after being washed.

    I am a beekeeper and the first time I worked my bees, I put my veil on and I had my hearing aids in. When I removed my bee veil, the close fit around my head apparently ripped out one of the hearing aids. I didn’t notice until later and I could never find it, so I bought a second set in order to replace the one I lost.

    It’s not difficult to see that I could easily have been on my 3rd set of hearing aids. . . I shudder if they had been the expensive models.

    I have 1 remaining, still in the box hearing aid and I am getting ready to buy a third set for backup. One of the hearing aids presently has dead spots in the volume control range, which I attribute to possibly being due to the corrosive effects of its hot water/bleach/detergent bath a few months ago.

    They are not the most invisible hearing aids. There is a small clear plastic tube which runs from the behind he ear unit, into the ear canal, but I can swallow a bit of pride and fashion for a savings of 1000′s of dollars. . .

    There are alternatives. . .

  28. I use a BTE aid for speech freq loss (got it in time for your Perth visit), and found myself defending the cost to an engineering friend simply on the basis of miniaturisation. Your discussion provides an overview of the cost of the technology even my audiologist could not give.

    It is perhaps worth mentioning a new device developed by a man formerly involved with cochlear implant technologies, and recently written up in Silicon Chip electronics magazine. He has achieved remarkable BTE package equivalent to my present device for a quarter the price, plus end user programmability and other bits and pieces. The company is called Australia Hears.

  29. You are right. It is easy to complain about “big corporations” exploiting customers with high prices, but in many cases -not just hearing aids- there is actually a lot of workmanship that goes into the product.

  30. I don’t know about the technology currently used in hearing aids, but the technology of silicon microprocessors has made great strides lately. Texas Instruments now offers “off-the-shelf” chips that can run on 0.9V. (See, e.g, http://ti.com/lowvoltagewiki ) I’m sure they’re not the only such manufacturer. So let’s hope this technology finds its way into hearing aids soon.

  31. I paid only around $375 for my BTE frequency tuned aid. Granted, the testing and fitting was at no cost to me as a military retiree. I don’t think Starkey contracted with Fort Bragg to loose money and Medicare and Tri-Care for Life pay nothing for aids. These aids had a one year customer satisfaction money back warrenty that my wife used to replace the more expensive in the ear aids with the more comfortable BTE with simple tube fits.

  32. I think this is a rationalization rather than an explanation. The basic excuse seems to be that the 1.5v battery requires using germanium, Ok, so use a 3v battery. There are other battery technologies around, and if there was a market, dual cell batteries could be fabricated in a form very close the current 1.5v cells.

    So how much more expensive is a germanium op-amp? 5x? 10x?

    Know how much a high quality, high gain, low noise *extremely( low current silicon op-amp costs?
    In quantity, less than $1.

    Sorry, I don’t buy the expensive op-amp rationale.

    As for fitting – ever been to a gun-show? or air-crew shop? You will often find people there selling custom fitted ear plugs. Yes, it may take a couple of tries to get the fit perfect, but the cost is typically less than $40, and the vendors will tell you that they make a healthy profit.

    My guess is that of the $3,500 for a hearing aid, something like $3000 is pure profit shared between the manufacturer and vendor.

  33. My dad just got a pair of these two years ago. I was shocked at what he had to pay (just over $3000 US). I understand now and will be printing this article (and comments) out for him.

    I’ll be joining him in the fitting room soon — kids, always wear your ear protection around heavy equipment and Iron Maiden in concert.

  34. One of the reasons that hearing aids cost so much is marketing. There are two providers in my the area that I am in now. In the five years that I have lived here I have gotten literally hundreds of pieces of junk snail mail from them because I am over 60. Now my wife is starting to get such mail as well. Between postage and other costs, I estimate that it costs about a dollar for each mailing. So hundreds have been spent by each of these two providers on mail to me alone. Quite a few of the mailings come in that junk format attempting to look as much like a government document as possible without actually crossing the line — “official business to be opened by recipient only. ”

    More is spent on media advertising — local papers, throwaways, TV and radio.

  35. I agree. I too believe that there is probably $3000 profit in a hearing aid. Look at the technology and miniaturization in the Iphone and look at what the Iphone sells for. . .and there surely is healthy profit in the Iphone. You cannot convince me the cost for hearing aids is justified.

  36. As a former certified ASHA-certified Audiologist and now hearing-impaired senior, I appreciate your comments. I can recall how primitive earlier aids were, and how I counseled my clients about them. If one is hearing impaired, there isn’t a price that’s too expensive, because to do without one (or 2) is to make one unable to function well in society. The field has progressed by leaps and bounds in the last few decades.

  37. Thank you, Anthony, for a very interesting topic, not least because of the light it throws in general on how people handle subjects that are “not quite” in their own field of expertise. I found I had a lot to learn when I was called on to help my sister with her hearing aids. Simple mechanical repairs after dropping (done under a binocular microscope) were possible. The habits of zinc – air batteries were something new – learning not to expect them to produce full voltage until they had their breathing orifice unsealed, and had time to breathe. But there are two points I would like to make. My sister, in her seventies, and not confident with things she regarded as technical, could not master the controls, even though they were only an Off – On switch, and a gain control that stepped up the level with repeated button presses, then started from the bottom again. I do not have a better answer for a user interface, but I can assure you that there are plenty of people in this world who need one.
    The second point is on molded earplugs. My experience with these has been for hearing protection on the rifle range. Individually molded ear plugs are in very general use, and are not expensive. Sometimes, not too often, a second try is needed to get a good seal and a comfortable fit, but mostly it is right first time. I appreciate that it may be a bit more demanding when the molding is to be worn most of the waking hours, instead of for just a few hours at a time. But I am going to fall into the trap mentioned for an outsider, and say “It can’t be that hard!”. Perhaps costs would be saved by having the protective ear plug molder on the job instead of the highly paid audiologist?
    But what an interesting and important topic!

  38. Anthony, thank you for your post. I always thought of hearing aids as an inconvenient and sometimes unsightly necessity. But I never knew they were to be purchased at such huge expense, or why. This is timely because my wife may need hearing aids soon. This is appreciated.

    Jerry

  39. My historical rule of thumb is the price of everything doubles about every ten years. This is equivalent to a compound rate or inflation rate of 7%

  40. About a dozen years ago, I had a nice expensive pair of hearing aids that worked beautifully. There was just one small problem: I was allergic to the hypo-allergenic plastic they were made from. I had noticed that my ear canals were a little itchy, but attributed that to not being used to the hearing aids. it wasn’t until a doctor kept noticing that my ear canals were constantly red and abraded looking that I realized what the problem was. After about six months, and several prescriptions of cortisone creams, my ears were back to normal. The hearing aids are in a box in a drawer, and I simply ask people to repeat things. Alas, even though hearing aids are hand-made, they are still made from stock materials which cannot be deviated from.

  41. Nice summary.

    I recently obtained BTE aids for $7000 the pair. These should require no such custom manufacture since the aid itself is in a large standard size/shape package that connects to the ear through a simple tube. I now question whether those types should be so expensive. Even if I returned them, the aid itself could be resold.

  42. 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.

    Too true. I currently live in Riyadh, Saudi Arabia, and I can’t even begin to tell you of the number of sophisticated Europeans who think they know all about the U.S. just from watching the movies. Also, I’ve found there are many people, as has been said, who, because they are expert in their fields of endeavor, feel that their opinions in unrelated areas should be given the same respect.
    We have a word for that: “Arrogance.”

  43. Philip Peake says:
    September 10, 2011 at 6:13 am
    “So how much more expensive is a germanium op-amp? 5x? 10x?
    Know how much a high quality, high gain, low noise *extremely( low current silicon op-amp costs?
    In quantity, less than $1.”

    It’s a DSP, not an OpAmp. A digital signal processor is to an OpAmp like a hydrogene bomb is to a stone axe.

  44. To put it bluntly, you don’t know what you are talking about! The hearing aid industry is 10% actually helping people and 90% scam.

    1. Germanium vs silicon is not the issue. Hearing aid technology is way behind the times. You only need a bluetooth device at the ear (with microphone) and then an app on your cell phone. After all, regardless of what the HA manufacturers want you to believe, a modern nearing aid is only an audio equalizer with possibly some noise reduction. It is ridiculous to try to stuff the electronics in or behind your ear. That’s like trying to put your entire cell phone in your ear.
    2. With the in the ear speakers or the audio tube to the ear, there is no molding required, just an assortment of different size tips. The open design of the tips let you use what natural hearing you have left. To plug the ear canal completely with a molded piece makes no sense, as you lose the benefit of your unaided hearing, which in lots of people, is completely normal at lower frequencies.
    3. One question here, if the spectral hearing test is so important, why are you not given a hearing test AFTER the fitting of the hearing aid to see how the HA improves your hearing? How many people reading this rant had a second test AFTER the fitting? At your next adjustment, ask for a post adjustment hearing test, after all, it only takes 10-15 minutes with a competent technician.
    4. See 1 above.
    5. See all of the above.
    6. Maybe the customer just wasn’t helped by the aid.
    7. That simple amplifier concept is still around as a marketing tool. Amplify small sounds up to full level and the customer thinks, wow, these things really work.

    Read Consumer Reports reviews of hearing aids. And before you drop $3-$6k on hearing aids, go to the local sporting goods store and buy a set of “hunters ears”, you might be surprised at what you get for .01x the cost of aids.

    YMMV :)
    Mitch

    REPLY: As a person who lost part of his remaining hearing due to the crude simple amplifier aids he was forced to wear as a child amplifying the wrong frequencies as well as the right ones, I’m quite certain you are laughably ignorant of the issues. Walk a mile in my shoes. Visit the factory and talk to the president like I did to check out the company and the product. Learn about the stigma of large unsightly aids for children, learn about how you lose the ability to identify sounds directionally or pick out words in a conversation from noise when you don’t have bidirectional advantage of both ears and the function the pinna provide, which can’t be duplicated with an iPhone and a bluetooth. Learn about feedback, especially for aids that restore 50% or higher losses and why custom earmolds are required for that purpose.

    Re: simple amps Wear “Hunters ears” or an iPhone setup 24/7 and tell me how good your hearing is in a week when you take them off.

    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.

    And finally, “Maybe the customer just wasn’t helped by the aid.” Learning to wear a hearing aid requires retraining your brain, like learning to use any prosthetic. Some people can learn to adapt to the new sound environment of a hearing aid, some can’t or won’t because they view it as a stigma, or loss of independence. Thus the success rate is lower than it could be.

    Learn all these things firsthand, and then you can comment intelligently on the issue from experience.

    - Anthony

  45. I always thought the big benefit, to hearing aids, was the ability to turn them off when confronted by vocal AGW/environmentalists. GK

  46. For several years I was a computerised notetaker for the deaf (sitting in a classroom typing what the instructors said on a laptop for a deaf student to read), and even now, as an English prof, I set aside some time each semester to do notetaking if there is a shortage of notetakers. (NB: There is always a shortage of notetakers.) Some of the classes I’ve been assigned to are for Hearing Specialists, so I’ve learned a fair amount about the processes involved in testing, fitting, and prescribing hearing aids.

