Identifying Barriers to Access Speech-Language Pathology and Audiology Services

Adapted from the chapter “Strategically Promoting Access to Speech-Language Pathology and Audiology Services,” by Brooke Hallowell in Professional Issues in Speech-Language Pathology and Audiology, Sixth Edition edited by Melanie W. Hudson and Mark DeRuiter (2023)

Introduction

Access to quality services for people with hearing, balance, speech, language, swallowing, and related concerns is limited in myriad ways, even though the number of people of all ages needing such services is steadily increasing. To counteract strategically the forces that threaten access to services, we must have a clear understanding of the barriers to access and a sound rationale for the need for our services.

Identifying Barriers to Access

A first step in considering how we may strategically promote access to services of audiologists and speech-language pathologists (SLPs) is to examine why many of the people who need these services cannot or do not obtain them. Identifying challenges to access helps us then consider opportunities for enhancing access by strategically addressing those challenges. Here, we will consider barriers to access that relate to infrastructure, funding, sociocultural influences on access to care, and navigation through health care systems. A host of additional critical barriers not addressed in detail in this chapter relate to systems of privilege and oppression, such as racism, sexism, xenophobia, ableism, heterosexism, ageism, and deep-seeded cultural complexities (Hallowell, Hyter, et al., 2021).

Addressing Challenges With Infrastructure

Despite wonderful progress in expanding our professions throughout the world over recent decades, many countries still lack formal programs to educate SLPs and audiologists. Many also lack the recognition of our professions by governments and health care systems. In some regions of the world, our professions are in their infancy. Even where the professions exist, there are insufficient numbers of clinicians to meet local and national needs (Ali & Syed, 2021; ASHA, 2022; Pillay et al., 2020; Royal College of Speech and Language Therapists, n.d.). Additionally, people living in rural areas throughout the world tend to have poorer access to services than those living in more urban areas (Eubank et al., 2022; Jones et al., 2017; Lowe & Nobriga, 2021; Morton et al., 2022). Thus, simply in geographic limitations, much of the world’s population does not have access to our services. Needs for transportation, facilities, and workforce are best addressed through collaborative efforts of government agencies, colleges and universities, professional organizations, nonprofit entities, and passionate professionals.

Examining Funding Challenges

In much of the world, reimbursement and funding problems constitute the greatest barriers for access to audiology and speech-language pathology services. In higher-resourced countries where the professions of speech-language pathology and audiology are well established, an emphasis on cost containment in all areas of health care delivery is at the root of many barriers to access. Children and adults with disabilities face unique difficulties as they attempt to obtain services through progressively more unwieldy health care systems. Overall, access to our services is being reduced by the coverage and reimbursement limitations imposed by third-party payers and ever-changing means of determining how our services are to be reimbursed.

In the United States, physician referrals are decreasing, authorizations for evaluations and treatment are processed slowly, insurance claims are often denied, and the appeals process can be cumbersome and lengthy. Additionally, public and private health insurance carriers’ reimbursement rates are at times well below the actual cost of providing services (Lim et al., 2010; McManus et al., 2010). As a result, some health care employers are eliminating positions or are placing clinicians on as- needed schedules, actions that further jeopardize access to services. Primary care physicians are more aggressively guarding scarcer financial resources to ensure the availability of basic health care for their patients. Many physicians see audiology and speech-language pathology services as a low priority (Zazove et al., 2020) or as services that should be paid for by other entities such as school districts, public service organizations, or clients themselves. Insurance companies are following suit.

Identifying Sociocultural Barriers to Access

Given increased diversity through worldwide migration and immigration and increasing work to empower marginalized groups and advocate for greater inclusion, clinicians everywhere are more and more likely to work with people who are diverse in multiple respects. To ensure access, service-providing agencies must demonstrate understanding of concerns and needs of people who are diverse, such as in race, ethnicity, religion, education, sex, sexual orientation, gender identity, age, income, education level, socioeconomic level, and languages spoken—plus the complex intersectionality of these constructs. If they do not, and if they do not engage actively in inclusive action of marginalized people, large populations of people will not gain access in the first place or will be alienated from services they need. Our cultural responsiveness as clinicians is vital to engaging diverse people to benefit from our services and helping them to retain access to us.

