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Why Are Hearing Aids So Expensive? (nytimes.com)
244 points by ezhil on Oct 23, 2017 | hide | past | web | favorite | 251 comments

>Experts don’t know exactly why hearing aids are still so costly

No, they do.

The short answer is: you need to develop your own custom IC's that 1) have analog circuitry 2) support Telecoil[1] - an ancient induction standard from the 1970's 3) are made by 1 of 4 companies in Copenhagen or Switzerland - one of which has 55% market share and 4) run on fumes. Seriously, the crest factor on these is ridiculous.

The long answer is available in this great podcast episode: https://theamphour.com/338-an-interview-with-jorgen-jakobsen...

Of course, Bluetooth alternatives to hearing aids are being developed. People in the industry know this and joke about it. But, crucially, they can't be called "hearing aids". It's a protected term. An interesting example are Bose's new $500 "Hearphones" strongly targeted at an older demographic[2] with features like Bluetooth and tunable noise cancellation based off their earlier $300 QC30 dynamic noise cancelling platform. But also not the exact same use case. More power intensive. More capable. But less endurance.

[1] https://en.wikipedia.org/wiki/Hearing_aid#Telecoil [2] https://www.bose.com/en_us/products/headphones/conversation_...

A large portion of the cost of high performance hearing aids today is not not the hearing aids themselves, its the overheads of the local office which are amortized over very few local customers. Generally, the cost of a high performance device is around $300-500 to an audiologist. This is why online companies, like https://www.embracehearing.com (full disclosure, this is my father's company), are able to sell high end hearing aids for about 1/3 of the price of retail.

Office overhead is just due to the monopolistic reliance on a few expensive aids. Optometry requires specialists of differing degree (optometrist vs. opthamologist) yet contacts are dirt cheap because of industry competition. The same is true of corrective glasses, LASIK etc. etc. Hearing aids shouldn't be any different.

Glasses are quite expensive in the US comparatively.

Compared to what/where? You can get a pair of prescription glasses almost anywhere for around $100.

My wife is Korean and was shocked that she couldn't get a pair for like $30. Also, I think the glasses she ended up with were probably considerably more than $100 but your options are really narrowed if you have an Asian nose (many glasses that would work fine for me just slide off of her face).

She can go to (say) zennioptical and pay $30 for a perfectly good pair.

I've never heard of it.

I can vouch too, $20 lenses and frames

I am currently wearing my "looking at the monitor glasses" that I bought from Zenni Optical.I bought it somewhere between 4 and 6 years ago for around $15.

I have three pairs of driving glasses, a pair for running,a rimless pair, and a pair for use at work. They are all from Zenni and were all bought 4 to 6 years ago. They have various levels of tinting from none to fairly dark. Antireflection and antiscratch coating were standard. The most expensive was $30.

I would like to buy some new glasses from Zenni, but my optometric prescription has not changed and the frames and lenses are still in ridiculously good shape.

I rejoiced when my work glasses has a nasal bridge fall off. Unfortunately, I found that I was able to repair it in a few seconds.

So despite the pittance that it costs, I still use these old glasses. Perhaps if I carefully drop some dumbbells on them.... :-)

I paid $30 for a pair of glasses from Zenniopitcal and they are of fine quality, not dissimilar than the $300 I used to pay. My girlfriend has been using them for a decade now and she's asian...

The little bridge nubins are adjustable though.

I think she didn't like those; the glasses she ended up with are the kind where the bridge is part of the plastic frame.

The Hearphones have a 10 hour battery life and don't have replaceable batteries. My hearing aids have a 3 day battery life and have replaceable batteries I can carry around on my keychain. They really aren't useful for the same things at all.

> The Hearphones have a 10 hour battery life and don't have replaceable batteries. My hearing aids have a 3 day battery life and have replaceable batteries I can carry around on my keychain.

What's the cost of your hearing aids?

How many 'hearphones' could you have for, say, 50% of that cost.

10 hour of hearing seems close enough to a day's usage, perhaps a bit shy but probably not by much. Certainly two recharged pairs should see you through a day.

How much charge do they need - or rather, what's the size of a recharge battery pack, and how would you compare the cap-ex of your hearing aids versus the cost /convenience trade-offs of an alternative?

Unlike a phone, I wouldn’t say “close to a day’s usage” is acceptable for a product that allows a user to hear.

No one's suggesting that people should be forced to go without.

Rather, the problem is that people are currently going without because hearing aids can cost as much as a used car. And the batteries - which do last longer, yes - are one-time-use instead of rechargeable.

Given the choice between recharging something in the middle of the day that costs $20 to a few hundred dollars, or theoretically having multi-day battery life with hearing aids that you can't afford, the former is an easy sacrifice to make.

Around-the-ear hearing aid can optionally have rechargeable batteries.

> Unlike a phone, I wouldn’t say “close to a day’s usage” is acceptable for a product that allows a user to hear.

I wasn't suggesting that people only be allowed to hear for ten hours out of every twenty-four.

As noted in the sentence that followed that one you reacted to, I went on to write:

"Certainly two recharged pairs should see you through a day."

TFA, and parent, is about how danged expensive hearing aids <tm> are -- while parent is all about the alternative of 'hearphones' that are around US$500 (about 1/6th of what hearing aids cost in Australia).

Yeah, the price makes a huge difference. My grandmother was last quoted $10,000 for hearing aids in Australia, whereas at US $500 & no medical visits I could maybe buy one as a gift, if I could be convinced it would be moderately helpful & get semi-frequent use.

(I worry that the smartphone / bluetooth connectivity is too complicated for tech-averse elderly, and that the inline volume controls are too small for arthritic hands. But I like the idea and I love my own QC25s.)

I have a friend who uses the bose headphones but when we go out to busy restaurants or other noisy places she tends to speak much to quiet for me to hear her...go figure the person without hearing loss ends up being the one having a hard time understanding!

I've got some passive noise isolating earbuds for concerts. I wore them to Gamescom and my wife kept asking me to speak up because I had the exact same problem your friend did. I could understand her speech perfectly, but felt like I became the person yelling and making all the noise.

Please can you tell me what they are called? I think I'd find them very useful.

I use 3M ClearE-A-R (UF01021), they're transparent and cost about 3€ for a reusable, washable pair on Amazon Germany. It does change the sound but I think that's inevitable (EDIT: for this price range, at least)

I would not say it's inevitable. As a musician, I use Elacin filters with custom moulds, and these are great. There is no noticeable change in the sound itself, you just hear the sound at lower volume and more clearly, without most of the echoes.

These are pricey though (around 200 EUR), but definitely cheaper than hearing loss.

I've also used he Etymotic "ETY Plugs" which are more expensive (about $12/pair) but are designed for flat frequency pass-through. They give moderate sound reduction without changing the sound.

I think the key word on the low-ish end is "High Fidelity"; these run appx. $15:

Etymotic https://amzn.com/dp/B0015WJQ7A

Hearos https://amzn.com/dp/B000V9PKZA

These are the earplugs I used. I'm not sure if there are better or worse out there. The price point was low enough that I just bought them without a lot of research and they worked perfectly.


Great. Now I have to carry around another pair of these relatively huge, bulky earphones.

The great thing about my hearing aids is I put them in and I can ignore them. Unless I'm swapping batteries, which is infrequent enough, I don't even notice I'm wearing them.

Yeah, my hearing aids were expensive. Yes, insurance doesn't usually pitch in at all for hearing aids unless there's surgery required (BAHA, cochlear, etc). It's worth it. The alternatives are toys that get in the way of just going about your normal life.

Great, now someone has to explain to you that this is not an attack on your freedom to use whatever you product you prefer.

> Unless I'm swapping batteries, which is infrequent enough, I don't even notice I'm wearing them.

Presumably when you're swapping batteries, you're not actually wearing them, no?

Anyway, I think you have missed the points being made. For people who can't afford, or don't have access to the services around, hearing aids, consultancy, replacement batteries, and so on, there's an alternative.

My point: Hearphones may be cheaper, but they aren't a substitute for hearing aids. If people want to use them in lieu of hearing aids, fine. But they're a poor substitute. Other products may be better in the future.

A more exaggerated example: Someone who is nearsighted using their smartphone to look at more distant objects. Sure, it works, but it's not exactly practical.

> Hearphones may be cheaper, but they aren't a substitute for hearing aids.

The fact that they are cheaper means that they are a substitute for hearing aids.

They may not be quite as good right now ... but we've been over the affordability aspect already.

For people without access to USD $5k for hearing aids, a 'poor substitute' may be a perfectly reasonable alternative.

As a counterpoint: my mother got the Bose Hearphones recently. She says they are worlds better than the hearing aids she used to wear.

The "technology costs money" argument makes no sense when you consider that the Apple Airpods retail for $169. They contain:

- mics

- DSPs

- drivers (speakers)

- custom wireless chipset

- batteries

i.e. all of the stuff that you need to build a regular HA. The differences are that:

- they have shorter battery life (but a lower capacity battery)

- built in larger quantities

- not 'medical grade'

Telecoil doesn't add significantly to the cost, but it does use a bit of internal volume. They are incredibly useful and are not going away anytime soon.

It's not like you need the 2017 model of HA; for most people the 2000 model would be just fine, and (for the company) the costs of IC development and regulatory have long been recovered. ASICs are expensive to produce, but not that expensive that it adds thousands to the COGS.

The real reason is simple market forces: people will pay a lot of money for healthcare. Insurance coverage in the target market determines much of the price.