    I hadn’t, though, ever heard how labour intensive and complicated the actual manufacturing of a hearing aid was. Thanks for the insight.

    (PS: If anyone is interested in becoming a notetaker for the deaf — and can type over 70 wpm — check out the Deaf and Hard of Hearing Services departments in your local colleges and universities. They are always in need.)

  47. Oh, and being a musician in my upper mid 40′s, though my own hearing loss is amazingly light considering the circumstances (a little in my right ear, the side where drummers usually reside when I’m playing bass), I recognize that one day I too will be faced with the prospect of having some sort of hearing aid to get along in this world.

    PS. Bass Players Rule!!!!!!

  48. I’m not buying it, either. If voltage were such an issue, they’ just have higher voltage batteries. Developing a battery to fit the silicon is a lot cheaper than developing the germanium to fit the battery.

    REPLY:
    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 get lost as heat instead of being applied to amplification use. -Anthony

  49. @DirkH: Tried looking up any specs? A DSP that operates up into the 100MHz region, operates from 1.2v, power consumption of 0.0012W — cost? $6.50 in 1k quantity. That’s an old one (2008 vintage).

    REPLY:
    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 get lost as heat instead of being applied to amplification use. – Anthony

  50. The silicon / germanium argument is a red herring. Perhaps true for bipolar transistors but not for FET’s. Several companies sell CMOS amplifiers, pico power, and operation below 1 volt. And as someone noted, HA could easily switch to lithium batteries, 3 volts and then some. My complaint is with non-rechargeable batteries. Why not Li-ion or Li-PO? I talked to an engineer at Starkey and he said “we can’t do that” and nothing more. Illegal? or an ‘arrangement’ with battery makers?

    Sorry to be so negative, but with 99% hearing loss and 40+ years in EE, including work with HA manufacturers, I’m not impressed by what I see. It could be done for a lot less.

    REPLY: Power consumption is an issue, if most of the battery power is used overcoming forward breakdown voltage it gets lost as heat. My visit was over two years ago, perhaps they have started to move on from Germanium now…I’ll check Monday- Anthony

  51. Anthony, the power budget of a hearing aid is beyond the scope of what can be intelligently discussed on a blog (which is why discussing climate science on a blog is risible), but if I had to guess, the final drive electronics use the bulk of the power, and an audio DSP made specifically for low power consumption isn’t that much of a draw.

    Having said that, if the hearing aid manufacturer is having chips made to the purpose, they may not even be true DSPs, they may be analog/digital hybrids. For example, Cypress has a chip called the PSOC which can do a lot of tasks that would otherwise require a full DSP, but in fact, they are an analog hybrid, and you use the digital core to configure the analog blocks into a filter, for example. Or, if you know ahead of time that the only DSP function needed will be, for example, an IIR, you can design a dedicated IIR machine, that will be a lot smaller and lower power consumption than a full DSP.

    Too little information to discuss this intelligently on a blog.

  52. Anthony or readers. For me this is a timely discussion, over the last 2 years my hearing has degraded ,but worse I have a constant ringing in the ear. There’s lots of info in the net but does anybody know if there is a real cure or research that will help this problem or am I dammed?

    REPLY: You have what is known as tinnitus. This product works for some people, worth a try http://www.quietrelief.com/.

    I used to be plauged with tinnitus, and I’m able to “think it away” I can’t explain how I do it, but I suppose somehow my mind is able to disrupt the condition when I calmly concentrate on it, sort of a reverse counting sheep method – Anthony

  53. F.Mitchell at 8.03am has a point about cramming all the electronics into the ear. I am dependent on a modern hearing aid (I only have one working ear) . Last year I updated to an Oticon Streamer which allows my mobile phone to connect via a Bluetooth adaptor (“Streamer”) worn round the neck) directly into my ear, a fantastic improvement which makes it so easy to use the phone and also the TV. So why cant my aid just be an audio Bluetooth driven speaker and have the microphones and electronics in a “Streamer” with all the benefits of battery size? I appreciate not everybody is happy to wear some evidence of their disability round their neck but it could drastically cut costs.

  54. “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!”

    Oh no! Can a dreaded “medical bankruptcy”, a.k.a., “any bankruptcy which includes a medical bill”, be far behind for our own Anthony?

    But fortunately, newly empowered Americans, bankruptcy itself is now no longer a problem for a fundamentally transformed America where the perpetual motion machine of more Great Central Gov’t deficit spending equals more taxation ‘revenues’ equals more spending and more balancing ‘revenues’ unto infinity, which is boundless and therefore inexhaustible as to its ‘wealth’. So there is obviously no need to create what can’t be exhausted to begin with! All we need to do is take it!

    Hence, Obamacare will either, 1] decide that everyone who decides not to buy hearing aids is participating in “commerce” and thus force them buy the aids for anyone needing them anyway, making them, voila, “free”! [Attn., Racist Teaparty Disbelievers: hath not a 'newly empowered alGoron woman' already decreed that birth control will be "free"?]

    Or else, 2] your super smart Great Central Planners will decide who gets the hearing aids based upon each one’s own very personalized “complete life” metric – of course “justly” excluding from the application of the metric the completely parasitic Planners themselves, who would in fact already owe a massive amount back to ‘society’ if the metric was applied to them, and, of course, if Infinity were indeed exhaustible.

    But otherwise, noble Workers and traders for glass beads, [dropping voice] yes, you will receive your very own “complete life” determination, roughly translated by the Great Central Planners as “Our perfect estimation of your current and future value to ‘society’ – ‘Because we say so!’ and, though Central Planning has never worked before, [again dropping voice] Because we are the people we’ve been waiting for! – necessarily including your ‘identity political group’ and how much ‘wealth’ you contribute to the Party Leaders, how perfectly you repeat only what we allow you to say, and how ‘correctly’ you vote, at least according to our Officially Modeled Figures assuring 100% agreement with us.”

    “The Utopian beauty of this process, you Flat Earth Disbelievers and other Racists, is that it will progressively result in the just determination that more and more people, hereafter known by Dear Leader’s newly coined term as ‘the bourgeoise’, are ‘not as equal as other people’ and therefore must still ‘sacrifice and give their fair share, er, back’; therefore leaving the hearing aids to be justly provided to less and less people, in other words, ultimately to only the Central Party Planners according to their own self-enlightened determination, and to their ‘Stazi’; but which will in turn drive down the cost to them to zero, thereby solving the Nationalized Debt Problem by the Nationalized Wealth Solution!”

    At least, that is, until the Nationalized Means of Production, ‘you, the Slaves’, either revolt or become too weak to work, when your own “complete life” value therefore equals “Zero”, you freaking Suckers!

  55. Anthony, I am deaf in one ear due to an auto accident and total severing of the nerve. I have been resistant to obtaining a hearing aid in my remaining good ear (right side) for the reason you state “amplification only increases hearing loss”. So I must ask, “Have you continued to loose hearing with the modern aids you purchase”?

    Mods, please forward this to Anthony as this is a genuine request. If he wants, he can e-mail me personally.

    REPLY: The early aids with simple linear amps did in fact cause additional loss over time. The new ones that are spectrum matched don’t appear to have caused as much, though there has been some. Some loss due to the elevated volume. Unless you are losing ability in the good ear, I would advise against it unless a doctor gives you some valid medical reason to do so. – Anthony

  56. Philip Peake (September 10, 2011 at 6:13 am) wrote:
    My guess is that of the $3,500 for a hearing aid, something like $3000 is pure profit shared between the manufacturer and vendor.

    That line of thinking is similar to the paranoid suspicion that a 100 mile-per-gallon carburetor was developed, but is locked up in some oil company’s safe. (For readers whose reaction is “What’s a carburetor?” — look it up!) It can be demonstrated from energetic considerations (I knew I’d find a use for that Thermodynamics class someday!) that there isn’t enough energy in a gallon of gasoline to propel an ordinary automobile anywhere near 100 miles. But neither math nor logic were strong suits of those who clung to the notion.

    The reality is that when there are multiple suppliers (and no cartel), each participant in a market will work to find the best way to source and market products and maximize return on investment, or go out of business. Market participants may compete by providing better products than competitors, providing equivalent products but better service at the same price as competitors, or by providing the same products and service at a lower price than competitors. Competition is often sparked by a low-cost provider, which is likely to grab the largest market share — for most people, saving money is very important. Other market participants then have to respond, to avoid becoming irrelevant (and eventually insolvent).

    Note that markets can sustain multiple models — compare the vehicle quality and level of service you receive from a Chevy dealer to the vehicle quality and service at a Lexus dealer. (I speak from experience. I drive a 1999 Chevy Cavalier, and my wife drives a 2005 Lexus RX330.) The dramatically better vehicle quality and level of service at the Lexus dealer is intentional (it’s a marketing decision), and comes at a significantly higher cost to the consumer. Some are willing to pay the extra cost, while others aren’t.

    You can purchase very simple (“Yugo”) hearing aids by buying one of the “amplifiers” advertised in the ads in the Sunday paper. A quick Google search for the phrase “hearing amplifier” shows prices between $15 and $40 (US). At the opposite end, powerful DSP-based (“Lexus”) hearing aids cost thousands. It appears the market is working perfectly well, providing a range of solutions at a corresponding range of prices.

  57. Dave says:

    September 10, 2011 at 9:25 am

    I have lived with tinitus for many years. Like Anthony, I learned how to live with it. Don’t let worrying about it reduce your quality of life. Accept it as your new norm.

  58. Re:JPeden says:
    September 10, 2011 at 9:49 am

    “At least, that is, until the Nationalized Means of Production, ‘you, the Slaves’, either revolt or become too weak to work, when your own “complete life” value therefore equals “Zero”, you freaking Suckers!”

    Lordy, boy! Take your meds!

    CH

  59. I’m losing a little high frequency in my opinion. Sometimes I can hear people well, but have to ask them to repeat so that I understand, especially when there is background noise. Happens mostly with women (no pun intended).

  60. Interesting. This really seems to suggest that the hearing aid industry is stuck in old fashioned kind of cottage manufacture sort of like for eyeglasses a couple of decades ago. A little careful thought might create its equivalent of Lenscrafters, which could come along undercutting everyone and changing it forever. I can think of three or four technologies that would make immediate improvements.

    Very helpful post. Thanks

    REPLY:
    With the potential damage to remaining hearing for “low cost fittings”, while some price reduction would be welcome, turning it into a commodity may not be a good thing. Think how well “discount surgery” has done over the years. Would you really want to entrust your remaining hearing to a cheap Chinese hearing aid? I wouldn’t. I’m thrilled that I can have this professionally done in the USA. And the cost/benefit ration is in my opinion high, given the alternative. New aids with proper care can last as long as 5-8 years, about the life of an automobile. Financing is a solution. – Anthony

  61. Might just be me, but I get ringing when I consume alcohol or free glucose/fructose food products.
    Explain that.

  62. Ha! I knew it. First, big Pharma, then big oil. Now, the latest corporate boogieman is……………wait for it………..big ears.
    I have a partial hand prosthetic, with individual powered fingers. The cost of this device is $68,000, mostly because the components are hand made, have to be fit and customized, and have a high initial failure rate, with a lot of rework being done. Until people come with standardized parts, not much can be done about it.

