[THEME III ] Hearing aid and acceptance

This article is the third in a series of 13, each of which refers to a theme that brings together a set of questions regularly asked by Internet users. The first two themes are available below :

• Theme I : What is the benefit of wearing a hearing aid?
• Theme II : Hearing aids and age

You will find access to the other themes on the summary page of this file.

What is the rate of hearing aid use ?

Hearing handicap / deafness : how many people wear a hearing aid ?

(France) – For people with a hearing disability / handicap, it is accepted that 90% of them are fitted with a hearing aid (when the disability is capable of being fitted, it is fitted). In this case, the reimbursement is almost complete (MDPH Deafness file). In France, it is estimated that the number of people with a hearing disability is around 700,000, so there are 630,000 people with a hearing disability who are fitted with a hearing aid.

Presbycusis : how many people wear a hearing aid ?

Concerning the European rate of hearing aid use for people with presbycusis, it varies from one country to another. Spain and Belgium are at the bottom of the class / the bad pupils with a rate of 15% ; Italy with a rate of 20% and France, with a rate of 25% (i.e. approximately 1,500,000 people with hearing aids). In France, one out of four people with presbycusis is fitted with a hearing aid and, among these, it is estimated that 10% to 15% of hearing aids sold end up in a drawer. At the top of the European ranking, we find the United Kingdom, Germany and Sweden with hearing aid fitting rates of 40%, 50% and 50% respectively. In the United States, depending on the source, it is estimated that between 14% and 33% of Americans are fitted with hearing aids.

Why are there such different rates of hearing aid use between countries ?

Before highlighting the differences, let’s look at the common ground. At the global level, 2 leaders share the market for “custom” or traditional hearing aids : the Amplifon Group and the William Demant Group. Through their own brand networks (for example, the Amplifon Group owns the Amplifon brands in Italy, France, Switzerland, Spain, Portugal, etc. ; Beter Horen in the Netherlands ; Maxtone in Turkey ; Miracle Ear and Elite Hearing Network in the United States ; National Hearing Care in Australia), they market their own manufacturers’ brands (for example, William Demant markets the Oticon, Bernafon, Sonic, Phonic Ear, and Frontrow brands through its brand network). The prices charged are therefore similar between the different brands (because they belong to the same group), for the different products, from one country to another. Acquiring a “traditional” hearing aid, from one end of the world to the other, is therefore done in the same brands, at the same prices and under the same conditions, due to a relatively closed market and an economic agreement between the players. The difference, from one country to another, is the level of government support and the acceptance of individuals.

Countries with a low rate of hearing aids have similarities :

• A long and regulated care pathway ;
• High prices and high out-of-pocket expenses ;
• Unsatisfied aesthetic criteria ;
• A complex hearing device.

A long and regulated care pathway to access coverage.

In France, for example, an ENT consultation is necessary to obtain a prescription for a hearing aid, which is itself indispensable for entitlement to reimbursement. However, the waiting time for an ENT consultation can be as long as 6 months in some regions. In Belgium, two ENT consultations are necessary : the first one allows the prescription of a hearing aid test which, if it proves to be conclusive (15 days) will lead to the prescription of a hearing aid during the second consultation. According to the Solidaris barometer, 3 out of 4 Belgians think that the waiting time between these two consultations is too long : from 3 weeks to more than a year. In Italy, given the administrative procedure to be followed, it takes between 3 and 6 months to get an appointment in an approved care center. The dropout rate during this stage is significant because the delays tend to discourage people who, from the outset, are reluctant to get hearing aids. It is on this observation and with the objective of providing immediate solutions that the offer of pre-configured hearing aids available without a medical prescription has been developed.

High prices, high out-of-pocket expenses.

In France, 80% of hearing aids sold are bilateral (both ears) at 3,100€ (middle range) according to UFC Que Choisir. State refund is conditioned by the medical prescription but also by the sale of an additional follow-up service, which represents 40% of the total amount of the bill, over 4 years (estimated life span of the hearing aid). In order to reduce the bill, the Macron law (2015) aimed to remove from the Social Security Code the necessarily inseparable character of the fitting, adaptation and follow-up. However, the Health Insurance, in its LPPR list (List of Reimbursable Products and Services), never acted on this modification and things remained as they were until the arrival of the RAC0 (2018). The RAC0 makes the additional follow-up service mandatory, as well as a proposal, in the estimate, of a hearing aid fully covered by Social Security and mutual insurance companies (class I devices). However, as pointed out in a study by 60 million consumers dated September 2022 and conducted among 8 hearing aid companies, and as UFC Que Choisir predicted in 2018, current commercial practices aim to give preference to class II hearing aids (not refunded by state) by denigrating class I devices. Today, class I devices are only offered in 10% to 20% of cases : the problem of high prices and high out-of-pocket expenses is still relevant, 4 years after the implementation of the RAC0 reform. In this time frame, however, it should be noted that :

• Class II devices have seen their prices increase,
• Mutual insurance packages, particularly those for pensioners – the first to be affected by this reform – have been revised upwards.