>built in larger quantities

That's the whole ball game in electronics.

As far as I'm aware a huge chunk of the cost is that hearing aids because of size and low power requirements need to use balanced armatures instead of dynamic drivers to produce sound[0]. Anyone involved in the high-end IEM world will know that a pair of those costs north of $80-$100 and at least for IEMs each earpiece will contain between 1 and 6 of the little things.

[0] https://en.wikipedia.org/wiki/Headphones#Balanced_armature

There's only a handful of companies creating BA drivers.





and supposedly sony creates(used to create) some

And probably some others I don't know about.

Some of them cost that much yeah, but not all of them. Nowadays you can get 10BA(though it's more likely 5 doubles each side from china for $600). There are a few exceptions like noble audio that are premium priced with custom units, but most people use factory devices.

You can get 3 BA sub 100 iems on aliexpress. Are they good? sometimes, but the point is I would say there's an audio revolution going on that is hardly noticeable unless you're actively watching it.

One can buy complex hearing instrument silicon now for $60 per ear quantity one. Dual mic, echo cancellation, equalization, noise cancellation, bluetooth, telecoil, etc. There is no excuse.

That runs a few days and does not sound terrible?

See, one balanced armature transducer will cost you about this much. Electronics is not the problem, power requirements and miniature size are. In a hearing aid, the main power cost is the transducers (including MEMS microphones) and amplifiers.

BA transducers are so expensive because only 3 companies make them. (Knowles, Sonion and one other I do not remember off the top of head.) Only a few more make MEMS microphones.

This is also on the verge or actually nanotechnology which is why Chinese manufacturers couldn't get in.

Trying to use a dynamic driver or microphone instead will cost you about half of battery life and will be larger.

I dont known anything, but a Knowles MEMS microphone on digikey is $1 qty 1 [0]. A few 100 uA consumption.

I'm pretty sure there is space for disruption here.

[0] : https://www.digikey.com/product-detail/en/knowles/SPW2430HR5...

Yes, MEMS microphones of ok quality are a few dollars but you need a few or an array (worse quality ones are cheaper), balanced armature of good quality are not cheap. This one has really bad SNR (-42 dB)

The space requires micromechanical research and manufacturing expertise. Good luck "disrupting" it.

- Does not work with the available voltage

- Far too big

- Requires about 1/3 of the entire power budget

> I'm pretty sure there is space for disruption here.

[hackernews noises]

> That runs a few days and does not sound terrible?

If they are 1/10th the cost, then the number of people that could benefit goes up tremendously. I'm sure lots of people would accept having two sets that they have to charge every night if the alternative is not having any.

Just to add to this - it is true. I have researched this subject incidentally many months ago. ON Semiconductor is one of the more relevant companies in this domain. They are a public company with a market cap of $8.5B. You can look at their Ezairo series of system-on-chip products - they are built for digital hearing aids (with all consideration of power requirements, DSP/programmability etc).


A quality Bluetooth headset covers all of those requirements except for Telecoil.

I don't know if it's the same as the Bose "Hearphones", but my Sennheiser PXC550 have what Sennheiser call a TalkThrough mode. It pauses the music (if it's playing) and uses the microphones to let through sounds on the wavelengths of speech. If you combine it with noise cancelling, it definitely makes it easier to hear people in noisy environments. Looks weird to talk with over-ear headphones on, though. To be honest it feels a bit creepy to hear what people say while it looks to them like you're listening to music and can't hear them.

> If you combine it with noise cancelling, it definitely makes it easier to hear people in noisy environments.

Does it also work when the source of noise is a crowd? I'm near-deaf on one side, which has the side-effect of not being able to isolate voices.

Hm I'm not sure, I haven't used it for that so I don't know. It's mostly designed so that you don't have to take them off for a quick interaction, so it's definitely not optimized for your use case. For example, the fan noise in our server room is at least partly in the frequency spectrum it lets through, so it's useless there.

Telecoil is, as I understand it, literally just audio transmitted at baseband over a magnetic loop system. The only slightly complicated thing about that is the receive antenna, and that's literally 1970s technology too. Also, ultra-low-power audio processing hardware is practically an off-the-shelf item these days thanks to technology improvements.

What IC manufacturers sell as ultra-low-power audio ICs typically consumes order of magnitude more power than you would like for industrial IoT applications with large Li-something batteries, not to mention power envelope of hearing aid, which I would estimate as additional order of magnitude smaller.

You will find a lot of cheaper alternatives that use off-the-shelves components but none of them work as great as ICs specially designed by the company themselves.

Source: I work in the industry.

So you're saying we can't just do it with a 555?

> But, crucially, they can't be called "hearing aids". It's a protected term.

If a doctor prescribed you hearing aids, could you get the Bluetooth kind instead, and still have them covered by your insurance? Or is this like the Epi-pen/Adrenaclick thing?

The key problem with this question is that most insurance plans do not cover hearing aids, regardless of whether your doctor/audiologist says you need them.

Then how is it a problem? Buy what works no? I don't grok your statement.

I can understand why you might have trouble groking this as it might be a slightly foreign concept, but not everyone even here on this forum is lucky enough to be able to throw money at all their problems.

I think you've misread the parent comment here. Grogenaut is saying, if insurance won't cover even expensive official hearing aids, then there's no reason not to go for a cheap alternative unofficial one if it's just as good or better.

However, Grogenaut has also misread Mgerdts's comment to some extent, as when Mgerdts mentioned a "problem" they meant that Derefr's question wasn't that relevant to reality, not that there's a problem selecting hearing aids.

I propose Nition be known as Explanator2000 from now on.

Agreed. I'll also try to not post from my phone.

Parent asked:

> If a doctor prescribed you hearing aids, could you get the Bluetooth kind instead, and still have them covered by your insurance?

If insurance plans don't cover hearing aids in general, they won't cover hearing aids in any specific situation either.

My insurance would cover a hearing aid for the ear that needs a hearing aid. Whether the hearing aid supports bluetooth doesn't come into the equation.

Since I only need one hearing aid, the bluetooth feature was of minimal interest. I've not heard of any hearing aids that have a microphone that is useful for the bluetooth headset profile. The microphones for this use tend to be an add-on device which may or may not come with a pair of hearing aids. Admittedly, I've not researched this area much.

> If insurance plans don't cover hearing aids in general, they won't cover hearing aids in any specific situation either.

GP was asking about insurance plans that do.

The question obviously concerns insurance plans that DO cover hearing aids, genius.

That's still useful information for someone like me in the UK, where hearing aids are covered by our basic level of national health care, that would probably assume that that most would.

Yes, but that doesn't make it a "key problem" with the question being asked. The question was fine, even though it wasn't global in scope, but why should it have to be?

> you need to develop your own custom IC's that ... 3) are made by 1 of 4 companies in Copenhagen or Switzerland

I'm confused - what part is custom and what is made by the Swiss and Danish companies?

All of the 4 points seem to refer to the IC or integrated circuit.

how much of the medical field is slow on purpose ? I know about heavy regulations and safety standards .. but still

Bose Hearphones app annoyingly/invasively forces you to enable GPS location tracking (also a waste of battery), and they data-mine (send back to bose servers) every song title you listen to plus your contacts list :-(

A few weeks ago I talked with a guy whose startup was developing a better hearing aid. As a few other commentators have mentioned, a hearing aid does not just amplify volume --- that is useless for people with hearing loss. The problem with hearing loss is generally not so much that you can't hear anything at all. It's that it becomes extremely difficult to distinguish speech from background noise.

The ideal hearing aid will amplify those frequencies at which speech is present, while suppressing frequencies that contain background noise. But currently hearing aids use a pretty dumb set of heuristics to figure out which is which. For instance they'll try to estimate how far the source of the noise is and will suppress it if it's more than, say 15 feet away. But if your SO is calling you from the kitchen that means that you're not going to hear them. Similarly they'll amplify frequencies associated with sibilants (s sounds, for example) because those are really important for speech, but that means that wind sounds or rustling paper also gets amplified.

There's a huge opportunity here to apply deep learning to determine which frequencies to amplify and which to suppress. It's a challenging hardware problem, but the deep learning part of it has largely been solved. (Or at least, the current state of the art using deep learning is way, way better than what commercial hearing aids currently do.)

> The problem with hearing loss is generally not so much that you can't hear anything at all. It's that it becomes extremely difficult to distinguish speech from background noise.

The problem with hearing loss is that you can't hear. In most cases, there's a loss of high-frequency hearing, you can't hear sibilants and thus can't parse the speech.

Speech-in-noise is a specific situation that HAs do not handle well. It's less of an issue with un-aided hearing thanks to the shape of our ears.

> The ideal hearing aid will amplify those frequencies at which speech is present, while suppressing frequencies that contain background noise

Every modern hearing aid does this already.

> a pretty dumb set of heuristics to figure out which is which

Dumb? Billions of dollars are waiting for the person who can make noise reduction work really really well. It's surprisingly difficult, even with unlimited computation power.

> they'll try to estimate how far the source of the noise is

This is 100% fiction. No HA on the planet calculates distance-to-noise.

You can spot the HAs that do because they require three microphones not in a straight line. Probably a triangle.

You might be thinking of beamforming, where the HA calculates the direction of the sound and can optionally focus amplification on sounds coming from that direction. Typically, sounds behind the listener are amplified less than sounds coming from in front of the listener. This is a useful refinement done by every modern HA.