  63. As I understand it, tinnitus is a steady tone “heard” inside the mind due to illness or inner ear damage – it isn’t actually a “noise” coming from external sound waves into the ear.

    However, couldn’t an iPod type device (or an equivalent ambient noise cancelling device) be used to generate “false” external vibrations/tones that act to cancel the tones “heard” from the inner ear nerves?

    That is, the user “hears” a tone at a frequency and an apparent volume: He (or she) tunes the iPod to create an opposing “real” tone at the same apparent frequency (but inverted in amplitude) that eliminates the tinnitus-created tone? Now, I admit, you would be driving the inner ear with “extra” energy and vibrations, rather than cancelling the energy as in sound-dampening devices, and so perhaps threatening to damage the inner ear and nerves … but heck, the nerves and eardrum are already damaged in tinnitus sufferers and are already creating the distracting tone anyway.

  64. The listed reasons for the expense of hearing aids explains why they should perhaps cost $500 or $1000 for a high end one, but not $3000. It can not be denied that there are many business men and even doctors who will sell you something at full list price (more than double what you could get it for if you shopped around or haggled) if you’ll fall for it. It has been documented that hospitals often bill more than three or four times the price they bill insurance companies. It is not imaginary that you will get highly overcharged if you don’t shop around. People often don’t shop around or haggle for their hearing aid.

    You can get a variety of basic amplifying aids shipped from dealextreeme for $10 to $15. That gives you an idea of the basic hardware cost. Germanium digital hearing aid chips with the basic signal processing features have been on the market for a decade, and thus should only cost a few tens of dollars more. The testing and customized fitting and frequency adjusting can be done at a profit for $1000 each on the lower end aids, proving those are not the sources of the huge cost of the $3000 aids. And of course if you go to the wrong audiologist, he may charge you $2000 for the exact same aid and quality of service that another doctor will give you for $1000.

  65. Insulated Gate Field Effect Transistors (IGFET) do not need forward bias CURRENT and can therefore work at much lower power levels than even a germanium junction transistor. IGFETs are like vacuum tubes, requiring virtually zero power to control the current flowing through them. Seems like the silicon vs. germanium argument is a bunch of hooey! IGFETs have been around since the 1070′s and are available in both enhancement mode (+ biases on) and depletion mode (+ biases off). I remain a skeptic!

  66. i’ve been wearing CiC’s since i was about 20 (i’m 39 now) and what i’ve always been curious about is how the price of an aid can drop 30-50% just by going down a quality tier or two when the labor is still the same. you might get 8 instead of 16 channels and maybe (slightly) less sound processing but you can save thousands of dollars….

  67. Applegate (September 10, 2011 at 7:50 am) wrote:
    [...] I recently obtained BTE aids for $7000 the pair. These should require no such custom manufacture since the aid itself is in a large standard size/shape package that connects to the ear through a simple tube. I now question whether those types should be so expensive. Even if I returned them, the aid itself could be resold.

    Welcome to the wonderful world of medical devices! The US Food and Drug Administration (FDA) has an endless collection of rules about medical devices. You certainly couldn’t sell a returned hearing aid as “new”, if the FDA permitted it to be resold at all. Whatever the outcome, the manufacturer takes a bath on each returned device.

  68. Janice (September 10, 2011 at 7:49 am) wrote:
    About a dozen years ago, I had a nice expensive pair of hearing aids that worked beautifully. There was just one small problem: I was allergic to the hypo-allergenic plastic they were made from. … The hearing aids are in a box in a drawer, and I simply ask people to repeat things. …

    If you want to try again, look into behind-the-ear hearing aids. Then all that will be in your ear is the earmold. Before you commit to buying anything, check around to see if there are alternative materials available for earmolds. You can get a hearing aid from one manufacturer and an earmold made by another.

    If all else fails, you can try my mother’s trick for things that irritated her skin. She’d paint a couple of layers of clear nail polish on the parts that touched her skin. Worked every time for her. When the nail polish began to wear off, she just painted on another coat.

  69. The only real problem I have with hearing aids is the absolute loss of common sense in people around us.

    I probably wrecked my ears with 72 years of flying airplanes, driving, running chainsaws and lawnmowers and such, all without ear protection.

    The problem is that people think that (for all problems including differing languages) by making things louder the problem will be solved.

    For people like me, if you talk so loud that my ears bleed, I will still be unable to understand you,

    The damage to my hearing (which I do not understand at all) is such that I can not understand what I hear.

    In an anechoic chamber (a really really quiet room) listening to an audiologist read a list of words at a fairly low volume (my best chance) through an earpnone there are some words I can not make out if I can’t see her lips.

    So, to stop family members and other “friends” from hammering on me about getting over my vanity and getting a hearing aid, I got one (a BTE, not-custom-molded) at a “reasonable” (see discussion above to calibrate “reasonable”) price and with it, I can hear and understand people sitting or standing (or lying) to my right in a fairly quiet room. Even it the HA is in my pocket.

    Somebody asked about on-going costs. The batteries cost a bit over a dollar apiece and last about a week. I replaced the ear-wax filter for the first time in nearly a year that I have had the device–there at most of about a dozen of the original package left–I have no idea what they cost if I live long enough to use them all up. The soft-rubber cone thing the receiver is in looks like it will fail eventually (it turns wrong-side-out sometimes when I take it out of my ear), I have another in the original set, and I have no idea what they cost.

  70. Dave says:
    September 10, 2011 at 9:25 am

    Anthony or readers. For me this is a timely discussion, over the last 2 years my hearing has degraded ,but worse I have a constant ringing in the ear. There’s lots of info in the net but does anybody know if there is a real cure or research that will help this problem or am I dammed?

    ###

    Your are probably only dammed if you are a river. Seriously, I have been dealing with sever tinnitus for decades. For me, according to the doctors, it is caused by nerve damage, and therefor not treatable.

    I have tried to learn Anthony’s trick, but have been unsuccessful. I can think away the pain and even somewhat the effects of burns, a skill I learned as a cook by applying what I was taught in Karate. But maybe because of my ASD, I just can not ignore sounds, though I am sure most normal people can learn to do it.

  71. The cost of materials is surely a factor, but the main driver of pricing is going to be labor and insurance. Start with taxes which more then doubles the cost of everything, but especially labor. Then add the insurance which more then triples the cost of medical devices. Then on top of this, add Government regulations which impede innovation and distort the market. E.g., does anyone have any idea how much it would cost and how many years it would take to qualify Li-ion batteries for hearing aid use? Is it no wonder that the cost of hearing aid has sky-rocketed.

  72. Re:Marcos says:
    September 10, 2011 at 11:30 am

    “i’ve been wearing CiC’s since i was about 20 (i’m 39 now) and what i’ve always been curious about is how the price of an aid can drop 30-50% just by going down a quality tier or two when the labor is still the same. you might get 8 instead of 16 channels and maybe (slightly) less sound processing but you can save thousands of dollars….”

    Labor hasn’t that much to do with the phenomenon you describe. A truism of the electronics business is that you’d better recover all your R&D costs and rake in probably 90% of all the profit you ever expect to make on a new widget in the first year after introduction to the marketplace. After that, competition (some of it copy-cat) will drive down the price to commodity proportions. I try to wait until they’re practically giving away long-in-the-tooth electronic widgets as door stops (can’t resist cutting edge artificial limb technology though).

  73. I am a retired electrical engineer (BSEE, MSEE and MBA, btw) who has done both electronic linear amplifier design and digital logic design in bipolar (both silicon and germanium) and CMOS (an insulating gate field efffect transistor, IGFET, which has been referred to in this thread) in my career. I am not aware that it is possible to build DSP processors with germanium… the chemistry of germanium does not have a well behaved oxide (like silicon dioxide) that allows what is called Planar Processing which is the manufacturing-process basis of all silicon-based highly integrated circuits, or what is commonly called “chips.” Germanium is only capable of discrete transistors, to my knowlege. I doubt that more than a relative few discrete transistors are being used in a preamplifier circuit and/or an output driver circuit. By comparison even a quite small CMOS silicon low power processor (whether DSP or microcontroller) can have many tens of thousands of transistors, and cost less than a buck in a general purpose version. The larger ones in your PC these days have upwards of millions of transistors (and the power dissipation adds up even though they operate at less than one volt!).

    There are CMOS technologies that would allow a custom DSP processor plus any required linear audio amplification all on one chip and operate at 1.3volts. Getting the absolute lowest power dissipation is a matter of custom design of such a chip (it would not do to use a general purpose DSP chip), and this kind of custom mixed analog/digital design was my career forte, although we never applied it to hearing aids as a product. We never saw enough market volume there to justify the Non-Recurring Engineering costs of a design effort. It may be different today, but it could be quite expensive per chip compared to general purpose chips that have huge markets.

    While it is true that a bipolar germanium transistor can dissipate less in the diode junction than a bipolar silicon transistor operating at the same current, due to the higher silicon forward voltage, as two commenters have already said this can be totally obviated by analog CMOS transistors where the insulating gate has virtually zero current (power = voltage x current).

    On the other hand, I have no doubt that engineering a good hearing aid has challenges and problems as well as solutions that I am entirely ignorant of. It would be interesting to know more about the claims behind the use of germanium in a hearing aid.

  74. About 25 years ago I worked with a venture capitalist who wanted to create a national chain of hearing aid stores, in essence doing for hearing aids what Pearle Vision and Lenscrafters did when they revolutionized the eyewear retailing industry. His hypothesis was that the “mom and pop” nature of hearing aid retailing was grossly inefficient and with changes in how the product was retailed, the costs could be lowered considerably. After a month or so we dropped the idea because we found that the density of people with hearing problems in most metro areas was not sufficient to support even a modest sized retail establishment. Given reasonable assumptions of the market share the new business concept might earn, the number of potential customers that lived within a reasonable driving distance of most strip malls was insufficient to generate a reasonable return on investment. We found that there were only to market areas in the country where the customer density was adequate — Sun City, AZ and Tampa, FL. People that believe the “market works” will not be surprised to learn that high volume strip mall hearing aid retail outlets already in operation in both of those markets. In spite of technological advances that we knew were coming, demographics and the frequency of hearing loss within the general population dictated that hearing aid retailing was and would remain for some time a cottage industry.

  75. Anthony:

    Re the 100 MPG Carburetor. It’s call the Garrett Carburetor. It’s an electrolysis, hydrogen supplement device. I refuse to get caught in a discussion of its “validity” for a variety of reasons.
    But the patent exists.

  76. Whoops, posted automatically when I went to get the patent number: 2,006,676

    Please note the “assignee”. Sunoco Oil company. NO they did not “buy Garrett out”. Consider the engineering level of the time, the Sunoco ENGINEERS looked at it, determined it had NO MERIT, and it was never pursued.

    Origin of the URBAN LEGEND. Pure and simple.

