Cochlear implants (CIs) have revolutionised the management of severe-to-profound hearing loss in adults and children throughout the developed world. For adults whose hearing loss has exceeded the capabilities of hearing aids, CIs have meant the ability to understand speech is returned, bringing relief from social isolation and a huge improvement in quality of life. Seeing this occur regularly is the most rewarding part of my work as an otologist.
Guitar et al,1 in this issue of the Journal, have shown that people on the Northern Cochlear Implant Programme’s waiting list had worse self-reported indices of mental and physical health than those who had received cochlear implants.1
It must be remembered that the people on the adult waiting list are by no means the only people with potentially compromised mental and physical health due to their acquired hearing loss. Whilst CIs have been available in New Zealand since 1987, the intervention still has a low profile. I have no doubt that there is a significant unmet need in the community.
It is not uncommon to meet patients who have had hearing levels which would have made them CI candidates for decades prior to their referral and subsequent implantation. My clinical (but untested) impression is that when people like this have been placed on the waiting list they have a great deal of hope which may actually improve their outlook on life. Whilst funding for cochlear implantation has certainly improved, this large unmet need means that the referrals keep coming.
CIs are expensive. The approximate cost of a (single) CI including surgery and support for 12 months is NZ$50,000. This large “up front” cost for what is principally a publicly funded service is one of the reasons for long waiting lists.
What are the current waiting list issues? An excellent summary of adult funding issues was provided by Robert Gunn in a previous editorial in thisJournal in 2010.2 Since that time funding has improved. The Ministry of Health manages to “find” extra funding on a one-off basis relatively regularly which the cochlear implant programmes gratefully accept.
Our requests for increased guaranteed funding was met earlier this year with funding now for 60 adult implants for the country per year, up from 40 prior to 2013. Extra adults are implanted privately and through charitable means. This extra funding has meant that there is no longer anyone waiting over 2 years in New Zealand, which is a significant improvement.
Whilst the 50% increase in funding for adults is a big step in the right direction, waiting list numbers remain high. Currently there are 142 adults on the combined waiting lists of New Zealand’s two cochlear implant programmes.
Demand for bilateral CIs in children will also stress funding. There is now very good evidence that congenitally deafened children are better managed with bilateral CIs.3,4 At the present time in New Zealand, children have effectively “on demand” access to a single CI. A proportion of parents fund a second implant privately through fundraising of various sorts, but there is increasing pressure to have these funded by the State. Many adults also perform significantly better with bilateral CIs but given all of our other issues no-one is asking for state funding for these.
With improving technology and device performance, CIs are becoming indicated for individuals with better hearing than in the past. There is also evidence for their efficacy in people with significant unilateral deafness.5 All of these factors add up to a growing list of candidates and more pressure on funding.
A significant long-term financial issue is the problem of upgrading the speech processor (outside) portion of the CI system. Due to wear and tear this needs to be done every 6–8 years at a cost of approximately NZ$10,000. There is another advantage in upgrading, there are significant technological advances which generally are measurably different over a similar time span. At the present time CI programmes commit to providing replacement speech processors indefinitely for publicly implanted patients. This is a huge long-term financial commitment of dubious sustainability.
Aside from the obvious solution—i.e. greatly increased funding— are there any other changes that could help ease funding pressures? The Australian Government does not provide CI upgrades after early adulthood. New Zealand could adopt a similar policy or could perhaps subsidise upgrades in the way they do with hearing aids.
The initial cost of a CI is prohibitive to many. Various ways of part-funding have been explored by our CI programmes but there are significant challenges to making these sorts of schemes equitable.
In summary, the paper by Guitar et al makes a strong case for increased funding for adult cochlear implants in New Zealand. Severe-to-profound hearing loss has a huge impact on the social, mental and physical wellbeing of sufferers and it has a reliable, effective treatment.
The success of cochlear implantation has created funding headaches for the CI programmes and their funders but an increasing number of New Zealanders are benefitting from this life-changing intervention.