In Belgium, the price of hearing aids is significantly more expensive than in France. To benefit from a 657€ reimbursement per device, the individual must have a hearing loss superior to 40dB on each ear, acquire the hearing device from an approved professional (list) and this device must be part of a list of devices reimbursed by the INAMI. This list includes 26 different brands which, due to the vertical integration of the market, belong to the same group of companies and among which 6 of them represent 90% of the sales in this country.

Switzerland, where the rate of hearing aids is 20%, is the country where hearing aids are the most expensive in the West, up to 50% more expensive than in France, for the same references. Only in the United States are the prices more expensive than in Switzerland! As for Germany, France, Belgium or Italy, the coverage is limited and the remaining cost is consequent.

Finally, let’s also mention that in 2012, an American clinical trial conducted in double blind and controlled by a placebo test, which aimed to compare preconfigured hearing aids and traditional hearing aids in the fitting of presbycusis, concluded on 2 points :

• The real benefits of preconfigured hearing aids for these individuals and the immediate adoption of these solutions by the participants ;
• The rejection of traditional hearing aids by participants as soon as the price is mentioned (end of study).

A preferential orientation towards BTE hearing aids.

BTE hearing aids represent 80% of worldwide sales of hearing aids, while at the same time many studies underline the advantages of in-the-ear positioning of a hearing aid (reduction of parasitic noise, spatialization of sounds, immediate restitution, great discretion) and the rejection of those concerned, who prefer a discreet device (in-the-ear) to a visible one (BTE), in particular because of the “fear of looking old”. In Germany, for example, in order to democratize access to hearing care, devices are provided by the public services, with an almost zero out-of-pocket expense for the individuals. These devices are BTEs that do not meet the identified aesthetic criteria: thus, many reject these solutions and turn to pre-configured invisible solutions. The European study ALCIMED (2018) on the prices of technical aids for the elderly emphasizes that in southern European countries (Italy, Spain in particular), users are very sensitive to the aesthetics of products and prioritize their choice criteria by prioritizing aesthetics, then ease of use and, finally, the solidity and reliability of the device. It appears that the aesthetic criterion plays an important role in the rejection of hearing aids and, along with the price and the complexity of the care process, it contributes to explain the low rate of hearing aid use throughout the world.

How do you accept to wear a hearing aid ?

At first glance, in our societies where getting older is frowned upon and where everyone chases eternal youth – sometimes with cosmetic surgery – it is understandable that a hearing aid is not well accepted. Either because it is perceived as an object that shows the passage of time or because it is visible and/or unattractive. However, the fitting rates show a limit to these possible reasons: the degree of discomfort felt without the hearing aid. Indeed, while one person out of four with presbycusis is fitted with a hearing aid (25%), 90% of people with a hearing disability are fitted, regardless of their age (often young) and the aesthetics of the device (necessarily a BTE). Consequently, only people affected by presbycusis are at risk of withdrawal, progressive isolation, depression and even dementia.

Let us emphasize, if it were necessary, that a person suffering from presbycusis, because of his or her hearing loss, has the choice between a BTE (visible) or an CIC / ITE (almost invisible) ; a traditional hearing aid (with a prescription, high price) or a pre-configured hearing aid (without a prescription, low price) ; a hearing aid sold with a follow-up service for 4 years (traditional hearing aid) or a hearing aid sold without (pre-configured hearing aid) : faced with the diversification of the offer, which makes it possible to find an immediate listening comfort, at the right price, with respected aesthetic criteria, it is no longer the hearing aid which must be accepted, but the hearing discomfort, however slight it may be. Especially since, as we have said, the latter is no longer the prerogative of “Seniors”: one third of people under 30 have a hearing loss of more than 20dB.

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To go further on this topic, you can consult our previous articles :

• Swiss hearing aid market : prices among the highest in the West !
• A study shakes up preconceived ideas about hearing aids
• Hearing aid : in-the-canal vs. behind-the-ear, what to choose ?
• Why is the preset hearing aid suitable for presbycusis?

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