  77. @JDN 8:36 am

    http://www.wikinvest.com/stock/Sonic_Innovations_%28SNCI%29/Data/Income_Statement#Income_Statement

    Sonic Innovations is losing money. Losing big money. Just thought those folks laughing off the price as pure profit ought to know, even if it likely won’t matter to them. “OK,” I hear them say, “but that’s just one money grubbin’ evil corporation.” OK, fine, lest I be accused of cherry picking:

    http://www.wikinvest.com/stock/Sonic_Innovations_%28SNCI%29/Data/Derived_Net_Income

    Comparison of Sonic’s competitors. Only three of twelve are turning a profit.

    Tried looking up Starkey, they’re private so no SEC fillings.

  78. Retired Engineer (September 10, 2011 at 9:10 am) wrote:
    The silicon / germanium argument is a red herring. Perhaps true for bipolar transistors but not for FET’s. Several companies sell CMOS amplifiers, pico power, and operation below 1 volt.

    The answer isn’t a collection of discrete parts, no matter how capable or low-power, but an integrated solution. It’s a very expensive undertaking, though, and takes several years to go from “let’s do it” to “it works”.

    The company I work for has integrated the major functionality of its pacemakers and implantable defibrillators. The pacemaker we released a couple of years ago, built on the integrated chipset, uses a 2.7 volt lithium primary cell for power, which is switched down to run the (silicon) CPU and DSP at 1 volt. With reasonable settings, the battery can be expected to last more than 10 years.

    A hearing aid requires more output power than a pacemaker, but has the advantage of using replaceable batteries (pacemaker batteries are most emphatically not replaceable). Output power can be significantly reduced over older designs by using a Class D amplifier (switched output transistors, followed by a filter).

    The ultimate goal should be to integrate the microphone amplifier, the A/D converter, the DSP, the controls, the output stage, and even the Bluetooth interface onto a single chip. From then on, you differentiate your products by changing the software. Occasionally, you update the chip set as newer technologies become available, allowing you to do more with less power, or to do new things you couldn’t do before.

    Retired Engineer (September 10, 2011 at 9:10 am) continued:
    … My complaint is with non-rechargeable batteries. Why not Li-ion or Li-PO? I talked to an engineer at Starkey and he said “we can’t do that” and nothing more. Illegal? or an ‘arrangement’ with battery makers?

    My last job was at a manufacturer of test and measurement instruments. We had a product (which I hadn’t designed) that contained a rechargeable battery for memory backup. We had two suppliers for the battery. One manufacturer’s batteries would grow metal whiskers through the separator, shorting out the cell, which allowed the memory contents to evaporate. The other manufacturer’s batteries would lose their electrolyte through the seals, eventually becoming an open circuit, which allowed the memory contents to evaporate. We had a second source for the part, but lousy results no matter which one we used. (My designs all used primary cells — non-rechargeable batteries.)

    In general, batteries are the pits. During their discharge life, the battery voltage and impedance change in ways that can cause the circuitry the battery powers to misbehave. Primary cells have fewer odd behaviors than rechargeable batteries, they have higher energy densities, and they’re more reliable.

    If your hearing aid battery (a primary cell) dies in the middle of the day, you can replace the battery and be back in business in minutes. If you had to recharge your hearing aid before you could use it again, you may well be out of operation for the rest of the day. For hearing aids, replaceable batteries are the way to go.

  79. Roger says on September 10, 2011 at 1:03 pm


    Germanium is only capable of discrete transistors, to my knowlege. I doubt that more than a relative few discrete transistors …

    Please be mindful of SiGe IC technology, which has evolved to the point of being used in commercial product today … albeit bipolar (NPN and PNP) transistor technology I think vs MOS (think: “Field Effect” transistors) …

    .

    Full disclosure (on this thread’s subject): My sister is a Cochlear Implant (direct connection of 5 – 10 electrodes to the sound ‘nerves’ that go to the brain with a DSP used to create the ‘stimulus’ signal) user/subject, in one ear for +18 years now and just last year had the 2nd ear ‘implanted’; if ever there was a miracle technology, CI would be it!

    .

  80. Excellent commentary.

    The author of the Slashdot post would also be upset, presumably, that an iPhone costs so much more than wireless household phones did in the 90s.

  81. Roger says on September 10, 2011 at 1:03 pm

    While it is true that a bipolar germanium transistor can dissipate less in the diode junction than a bipolar silicon transistor operating at the same current, due to the higher silicon forward voltage,

    Not even sure where you were going with this Roger, but, substantially anything you can do with a Si device I can do with a Ge device, notwithstanding some limitations for power dissipation on account of the tendency for Germanium devices to ‘self forward bias’ at elevated temperatures as minority-majority (hole-electron) carrier pairs self-generate regardless of control input (Base or Emitter) currents … thermal runaway, secondary breakdown etc are some of the issues moreso with Ge than Si bipolar technology (veteran of moderate to high-power power supply and RF transmitter design and test here) …

    .

  82. An article on WUWT that I know about! :) In my real life, I’m the CTO of a hearing aid company (and I spend way too much time in Xiamen, China – the heart of hearing aid assembly worldwide). The costs borne by the customer aren’t just for the hardware – it’s the fitting, diagnosis, and tuning that is the expense.

    The average person goes back to the audiologists between 12 and 18 times in their first year – and that is almost always covered in the purchase price of the aids. At an average cost of $100 per office visit, it’s quick to see that upwards of $2500 of a set of hearing aids can be just for the audiologist’s office time. The profit on the hardware sales side is considerably less because of the large margin given to the seller to cover their costs on the tuning and service of the client for the first year.

  83. This makes me feel very humble. Thank you everyone. It puts in perspective the £500 it costs here for me to get a pair of hearing aids with Specsavers, or free for one non-adjustable hearing aid on the NHS.
    I’ve become painfully aware of my hearing problems in the last month, after flying to Norway, losing a substantial part of my hearing after the flight, and having the embarrassment of asking my hostess cousin to repeat almost everything she said, whether she spoke Norwegian or English. It really was not nice after a week.

  84. Cochlear implants are one way to go. Another is Cochlear’s Baha hearing aid system that will work when a conventional hearing aid is not the optimal solution due to ear canal problems or permanently perforated eardrums. The Baha system works through direct bone conduction. A titanium implant is emplaced in the mastoid bone behind the ear and the custom tailored hearing unit is attached to the implant. Details can be found at: http://www.cochlear.com

  85. Polistra:

    “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.”

    You might have been told that it was cartel, but in the real world there are very few cartels that operate successfully. It can only “work” with things of limited supply. Hearing aids, or anything that can be manufactured in infinite quantities are a poor choice for a cartel.

    Like commenter Shanghai Dan, I too spent way too much time in China. Shenzhen, during the boom years of late 1980′s to late 1990s in my case & high tech. Any time a company tries to gouge the consumer, they are very quickly undercut by competition. An attempted cartel is undermined by competition that will appear very quickly.

    Therefore – if there really is a cartel, I would propose to Shanghai Dan that we go into business together, launch a cheaper copy and break their cartel ;)

    To the commenter who questioned labor competing, thus lowering labor costs. Yes and no. Labor is in finite supply, especially skilled labor, which is why CEO’s and sports stars make so much. If a labor market has over supply wages go down but if it is tight, as it will be in any good economy, wages go up. Just like any market. The role of government should be limited to just making sure markets are free, fair, open and functioning. Beyond that, freedom leads to prosperity, with a few bumps along the way of course.

  86. I have been wearing hearing aids for about 15 years, I am 39 now. I can add a few notes. Expect average replacement at 2-3 years. Also, they have increased in cost, about double, during the last 6-10 years for a comparable product. Just my 2 cents.

  87. Perhaps a better ‘picture’ of hearing aid low-power digital developments:

    http://www.sounddesigntechnologies.com/aboutUs_History.php

    2000′s – Innovations in ultra low power Digital Signal Processing as Audio and Wireless Division of Gennum Corporation

    2007: INSPIRIA™ Digital preconfigured DSP with Adaptive Directionality, Feedback Cancellation with up to 30 dB of Added stable Gain, 128 bands of Adaptive Noise Reduction
    – Shipped over a Million FOUNDATION® DSP hybrid packages

    2006: Introduction of 128-band psycho-acoustics based Adaptive Noise Reduction with VENTURE™ family of products
    – Shipped over a Million PARAGON® Digital hybrid packages

    2005: VOYAGEUR™ DSP
    – First 130 nm fully programmable DSP product
    – Unsurpassed MIPS vs. current and processing capability

    2003: FOUNDATION® Digital
    – Enabling affordable digital hearing aids

    2001: PARAGON® Digital
    – First pervasive off-the-shelf digital product
    – First DSP with extreme wide bandwidth (16kHz)

    More info – a white paper titled:
    Signal Processing in High-End (Digital) Hearing Aids:
    State of the Art, Challenges, and Future Trends
    (starting pg 12)

    Note: It appears that the first 7 pages are blank, there is content on page 8 onward …

    Example digital product from Gennum/Sound Design Technologies back in 2001
    Power PARAGON™ DIGITAL Four Channel DSP System with FRONTWAVE

    Note the minimum supply voltage shows to be 1.0 volts …

    .

  88. I’m not losing my hearing; you guys are just mumbling, and you’ve been getting worse for a long time! But if I ever do get hard-of-hearing, I’ll buy the “green” version–no dangerous EM radiation or toxic batteries to foul the environment. Al Gore approved!

  89. Spouse’s tinnitus was one of several symptoms/effects of scurvy – which is what she had. I was reading the Patrick O’brian Aubrey-Maturin series at the time and put the symptoms together, suggested she return to her GP, tell him what it was and see his reaction.

    “Of Course! Vitamin C Deficiency.”

    The deficiency was an effect of a medication she was taking and adding more vitamin C into the mix cured the tinnitus and the other related complaints.

    She had made the rounds of the usual specialists who had failed to diagnose scurvy – as one of them said, “We never see scurvy, as such.”

    This is of course not to suggest that tinnitus is always a symptom of scurvy (Vitamin C deficiency) but it may give a few of you who have this problem something else to look into.

  90. Kozlowski,

    Drop me a line…:) Always looking to expand markets! But the reality is the $300 of parts in the hearing aid as the BOM cost translates to $600-$700 (after import duties) cost for the brand, who sells for maybe a 40 point gross margin to the audiologist – who charges a lot to cover the costs of office visits and fitting.

    There really isn’t a huge amount of margin in it – because it’s an extremely time and labor intensive process to get them working right. Medical practitioners are not cheap per hour – you drop 18-20 hours of audiologist or doctor time into diagnosis and fitting and it’ll easily eat up $2000 right there.

  91. I appreciate this topic. When I was 28 I lost most of the hearing in my left ear due to infection. First thing I noticed was the loss of stereoscopic direction finding. Like dropping the soap in the shower with your head lathered up and finding the bar without opening your eyes because your hearing allows you to pinpoint its location. I don’t have a hearing aid (can’t afford one).

    Anyway about 8 weeks ago I had another stroke and lost a significant degree of my hearing in the remaining ear. I have been able to get along with work as long as I can sit in a quiet room with no radio or TV on, None at all as even at low levels I can’t hear my patients speak. My problem is I need HA’s but I can’t envision taking them out 20 times a day to listen to heart, lung, and bowel sounds. Anyone have a constructive idea? I don’t qualify for disability and have no money to retire on.

