Repositioning Audiology in the Post-OTC Era: From Product-Driven Practice to Profession-Centered Healthcare

INTRODUCTION Today, audiology occupies a unique and historically conflicted space between healthcare and commerce. Unlike most clinical professions, audiologists in the United States rely heavily on the sale of hearing aids as their primary income source.1 Their professional clinical services—diagnostic evaluation, fitting, verification, counseling, and rehabilitation—have been bundled into the cost of a device.2The 2022 FDA ruling authorizing over-the-counter (OTC) hearing aids for adults with perceived mild-to-moderate hearing loss disrupted this long-standing economic and professional structure. While the rule was designed to improve access and affordability, it has also exposed a deeper vulnerability: audiology’s dependence on a retail product to sustain a doctoral-level healthcare profession. This paper argues that to continue as a profession, audiology must undergo a strategic restructuring—from a product-driven occupation to a profession-centered healthcare discipline grounded in diagnosis, rehabilitation, and long-term auditory management. THE OTC HEARING AID RULE: IMPLICATIONS The FDA’s creation of an OTC category allows consumers to obtain amplification without a medical exam or professional involvement.3 For individuals with straightforward hearing difficulties, this may improve access. However, it also reframes hearing care as a consumer electronics activity rather than a healthcare service. The implications for audiology include: Loss of exclusive control over amplification Downward pressure on device pricing Erosion of the traditional bundled revenue model. In this environment, audiology cannot compete on convenience or price. The profession’s true value lies in the clinical expertise of its practitioners, not in retail distribution. HISTORICAL CONTEXT AND STRUCTURAL WEAKNESSES It is understood that audiology’s identity developed in tandem with the electronic technology developments of the 1940s and 1950s. This is true for the diagnostic tests and procedures that audiologists use, as well as the hearing aid technology they adopted for aural rehabilitation. During the 1980s and 1990s, hearing aids became more sophisticated, and audiologists quickly assumed responsibility not only for their evaluation and fitting, but also for their sales. Unfortunately, core clinical services—diagnostic testing, aural rehabilitation, and counseling—became economically invisible, absorbed into the price charged for hearing aids and related products. This “bundling” model produced several structural weaknesses: Economic dependence: Audiologists’ income became tied to product sales rather than the professional services they provide. Public misperception: Audiologists were increasingly viewed as hearing aid dispensers (retailers) rather than healthcare providers. Reimbursement limitations: Third-party payers failed to recognize the role of audiologists as independent providers of rehabilitative and diagnostic care. Another weakness associated with the current delivery model is the persistently low adoption rate of hearing aids. While approximately 63% to 64% of U.S. adults with vision impairment use eyeglasses, only about 30% to 40% of adults who could benefit from hearing aids adopt them.4,5 Low uptake constrains total unit volume and forces practices to recover largely fixed operating costs from a relatively small pool of purchasers. Hearing aid industry benchmarking reports suggest that moderate-sized audiology clinics often operate with six-figure monthly expenses, driven primarily by payroll, facilities, marketing, and inventory. They are also reported to dispense relatively low numbers of hearing aids, with averages in the range of approximately 8 to 15 units per month per full-time clinician.6 Under these conditions, even modest reductions in unit volume place disproportionate pressure on practices to increase per-unit margins and intensify marketing efforts simply to remain viable.7 CONSEQUENCES OF MAINTAINING THE STATUS QUO If audiology continues to anchor itself to hearing aid sales, several risks emerge: Economic erosion: Device margins will shrink under competition from big-box and online vendors. Professional marginalization: Audiologists will become optional accessories to consumers’ use of technology. Educational devaluation: Doctoral training loses relevance to real-world economics. Loss of authority: Hearing healthcare migrates from medicine to consumer culture. In effect, audiology risks becoming more of a technical trade rather than a clinical profession. A PROFESSION-CENTERED MODEL FOR AUDIOLOGY: A RECOMMENDATION To remain viable as a healthcare profession, audiology must transition back to a service-driven model in which clinical expertise, not product sales, forms the core of professional identity and value. Achieving this shift requires restructuring the profession’s educational entry points and repositioning the AuD degree within a narrower, higher-tiered workforce position. Rather than a single, undifferentiated pathway into “audiology,” as is currently implemented, a restructured model should adopt a four-tier approach that aligns education, scope of practice, and clinical responsibility with clearly defined roles and opportunities. Tier 1: Audiometric Technician/Hearing Care Associate/Licensed Hearing Aid Dispenser Aligned with Undergraduate Communication Sciences/Allied Healthcare Programs Students completing an associate or bachelor’s degree in communication sciences or allied health would pursue certification as Audiometric Technicians or Hearing Care Associates. This tier would also formally incorporate currently licensed hearing aid dispensers, recognizing their credentials and established role in device provision and community-based access to care. The scope of practice would emphasize structured, protocol-driven, and technical functions, including: Industrial hygiene/hearing conservation Industrial and occupational health screening Basic audiometric testing (screening and threshold assessment protocols) Hearing aid dispensing, fitting support, and device orientation Hearing aid support services and sales facilitation Device maintenance, troubleshooting, and logistics management. JUSTIFICATION STATEMENT This tier is justified by the need to clearly differentiate routine, standardized procedures (i.e., hearing screening, etc.) from advanced clinical and rehabilitative decision-making. It formally recognizes that much of hearing healthcare—­particularly hearing aid dispensing—consists of protocol-driven activities that can be competently delivered by well-trained, certified personnel operating within defined scope parameters. Incorporating current licensed hearing aid dispensers into this tier preserves workforce continuity while