IMPAIRMENTS
House Bill 5522 as passed by the House
Second Analysis (10-23-00)
Sponsor: Rep. Mike Kowall
Committee: Health Policy
THE APPARENT PROBLEM:
The American Academy of Pediatrics (AAP) reports that significant hearing loss is a common abnormality of newborns. Approximately one to three infants per one thousand births of otherwise healthy babies are born with a significant hearing impairment, but the ratio rises to two to four newborns per 100 births for infants in the intensive care unit population, such as premature babies. It is well documented that speech and language acquisition primarily occurs before the age of two and a half, and that early identification of and treatment for a hearing impairment can significantly prevent delays in a child's speech, language, and cognitive development. However, many children do not receive a hearing test until after the age of two.
In Michigan, the practice of screening newborns in hospitals for hearing loss is voluntary and is usually done through selective screening. For example, children at higher risk for having a hearing loss, including premature babies, children with a family history of hearing loss, children who have been treated with certain antibiotics, and children with certain facial abnormalities would be selected for screening for hearing impairments. It is reported that about 75 percent of the children with hearing impairments are identified by the practice of selective screening.
Medicaid, however, already includes hearing screenings in the bundle of tests performed on newborns that is required for each Medicaid-covered birth, and any hospital performing 15 or more Medicaid-covered births is required to perform the hearing screening tests on site. In addition, recent medical guidelines have established newborn hearing impairment screening as a standard of care, meaning that it should be included in the routine care given to newborns. In light of the importance of early identification of hearing loss, and considering that such tests are now deemed to be a standard of care, it has been proposed that screening for hearing loss be expanded to include all children born in the state.
THE CONTENT OF THE BILL:
The bill would amend the Public Health Code to require all newborns to be screened for hearing impairments. Beginning no later than October 1, 2001, hospitals that provide birthing services and health professionals who deliver babies outside of a hospital would have to have a health professional or an audiologist perform hearing impairment screening for each newborn before discharge from the hospital or before the health professional leaves the site of the birth. If the screening cannot be done before discharge, it would have to be performed within 90 days after birth. "Hearing impairment screening" would be defined as the employment of one or more of the following tests:
Each hospital and health professional that provide birthing services would have to transmit the results of the hearing impairment screening to the department; the child's parent or guardian; the child's primary care physician, if known; and the child's provider of audiological services, if known. In addition, a health professional or an audiologist who performed a hearing impairment screening would have to recommend to the parent of each child who had an abnormal test result that the child undergo an audiological evaluation as soon as practicable. A "hearing impaired infant" would mean a newborn infant or other infant who had a disorder of the auditory system of a type or to a degree that caused a hearing impairment that interferes with the development of the child's language and speech skills.
The health professional or audiologist would also have to provide the parent with a list of agencies and health professionals and audiologists that provide such hearing evaluation services. A hospital with 100 or fewer births per year could have the hearing impairment screening performed at another facility. The department could promulgate rules to implement the bill's provisions. An "audiologist" would mean an individual with a master's or a doctorate degree in audiology from an accredited university approved by the department. The health code defines "health profession" as those occupations licensed or registered under the code.
MCL 333.9451
FISCAL IMPLICATIONS:
According to the House Fiscal Agency, the bill may result in additional costs to the Department of Community Health, as the department would have to receive and retain the screening results for each newborn infant. However, since the department already has responsibility for the laboratory processing of other newborn screening tests for metabolic disorders, the department may be able to handle the additional responsibilities regarding the hearing impairment test result records without significant additional cost. There also may be additional medical care costs for the state in providing this service to the children of employees and from state programs that provide medical care coverage for low income persons. (10-23-00)
ARGUMENTS:
For:
Hearing loss in the very young can significantly delay the acquisition of speech and language skills, delay cognitive development, and also affect a child's socialization. Intervention and treatment in the first six months of life can decrease the negative impact from a hearing impairment on a child's development. Unfortunately, not all children with a hearing loss are identified during this important formative period. Currently, testing of newborns for hearing impairments is done on a voluntary basis. Typically, testing is reserved for those children considered to be at a higher risk of having a hearing loss, such as babies born prematurely, those with a family history of hearing loss, facial abnormalities such as skin tags by the ears, and children who have taken certain medications. It is reported that such selective testing picks up about 75 percent of those children who have a hearing loss. Though that certainly is a significant amount, it still means that 25 percent of children with a significant hearing loss are not being identified until much later.
The bill would remedy this situation by requiring those health professionals who deliver babies, such as family doctors, nurse-midwives, and obstetricians, to have a health professional or audiologist perform a hearing impairment screening test on each newborn before the baby leaves the hospital or facility where the birth occurred or before the health professional left the birthing site. The bill would provide that under exigent circumstances, the health professional could have a health professional or audiologist perform the screening within 90 days of the birth. If a screening test identified a possible problem, the parents would have to be referred to a health professional or audiologist who performs such screening procedures for further audiological evaluation services.
Testing all infants, rather than just those at a higher risk for hearing loss, should increase the chance that any child born with a hearing impairment can be identified and receive the treatments and services necessary to encourage proper development. Though a hearing impairment is not a deadly condition, it is one that can affect a person's quality of life and productivity. Therefore, early detection and intervention is crucial to enabling a child to fully reach his or her potential.