    Again, Thank you Anthony for this topic. I am a regular reader but rarely comment because all the smart people here would make my comments seem silly. I am an electronic engineer but now practice medicine so this has been very interesting on two levels.

  92. Hearing aids are controlled by a cartel. There is no place to obtain even a rudimentary hearing aid circuit drawing to see what’s really involved. There is virtually no detailed information available, frequency response, etc. You have to rely on the vendor; for him the sky is the limit. A lot can be done with dsps and their programming these days. Once you have a good algorithm (one time expense), it can be tweaked and tweaked and tweaked. If hearing aids were sold in a way that was competive, you would be surprised how quickly the price would decrease and the utility would increase. Competition is non-existant in the hearing aid field! It’s the difference between a Volkswagon and a Lexus. Both will get you where you’re going.

    The OP works for Starkey. Of course he will justify the high cost. Every one of his arguments can be refuted, but everyone here seems to believe him. Competition and openness will bring prices down — way down.

  93. Sorry Anthony, I agree with much that you say and read your blog every day, but you really CAN pay a lot less for DSP Hearing aids including CIC and RIC type – and you can adjust them yourself. I have done so. I have also had multiple poor/fraudulent service from hearing’professionals’. For example, you can chose from 6 channel units eg from http://www.audicus.com/ for $998/pr, 12 channel units from http://www.diyhearingaids.com/ for $1990/pr, 16 Channel Siemens Pure 701′s from http://www.thehearingcompany.com/ for $3295, or 32 channel units from http://www.americahears.com/ for $1798 & etc. All of these can be self-adjusted to match an audiogram, or to taste.They can also be matched up to all the latest bluetooth/telecoil etc technology. The people selling these are still no doubt making hefty profits. There really ARE multiple scams in the hearing aid supply/fit field. I am sure that the aids themselves ARE being made in China for a fraction of the sale price eg $100 per unit. The voltage differences and the germanium/silicon difference are probably just promotional stunts. This is not to say that people should purchase really cheap amplifying aidsvfrom ebay, hunting stores or elsewhere which might damage their hearing.

  94. “Power consumption is an issue, if most of the battery power is used overcoming forward breakdown voltage it gets lost as heat. ”

    Not with FET’s. They can operate on very low voltage and low power. All DSP chips are MOS, from day 1. First NMOS in the 70′s and now some CMOS. Power and density. Y’all can’t make that out of Germanium. So it remains a red herring. ‘Forward voltage’ refers to the drop across a P-N junction (diode) which doesn’t apply to MOS. Some DSP ‘cores’ now run at 0.9 volts. Faster and lower power. In the last 20 years, possible to combine both analog amplifiers and digital signal processing on the same chip.

    Germanium is nonsense.

    Starkey doesn’t really overcharge, given the engineering they put in. (they have or had an R&D faciliy in Colorado Springs) but I question whether they really need that much engineering.

    As for rechargeable batteries – been using them for years in many applications. Growth of microfibers was a problem with Ni-Cd’s. NiMH cured that. Lithium made it even better. Pacemakers already use primary (non-rechargeable) lithiums. Did some work for CardiacPacemaker in MN a long time ago. HA’s could use inductive coupling, charge overnight in a small dual ‘bucket’ on the nightstand. Single cell lithiums (various types) are quite reliable.

    As for tinnitus, have had it for years, many possible causes, no real cures. Sometimes tones, sometimes a whooshing. Comes and goes, fatigue seems to make it worse. You might think there would be more ongoing research, my ENT doc says not really.

  95. Don’t forget that Obamacare imposed a 10% tax on medical devices. This tax, perhaps the most bizarre, regressive, invidious, and anti-business tax n the entire world, is already driving thousands of jobs, even entire companies, overseas, as well moving the entire medical manufacturing processes to China, where they will be lost to us forever. Manufacturers must lower labor costs to afford the tax.

  96. Azygos says on September 10, 2011 at 6:29 pm

    I have been able to get along with work as long as I can sit in a quiet room with no radio or TV on, None at all as even at low levels I can’t hear my patients speak. My problem is I need HA’s but I can’t envision taking them out 20 times a day to listen to heart, lung, and bowel sounds. Anyone have a constructive idea? I don’t qualify for disability and have no money to retire on.

    My CI implanted sister (who was also an RN before raising a family, and now is interested in medicine again) informs me that there are a number of GPs and other medical professionals sans hearing; all is not lost, there are workarounds e.g. the ‘digital’ stethoscopes such as these models which can be used with full-sized headphones rather than just earphones it would appear:

    http://www.digital-stethoscope.com/eng/sub02/sub02_01.htm

    Also, there is product out there what works with a laptop PC to display the ‘waveforms’ from internal body processes … A year ago I wrote a short audio processing application in LabVIEW that shifted _up_ the low-frequency spectrum output from an electronic stethoscope sensor head (in the range of 50 some Hz) into the a higher frequency range of ‘normal’ human hearing (which becomes operative somewhere over 100 to 150 Hz) and into the range frequencies (say 250 to 300 Hz) that is better processed by hearing aids (based on what frequency sound range they are listed in the specs as being able to ‘handle’ and amplify).

    There are forums where these sorts of issues are discussed, usually amongst the CI (Cochlear Implant) crowd where electronic interface to a Stethoscope is mandatory. Below is one link that touches on the interfacing of stethoscopes and CIs:

    http://www.audiologyonline.com/askexpert/display_question.asp?question_id=548

    .

  97. Wayne,

    It’s not a cartel… There are roughly a dozen suppliers of DSPs used in hearing aids. Most are assembled as a dedicated, custom-designed hybrid chip using a customized DSP core (RAM, ROM, auxiliary processors as needed), firmware, ASIC for glue logic/memories and analog front-end. It’s not cheap to develop something small enough to fit in a hearing aid, yet process at a low power what is needed. We’re talking adaptive filters, variable compression/expansion, noise cancellation, auto-switch for telecoil use, and so on.

    Now run all that off a 1.4V battery with 60-70 mA-hr rating – that’s less than 0.1 Watt-hour, so for 48 hours of duration – you better optimize for almost no current consumption.

    It’s not a simple “op amp with gain” if you’re talking anything digital – and the new digital units offer significant improvements in intelligibility over the older fixed-gain units. It turns out that intelligibility is a function not only of frequency but amplitude as well, and having your multi-band filters adjust gain and Q based upon overall signal level can help a person understand what is said. The simple device you’re talking about is a pair of tin-cans with strings compared to the 24/96 kHz streaming solutions that modern DSP-based hearing aids provide.

    So, if you’re comfortable stitching a DSP core, an EEPROM, a 14 bit CODEC, some analog front-end, and designing an ASIC – plus writing your own firmware – the circuit’s quite simple. Of course, the circuit in a CD player or cell phone is also quite simple, but most people aren’t capable of actually making an actual device…

  98. Thanks for an interesting post Anthony. I’m 72 and have worn hearing aids for about 12 yrs now. So I have moved from the analog to digital types and now to the blue tooth eqipped latest technology from Phonak (Swiss). Yes they are expensive but without them I am nearly deaf. In my case, both my parents needed hearing aids in their senior years and their working environment had little to do with their or my hearing loss.
    One of the things I haven’t seen mentioned in the posts is that for people with severe hearing loss, behind the ear types are essentially mandatory, in order to build in the power that is required. However the latest are less bulky than those of 4 years ago in my case and this is helpful when eyeglasses arms compete for the space behind your ear. I get nearly two weeks out of batteries with essentially full time wear.
    The technology in this field moves as fast or faster that that of computers, in my experience. More advanced models with improved features every two years or so it seems. Directional microphones, multiple programs for ditterent situations and bluetooth devices to wear to help with TV listening. However trying to hear, or understand a conversation is a crowded dining room or meeting room is still a real challenge. The directional microphones have helped here.
    As others have mentioned, the facility where I bought these aids are always there to service them when it is required and usually for no or little charge. The tubes and filters need to be replaced about every six months and adjustments to the programs made using their computer software. They can even tell how many hours a day you wear your aids, how often you crank up the volume and which programs you tend to use most. In other words, these are not simple devices.
    Yes they are expensive, but compared to doing without them I am very glad they are available and will scrimp on other items to make their purchase possible.
    Thanks again for a very interesting post.
    Ron Sinclair

  99. I think that there is a limited group of people who are going to buy hearing aids therefore dropping the price of these modern hearing aids is not going to result in a huge increase in demand.The research and development costs are high and must be paid for but we would expect the price of hearing aids to fall in the long run.I have high level hearing loss but I am reluctant to buy a hearing aid at the price they are now even if they are much better than they used to be because of modern technology.

  100. Azygos, here is a discussion I came across some time back regarding hearing impaired med professionals and stethoscope use; it is behind a login wall, otherwise I would just post a link (names/IDs removed):
    - – - – - – - – - – - – - – - – - – - – - – - – - – -
    … the (stethoscope) frequency range of interest is relatively wide: 22-650 Hz approx.

    This encompasses the low-freq heart sounds (most studies record the lowest heart sound at 24.5 Hz) and the not-as-low freq lung sounds. …

    Noise-canceling headphones should be a must, along with an easy-to-use volume control! But the fact is, even with my bilateral Harmony / 90K combo, I have not had trouble with heart sounds or lung sounds – no matter what is “supposed” to be the case. I just make sure I have fresh batteries in the E-scope and in the Headphone (if I am using a noise-canceling set). Somehow, reality derfies theory. But for challenging diagnostic cases, it would be interesting to see what a freq-shift would do…and it would be a great help to so many out there!

    I use stethoscopes every single work day and have used some very curious combinations in my time. Before getting CI’s, there were times that were very challenging. At one point I had my RN staff do most auscultation because I could not trust my hearing. Today, I am finding things my staff missed! Its not that they do not hear well, the fact is we Hoh folks know what we are missing so we try harder and get the most out of the little we have.

    At the present time, I use the Cardionics E-Scope II with a set of headphones. Keep in mind that the E-Scope requires a mono headphone or you just hear out of one side. So I use a mono-to-stereo adapter jack that plugs into the scope and the headphone plugs into it. Yes, I have also used the famous Howard Samuels ear buds. They do work well IF you buy good quality ear buds. They are small and portable. The only difficulty is the 30 seconds it takes to slip them onto the t-mic and make sure the cord is not tangled.

    Cord management is a big issue. I keep my headphone cord on a small rubber spool that holds the excess so I have no trailing wired. The E-scope clips on my belt like a phone. The Headphone wire goes straight to the headphone around my neck. Then the stethoscope chest-piece goes into my trouser pocket. If you wear scrubs, the modern ones have a zillion pockets so even the headphones can be in a pocket. Check out AviatorScrubs.com. But you can get pretty cool scrubs at a local uniform store.

    Unfortunately, interference is a huge problem with neck loops and t-coils in almost every medical environment.The buzz makes the t-coil a poor choice for everyday use around medical equipment. In a quiet room, I sometimes plug in a small folding stereo speaker / amplifier set I got from Radio shack years ago. Patiernts love it because they get to hear their own heart beat and lung sounds.