> wind sounds or rustling paper also gets amplified

That is unfortunate. There is significant research going into recognising speech patterns so that the HA can make these decisions better. Unfortunately, none have shown useful results yet.

> huge opportunity here to apply deep learning

To do what, exactly? Why DL? How do you propose to run DL on a 1MHz CPU with 16kb of RAM and a battery the size of a bee's genitals?

> It's a challenging hardware problem

The hardware has been known and fixed for 20 years. What would you change? Software is where all of the improvements have come from for a very long time.

> deep learning part of it has largely been solved

Cite me a paper and we can make billions.

It sounds like you know a lot about this field! I'll confess that I'm a neophyte. I'm working on audio research right now, but all I know about hearing aids is my one conversation with the whisper.ai CEO.

> Cite me a paper and we can make billions.

The relevant paper is Hershey et al., 2015 [1]. There are some audio examples here as well [2]. The idea is that a deep NN can apply a spectral mask and isolate a single speaker when many speakers are talking (or there's background noise). Of course a standard hearing aid has pretty limited hardware, which is why the hard part for them is developing a small enough device that can do the inference in real time. (They cheat a little bit and actually do all the processing on a larger device that you keep in your pocket --- it's not done locally behind the ear.)

[1]: https://arxiv.org/abs/1508.04306

[2]: http://www.merl.com/demos/deep-clustering

Curious to know what in what ways would old fashioned DSP (Fourier, STFT, Wavelets), or for that matter compressed sensing be lacking compared to deep learning.

In no way at all, especially statistical techniques for speech enhancement using Emax or Bayesian given Gamma prior.

You can also toys in some more advanced stuff like ICA deconvolution.

This on top of some nice improvements in plain DSP techniques. (E.g. modified gammatone transform or variants of Stockwell transform)

All in low latency.

The main problem is ruining this on a tiny jellybean power efficient micro. Deep learning on a Cortex M0 with decent quality and less than 5ms latency? Good luck.

I read the suggestion as "applying deep learning to optimize the parameters of the process", not running it on the device itself.

For optimization of parameters you can go full ham and apply even genetic algorithms.

The problem is actually finding a "legibility" and "quality" metric. Codec ones like PEQ are not good enough.

Man - I wish the ML side was completely solved, though I think we've actually figured most of the hardware out! Lmk when you want to chat next Anthony - we've had some fun progress since last time!

Ha, maybe I exaggerate a little! But the ML part seems much more tractable than the hardware side for me! (Mostly because I don't know much about hardware and it seems, well, hard!) :-)

what if they made a cb radio for the home, when living with my mother she'd have the tendency to ask for something from another room. a in house star-trek-style communicator could help with that.

It's called a 'spouse mic'.

Mind sharing the guy's name? I love making small electronics.

Dwight Crow at whisper.ai. I do know they're hiring!

Working inside the industry I can tell you that there are a lot of misconceptions when you look at things from the outside. Hearing aids are not so expensive because of the hardware but because of two other things: 1. customer acquisition cost and 2. service cost.

1. People do not want hearing aids (typically they do not even want to accept they have a hearing loss). You need to spend an awful lot in communication and marketing and humans you can talk to in a store to convince them to try one.

2. Hearing aids are not glasses that you put on and the problem is solved. It takes 6-12 months to get the full benefits and you need multiple visits to the store with humans to hand-hold you through the process or you will just stop wearing them.

And did I mention the average customer is 70 year old? Explain to me how a 70 year old that does not want a hearing aid will buy one online

Well from my point of view this is completely opposite to what I've witnessed firsthand. People DO know they have hearing loss and WANT to fix it. It becomes very awkward for them in social settings and they are not able to follow the simplest group conversation.

Case in point: my dad and grandma. They both got the 'free' hearing aids (we live in Canada) and these supposedly really cost the government (or taxpayers) upwards of $2000 for each ear, and they SUCK. The alternative was to dish out $5000 per ear for a marginally better product. They both ended up not using them because it was such a hassle and it basically drove them nuts. They didn't fit very well and constantly amplified even the slightest noise, and basically did nothing in ways of helping their hearing at a normal conversation.

Recently though, they finally got a great hearing aid (forgot the name) and paid less than $500 (from their wallet) and it vastly outperforms any other hearing aid they've ever tried. I know they work because because they actually WEAR them now because they are NOT ALWAYS BUZZING and amplifying ambient noise and they are ADJUSTED PERFECTLY to hold onto their ears. That's disruption for ya ....

Of course there are people that want to get help but you might be surprised to know that on average people wait for seven years before wearing a hearing aid starting from when they would benefit from one. There are customers (more than you would believe) who have hearing loss, that test the product for a month and still decide not to buy it.

Also the type of hearing aid you need is highly dependent on both the hearing loss profile and the specific life situations when you don't hear well. If you have profound hearing loss and stay mostly at home and need help to watch TV or have conversations in a silent enviroment you can benefit from a basic hearing aid. If you are a bartender with a slight hearing loss and need help in noisy environemnt even a top of the line one might not make an appreciable difference.

Finally free hearing aids always suck because the free service you get with them sucks and they do not take the time to see you multiple times and fix the fitting for you. It is normal to see a customer in the shop for a one-to-one with the audiologist 4-7 times in the first three months. That is expensive and difficult to disrupt because the value is the in human interaction

I'm a hearing aid user in Canada and your numbers seem off. Canadian government will pay $500 / ear. I have near top of the line Widex hearing aids and they were more like $2750 / ear including a 3 year service contract which included batteries for the full term.

If your relatives got "free" hearing aids, it's likely they were low end (i.e. less than $500 so totally covered by the government grant). My father had a similar experience with low end devices and thankfully recently bought a much better pair and has finally successfully adapted to wearing them.

I guess it's different for different persons. Everybody tried to convince my stepfather for years and he didn't... listen (ahem, sorry) even if he has no problem paying for the aids.

When he finally accepted to wear them, the situation has been pretty much what you describe. So I would really appreciate if you could remember or ask the name of the working ones.

Could you please look up and post the name of these?

The model they use is the AIR from mdhearingaid.com.

I am in no way affiliated to these folks. But I would like to thank them for a great product (on behalf of my family)!

But is there a place online where you can buy cheap hearing aids that you can tweak yourself?

I'm genuinely interested in the answer, as I am very likely to get hearing loss in the future, and might start being pro-active if there is a cheap alternative I could try right now, before my hearing gets bad.

In which country do you live?

Keep in mind that the smaller the hearing loss the more sophisticated the hearing aid you need to get a benefit. If you have a slight hearing loss you will experience issues in the "hardest" situations for hearing aids to cope with such as conversations in noisy places or bad telephone reception.

Finally, the over the counter hearing aids come with a limited number of pre-fitted configuration (e.g., 4) and "tweak yourself" means choosing one of them. To get a hearing aid fine-tuned to your specific hearing loss you need a professional in a shop equipped and trained to use with the professional fitting software of the hearing aid

> Keep in mind that the smaller the hearing loss the more sophisticated the hearing aid you need to get a benefit. If you have a slight hearing loss you will experience issues in the "hardest" situations for hearing aids to cope with such as conversations in noisy places or bad telephone reception.

I wonder if improving performance would make hearing aids become a "want" rather than a "need"? Bionic ears outperforming natural ones, allowing the user to select different bands/ranges to listen to, sounds like a pretty neat futuristic thing to have.

It's not like people are shy about enhancing their natural abilities with the help of technology, it's pretty much in the current zeitgeist.

I agree with you, I have normal hearing and would totally buy devices that could help me understand better in noisy situations like restaurants, bars, etc.

Alas, even top range hearing aids cannot do that today.

And if people with normal hearing would wear those it would take away the stigma for people with hearing loss.

I live in France. My father recently spent north of 5k€.

Thanks for your answer. I guess it's not really feasible to get ahead then. I'll probably start with over the counter hearing aids when the hearing loss will start to be noticeable.

You can get OTC hearing aids (technically called hearing assisted devices) in France in Pharmacies but they frankly are not that good.

I know it will not sound much to you but for those 5k I believe your father got not only top of the line hearing aids but also a trusted audiologist he will be able to see as much as he wants free of charge for the coming years until he decides to get new devices.

>To get a hearing aid fine-tuned to your specific hearing loss you need a professional in a shop equipped and trained to use with the professional fitting software of the hearing aid

Or you need better fitting software that doesn't require a trained professional to use.

>People do not want hearing aids (typically they do not even want to accept they have a hearing loss). You need to spend an awful lot in communication and marketing and humans you can talk to in a store to convince them to try one.

Ugh. That's my dad. He seems to be willing to spend the rest of his life making everybody around him repeat what they said at a higher volume so he doesn't have to try a hearing aid.

Botched medical regulations gone haywire.

The same reason health care is expensive in general.

When side step the regulations and buy outisde the health care industry - say, amazon.com - hearing aids magically become $38.


Health care is more than ripe for deregulation and monopoly/union busting - but the American medical association lobby is one of the strongest in the world.

You may be right, but consider another alternative, that some markets have a lot of money sloshing around and have yet to be disrupted.

A great example is the home infusion industry. People used to make money hand over fist. It took some knowledge to offer home infusion to patients (have a pharmacy, hire some nurses), but it wasn't rocket science. The market was made up of a ton of small companies, all making good money servicing only a handful of patients with certain conditions. We're talking each patient bringing in tens of thousands of dollar of profit each.

