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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“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
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.
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.
Why is no one using lithium electrochemistry to provide a 3 volt supply and circumvent the low bias voltage circuit requirement?
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. . .
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.
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.
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.
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.
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.
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.
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.
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.
Yikes! Watts is on the payroll of Big Hearing!!! Somebody alert Sourcewatch!!
ps 😉
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.
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!
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
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%
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.
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.
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.”
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.
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
I always thought the big benefit, to hearing aids, was the ability to turn them off when confronted by vocal AGW/environmentalists. GK
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.)