    Noise canceling headphones are a wonderful idea in the ER and when people areound are talking. In such challenging places, my little on-the-ear Sennheiser NC headphones do not block out sufficient noise. Over-the-ear sets work best, such as my Bose QC-15. The problem is they have another switch to flip and are too bulky to keep around my neck all the time.

    Littman makes some wonderful Bluetooth stethoscopes for folks with bluetooth-enabled HAs or CIs. I did not get these as I would have to use a bluetooth neck loop with its inherent T-coil problem, AND I do not fancy paying over $1K for a “scope when the e-scope works.

    - – - – - – - – - – - – - – - – - – - – - – -

    If you’re interested, one can join the forum (get a login ID) at:

    http://www.hearingjourney.com/

    and search for “stethoscopes” to see the discussion.
    .

  101. extremist says:
    September 10, 2011 at 1:19 am
    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?

    Replacing them after you leave them on the coffee table within reach of the dogs!

  102. All very interesting. Neither of my parents ever had hearing aids, Daddy because he didn’t need one and Mom because she didn’t think she needed one. :). Her hearing loss was the result of a bout of Scarlet Fever when she was 8, and evidently–she said–a hearing aid wouldn’t help her much. Plus she was very cheap, and since she’d got along for 60 years without one clearly she could save her money for something else.

    So far my hearing is fine, but it’s nice to know the technology is out there when/if it stops being fine.

  103. I have been using BTE aids for a year to reduce tinnitus I got by living too close to an 8 in gun battery in Vietnam. At the beginning my tinnitus was matched by a 57dB tone at 6KHZ. After a year it matched a 32dB tone at 6KHZ. Subjectively the difference went from a steam whistle close by to an organ in a church across the street with a key stuck down. It is still annoying when I think about it but not nearly as painfully distracting as before. So far the improvement continues even if I do not wear the aids for weeks.

    The BTE aids I used for tinnitus produce a continuing sound like a zylophone playing random notes. Neither the Audiologist nor my General Practitioner understand why it works. Maybe it’s placebo, but as long as the improvement persists I don’t care.

    Yes they are expensive and in my case not covered by insurance. Whether the price is based on cost or other factors I do not know. But I suggest, if you are convinced that there is excessive profit involved, that you start making and selling your own brand. That’s how markets work.

  104. Re the comment that you should expect hearing aids to last for 2-3years. I’ve been wearing hearing aids for 40years. My last 2 aids, both analogue, have lasted well over 10 years each.

  105. Hi Anthony,
    Some healthy skepticism may be required.
    This post caught my attention as I wear BTE hearing aids, and I have a good friend who is our city’s ear nose and throat specialist, and before I got my hearing aids (about 2 years ago) he told me what I should expect to pay. It was along the lines of $5000 (NZ), which is about $4,000 (US). He commented then that the price was way too high and could be lower. I forwarded him your post. Here is Wayne’s comment:

    “Thanks for that. However the justification for the high price in totally unconvincing. When the NHS in the UK put out a tender for hearing aids the price dropped from 900 pounds to 90 pounds for the same item. They can still make money on 90. It doesn’t include fitting fee, but that is usually quite reasonable. No – there is definitely strategic price control going on somewhere in the process.”

    Robin (New Zealand)

  106. Anthony, thanks for an excellent post on hearing aids. I can see why they are relatively expensive. While there may not be a cartel keeping the prices high, I would have thought that, with time, procedures could be standardised so that people could do a lot of the preparatory work themselves. And competition should, over time, drive down hearing aid prices. Even so, because hearing is so precious, professional help is probably best, and that costs money.
    I have loss in my right ear, from otosclerosis see http://en.wikipedia.org/wiki/Otosclerosis , which has now given me high frequency tinnitus in that ear. My choice was an operation (stapedectomy see http://en.wikipedia.org/wiki/Stapedectomy), which the ENT surgeon thought would be too risky, or a hearing aid (Phonak Versata). This helps me hear better and also helps to mask the tinnitus, though this varies from day-to-day. Today, my right ear humming away!
    Dave asked about what can be done for tinnitus. From my own experience, I suggest he sees an audiologist who will be able to say whether the tinnitus is due to otosclerosis or it’s sensori-neural or there’s some other cause. If it’s sclerosis then a stapedectomy may be the answer. If this cannot be done then a good hearing aid will help to mask the tinnitus. I’ve tried an aid that generated white noise, which helps some people. In my case it didn’t but may do the trick for Dave.

  107. My mother had a hearing aid from the UK National Health Service in the 1960′s that was around the size of an old Sony Walkman with a not dissimilar ear cord to an ear mold. I have been wearing hearing aids for the last 30 years – due to inheriting my mother’s problem greatly assisted by too many hours working alongside fighter aircraft in reheat.
    The first aids I had were from the UK National Health system and were simple Behind the Ear (BTE) analogue amplifiers with clipping of the highest output. The NHS only started supplying digital hearing aids around ten years ago. I moved to a commercial In the ear (ITE) aid in UK at the cost of £2,400 in the early 90′s this was digital with adaptive volume control and a simple graphic equalizer. I replaced that in the US for $2000 with a more updated aid 6 years later. As my hearing got a little worse I updated to a digital BTE with several different settings and ‘bluetooth’ at a cost of $3000 – around the same price as the early digital aid that I got in UK 15 years previously.

    When I got my first hearing aid I was very self-conscious as being deaf and failing to hear people seems to be treated in a less friendly way by society. People seem to think someone who does not hear them is stupid or rude; hiding the hearing aid only reinforces their assumption. I am now beyond being embarrassed and would rather have a hearing aid that works and allows me to do my job even to carrying around a Walkman sized device similar to what my mother used.. My current Oticon hearing aid has a neck pendant called a streamer that provides Bluetooth connectivity and with its own microphone allows me to answer my cellphone even if it’s in my pocket or somewhere within 30 feet. The people I work with have got used to me apparently talking to myself.

    As to your points Anthony. I can understand that hand tailoring a set of hearing aid circuits to fit inside the ear canal is extremely manpower intensive and skilled. But I have to wonder if that is due to the wish for the recipients to have a contact lens equivalent in hearing aids. A standard small electronics container could be fitted to any earpiece and if it cannot be buried right in the canal then it is just an In The Ear aid alternatively the microphone and speaker could be in the canal but all the electronics in a standard ‘pack’ behind the ear. Both these methods would standardize the electronics for the aids and make them more mass-producible reducing their price.

    Feedback is an area that you did not mention. Although electronics can be used to limit feedback it is difficult when the speaker and the microphone are both in the ear canal. With my hearing loss the power output is such that feedback can only really be avoided with a BTE aid. This means the microphones are also BTE but there are 3 on my aid which allows noise cancelling and user choice of which ones to be active.

    Finally, thanks to the way people use Walkman, the iPod and other digital music systems the number of people with deafness is about to increase dramatically. This will change the market from specialist providers to a mass market. As soon as that happens (and posts here suggest it is happening) it will be seen as a business opportunity and the current trio of major hearing aid manufacturers will suddenly have to defend their market share. If as some posters here are surmising the germanium issue is just a marketing ploy, then the mass-market will soon bring in changes. In real terms the price of hearing aids is already dropping, I think that this will continue.

    For those with tinnitus – I have occasional very severe tinnitus (up to the level of sitting close to the engines in an aircraft at takeoff) but have found that a cocktail of vitamins and protein supplements appears to greatly assist. There is a fair amount of research on this area to be found on the internet and everyone is different in their vitamin balance it may be an idea to have some tests done to see if you are not absorbing enough of a vitamin or protein.

  108. WOW!! What an informative and useful discussion.

    After owning 3 sets of HAs over the past 20 years, I have an observation about the following comment …

    “The average person goes back to the audiologists between 12 and 18 times in their first year – and that is almost always covered in the purchase price of the aids. At an average cost of $100 per office visit, it’s quick to see that upwards of $2500 of a set of hearing aids can be just for the audiologist’s office time.”

    The average of 12-18 visits strikes me as quite high. In my experience, in two of my HA cases, there was no need for a follow up visit, while in the 3rd case an adjustment was necessary to tweek my right-side HA. Thus, counting the initial hearing evaluation visit and the subsequent “installation visit” for the aids (two ITE and now a BTE), the average time spent with the audiologists for each set of HA was less than 20% (at most) of the claimed 12-18 average.

    Hmmmm … maybe that provides a persuasive reason to negotiate/obtain a better price with the audiologist next time.

    Many thanks, Anthony, for getting this “off topic” topic in front of such a well informed group of readers.

  109. I’m an analog IC designer (Ph.D. EE with 25+ years experience, if you care) who works on nanometer scale chips. I also work in the Minneapolis area so I have friends who work in the medical electronics business. So I can make a few observations on the technology involved, and in short, much of what makes the iPhone cheap doesn’t apply to hearing aids.

    The newest technologies in say 45nm would certainly be feasible for these projects in theory, since the digital voltage is around 1V max. I’d hate to do the analog design, though. The transistor gates in a 45nm process are around 14-15 atoms so you get significant quantum mechanical tunneling through the gate, and the drain to source leakage is very, very high. That is a factor even in what I call low-speed analog design in these technologies of 100 MHz or so. But at audio frequencies the leakage would be exceptionally difficult to deal with for the analog part of the chip. The digital would be straightforward, but since there’s relatively little digital processing, the chip for a hearing aid would be what we call “pad limited”, meaning that the chip size would be dictated by necessary communication paths off the chip, which would significantly drive up the chip cost since silicon is expensive for these processes.

    But you could never, ever make a hearing aid design work economically at 45nm. What we in the business call NRE (non-recoverable expenses) in this technology start at around $20M per project, so you can really only contemplate these technologies for things that are going to be selling hundreds of millions per year, while hearing aids don’t even hit the 2M/year level. Doing the math on the back of my napkin, the entire hearing aid industry would have to submit the minimum order for wafers every other year to supply itself (details later if there’s demand). At such low volumes your NRE is easily going to be $40M+ since the foundry isn’t going to be cutting you a break, if you can even get in, since they don’t like low volume customers.

    To give you a feel for what it takes to really make use of one of the modern, cheap-in-volume processes, we order twice as many wafers a day as the entire hearing aid industry would use in a year and it’s still hard to justify the various expenses.

    Overall, you’re far better off using an older, lower speed (and lower leakage) CMOS process. The expenses of designing a single mask set in something like a 180nm process are around $20K vs. $2.5M+ for a 45nm process. You get a similar break in the software needed to design the chips, too.

    The germanium issue is also a bit oversold. In the last 20 years there’s been a huge increase in what we call subthreshold design techniques that would allow replacing the germanium power amplifier with an integrated solution in CMOS at nearly the same efficiency. The design techniques aren’t as well known as what I assume the germanium users are doing, but they’re out there and used in many areas such as watches and the like. They’re useful for slow designs like these audio frequencies, but they’re not what I’d call mainstream.