There were no regulations or evil conspiracies holding this industry up. It just wasn't big enough for anyone to do anything about. Insurance companies were worried about bigger fish to fry.

Then the large specialty pharmacies came along, bought up all the small players. They used the profits to boost their bottom line.

Then some bean counter somewhere figured out insurance companies were paying way too much, so they renegotiated their contracts, squeezed the profits out of it and now it's like a lot of medical services, single digit profit margins.

There are a lot of markets like this out there. I'll bet hearing aids are one of them.

I am reluctant to accept an anti-regulation message from someone whose name seems a likely riff on Ayn Rand, but setting that aside...

I'm also reluctant to look at deregulating hearing aids without looking at some of what the regulations do...

Like, something that came up on HN a few years ago was another thread about hearing aids, and one thing I remember from that was that cheap hearing aids can actually do further damage to a person's ears, because of how they do or don't amplify the sounds appropriately.

Maybe the regulations, in this case, are there to prevent people from paying $38 for a hearing aid that wrecks their sense of hearing further. If that is the case--and I don't know that it is, but I think health equipment merits a degree of caution--then I think that's a good place for regulations.

Very few people would be able to properly evaluate whether a given cheap hearing aid would be one that worked without harm or would be one that caused further hearing loss. Very few. That's exactly the place in society for regulations--when few people are capable of making an informed decision, etc.

It's certainly easy to blame regulations for this and everything wrong with American health care, but I don't know if it's sensible here or in general--or if blaming regulations (and consequently removing them) would actually lead to the outcomes people claim they would. My gut tells me that the problems we have lie elsewhere in the medical system, not in the regulations concerning medical devices or medicines.

I wear hearing aids selected by an audiologist, have probably had some extra damage to my hearing from them, and wish I could buy open hearing aids I could program myself. I don't blame the system for the damage, but do for the restricted choice.

Generally consumer protection by regulation seems to suffer from a form of regulatory capture -- measures that are great at entrenching the existing players get disproportionate emphasis. You end up e.g. restricting the supply of doctors and then not bothering to make them wash their hands. I'm not saying regulation can't ever do net good, but you have to watch it like a hawk, and who has the incentive to?

> Generally consumer protection by regulation seems to suffer from a form of regulatory capture ...

I've heard these theories a lot, but I almost never see much evidence; is there any evidence it applies in this situation?

> doctors

I think it's very important to regulate doctors and medical care. I don't want any quack hanging out a shingle and treating people. The same goes for medical devices.

Earphones aren't regulated and have all the same risks. In fact neither are all the cheap not-quite-hearing-aids. I have one that looks just like an old hearing aid but cost maybe $50. Safety really isn't a risk here any more than it is for consumer goods.

As a spouse of someone with a cochlear implant I've asked this question repeatedly. The cost of everything around that hearing device is insane - want a cord so you can listen to audio? That's $500. Want a device to make it easier to hear TV? That's another $750. Operate over bluetooth? Nope we can't do that. Need a new battery? That's a grand. Its insane what they get away with

Don't forget that cochlear implants are basically a locked-in monopoly. If you've got an implant from company A, then you're stuck with company A's processors and accessories unless you plan on having another surgery to take out the implant and put in a different one -- which most surgeons would not recommend for any reason short of actual damage.

I picked Advanced Bionics and regularly pay around $2000 a year in batteries, parts (cables, various pieces) etc. alone -- none of which is covered by my insurance here in Japan. Currently I'm waiting on a replacement processor (which is two or three generations old) that I'll pay around $600 out of pocket for. It doesn't seem like much, but due to rain and humidity I end up opening it myself and cleaning it several times a year because I can't afford to get it repaired/replaced.

If I want to upgrade to the newest processor, which is lighter, has better audio quality, and is MUCH more water resistant (a major problem with my current model), it will cost me around $7000 -- and that's a DEAL because the processor JUST got approved in Japan.

After March 2018, the price will go up to $14,000 for a processor. Of course, it's not covered by insurance, so I have to pay for it all out of pocket.

I asked the doctor I was seeing what Japanese cochlear implantees do; I've seen so few successful/independent ones and couldn't imagine any of them paying for any of this. He said they usually hobble along with replacement parts/charity and never upgrade the processor because they can't afford it. He also mentioned that many of them have such a low level of recovered hearing and speech that newer processors, frankly, would not give a measurable QOL benefit, which is another rant entirely...

I'm glad I'm not bilaterally implanted -- there's no way I could afford TWICE the costs.

That's the great thing about being in New Zealand, I get upgraded for free every 7 years. A pack of 50 batteries will cost me $30. But mine has rechargeable batteries too if I need.

Surprised Japan doesn't do the same. However, maybe it's an Advanced Bionics thing - we can't get them on the public system here. I chose Med-el (the other option is Cochlear).

I'm on AB and my friend is on Cochlear; he's always amazed at the terrible service I get and the prices I pay.

> I get upgraded for free every 7 years.

I trade mine in for replacement (on my dime) because it's completely broken every 4-5 years.

> A pack of 50 batteries will cost me $30

A single battery runs me around $200-300. My charger breaks all the time too, so that's another $100-200 depending on what's broken... how are you getting a pack of 50 for $30? What do you even do with 50 batteries?

I have four that I cycle through (the big powercels) but that's because I apparently have thick skin/a thick skull and I only get 10 hours of use out of a battery rated for 20+.

Edit: Oh -- misread! I thought you said you were on AB, but you've got a MedEl. I don't think I've ever actually seen those... they weren't even an option at Hopkins when I was going through the pre-screening. The two options I got were AB and Cochlear.

That's odd, if it's completely broken before 7 years, then it's replaced under warranty for me. Still free.

By batteries, I'm talking disposable batteries, not the rechargeable ones. So 50 will last me a while. I like the disposables best.

This is mine: http://www.medel.com/int/sonnet

I'm doing a little better with a Cochlear Freedom. Granted the processor costs $15,000 out of pocket, but my last one lasted 7 years without problems, and my replacement cost was reduced to about $700 through a government program. Said government program is not reliable - I have to jump on it when the money is available, god help me if my CI fails when the money isn't there.

Batteries are about $500 each and they last at least a year before they start to degrade. Accessories are not only absurdly expensive, but also basically useless, so I don't waste money on them. It could be a lot worse. It could also be a hell of a lot better. I'd like to be able to hear on my left side too, almost badly enough to pay the $50,000 or so out of pocket that it will cost to get the second implant. My main problem is figuring out who to give the money too. Privately-paid health care is more difficult to get than I imagined.

> Batteries are about $500 each and they last at least a year before they start to degrade.

Wow, that sounds killer for me. My batteries are about half that and last the same amount of time; I buy four or five a year since I cycle through them due to my thick skin/skull that causes me to get half the expected life out of them every day...

What about cables/headpieces/earpieces for that?

Is your government program the Office of Vocational Rehabilitation, by any chance? I went through them in PA and they were spectacularly flaky... and it wasn't helpful that my liaison was someone I'd known for a while since I was friends with her son and she kept pushing me to "give back" in return for receiving benefits.

No, Canadian here, which explains most of the price difference as well. CAD is weak at the moment. There's a waterproof sleeve thing that you can use for swimming - I believe that was $700. There's a bluetooth dongle that works with my iphone, but it's incredibly frustrating to use, so I mostly don't. That was $350 if I recall. All these things are tax write-offs for me, which is helpful, but I still have to pay out of pocket. It doesn't help much in low-income years, either.

BC Medical tends to get a pile of funding every couple years for CI patients, like 10 million or whatever, and out of that pile they prioritize younger adults who need at least one CI to be able to hold down a job, people whose equipment is starting to fail, etc. If there's any left after everyone who needs one CI or replacement equipment has got what they need, they can offer second implants. They've never gotten that far down the list though.

> BC Medical tends to get a pile of funding every couple years for CI patients, like 10 million or whatever, and out of that pile they prioritize younger adults who need at least one CI to be able to hold down a job, people whose equipment is starting to fail, etc. If there's any left after everyone who needs one CI or replacement equipment has got what they need, they can offer second implants. They've never gotten that far down the list though.

That sounds like a relatively reasonable methodology... I would really like to see the balance sheets of these companies to see how much they're gouging us -- I refuse to believe that what's essentially a condom and plastic tweezers really costs $700.

>I would really like to see the balance sheets of these companies to see how much they're gouging us

Not broken down to each accessory or anything, but you can see overall profit margins and such.



That sounds like exactly the kind of thing that government should regulate with extreme prejudice. Really, anything that gets implanted into one's body, and is not easily swappable, should be.

Likewise, my best mate has had hearing aids since ever, and now a cochlear implant. According to him, the official line is that prices are high because volumes are low and medical devices are expensive to design. The unofficial line is that they're price gouging because they have a captive market and no real competition.

If I needed hearing aids, I'd pay anything for them.

You need water to live and would pay anything for it, but this is not sufficient to explain a market failure.

I was under the impression that modern water markets were all either massively regulated in response to historical market failures (public utilities in developed nations) or currently undergoing market failure (developing nations, c.f. Nestle's shit in Africa).

My point is not that markets in water and hearing aids can't fail, it's that "the demand curve is almost completely inelastic" isn't an explanation. Water and sewage are generally provided by public utilities (in non-rural areas, at least), but the conventional justifications involve the "natural monopoly" of the associated infrastructure, not the shape of the demand curve. People in developed countries would pay almost anything to have flushing toilets, but septic systems (to which infrastructure arguments don't apply) are usually provided by private companies.