aligning educational preparation with scope of practice. Under this model: Tier 1 professionals manage intake, screening, standardized testing, earmold impressions (where permitted), fitting under prescriptive protocols, and device logistics. Master’s-level hearing specialists (Tier 2) focus on rehabilitative counseling and complex amplification management. Doctoral-level audiologists (Tiers 3 and 4) concentrate on diagnostic evaluation, differential diagnosis, medical interface, advanced clinical decision-making and research. This structure enhances access, improves efficiency, reduces cost, and preserves quality by matching training intensity with task complexity while maintaining a coherent professional hierarchy. Primary Compensation Sources Primary compensation for professionals in this setting is derived from the following sources: Employer salary/wages (private practice, retail hearing centers, occupational health services) Contract revenue from employers/industries for hearing conservation programs Per-service fees bundled into institutional screening or surveillance contracts Device-related revenue associated with dispensing and support services Operational compensation models (structured salary or productivity-based models rather than purely commission-driven sales). TIER 2: HEARING SPECIALIST/AUDITORY REHABILITATION CLINICIAN Aligned with Master’s-level Speech-Language Pathology Training Programs Students completing a master’s degree in speech-language pathology who have an interest in working with individuals with hearing loss, would earn post-master’s certification as hearing specialists with advanced competencies in habilitative and rehabilitative therapeutic domains, such as: Cochlear implant habilitation and therapy Auditory training and rehabilitation Auditory processing disorders (child and adult) Aural rehabilitation across the lifespan. JUSTIFICATION STATEMENT The hearing specialist certification tier is justified as a bridge between technical support and full professional practice. Individuals at this level can provide clinical services, patient education, and follow-up care while adhering to established protocols. This tier enhances continuity of care, expands service capacity, and preserves professional oversight, ensuring that complex cases and ethical responsibility remain with fully credentialed hearing specialists. (Patients fitted with hearing aids or with cochlear implants would receive habilitative or rehabilitative services). Primary compensation sources would include: Insurance reimbursement for therapy and rehabilitation services—CPT codes aligned with aural rehab, auditory training, and habilitation Educational and medical system salaries (schools, rehab hospitals, clinics) Public and private payer funding (e.g., Medicare/Medicaid where applicable, private insurance) Service-based cash pay for structured rehabilitation programs. TIER 3: MEDICAL/CLINICAL AUDIOLOGIST (AuD) Aligned with a Physician-Assistant–Style Medical Training Model The Doctor of Audiology (AuD) degree would be reconstituted as a medical doctorate in hearing and balance sciences. Its training would be structurally similar to that of a physician assistant education/training aligned with the fields of otology and otolaryngology. Entry would require at least a Master’s degree in speech-language pathology with a hearing science specialization, or its equivalent. Graduates would function as medical audiology practitioners, working with or under the supervision of: Otologists Otolaryngologists Neurotologists Related medical practitioners. Their role would focus on: Medical diagnostics of auditory and vestibular disorders Intraoperative monitoring Balance assessment and management Complex case coordination/collaboration. Justification for the AuD tier: The AuD tier is justified as the core of audiology, defining it as a healthcare profession. Doctoral-level preparation is necessary to ensure competence in diagnosis, differential ­assessment, treatment planning, outcomes measurement, and interprofessional collaboration. This tier safeguards patient safety and reinforces audiology’s identity as a clinical discipline rather than a product-distribution trade. Primary compensation sources include: Medical insurance reimbursement for diagnostic and vestibular services Hospital/medical group salaries Value-based care contracts/bundled payments within ENT and neurology practices Professional service billing for: Diagnostic audiology Balance assessment Intraoperative monitoring Medical consults and care coordination. TIER 4: AUDIOLOGY SCIENTIST/RESEARCH FACULTY (PhD) Aligned with Traditional PhD Programs in Communication Sciences and Disorders This tier prepares researchers, educators, and policy leaders through a Doctor of Philosophy in Communication Sciences and Disorders. Graduates would advance: Basic and applied hearing science Clinical outcomes research Public health and systems-level analysis Audiology education and workforce development. Entry would require at least a master’s degree in speech-language pathology with a hearing science specialization or a related clinical/rehabilitation discipline. JUSTIFICATION STATEMENT Advanced and specialty tiers, like this one, are justified by the increasing complexity of hearing and balance care, research translation, and healthcare systems leadership. These professionals drive innovation, develop evidence-based practices, educate the workforce, and influence policy. Their role is essential for maintaining scientific credibility, advancing the profession, and ensuring that audiology remains grounded in clinical and research excellence. Primary compensation sources include: University and academic salaries Research grants and contracts (NIH, NSF, foundations, industry partnerships) Policy and consulting roles Professional leadership appointments. SUMMARY VISION Together, these tiers establish a vertically integrated profession in which educational preparation, scope of practice, and clinical authority are aligned with patient needs and long-term workforce viability. Product distribution activities (e.g., hearing aids and assistive technologies) are delegated to roles emphasizing access and technical support, while the clinical tiers center on diagnostic, rehabilitative, and medical expertise. CONCLUSION Audiology stands at a defining crossroads. It may cling to a declining product-based model, or it may reassert itself as a healthcare profession rooted in diagnosis, rehabilitation, and prevention. Long-term viability will require aligning professional education with clinical science and patient needs and achieving full recognition as independent providers by health insurers, especially Medicare. The future of audiology will be secured not by selling devices, but by demonstrating that audiologists deliver hearing healthcare.