    Most frustrating to me would be the overall design cycle, though. From talking to my Medtronic neighbor the FDA is a pain to deal with. His example was a medical chip, where he finished the design in about 12 months. Then it went out to trials and those trials are expensive in terms of insurance, medical doctor’s time, result analysis, lawyers to look over paperwork, paperwork required for engineers to submit, etc. All the while the FDA was in the loop to slow things down, sending things back to make a few tweaks, etc. Overall it took 5 years for approval, which is better than the typical 7 for a pacemaker. But in that 5 year span the original foundry nearly went out of business and if it had he’d have had to start over. Compare that with the overhead of the FCC, where approval of a wireless chip usually is done in less than a month at a relatively low cost, and from design start to volume production can be less than 18 months. I understand the need to be safe, but those “hunter’s ears” you’re talking about don’t go through the FDA and that’s one of the bigger reasons they’re much cheaper. When you get the FDA into the loop you automatically delay the process and drive up the cost immensely.

  110. Ian E says:
    September 10, 2011 at 2:07 am
    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?

    I can tell him definitively, yes. We have Medicaid and other programs that make such things cost almost nothing for the poor. It is the “working poor” who have trouble with these prices. They make too much for the handouts, but not enough for unusual expenses.

  111. If I may be pardoned for going OT from the OT topic, I was interested in the case of tinnitus being dealt with as a vitamin C deficiency. I have an inner ear problem, not hearing but balance. At first it was assumed to be an inner ear infection, but antibiotics and elapsed time, both usually equally effective for infections, did not help. I did a lot of reading, and found the answer: I had a manganese deficiency. A supplement fixes the problem for me, but not for everyone. Didn’t seem to help my tinnitus, though. I just had to get used to having my own flock of cicadas following me around.

  112. There has also been consolidation in the industry. Many smaller companies doing the most advance technology (I actually worked at one) in the 90s have been bought out by larger firms.

  113. A few months ago I got an infection in my left ear that caused a temporary loss of hearing. After the infection cleared up, my hearing returned to its previous state. Based on my doctors tests, he sent me to an audiologist for a hearing assessment which confirmed that I had mild to moderately severe, age-related hearing loss in both ears. I was offered three levels of hearing aids ranging from $3,750 to $6,000 for a pair of hearing aids. I thanked the audiologist and explained that I believed that I could get near-top-of-the-line house-brand hearing aids from the Costco store across the street for $2,000 per pair. A little further research confirmed the hearing aids offered by Costco were manufactured by one of the top manufacturers and the specifications were comparable to that manufacturer’s top hearing aids which were available from full-service, independent audiologists for $6,000.

    The latest hearing aids are true digital signal processors and are nothing like the simple hunter’s ears amplifiers. My hearing aids have sixteen frequency channels which can be individually set to fit the aids to my hearing loss. I have five different programs that help match the ambient hearing conditions. The hearing aids communicate with each other wirelessly to locate speech sounds and discriminate against annoying background noise.

    http://shop.costco.com/In-The-Warehouse/Hearing-Aid-Center/Kirkland-Signature.aspx

    I don’t have complicated hearing problems, so I felt comfortable using a licensed Hearing Aid Specialist with a Master’s degree instead of a PhD audiologist. With more difficult hearing problems, I might have chosen otherwise. For many years, I used optometrists for my glasses, but I am going to an ophthalmologist as my eye problems get more complex. The service at Costco has been excellent. The woman I work with encourages me to return frequently (at no additional cost) for inspections and to try tweaks to the programs. I have returned for inspections/adjustments six times in six months – not because of problems. We have made changes and improvements at each visit. The Hearing Aid Specialist has used these visits to provide an on-going educational process. Hearing aids are not just plug-and-go. You need to learn how to maintain them and use them, and you need to learn to have realistic expectations. I use a behind-the-ear model. The sound generating module is on a wire and it slips into the ear canal and is held in place by a small plastic cone.

    My only connection with Costco is as a satisfied customer. They offer a 90-day money-back guarantee – and it works. I have a friend who returned his after 89 days. Here’s another link to the Costco hearing aids showing the available models and price ranges.

    http://shop.costco.com/In-The-Warehouse/Hearing-Aid-Center/Styles.aspx

    That’s a $2000 price for two top-of-the-line hearing aids all services included: ninety-day trial, no charge for followup adjustments, loss and damage replacement, rechargeable batteries with charger. Costco requires a $50 annual membership. That $50 is your only risk if you choose to try Costco hearing aids.

    My ophthalmologist said he was not allowed to recommend eyeglass suppliers, but he did “suggest” that I consider the price and service from the Costco opticians. The price for my no-line bifocals at Costco was about half that of Lenscrafters, and I have been pleased with them.

    If nothing else, you can use this as a bargaining chip with other suppliers. I had some follow-up negotiations with my first audiologist, and she offered some price concessions after she had a chance to review the Costco product offering. She admitted that she could not come close to matching the Costco price for a comparable product. The Costco Kirkland Signature is a re-branded Rexton hearing aid. Rexton is a subsidiary of Siemens. At the time I purchased my hearing aids, the Costco Kirkland Signature specifications seemed to be nearly identical to those of the Siemens Pure 701 models. Keep in mind that hearing aid manufacturer’s are getting into the new-model-year style of marketing, so you can expect rapidly changing model specifications to promote the latest and greatest features.

  114. Anthony – I recommend you check out products by Oticon at oticon.com

    They are based in Copenhagen, Denmark, I visited the company a decade ago. At that time they were world leaders in miniaturised hearing aids, I expect that may still be the case. They make nothing else.

    All the best.

  115. Retired Engineer (September 10, 2011 at 7:53 pm) wrote in part:
    As for tinnitus, have had it for years, many possible causes, no real cures. Sometimes tones, sometimes a whooshing. Comes and goes, fatigue seems to make it worse. You might think there would be more ongoing research, my ENT doc says not really.

    Like Retired Engineer and many others, I have tinnitus. Mine isn’t caused by a condition that’s presently curable, so my left ear whistles along 24/7, with my right ear making it a duet from time to time. It’s a high-pitched whistle at relatively low volume, so I normally don’t notice it.

    If my tinnitus were louder, I would avail myself of current treatments. One that I have (but don’t use) is a CD that has tracks with tones of various frequencies. Listening to a sound that’s close to the frequency of the tinnitus whistle can cause the tinnitus to become less obtrusive by taking advantage of the self-masking effect.

    If a person is in an area where there’s a repetitive or recurring sound (e.g., a hum from fluorescent lighting or the “tick-tock” sound made by a mechanical clock), the brain will soon assign it nearly zero significance. From that point on, only changes in the background sound will be noticed. Adding a masking tone to the “background” that’s close to the frequency of the tinnitus often causes both the masking sound and the tinnitus to be suppressed.

    Masking tones don’t have to be continuous, or of a constant frequency. Allanj (September 11, 2011 at 1:03 am) reported that he has a hearing aid that produces “a continuing sound like a [x]ylophone playing random notes.” He says it has reduced his tinnitus by 25 dB, going from a very loud and obtrusive sound to a soft one that is much easier to live with.

    To find out if you can be helped, you need to begin with an audiologist or with an Ear, Nose, and Throat (ENT) specialist who is both interested and experienced in the treatment of tinnitus patients. If the first audiologist or ENT you go to tells you, “You’ll just have to live with it”, dump him and find one who is more knowledgeable.

    If you’re having trouble finding treatment where you live, search for “tinnitus treatment center”. A Google search for that phrase found 437,000 results. With any luck, there will be one near you. (Be wary of any “tinnitus treatment center” that isn’t associated with a major hospital and/or medical school. It may consist of little more than a cynical GP who’s certain he’s stumbled upon a surefire get-rich-quick scheme.)

    Research into cures for tinnitus is ongoing. You can find information about current research, along with information about available treatments, from the American Tinnitus Association. If you want to make a contribution to help push the research forward, I’m sure they won’t refuse it.

  116. I’m afraid Anthony, I must join those who are saying that CMOS is the solution. Only if you are working with analog circuitry do you have to worry about the forward conduction voltage, and with analog circuits out of CMOS, this doesn’t exist. You have the conduction resistance in the source/drain connection, and the parasitic losses in the RC constants when switching in high speed (not normally a problem for audio circuitry).

    With CMOS the only time current flows is while the P transistor is turning off/on while the N transistor is turning on/off (they work in complementary pairs – P-N). CMOS is short for Complementary Metal Oxide Semiconductor. CMOS kept the semiconductor industry from running into a wall of power consumption because it only uses power when switching (apart from microscopic, maybe nanoscopic leakage currents.

    I have recommended to a number of friends who have hearing problems that they try the DSP-based hunter’s ears. The response has been great. If you look at what is offered in that space you will find a plethora of choices – Cabella’s, Midway USA, are two organizations with excellent service. Both of them are on the Web. OpticsPlanet is a quality third vendor.

  117. I am fortunate to still have excellent hearing.
    My wife was born hard of hearing. The simple hearing aids of the time were expensive and made her hearing worse after a few hours, and irritated her ear canals.

    If I needed a hearing aid I would not relish spending thousands of dollars every few years, plus buying tiny expensive batteries.
    How about a cheaper solution – attach cheap larger amplifiers and larger batteries to spectacle frames and connect to the ear through a simple tube. Thus allergic reactions are less likely. Unobtrusive controls on the sides of the frames would be easy to adjust.

    Anyone who comments on the apperance of hearing aids can go jump in the lake. Do they laugh at crutches and wheelchairs too?

  118. The discussion of the high cost of hearing aids has generated a lot of heat but not much light. Any business has many costs above the hardware costs of its products. Unless you have actually run a business or had responsibility for product pricing, it is likely that you don’t have a good grasp of the magnitude of these other costs. You can start by considering the costs of executives, managers and supervisors, accountants and attorneys, engineers, shipping clerks, and janitors, oh my! But you haven’t even scratched the surface. Marketing, sales, and support are major cost items in any business. Let’s concentrate on these items.

    Speculation to the contrary notwithstanding, the hearing aid market looks to be very competitive. There are many competitive brands, possibly too many for efficient competition given the restricted market for the products. The manufacturers’ marketing departments are kept busy producing slick brochures and other marketing materials to attract the attention of the audiologists who sell the hearing aids. They also produce the brochures and other advertising material used by the audiologists in their sales to the consumer. Given the technical nature of the products, the sales from the manufacturer to the audiologists are handled by manufacturers’ representatives who do one-on-one selling to the audiologists. And the audiologists have to rely on the manufacturer for technical support. These costs are not insignificant, and the per unit cost of marketing, selling, and support at the manufacturer/audiologist level is high in comparison to other consumer electronic products.

    Things only get worse at the audiologist/consumer interface. If you are at retirement age, you know how audiologists push their products. You get weekly or more frequent, advertising mailings inviting you to participate in a special hearing aid trial. A response of one percent to a direct mailing is typical. Many of those who do respond do not have the financial resources to go forward with a purchase. And among those who are financially qualified, only a fraction will enter into a trial program. And only a fraction of those will actually complete the purchase. Just to play with some numbers, assume that it costs one dollar for each postal direct mailing item, and that you have to send out one thousand items to generate one sale. That’s a thousand dollar direct mail load on each sale. Add a ten percent sales commission, and the costs of on going support for the sale, and the costs mount up.

