MarkeTrak VI: Measurement Drives Success – Consumer Feedback on Needs, Benefit, Satisfaction & Value Sergei Kochkin, Ph.D. Better Hearing Institute

MarkeTrak VI:Measurement Drives Success –

Consumer Feedback on Needs, Benefit, Satisfaction & Value

Sergei Kochkin, Ph.D.

Better Hearing Institute

Agenda• Factors impacting choice of dispenser• Factors impacting choice of brand• Improvements in H.I. sought by consumers• The impact of VC on satisfaction• The issue of value (price, benefit &

satisfaction)• Toward a best practices protocol

Factors Impacting Choice of Dispenser & Brand

Factors Impacting Choice of Dispensing Practice (n=2,251)

(Importance scores =4-5 on 5 point scale)

77

64

63

63

59

52

51

50

46

41

31

Professional staff

Convenient location

Convenient hours

Price

Free hrg screening

Range of hearing aids

Physician referral

Live demonstration

Insurance coverage

Previous purchase

Friend recommended

0 10 20 30 40 50 60 70 80 90 100

% highly important

Example of Professional OfficeDr. Gyl Kasewurm – St. Joseph MI

Number of hearing health providers visited prior to deciding on current hearing instrument purchase.

None1.4%

One61.1%

Two28.5%

Three or more9.0%

Amount of Counseling Time Spent with Hearing Aid Users During Last Hearing Instrument Purchase (H.I. < 6 years compared to H.I. < 1 year).

3.3

13

31.7

25.1

18.3

4.4

4.3

2.2

14.4

31.4

24.3

19.8

4.6

3.4

2.2

12.8

29.2

25.2

20.7

5.7

4.3

None 0.25 0.5 0.75 1 2 3+

Counseling time spent (hours) with users

0

5

10

15

20

25

30

35Percent of users

H. I. UserNew < 6 years

Experienced < 6 years

All <1 year

Modal time is half hour

Percent of Consumers Receiving Follow-up Customer Satisfaction Survey (H.I. < 6 years compared to H.I. <1 year in age).

58.9

21.1

9

5.3

4.1

1.7

57.2

21.5

8.7

7.1

2.6

3

None

Verbal office

Mail

Written office

Phone

Computer office

Post-survey method

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70

Percent hearing instrument owners

Age of H.I.H.I.< 6 years

H.I.< 1 year

Overall Customer Satisfaction Ratings as a Function of Counseling Time Spent with Users During Last Hearing Instrument Purchase (H.I. < 6 years compared to H.I. < 1 year).

39 42

54 5

9 60 6

5

53

45 5

2

63 64 68

68

65

42 4

8

59 62 65 67

59

None 0.25 0.5 0.75 1 2 3+

Counseling time spent (hours)

0

10

20

30

40

50

60

70

80

Pe

rce

nt

of

us

er s

H. I. UserNew < 6 years

Experienced < 6 years

All <1 year

Overall Satisfaction with Hearing Instruments as a Function of Post-fitting Survey Follow-up(H.I. < 6 years compared to HI < 2 years).

54

62

68

69

64

62

57

60

71

72

69

61

None

Verbal office

Mail

Written office

Phone

Computer office

Post-survey method

30 40 50 60 70 80

Percent overall customer satisfaction

Age of H.I.< 6 years

< 2 years

Key Conclusions• Top factors in choosing dispenser:

– Professionalism– Convenient location– Convenient hours– Price

• Minority of dispensers conduct formal post-purchase survey with consumers.

• Post-purchase survey + related to satisfaction.• Customers shop around for dispenser (4 in 10).• Modal counseling time spent by dispenser is one-half hour.• Amount of counseling + related to satisfaction.

Factors Impacting Choice of Brand

Factors Considered Helpful When Choosing Brand of Hearing Aid (n=2,273)(Helpfulness scores =4-5 on 5 point scale)

766160

5549

463736

262524

2220

1615

121110

5

Audiologist recommendationH.I.S. recommendation

Medical doctor recommendationOther hearing aid owner recommendation

Consumer reportsFamily members recommendation

Manufacturer brochuresScientific papers

Magazine articlesBooks on hearing aids

Newpaper articlesAARP recommendation

Direct mail adTV ads

Newspaper adsHHP websites

Manufacturer websitesRadio ad

Internet chat sites

0 10 20 30 40 50 60 70 80 90 100

% helpful

Number of Hearing Instrument Brands Taken

Home at Last Fitting Prior to Final Purchase (n=1,387 instruments < 5 years of age )

One87.0%

Two10.0%

Three or more3.0%

Greater likelihood of receiving multiple brands if the customer is an experienced user with a severe loss.