As far as I know, there's no real water market anywhere, it's all granted by governments. Unsurprisingly, some governments are better than others at managing such resources, and large companies take advantage of that.

And that's the reason why anything and everything medical costs as much as can be gotten away with.

You've just described the intersection of capitalism and human survival instinct in a nutshell.

Yep, and the reason why governments are useful in the first place. To protect us against capitalism failures.

That presupposes you'd have the money for them. I'm fortunate to be able to either have had insurance coverage or pay $5-6000 out of pocket every 3-5 years for new hearing aids, but there are many many people who can't afford that.

My daughter played with another child with cochlear implants the other day and as far as I could tell her hearing was perfect.

My mother, who was deaf and wore hearing aids, died in 1989. I always wonder what difference they could have made to her.

Presuming you have access to the money and/or some expensive insurance to cover them. Don't forget about 99%.

Building medical devices is extremely difficult due to regulation. I don't know if they are price gouging or not, but it is expensive to do.

This is the reality. Prices are set based on what the market will bear, which is determined primarily by what health insurance will pay for. The same HA or CI costs different amounts depending on whether you're buying it in the USA, Europe or Australia.

If you're paying out of pocket, I strongly recommend that you check out eBay. Second-hand gear is quite cheap.

This is my field, more or less, though I'm on the basic research side.

Traditional hearing aid companies have no idea how large a freight train is barreling down on them in the form of Apple and Google. It's going to be a fun ride.

Former Starkey Engineer: the executives are/were totally aware of what's going on with regards to wearable technology. So much so, that the 5 or 6 top executives thought they could get away with embezzling millions -- siphoning funds from Starkey into their start-up. Internally, Starkey employees were confused why we weren't moving in on wearables. Starkey already owned the ear among 65+, why not go for the giant market of people with ears under 65? The FBI case hit the papers and it all made sense. Fucking assholes. I left the company over it, and I'm only a little bitter about it.

Thanks for this. I had no idea.

I'm disappointed in the lack of innovation in the tech industry. Many people talk about many different topics, and come back to the refrain "Wait for Apple and Google to do it".

Why not make a startup?

Waiting for large companies to innovate is like saying "I won't build the Apple II because I'd rather wait for the IBM PC to be invented".

The fact that these market leaders (IBM and DEC then, Apple and Google now) have so much power to uproot industries means that people are afraid to pursue their ideas. I don't have a full solution, but investors like Y Combinator are certainly helping.

>Why not make a startup?

as other commenters on this thread have noted (correctly), medtech doesn't work that way. You need a long runway, and the regulatory scene does not favor "move fast and deafen people".

Deafening is easy to avoid. The main concern is about effectiveness and this is tested in medical trials. Second concern is with infections caused due to design.

There are start-ups in the "hearable" marketplace. Things like https://www.nuheara.com/ have products out already and there's various ones like http://www.waverlylabs.com/ coming along focusing on things like instant translation as well as hearing augmentation.

Of course whether they'll all just getting steam-rollered by Apple/Google is another matter...

> Why not make a startup?

Why would you want to buy anything so important from a startup? Either it'll suck or it'll be good, and if it sucks you don't want it, and if it's good, Google or FB or someone will acquihire the engineers and shut down the product.

Not going to happen. Too large a pain in the ass for too little profit margin.

Apple has already invested heavily in accessibility across all of their platforms. The market for hearing aids is far larger than some of the tools that they currently deliver.


While Apple is arguably ahead in the quality and features of their accessibility technology, the potential convergence of hearing aids and voice based tools means that Google, Amazon and Microsoft are certainly looking into this.

Accessibility doesn’t require FDA approval.

we're living longer, going deaf earlier, and believe that our phones can do nearly anything. The market keeps getting bigger and bigger.

Does there really need to be a hardware difference between AirPods and hearing aids down the line?

These types of comments always restore my faith in the world.

Nothing like a bit of justice.

I have nothing against the major hearing aid companies per se. Their approach to product development is hidebound and stuck in about 1987, though, and they are going to find out in short order that that doesn't fly any more.

Personally, my money is on Apple and Google squabbling over who gets to buy Cochlear, Oticon, and Starkey for their IP and regulatory know-how, and then just mopping up the floor with the rest of the players in the space.

It's already begun, actually: https://www.wired.com/story/how-apple-is-putting-voices-in-u...

Wired fundamentally does not understand how crappy CIs can be, so it's too enthusiastically reported, but I'm pretty sure this is the opening salvo.

The way I see it though, the limitations of CI implants are primarily driven by the internal electrode interface that limits the number of available frequencies to the person. This isn't something that any of the "big tech" companies are positioned to innovate in. I'd be more interested if Hewlett Packard got involved because they actually have a significant and successful micro/nanotech group.

Hearing aids though could be ripe for disruption by improved computational power and large supply chain leverage. So it will be a matter of whether or not Apple/Google/ back off once they meet the intractable reality of regulatory compliance in a limited market a la their infrastructure plans.

I think it's most likely that they will buy up those medical companies for expertise, then spin off the medical device manufacturing into a new separate company or otherwise sell it off but keep the key engineers to roll into other random consumer products that are less regulated and more profitable. This is what Google has more or less done with robotics after buying basically every major robotics research company in the US a few years back.

> Wired fundamentally does not understand how crappy CIs can be

Just curious, can you explain what you mean by CIs being crappy, or point to an existing explanation?

Briefly, you get 16 frequency bands if you’re lucky.

A healthy ear has about 3,000.

It’s more complicated than that, but in a nutshell, the fidelity with which CIs can represent the world is very limited. They work for speech, mostly, in quiet. There are simulations of what they sound like on YouTube, somewhat.

"Crappy" is one way of putting it. Those 16 frequencies, for me, are the difference between a life worth living, and a life in crippling, hopeless isolation, ended by suicide at an early age.

just to be clear: i’m not knocking their utility! many normal-hearing people just seem to believe that CIs are bionic ears with perfect performance, though, and that’s manifestly false.

the CI users know are glad to have them, and they are, as you say, a lifeline for many. i’m glad my research ultimately contributes to better ones. we just have a long way to go.

Hum... I'm pretty sure my life wouldn't be much different if I could only communicate non-verbally.

This needs to be more widely known. You'd think from reading marketing material that you would be listening to Mozart and jazz the week after implantation.

The reality is that you have basically no pitch perception. 16 frequency bands across, say, the four octaves that music is interesting? You're lucky to discriminate half-octaves let alone semitones.

Temporal aspects of music come through alright. I suppose you could be a drummer.

You would be surprised. Closer to 100 or 200 bands actually, overlapping. There is a plenty of redundancy. The number cited is about the number of neurons.

I am not sure I agree with you.

Given that you get ~16 electrodes, and some greenwood-like frequency-place map along the basilar membrane, and given that the place specificity of stimulation from those electrodes is significantly larger than the width of an inner hair cell, I'm not really seeing "200 bands".

Apple and Google have no idea how sewn up the market is with regulation and patent warfare.

The tech is easy and well-known. Being able to legally sell the product without getting sued? That's hard.

My wife is an audiologist, so I admit to being a bit biased, but it seems like most of the comments are missing one of the main drivers of hearing aid cost.

Traditionally, audiology offices undercharge dramatically for their initial consultation and testing, then provide full service for the lifetime of the device. And not just normal electronics service. Often patients will come back every week or two for months to get the fit just right or to get some coaching relearning how to hear conversations or just having the nice lady in the white coat show them how to replace a battery for the fifth time. A lot of clinics will even throw in "free" batteries for life. The cost of all that service ends up getting rolled into the initial purchase price for the hearing aids.

This is dumb. Most audiologists that I know think it's dumb, but it is the status quo. There's a move in the industry toward "unbundled" billing (i.e. charging an hourly rate for services and selling the aids at a much more standard retail markup) that I hope catches on, but it's a hard sell to charge for services that the clinic down the road is providing for "free", even if the total cost of ownership is the same.

I was going to bring up the cost of glasses as something similar, but I think your answer explains a lot of that, too.

I recently went and got my eyes checked, and the doctor assured me that they had low-cost glasses. Their progressive bifocals lenses only started at $300. I pretended to still be interested, then gave an excuse and left.

I purchased some online and got them for less than $100, shipping included. I threw in a regular pair of distance glasses for less than $40, too.

Why is it so much cheaper? Because they can charge it. I'm sure some of the cost is in maintaining staff to help adjust the glasses, and sell them in the first place. But I got my main glasses for less than 1/3 of the prices that they wanted for just the lenses.

Their frames were $100+ that I saw. I'm sure they had some around $50, but that's still more than my entire pair of distance glasses cost.

In Switzerland, at least one big shop makes this service optional. It costs me about 1500 US$ (for a total of 6000 US$) to get the extra service (additional warranty, free batteries, regular visits for cleaning and updating settings). I think this is worth it as it ensures a great longevity to the hearing aid (my previous hearing aids are 8 year old and still working).

I cannot wait. There is such an opportunity for innovation as well. Hearing is such a psychological thing as well as physical. I had to really research on my own and bother an audiologist directly in order to tweak mine properly.

I wanted to take advantage of my hearing loss to also allow myself augmented, improved hearing for specific scenarios as well. I would love a platform that allows me to do so!