Response:
The bill makes a good start, but doesn't go far enough. Reportedly, those facilities conducting newborn hearing impairment screening tests currently report certain information to the Department of Community Health, such as how many infants are referred for additional screening and evaluation and also to where or to whom are they being referred after being reevaluated. In this way, statistics can be kept to track if newborns who are identified as having possible hearing problems are being referred for further evaluation, if they are being reevaluated, and if those deemed to have hearing impairments are being referred to the proper sources for help. It is important that as universal screening is offered to all newborns, that some mechanism be in place to track those newborns found to have an abnormal result on the initial screening, so that children do not fall through the cracks and still go without proper hearing intervention services. At a minimum, the tracking procedure currently being done should be placed in statute to ensure that it will continue to be done in the future.
Against:
The bill would put an undue burden on hospitals and those health professionals who deliver babies to pick up the tab for the equipment necessary to perform such tests and for qualified medical professionals and audiologists to perform the tests. According to the Michigan Health and Hospital Association, the cost to purchase the necessary equipment to do the tests is $70,000. Costs to maintain the equipment and train staff could be about $100,000 annually, depending on the number of births, with professional fees for the interpretation of test results to be around $40,000 for about 350 newborn tests. With many hospitals floundering financially in the face of reduced reimbursement rates from insurers, Medicaid, and Medicare, many hospitals simply could not afford this additional cost without assurance that insurers would directly reimburse a hospital for the cost to perform a test. It is estimated that the current cost of such hearing screening tests is approximately $50-$75 per newborn.
Response:
Currently, 77 of the 104 hospitals in the state that deliver babies already provide this service on a voluntary basis, and so would have the necessary staff and equipment to implement the bill's provisions. All but a few hospitals are expected to have the necessary equipment and be ready to conduct the tests by the end of the year. Further, Medicaid already reimburses providers for newborn hearing impairment screening tests. Since Medicaid covers roughly one-half of all births in the state, obviously many of the screening tests would be reimbursed. It should be noted that the medical industry has deemed the testing of newborns for hearing loss to now be considered a standard of care. Though the bill is silent with regard to payment for the screening, and though there was no testimony given by health insurers at the committee hearing concerning this matter, typically, those procedures and services considered to be a standard of care are covered by health insurance contracts and policies. Regardless, though, of who pays for such tests - whether by health insurers, hospitals absorbing the costs in their general operational budgets, or parents paying out-of-pocket - the fact remains that such testing is now a standard of medical care and necessary for the early detection of hearing loss. The impact of early treatment for hearing loss on a child's development and subsequent quality of life certainly makes the testing of all newborns a worthy proposal.
Rebuttal:
Though Medicaid does "cover" newborn hearing impairment screening, it does so by including such tests as a bundle of services reimbursed by Diagnostic Related Group (DRG) 373, which refers to routine obstetric and pediatric care associated with an uncomplicated delivery. Since the payment associated with this DRG did not increase when the hearing impairment screening test was added, it could be argued that there has not been any real coverage given.
For:
The House-passed version of the bill specifies that audiologists, in addition to other health care professionals, could conduct the hearing impairment screening tests on newborns. The bill would also require that audiologists be included in the list of professionals who perform audiological evaluation services that is to be given to parents of the children who had abnormal results on a screening test. This is an important inclusion for several reasons. Audiology is the practice of identifying, assessing, and rehabilitating auditory and vestibular disorders. Audiologists must complete a stringent academic and clinical program. To practice as an audiologist, a person must possess a master's or doctoral degree in audiology, complete nine months or more of supervised full-time audiology services after completion of the degree, and successfully complete a standardized national examination. Beginning in January of 2007, a doctorate in audiology will be required for entry into the profession.
It is clear that audiologists are the professionals who possess the specific training and experience necessary to perform and evaluate hearing screening tests. Health professionals regularly refer patients to audiologists for assessment of hearing problems. However, the bill as introduced only referred to "health professionals" as conducting the hearing impairment screenings. Since Michigan does not license or register audiologists, they are not considered to be "health professionals" as defined under the health code. If audiologists were not specifically mentioned in the bill, members of this profession would be excluded from conducting the required hearing impairment screenings on newborns.
Response:
Some are concerned that by specifically mentioning audiologists in the bill, that it may be construed to require that the services performed by audiologists be reimbursed by insurers. Others are concerned that this might be an attempt to have the profession of audiologists regulated under the health code.
Rebuttal:
Neither of these concerns is founded. Recent legislation has made it clear that new references to a health profession, or even newly regulating a health profession, are not to be construed as a mandate for insurance reimbursements. Further, placing audiologists in this bill, and therefore into the health code, would hardly constitute a bid for regulation. The reference to audiologists would simply allow members of that profession to do the job they are trained to do. Without referencing them, audiologists would not be allowed to perform the newborn hearing impairment screening tests that the bill requires to be done, nor would their names be included on the list of those who could do further evaluations and tests on hearing impaired infants. Since the education and training of audiologists make them uniquely qualified to conduct such tests, it would simply be wrong to exclude them just because the term "health professional" only includes those health professions currently licensed or regulated by the state. It should be noted that Michigan is the only state that does not have a system of licensure or registration for audiologists.
POSITIONS:
The Department of Community Health supports the bill. (10-16-00)
The Michigan Academy of Audiology supports the House-passed version of the bill. (10-12-00)
The Michigan Association for Deaf, Hearing and Speech Services supports the concept of the bill. (10-18-00)
The Michigan Coalition for Deaf and Hard of Hearing People supports the concept of the bill. (10-18-00)
The Henry Ford Health System supports the concept of the bill. (10-12-00)
The Michigan Health & Hospital Association (MHA) is neutral on the bill. (10-20-00)
Analyst: S. Stutzky