    I mentioned earlier that my audiologist offer me hearing aids with prices ranging from $3,750 to $6,000 per pair. I actually bought full-service, top-of-the-line hearing aids from Costco for $2,000 per pair. Does that mean that the audiologist is getting excessive profits? More likely, it means that the audiologist’s prices reflected the audiologist’s cost structure while Costco has a completely different cost structure.

    Costco will purchase many thousand hearing aids from the manufacturer which will reduce the manufacturer’s per unit selling expenses. The Costco sales may materially increase the manufacturer’s total sales volume thereby spreading all of the manufacturer’s fixed costs over more units. Costco can substitute its own sales materials for those of the manufacturer. Costco is primarily a marketing entity, and it may have special efficiencies in marketing it’s products to its customer base. The Costco stamp of approval and guarantees add value to its sales transactions. Instead of dedicated direct mailing to potential hearing aid customers, Costco’s hearing aid promotions occupy a few square inches in its multi-page monthly promotional mailing. Costco’s “office” for it’s hearing aid business is a soundproof booth, a desk, and a small display case in the corner of its large warehouse store.

    I have been told, but I don’t know it to be true, that Costco employees are salaried and do not receive commissions. Nevertheless, Costco customer service is well regarded.

    We may be witnessing a paradigm shift away from PhD audiologists selling hearing aid hardware and, instead, charging for professional services for hardware purchased elsewhere.

  119. Retired Engineer (September 10, 2011 at 7:53 pm) wrote:
    … As for rechargeable batteries – been using them for years in many applications. Growth of microfibers was a problem with Ni-Cd’s. NiMH cured that. Lithium made it even better. … HA’s could use inductive coupling, charge overnight in a small dual ‘bucket’ on the nightstand. Single cell lithiums (various types) are quite reliable.

    There’s no question that today’s rechargeable batteries are leagues ahead of the old NICADs. They still have fundamental problems, though. Most people think of batteries as electrical components. They aren’t. They’re chemical components whose chemical reactions separate atoms into positive ions and electrons. When a lithium battery is discharged, the positive lithium ions move from the anode to the cathode through the electrolyte, crossing the separator on their journey from one plate to the other. The electrons flow out of the anode (the negative terminal), through the circuit that’s being powered, and back into the cathode (the positive terminal).

    When a rechargeable lithium battery is charged, the process is reversed. An applied voltage drives current in the reverse direction, causing lithium ions to flow through the electrolyte from the cathode to the anode. Unfortunately, no one gave the little ions house numbers or street addresses, so instead of going back to the spot they left, they return willy-nilly. The cycling of lithium ions back and forth between anode and cathode causes a gradual degradation of the positive and negative plates. This changes the battery’s discharge characteristics, gradually decreasing the available energy and altering the voltage and impedance during discharge. That’s the reason your new laptop runs six hours on a charge, but a year later runs less than two hours before needing to be plugged in.

    Rechargeable batteries can be used in non-critical applications. Bob Sullivan (September 11, 2011 at 2:27 pm) pointed out that Costco is selling hearing aids at dramatically reduced prices, including a pair of digital hearing aids for $1,999.99. The pair comes with both rechargeable and zinc-air batteries. Normally, one would use the rechargeable batteries, but if a rechargeable runs down during the day, it takes only a couple of minutes to pull it out, tuck the rechargeable battery away safely, and insert a zinc-air battery.

    Retired Engineer (September 10, 2011 at 7:53 pm) also wrote:
    … Pacemakers already use primary (non-rechargeable) lithiums. Did some work for CardiacPacemaker in MN a long time ago. …

    During their lifetime, pacemakers measure the battery’s characteristics (output voltage and impedance) to calculate when the battery will be six months from exhaustion. That point begins the “Elective Replacement Interval” (ERI), during which time the pacemaker needs to be explanted and replaced. When it enters ERI, the pacemaker turns off some features and reduces the pacing rate to prolong battery life. If a rechargeable battery were used, the incremental modification of the battery’s characteristics would make it impossible to perform the ERI calculations with any certainty.

    Pacemakers use primary cells, and that’s unlikely to change for a very long time. Pacemakers are safety-critical systems. If the patient is pacemaker-dependent, failure to provide appropriate pacing support will kill him. Safety is such a priority that the batteries aren’t soldered into the circuit — they’re welded. In such an environment, rechargeable batteries pose too great a risk.

  120. I recently got a pair of Receiver-In-Canal BTE aids with wireless capability from Costco for $1999. With the RIC, you don’t need custom earmolds, and you don’t get wet ear problems. The technician did a hearing assessment that found my loss (as bad as -80 dB in my left ear) and also measured my discomfort level- the aids won’t output above that level, preventing hearing damage and most discomfort. She programmed the aids in just a few minutes, connected to a computer. If one aid detects a loud noise, _both_ reduce their gain, using a standard wireless connection. They can optionally serve as a Bluetooth telephone headset and hi-fi audio earbuds for your Bluetooth MP3 player (I didn’t bother with the option). One press of the mode button on either unit switches the amplification mode for both, a longer press cycles them on & off. Up to five programs can be loaded.

    The results have been stunning- I can hear turn signals, sneaker footsteps, clothing rustling, and crickets. I hadn’t heard crickets in decades, now they can be annoying- but banished with the press of a button. I now need to ask my friends and coworkers to lower their voices; for years they’ve accommodated me by raising their voices, now I have to ask them not to shout…

  121. The process of assembling hearing aids that Anthony described is archaic and goes a long way towards explaining the outrageous cost of these simple devices. Instead of a room full of technicians there should be a line of robots, assembling the devices faster, more accurately, and far more cheaply than human hands. But a monopoly doesn’t need to make capital investments, and gathers its inflated profits despite using technology that is a full 3 decades behind the times.

    I’m an electrical engineer, small business owner, and economist. Like every other electrical engineer who has commented on this thread, I say that the germanium use is not only a red herring, but a sign of archaic technology. The developers of battery-operated devices everywhere have to worry about power use and battery life, and they don’t use germanium. The job of hearing aid is precise and delicate but straightforward.

    You can buy a wireless residential weather station for about $100 that runs a year or two from one set of batteries, with 5 different sensors and an RF transmitter – and there isn’t a spec of germanium in it. Give that one up, it’s a losing argument.

    There are 4 reasons US hearing aids cost 10x more than they should:

    1) FDA regulation of hearing aids as class 1 medical devices. FDA rules drive up costs and restricts competition and new entrants to the market.

    2) State licensure of audiologists. This cartel is behaving exactly as economists know all monopolies behave: prices go up, and quality of service goes down. Audiologists used to be masters-level degree programs. In 2007, the Doctor of Audiology (Au.D.) started being required by many states. There are no longer any professional programs in audiology which offer the master’s degree.

    The profession did not grow more demanding in 2007. The tools and technology are better, the process should be simpler. This is simple monopoly economics as work: restrict the supply of audiologists with ever-increasing education and license requirements so that they can charge $100 per hour or more.

    3) A limited market. High prices cause demand to be low. As one commenter pointed out, only 2 cities in the country have enough demand to support a mall-type store – and they already have them. The fact that the market is limited by the outrageous prices doesn’t bother the people collecting their monopoly profits.

    4) Some people are willing to pay. There’s nothing wrong with Anthony and the other defenders of the status quo being comfortable paying thousands of dollars for their equipment, it is their money and their choice. What is wrong is a system that raises prices so high that millions of people go without hearing aids rather than submit to the gouging. Their loss hurts all of us.

  122. No personal experience of hearing aids, but I do recall about 30 years ago noting that bicycles cost around $200 in Australia. I expected that they would get cheaper in the future, but I was wrong. The got more expensive, and a lot nicer. Indeed, there is a seemingly endless stream of wonderful bicycle technology. I guess the thing is – you don’t need a bicycle, but you may well need hearing aids.

    About 15 years ago, my dentist told me I needed an occlusal splint – which would cost about $500 – which I didn’t have at the time. She jokingly suggested using a mouth guard. So I made an occlusal splint out of a mouth guard, and then modified it until it stopped changing the shape of my face! I’m still using the home made variety. Orthodontists no doubt have some expertise, but it is pretty easy to do it yourself.

    It is understandable that professions try and keep their secrets, and protect their income. I don’t mind, as long as they don’t get governments to make laws to stop others competing.

  123. The medical business can confuse people. The price of a device in theory may include much time measuring (which Anthony covers) or coaching on its use (as its required with CPAP sleep apnea equipment, as well as trying other interfaces to get proper fit). “Shanghai Dan”’s post covers that in part. That cost to the provider will vary considerably with the individual customer. Note however that subsequent purchases of the same product will not need that service so should be priced lower.

    The key is to ensure your provider is providing full service – quiz them, get a promise of support in writing.

    Another problem is insurance companies, which in the US are driven substantially by government meddling (and in Canada and UK are the government, with the same bureaucratic methods as the US combination of insurance companies and government (all government in the case of Medicare). They usually pay providers far less than list price, sometimes the providers try to make it up on non-insurance customers, but some businesses (like a dentist I used) give a discount (in part for no paperwork & immediate payment).

    Medical providers like doctors get wrapped up in that system and become inefficient – and arrogant.

  124. As for “Janice”’s allergy experience, yes the material must be quality and suitable for the purpose. For example, it it were silicon it must be platinum cure not tin cure as the latter sometimes causes a reaction. Standard stuff to any designer who does their homework.

    And people like “ChE” sound ignorant – do the electrical math, power is power in principle, but you have to know the circuitry technology in detail to evaluate properly.

    Thank’s “Kozlowski” for the point about the infeasibility of cartels. I address monopolies in http://www.keithsketchley.com/monopol3.txt.

    Do note that Anthony seems big on visibility of the aid, which logically affects price (due higher cost of miniaturization).
    Anthony, you should show this thread to the company president you know, he may provide technical rebuttals or learn something (note retired EE Roger’s comment on mitigating the forward voltage problem with silicon, which is not saying a chip can be made – Roger says it couldn’t in his time due economics, and he may be talking analog only (which audio ultimately is).

  125. BTW, for those whose hearing seems to be deteriorating, do check for ear wax buildup (your doctor should be able to check that). And do be aware that there is a phenomenon that increases with age of the brain not being good at screening out interfering sounds – I have great difficulty where there are echos or many people are talking in the background. I _speculate_ that hearing loss in one ear could have similar effect due not supporting any ability the brain has to selectively listen – a good ear exam is probably wise anyway. (I _speculate_ that with both ears working the brain can screen out , if you can see the speaker. Oh, there is the problem of people’s voice quality (some people limited frequency range, some do not enunciate clearly (one cause is tilting head downward to read notes – get a teleprompter! (maybe one of those little displays worn on glasses?).

    OTOH, lip-reading sounds like a good skill for us aging types to develop. ;-)

    An example of inefficiency is my mother’s eye doctor. She had separate visits for a peripheral vision test, a redo of the test, and seeing the doctor.

    In contrast the eye doctor I go to has technicians doing that test and others, redoing as necessary (including re-educating me as the test depends on the user’s approach to how sure to be that they saw the fleeting gray patch, then after a short wait I see the doctor who may require redo on my way out (and returning to her office if I fail again) – one visit.

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