Regardless of the poor quality of the article, the relevant legislation is Over-the-Counter Hearing Aid Act of 2017


Are you sure this legislation isn't a covert increase in regulation of hearing assit devices by the hearing instrument cartel?

There have been talks about this sort of regulatory change has been a long time coming and has been trending this way for a least a couple years (see link below). This is just the first time the hearing instrument cartel hasn't been able to beat it back. Based on my educated guess it is no coincidence that the bill was introduced by a Senator whose state shares a headquarters with Bose.


Has everyone noticed that Apple might be moving into this market in some form?

- https://www.engadget.com/2017/07/26/apple-cochlear-made-for-...

- http://www.hearingreview.com/2017/08/president-trump-signs-o...

- https://www.nytimes.com/2017/06/12/health/hearing-aids-congr...

- https://www.technologyreview.com/s/608597/how-your-apple-wir...

I've been following it, and it all looks rather interesting. I wonder what changes we'll see soon.

My nephew (3) was just given the Nucleus 7 cochlear implant and my sister says it's great. She can tell all sorts of things - how much he's heard, where it is, and all that jazz - including wireless streaming to the device from an iPhone.

Some of the comments on here demonstrate that few readers actually know what a hearing aid does. In a majority of hearing loss cases, you can't simply amplify the sound and call it a day. If you want to do that, go buy a $20 amplifying device online. Hearing loss is usually characterized by an inability to hear different frequencies at differing levels. When you get a hearing aid, the audiologist has to tune it to your particular graph. Most modern hearing aids also come with speech detection, background noise reduction, etc., also tuned to the wearer's loss. Mine have bluetooth capabilities built in as well and can be synced to my phone, laptop, etc.

Not everything is something you can throw some Arduino parts and Python code at, contrary to what half of HN seems to think some times. This isn't to say that prices are not ridiculously high, but at the end of the day, they are a medical device that require a trained professional to tune.

Source: worn hearing aids since I was 3 years old.

My relative has had hearing aids for many years. Her loss is profound, and her hearing aids are apparently quite sophisticated. The "tuning" consists of the audiologist fiddling with a GUI while my relative says if it sounds better or worse.

Maybe it's not a racket, but they're trying awfully damn hard to make it seem like one.

That isn't how it works at all. It is far more than an audiologist "fiddling with a GUI". The audiologist first does a hearing test, which is gives an audiogram which is a gain versus frequency plot that takes into account equal loudness curves. This is how they know to recommend hearing aids in the first place. This is the initial basis for tuning. Final tuning lets them adjust for things like ear canal size.

If patents tuned it themselves, they would have too little gain at high frequencies since they may not have heard these frequencies in years and think they sound unnatural. It takes a while to become "used" to hearing aids because patients haven't heard the usual sounds of life like paper rustling in years.

That's why the real question is whether audiologists can be automated away. Is it really so hard to imagine an at-home, self-administered hearing test? Put on a harness, hook it up to your smartphone, answer questions whether the tones are too loud or too quiet by tapping on the screen. Answer speech-comprehension questions by tapping out the word you hear. The app can then program, based on the test results, your hearing aids, sold to you by the same manufacturer of the app and the harness.

People who think that hearing aids can be replaced by a $200 in-ear amplifier don't understand the domain they're talking about, but there's still much that could be disrupted within this space.

That's an interesting idea. You are missing the part where an audiologist inspects your ear to see if there is a ton of earwax, infection, or other foreign body. There is also more test equipment than that often goes with a hearing test. I know some audiogram and reflex results can be indicative of things like a brain tumor which will result in an immediate referral to a ENT.

And there's the whole counseling aspect of telling someone they (or their child) has a hearing loss.

Checking if an ear is affected by earwax / infection / foreign body can be carried out by a nurse, who doesn't need nearly as much education. This is besides the fact that audiologists don't typically deal with earwax / infections / foreign bodies anyway, and typically refer to an ENT anyway. Even after regulation which only permits the sale of the physical equipment which would pair with your smartphone after a prescription from an ENT who sees no sign of other problems, it would still drastically reduce costs for the end consumer, who would never need to set foot in an audiology office.

And pediatric hearing loss is a fraction of all hearing loss patients... don't make the perfect the enemy of the good ;)

So it sounds like you are proposing a way of doing audiograms at home. I don't think this is the most significant cost of hearing aids. What is the average cost of an audiogram, maybe $100? You can already buy hearing aids online if you submit an audiogram. If you still need to visit an ENT office anyway, many larger ENT clinics (especially at hospitals) have audiologists in the clinic already.

It may not be a racket, but as someone with hl i can assure you there is no reason why these shd cost less than 10x their current price.

The ability to program the HA per user is not really difficult and in today's world should not even need a direct person it should be able to be done directly.

I personally feel amplification should be done on the phone, good ML algorithms utilized there depending on the ambient sounds and then transmitted to bluetooth HA.

If an industry can make near invisible bluetooth HA they will unlock a huge market

OK, then. Give that GUI to patients, and let them tune it themselves.

IHear Medical was a IndieGoGo project intended to bring the price of hearing aids down to $200. That was back in 2014. Several years later, they're up to $1000 for a "complete package".[1]

[1] http://www.ihearmedical.com/vippackages/

That's interesting: for the iHearHD, you go from 1000$ to 1500$ if you want a 2-year warranty. I always got at least a 4-year warranty for my regular hearing aids. Even assuming a linear cost, a iHearHD with a 4-year warranty would be around the same price as regular hearing aids.

You go from 1000$ to 1500$ if you want a 2-year warranty.

That's incredibly high. Even Best Buy's overpriced warranties aren't that expensive.

This also includes 1 additional year of batteries (something worth 50-100$). But this may also be a signal they are not confident they are reliable enough?

This sentence gave me alarm bells of weak or biased science writing:

> Experts don’t know exactly why hearing aids are still so costly, except that companies continue to invest in improvements, and fees usually cover the services of a highly trained audiologist.

I don't buy that argument.

When I went to an audiologist and ENT before getting my hearing aid, I had to pay a copay and my insurance company payed thousands (ENT ordered an MRI). A hearing aid from that audiologist would have been at least $3000.

I went to Costco and got an equivalent test with mostly the same audiogram for free. The hearing aid there was $800. I have gone back for free adjustments.

Let's compare this to getting an eye exam and glasses (for both eyes!)

https://www.google.com/search?q=audiologist+salary $74,890

https://www.google.com/search?q=optometrist+salary $103,900

My most recent eye exam plus glasses (after insurance) was way less than $100. The no-insurance no-coupon price on the same would have been about $300. I spent about as much time with the optometrist as I did with the audiologist for the exams. The key difference is the fitting of the hearing aid was done by the audiologist but the fitting of the glasses was done by an optician (salary about a third of an optometrist's salary).

The optometrist also has lots of specialized equipment. The optometrist also has lots of inventory (maybe 1000 frames?) because glasses are a fashion thing too. Audiologists just need to have samples and perhaps a week's worth of inventory. The audiologist's inventory seems more likely to be sold before payment to the supplier is due.

Although this is interesting, there are some logical weak points. A few that came to mind:

* CostCo has a proud reputation for using their annual membership fees to provide door-buster prices.

* Salary is a coarse and incomplete proxy for the cost of an audiologist visit.

* I see no justification for comparing ear exams to eye exams. Why not proctology?

* You seem to imply that doctors pay cash out of pocket for their medical inventory, instead of operating more like a car dealership, where inventory is held on credit

I bought my Costco membership so I could buy a hearing aid, so call the cost of the hearing aid $855 if you must. That's still more than $2000 in savings. The free hearing test was performed before paying for the membership.

Sure, salary is an incomplete proxy. Each also requires a bit of real estate, support staff, and equipment. Both my optometrist and the Costco vision center have a larger space than the Costco hearing center. The Costco hearing aid area typically has one assistant (not an audiologist) working. The optometrist also has at least one assistant (optician).

I chose eye exams and glasses because it is probably an experience that more people can relate to. Proctologists are MDs ($389,700/yr), have more complex facilities and equipment, need more support staff (reception, nurses, aenesthesiologist), have more complex sanitary needs (proctologists perform surgery), and tend not to send patients home with custom-fit devices.

As for inventory - it very well could be that an optometrist does not pay for it up front.

> CostCo has a proud reputation for using their annual membership fees to provide door-buster prices.

No, they limit margins and costs (e.g., by limiting SKUs) to keep prices down; paid memberships build psychological attachment, but the $55/yr membership isn't paying for much in terms of lower prices.

Those membership fees provide the majority of Costco's profit, though.

Correct. They do indeed work hard to minimize markup margins. They also sell some items at a definitive loss.

And they attribute their revenue to the membership fees.

> And they attribute their revenue to the membership fees.

No, their profit is largely attributes to membership fees; their revenue is almost entirely sales (for the 53-week “year” in their most recent 10-K, $126+ billion in net sales, less than $3 billion in membership fees.)

Basically, Costco uses a giant near-zero-profit sales operation as a the key benefit to sell memberships, which are its profit-making business.

So it sounds like they do know why they are still so costly...

My cynical reaction is it sounds like they know, but the author didn't like the answer: experts, plus tech-medical research, is expensive.

Also, for something as life-transformative as a high quality modern hearing aide, the prices didn't strike me as outrageously expensive.

And the next question is: "Why can audiologists charge so much?".

Two hearing aids cost $7,000 because they cover a Dr visit?

And the point of the Dr. visit is to tell you if your hearing loss requires a hearing aid, or is just the result of wax buildup.

