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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Sonic Innovations (a hearing aid company) is publicly traded. I can find yearly profit figures but no sales numbers. If someone can put together the sales numbers (even approximately), you can get an idea of the net profit.
http://www.healthyhearing.com/content/news/Hearing-aids/Manufacturers/26678-Sonic-innovations-inc-celebrates
Anthony…. I’ve been a regular here from the beginning of the WUWT enterprise…This actually may be one of the best posts you’ve even written,,,, And that’s saying a lot!!!!
Sonicfrog
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!!!!!!
I have seen some discussion about using an iPhone as a hearing aid. http://iphoneapplicationlist.com/forum/have-an-idea-for-a-cool-app/i-phone-as-hearing-aid/ http://scienceroll.com/2009/07/12/iphone-hearing-aid/ It sounds like a pretty cheap solution.
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
@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
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
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.
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
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.
“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!
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
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.
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.
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
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).
And I appreciate your response. Thank you.
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
Might just be me, but I get ringing when I consume alcohol or free glucose/fructose food products.
Explain that.
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.
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.
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.
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!
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….
Oops! “since the 1970’s” — fumble fingers!