When expanding services for specific populations, it is important to consider cultural beliefs such as those regarding health care and the nature of disabilities. Hospital- based services may not attract people who would more likely gravitate to community-based and nonmedicalized models of care. Not having proficient speakers of a person’s primary language available to provide services severely limits what we can offer. Disregard for cultural and religious beliefs leads to stunted opportunities for access to care. For example, consider the consequences of the following on a person’s willingness to engage in our services:

■    The assumption that a person is comfortable with the diagnostic process of labeling a disability despite a strong sense of stigma associated with disability, or a desire to protect a loved one from being labeled as having a problem

■    A lack of recognition that a person may see their engagement in rehabilitation as a refusal to accept a disability that was bestowed on them by a higher power

■    Prioritization of foci on impairments and deficits rather than on life participation

■    A focus of interventions on individuals rather than on their families and support systems

Recognizing the Burdens of Navigating Health Care Systems

Understanding today’s medical literature and health insurance materials can be daunting for even the most sophisticated person. For those with literacy problems, difficulties are substantial and, as a result, differentially impact access and related needs for patient support and advocacy.

References

Ali, I., & Syed, E. (2021). So you want to learn about speech-language pathology? An introduction to the speech-language  pathology profession. Speech-Language Pathology & Audiology Canada. https://www.sac-oac.ca

Eubank, T.N., Beukes, E.W., Swanepoel, D.W., Kemp, K., & Manchaiah, V. (2022). Community based assessment and rehabilitation of hearing loss: A scoping review. Health & Social Care in the Community, 30(5). https://doi.org/10.1 1 1 1/hsc.13846

Hallowell, B., Hyter, Y.D., Watson, J.B., Combiths, P., Lansing, C.R., Ramkissoon, I., & Flynn, T. (2021). Final report by the ad hoc committee to develop guidance for members and students engaging globally in clinical, scholarly, and other professional activities.  American Speech-Language-Hearing Association. https://www.asha.org/siteassets/reports/

Jones, D.M., McAllister, I., & Lyle, D.M. (2017). Rural and remote speech-language pathology inequities: An Australian human rights dilemma. International Journal of Speech-Language Pathology, 20(1), 98-101. https://doi.org/10.1080/17549507.2018.1400103

Lim, S., McManus, M., Fox, H., White, K., & Forsman, I. (2010). Ensuring financial access to hearing aids for infants and young children. Pediatrics, 126(1), S43-S51. https://doi.org/10.1542.peds.2010-0354i

Lowe, S.M., & Nobriga, C.Y. (2021). Head and neck cancer in a rural U.S. population: Quality of life, coping, health care literacy, and access to services. American Journal of Speech-Language Pathology, 30(3), 1116-1133. https://doi.org/10.1044/2021_ajslp-20-00223

McManus, M.A., Levtov, R., White, K.R., Forsman, I., Foust, T., & Thompson, M. (2010). Medicaid reimbursement of hearing services for infants and young children. Pediatrics, 126, S34-S42. https://doi.org/10.1542/peds.2010-0354h

Morton, M.E., Gibson-Young, L., & Sandage, M.J. (2022). Framing disparities in access to medical speech-language care in rural Alabama. American Journal Speech-Language Pathology, 31(6), 2847-2860. https://doi.org/10.1044/2022_ajslp-22-00025

Zazove, P., Plegue, M.A., McKee, M.M., Dejonckheere, M., Kileny, P.R., Schleicher, L.S., . . . Mulhem, E. (2020). Effective hearing loss screeing in primary care: The early auditory referral-primary care study. Annals of Family Medicine, 18(6), 520-527. https://doi.org/10.1370/afm.2590