So...basically, the Dr. visit could be replaced with a Q-Tip.

Maybe each pair of hearing aids results in $6,500 worth of audio research, but if so, I think those researchers may not be a great return on that money.

It's a matter of time before Apple's Ear Buds, come with a $200 hearing aid upgrade.

By the way, don't stick a Q tip in your ear. Even the manufacturer tells you not to, or at least their lawyers have told them to say that.

http://www.sciencemag.org/news/2017/01/no-more-q-tips-your-e... . Or if you prefer video, https://www.youtube.com/watch?v=cYqeUJda2Qs

Yes, the modern medical recommendation is "don't fuck with your ear canal". Nothing goes in there, and Q-tips are "officially" just for cleaning around the outer parts of your ear (lol ok). They can cause some real hardcore wax impaction and introduce germs, they are not a medically recommended product at this point.

Earwax is a natural antibacterial mechanism, like mucus. If your ears are fucked up they do sell Debrox kits with a compound to soften it and an irrigation bulb, use those. The irrigation does a number on your ear's protections too though.

Hearing loss has many possible underlying etiologies. Some are easily treated, like wax buildup. Some are not, like noise-induced sensorineural hearing loss. Both of those are not dangerous, but others like acoustic neuroma and cholesteatoma are potentially fatal if left untreated. There's good reason for someone to be checked out and cleared by a specialist before they are fitted with hearing aids.

I don't know much about audiology, but I suspect it's a niche expertise that is much more complicated than deciding between a Q-Tip or a generic hearing aid.

There's a lot of different types of hearing loss, and being able to determine the exact requirements for any given person (right hardware, right settings for it, etc) is (as I'm led to believe) not trivial. Sure, you can get better hearing with something off the shelf, but the comparison is similar to off the shelf glasses compared to ones measured specifically for your eyes.

Lots of armchair experts here. Ultimately, a hearing aid is much more than just a sound amplifier. Imagine wearing a cheap sound amplification device that gradually increases hearing loss and causing tinnitus.

I just wish hearing aids were covered by insurance. Mine aren't, which means if mine breaks, I'm paying $3500 out of pocket... for one. And I'm one of the "lucky" ones in that I can only hear out of one ear (and thus only need one hearing aid). For someone who needs two, that's $7000.


I also only need one hearing aid. Luckily I was able to get it from Costco ($800, free exam) and insurance picked up 80%. This year insurance changed such that the hearing aids are mail order and are more expensive than my co-pay at Costco.

The one hearing aid scenario is problematic for any sort of headset. If I use earbuds, I can only hear well in one of them. If I were to spend the extra money to get the bluetooth accessory, that would only go to the ear with the hearing aid.

I'd love to be able to input my audiogram into my phone and have it adjust the headset amplification at various frequencies in each ear accordingly.

Even better would be for noise cancelling headphones to be able to also use an audiogram to have the headphones act as hearing aids when not in noise cancelling mode.

My hearing loss is severe, so I can't just get Costco hearing aids... and insurance never covers it. They cover the audiologist exam, but not the hearing aid itself. It sucks so bad. And yes, if I want Bluetooth accessories, it's even more expensive. My current hearing aid is "Made for iPhone" or whatever, so it can stream directly from my iPhone, which is awesome. Unfortunately, my brand new Apple Watch isn't, so I still have to carry my phone with me on runs or whatever, while my wife can just wear her watch and Bluetooth headphones...

First world problems, I guess?

Few hearing-aid companies. Highly specialised product. They can charge pretty much what they want. And they do. The retail price has a very sizable level of over-charging built in, and many times the client is talked into a product which is much more costly than the one which is necessary.

(The place I worked at many decades ago used to be an agent for one of the major hearing-aid companies.)

I've been to so many concerts (450+ shows from 300+ bands) and I listen to music all day at my desk. My Gran has hearing aids, and her mum was totally deaf. My dad's hearing is getting worse too. I'm sure that I'm going to go deaf eventually, and it will be a sad day when that time comes.

If you're interested in real-time audio effects on smartphones, AudioGraph is an app I've been playing with.


It lets you listen to input signals through the iPhone microphone, do some effects, and pass the output to headphones.

With the right hardware, it's also possible to turn the iPhone into a wireless mic using a Bluetooth headset adaptor (e.g. Sony MW600). Plug the MW600 into the speakers, plug a Kokkia Bluetooth transmitter into the iPhone, run AudioGraph, and speak into the iPhone mic. There's a little lag, but it works well enough for me.

I expect that when my hearing gets worse, I'll use regular headphones (maybe custom-molded Ultimate Ears UE4s) with my iPhone, and do the "tuning" effects using AudioGraph. Being able to pass my smartphone to someone so they can speak into it like a microphone would be much easier than having to lean over so a hearing aid could be closer.

Or you could, you know, wear ear plugs at those shows. That’s what the musicians do.

And then you'd actually hear the music instead of constant thrashing.

If I want to listen to music, I'll get the CD version and listen to it in a quiet room on my nice headphones.

I go to concerts to mosh, buy signed CDs/T-shirts/posters/pins, and meet other fans.

Meeting people requires talking. Earplugs, like the headphones I wear in the office, are a social signal to tell people "don't talk to me". I'm well aware of the dangers to my health, but I've met too many good friends at shows to stop trying to socialise with people who obviously share something in common (taste in music). I'm shy around total strangers, so it's at common-interest events like concerts where I have a starting point to talk about, and thus meet people.

> Meeting people requires talking. Earplugs, like the headphones I wear in the office, are a social signal to tell people "don't talk to me".

That's a hell of a sacrifice to make based on something that's almost purely your imagination. You can have custom earplugs made for $140 that are clear and almost unnoticeable, which will block the majority of damaging frequencies while still allowing you to hear talking pretty well. I promise, no one is going to stop talking to you when you have them in.

The isolation I've experienced from hearing loss is so profound and damaging that it's painful to see how casually you treat it. I'd pay any amount of money to get my hearing back.

Even the earplugs you can get for around 20 protect your hearing enough with their 12dB reduction, and there are models do not noticeably change the sound. Plus: most are simply transparent plastic and hardly noticeable at all. I wear some of these for years now, and I usually keep them in my ears the whole evening once the first band started since you hardly notice them, and talking is still very much possible...

>Earplugs, like the headphones I wear in the office, are a social signal to tell people "don't talk to me".

Interesting that you see it this way. I usually always wear custom-moulded earplugs at concerts, and I've never intended or encountered this signaling.

Have you considered high-fidelity custom earplugs? They're rather inconspicous and the sound is much less muffled than with plain old foam plugs. You can carry on a conversation with them, though obviously not as easily as without. I had some made probably a decade ago and they're still going strong. You can get different filter strengths too.


"Why are hearing aids so incredibly costly?"

"...Experts don’t know exactly why hearing aids are still so costly..."

So the article headline poses a question that writer confesses in the second paragraph not to know the answer to. No, strike that. The author claims that experts don't know the answer to that.

And I scan HN and get answers almost immediately.

HN is great, no doubt, but it's not HN. This is an author who doesn't know how pricing works and doesn't know how to talk to people about how pricing works, which is much more troubling. And the editors must feel that this is the normal state of things.

Pricing may be a bit of a black art in certain markets, but it's no mystery unsolvable by experts. You can bet somebody is setting prices on these things, and when they set them there's a lot of market and historical data being used to do so.

There are simply not-so-many reasons why some things are priced much higher than other things, and these reasons are all well-known and understood. When I read articles like this, it makes me much more critical of every other NYT times article that involves "experts".

Great article for HN because it involves startups, markets, new business opportunities, tech, and so forth. Not such a great article for the NYT, sadly.

A social business in Brazil has an alternative:

http://www.solarear.com.br/ (There is an english version, just click the british flag closer to the footer)

"Solar Ear manufactures low cost, solar rechargeable and environment friendly hearing aids so you can hear perfectly again. Our products are manufactured by deaf workers with high quality components."

Disclosure: I'm not a doctor or audiologist.

Hearing loss runs in my family. When it's time for me, I plan to roll my own. I suspect that if you get rid of just one requirement, it becomes easy. That requirement is to stuff the whole thing in your ear. If the electronics can be in a separate box (or in a smartphone as mentioned), then analog, signal processing, and battery power all become trivial.

My dad is 81 and started having hearing loss a few years ago. He just sent me a pic showing the degree to which he was able to shrink his DIY hearing aid once he settled on the circuit design:


(Stereo mics and amp with two-channel parametric EQ on each side. About 6" wide and runs on two 9v batteries, if you're curious!)

He took it to a Bose showroom to compare it to their Hearphones. All (Bose people included) agreed that his amp and EQ was superior. Cost for parts is ~$200. He's had a lot of fun building them for himself and his friends.

I'd bet it'd be possible to make this much smaller and about half the cost. But I think it'd also end up a lot more difficult to adjust as needed since you'd end up with either tiny pots for adjustment or having to fix the values of everything and use single resistors. Going full DSP would allow you to make this fairly small and cheap (maybe the size of a 9 volt battery) but much more annoying to build and work on if you don't have the skill set. I'd bet this would be a good spot for someone to design a nice open hardware project that'd benefit a lot of people, and if it's setup as kits for headphones that just happen to work well as hearing aids you can probably avoid some of the regulatory issues even though you couldn't ever call them what they are.

Would your Dad be willing to open source his design?

