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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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.
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.
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.
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.
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?
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.
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.
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…
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.
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.
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.
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).
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.
Sorry, my article on monopoly is at http://www.keithsketchley.com/monopol3.htm.