Ideally, you need a mic and a speaker inside each ear so sound can be localized by turning the head. You can put the electronics and battery in a separate box, but wired is better than bluetooth/smartphone because it's hard to get the latency small enough with BT and a smartphone. (This is tougher with Android than IOS.) You don't want the direct sound leading the processed sound in the ear by more than a very small time. Probably single-digit milliseconds, IIRC.

I'm having a hard time finding it, but I learned a while ago that the Cochlear implant system went through a stage where the coil went to a small box worn as a small harness/backpack on the back.

One set of keywords that seems to turn up some of the limited info out there is "cochlear body worn processor".

The commercial Bodyworn systems were a box that fits on your belt; they were totally analog.

Current material refers to 'bodyworn' for babies and toddlers who tend to lose BTEs. You get the same BTE, but it's strapped more firmly to the body.

Anecdotal and I'm in the UK but you can get them from £10 up, eg. this one for £20 https://www.amazon.co.uk/Hearing-Rechargeable-rAdjustable-Am... but my dad pays £2000+ for similar looking but much fancier state of the art ones.


- better quality - the good ones are small computers that use very little power and try to pick out voices from background etc. Apparently the challenging bit for him is dinner parties where you are trying to hear one voice out of several people talking.

- it includes an Audiologist - he's 87 and needs a bit of help on the tech side

- I guess he has the money and values hearing more than the 2k.

It would be cool if computer analysis could understand the several conversations at the party and you could click on the one you wanted or point that way or similar. Maybe in the future, probably won't be cheap.

I thought they were expensive because you have to individually tune some sort of equalizer, depending of the damaged frequencies of the user.

Also the hardware is not really very cheap either, you have to insert it deep into the ear, and the microphone should be sensitive enough to capture all kinds of sounds, at at all distances and air conditions, removing noise, etc. Microphones have always been expensive. It also would be running 24/7.

But to be honest, price should drop indeed. But everybody knows that everything relative to health will often be overpriced if not regulated, especially if it involves any sort of technology.

"But everybody knows that everything relative to health will often be overpriced if not regulated, especially if it involves any sort of technology."

How much is a band-aid? Oh, technology. Ok, how about a digital thermometer?

I think the problem is the opposite. Lots of regulation, however benefits they bring, will raise prices and discourage outsiders from offering competitors.

From the article:

"[A new law] includes a provision for selling hearing aids over the counter to adults with mild to moderate hearing loss in two to three years. [...] Under the new law, hearing aids are expected to cost around $300 or less per ear."

This seems to imply that today, and for the next two years, you cannot legally sell a competing, cheaper aid unless you can get doctors to recommend it. Even if it's just as good, it will take a large marketing effort to show it to doctors.

Now, these regulations do bring benefits. But let's not lose sight of their costs.

> “Eighty percent of people who could benefit from a hearing aid don’t get one,” Ms. Kelley said, often because of cost or access to care. “Some of the reason is stigma: They don’t want to be seen as being old.”

I'm hopeful this will change. I know a fair number of people around 30 with mild hearing loss, and one who does wear a hearing aid. A history of dangerous headphone volume among my cohorts will probably exacerbate things. Ideally hearing aids would carry no more of a stigma than glasses (FSVO "ideal" :P ).

Going by what I've heard from a relative who is an MD, the question is rather why low-quality hearing aids are expensive. The thing is, the average consumer doesn't know much about these things and how they are supposed to work. What the general sound quality should be. How long are they supposed to last etc. So you have loads of companies selling low-quality hearing aids at the same cost as the good quality ones. The consumers don't really know better because they are relying on the word of their doctors or consultants. Surprisingly, not many doctors know much about this industry either.

Reading replies here, sounds like the problem to get HA on budget are decent power consumption and miniaturization.

I wonder if coming up with a earpiece-with-smartphone like combo can be a solution? So the main device with the battery and signal processing SOC is separated from the earpiece. This main device can live in a pocket or attached to the user's belt, while connected to the earpiece through wire.

Perhaps no the most convenient solution, but would it be possible to make such device available cheaply off the selves?

I developed a hearing aid/amplifier app for iOS a few years ago, and I think many people now realize that a free or cheap app can really help with hearing loss. I probably ought to dust off the codebase and modernize it.

People should still go see an audiologist to properly characterize their hearing loss and use that knowledge to choose a suitable product. There are a lot of hearing aid alternatives already out there, but they cannot be marketed to people with hearing loss until the new law takes effect.

Hearing aids are covered by insurance, so there is no cost pressure to bring the cost down. Contact lenses are one of the only medical devices where their price went down in the last few decades. This is because people pay out of pocket. It's the same concept behind rising tuition. If people don't see the cost directly come out of their own pocket (either through insurance or student loans), they don't complain about cost as much, and it sky-rockets.

Which country are you from? In the US, hearing aids are not covered by most health insurance (much like glasses.) In fact I think it is explicitly written in the Medicare laws that they are not covered. So I don't think the rest of your thesis applies.

Hearing aids aren't actually covered by insurance nearly as often as one would expect. The majority of patients pay out of pocket already.

Things that are paid for by other people tend to be expensive.

Sadly, insurance does not typically offer any coverage for the devices themselves. (src: been wearing them for over twenty years, have seen one employer plan that offered any benefits in that area)

Scandinavian here—wait, the paid health insurance doesn't cover the devices themselves?

I assume that people in the US are probably tired of "grass is greener on the other side" stories, but I'm seriously surprised that the paid insurance doesn't cover.

Here, the free public health insurance covers the devices needed with no price limit, and cover all battery expenses for life. If you want to get the devices themselves from the private sector, the public health insurance covers up to some fixed price, with you paying the rest.

> Things that are paid for by other people tend to be expensive.

A clever statement, but do you mean it seriously? Is there some basis for it?

Looking at healthcare and drugs, they cost around a third less in countries with national healthcare than in the U.S., where most healthcare is paid for by individuals or by their employers.

Hearing aids are surprisingly quite often not covered by insurance.

Auto-repair/auto-insurance doesn't fit this explanation. Repair is still a competitive industry with rather low margins.

That's because tons of people have to pay for their own auto repairs.

And yet, it's still expensive.

The counter argument would be that there is enough business that isn't paid by insurance companies to keep competition high.

If no one paid for car repair out of pocket, prices would be much higher.

They are too high at the dealership. At least, they feel high compared to what a knowledgeable friend who knows how to get used parts (junkyard etc) will charge for parts.

Could be. Sounds like a decent argument against universal health care insurance, too. More things should be out of pocket.

You don't have to be accredited to fix cars. You just need to open up a shop. As such, there is plenty of competition.

Only a few states have no specific licensing requirements. Many states require an exam. Some cities even require ASE certification.

Sources: http://work.chron.com/state-requirements-auto-mechanic-30132... http://www.michigan.gov/sos/0,4670,7-127-49534_50302---,00.h... https://en.wikipedia.org/wiki/Automotive_Service_Excellence

Consider going to Costco. I think my Dad pays around 500 CAD for his set. They would likely cost more than double at other places. The service at Costco is great as well.

Also, as other people have said, they are expensive because they are technologically advanced and expensive to manufacture. You can build some kind of hearing aid for less than $100 but it will not compare with a $500 one.

Canada may be cheaper than US. But still, I've heard the same advice in US.

I bought my glasses from Costco, even though it's "out of network" for my vision insurance. Still a hell lot cheaper than Lenscrafter, etc.

I imagine the same applies for hearing aside

As with everything else, they are expensive until someone decides to reduce the production cost and sell them cheaper.

I wonder if there some day will be therapy (stem cells?) or a medical procedure to repair damaged ears.

There are a couple of genetic therapy cures in trials...


Also promising is a solution using Crispr


The Siemens Orion is sold in India for around $250.

While it is not a premium hearing aid, it appears to be adequate for at least some.

Unbranded Chinese hearing aids are available for around $25.

My solution - buy a high end smart phone - the more (directional) mics it has the better. Add a high quality "spouse mic" that you can place whereever you want on conference table/dining table/nightstand/next to the door bell. Most phones, home assitants, the kinect etc come with with mic arrays and have ridiculously sophisticated audio stacks. You can't do cutting edge speech rec without those stacks.

These ridiculous hearing aid companies are going to go the way of dinosaurs soon. And good riddance.

I'm not really sure what you're proposing here. Any system that requires location-based setup seems obviously inferior to a system that rides in your ear and just works wherever you go.

I'm going to be that annoying guy: They're free* in Scandinavia, including batteries for life.

* "Free" meaning "paid for by the tax-sponsored public health insurance", which people up here would call "free".

An alternative phrasing could be:

> In Scandinavia, hearing aids (with a lifetime supply batteries) are supplied without additional cost as part of the national health care program.

Ah, thank you! That phrasing is much better, and saves the footnote, without which someone would surely respond about how it "clearly isn't free"...

As someone with un-impaired hearing I really don't get why I can't a programmable enhanced hearing device for less than $100.

Fuck Magic Leap, surly enhancing hearing is easier and cheaper.

Block traffic. Enhance birds. Perhaps translate. Listen to tv how I want.

There are things like SportEar, marketed to hunters, where they want (a) enhanced hearing in quiet environments, and (b) suppression of very loud sounds. Some of them are just rebadged hearing aids with unvented receivers.

AirPods is the closest you can get right now.

I've considered buying Resound wireless HAs for that purpose before. Instead I just walk around with IEMs and push-to-hear mic all day.


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