Prior Knowledge

• 60% of consumers had “some” to “good” knowledge of technology prior to purchase.

• 40% of consumers knew the brand of hearing instrument purchased.

Conclusions• Top factors considered to be helpful and reliable when

choosing a hearing aid brand:– Audiologist recommendations– Hearing instrument specialist recommendation– Medical doctor recommendation– Hearing aid user recommendations

• Less than 20% consider marketing material or websites as helpful in their purchase decision.

• 13% customers receive multiple brands at first fitting.– Equates to the 16% return rate in our industry

Conclusions• Brand awareness is low (40%); technology

knowledge is higher (60%).

• Limited usage of Internet by our key customer (elderly).

• ALD usage is low – highest is phone amplifier (27%).

The Impact of the VC on Consumer Satisfaction

Issues

• Consumer accessible VC (ease of regulating volume) is diminishing with CIC and digital hearing instrument growth.

• Previous MarkeTrak research:– Use of VC rated desirable (77.5% consumers in US market).– Easier regulation of volume is on wish list of 72% US and

65% German consumers.– Customer satisfaction with volume regulation declined by

11% points in last 10 years.

• Is removal of VC negatively impacting overall satisfaction with hearing aids?

Percent of in-the-ear Hearing Instruments with Volume Controls by Year of Purchase

(MarkeTrak VI – n=2352)

98 91 88 85 81 78 75

0102030405060708090

100

<1994 94-95 1996 1997 1998 1999 2000-2001

Year of purchase

Per

cent

wit

h V

C

Customer Satisfaction with Hearing Instruments as a Function of Desire for Volume Control

(MarkeTrak VI - H.I.< 6 years)

66

7973

6066 6360

3948

0102030405060708090

New User Experienced User Total Users

% S

atis

fied

No Not Sure Yes

Straight Comparisons of Hearing Instruments With and Without VC

• In general ITE hearing instruments without VC receive higher ratings (>10%):– Visibility– Comfort with loud sounds– Whistling/feedback– Use in noise– Telephone and cell phone usage

• The individual who wants a VC but does not have one rates 35 MarkeTrak factors lower by at least 10% points – clearly dissatisfied with the total experience.

Isolating VC effect

• Analysis of covariance– Control for H.I. style, experience, technology

• On average , presence of VC shown to have negative impact on:– Comfort with loud sounds– Use in noise– Cell phone usage

• Presence of VC shown to have positive impact on:– Battery life

• However, there are significant interactions due to experience in favor of the VC.

Frequency of Desired Volume Adjustment – Consumers without a VC

Source: Surr, Cord, Walden (HJ 2001 n=79 users)

Half the time10%

Occasionally36%

Seldom20%

Generally6%

Almost always

5%Always

0%Never23%

Currently the VC is removed for a minority segment

Conclusions

• Consumers do not like to fiddle with their hearing instruments every 10 minutes.

• Automatic hearing instruments for all consumers should be our goal.

• Until hearing instruments are PERFECT the categorical removal of the VC will be problematic for some consumers.

Conclusions• Most likely problem areas are:

– Automatic hearing aids are not perfect and cannot predict consumer needs in 100% of listening situations.

– Some consumers psychologically need some control over their hearing instruments.

– Experienced users are unwilling to part with the VC through habit.

• The dispenser needs to be especially vigilant to the consumer’s need to control the volume of their hearing instrument---especially experienced users.– Even an “occasional” or “seldom” need is indicative of the need

for a VC.

Hearing Instrument Improvements Sought by

Consumers

Hearing Aid Improvements Sought by Current Hearing Aid Owners (n=2,428)

(Highly desirable scores =4-5 on 5 point scale)

9588

858483828281817977

7473

Speech in noiseBetter sound quality

Less whistle/buzzingLower price

More soft soundsLonger lasting batteries

Work better on telephoneLoud sounds less painful

Speech in quietBetter fit & comfort

Should have VCLonger money back guarantee

Less costly to repair

0 10 20 30 40 50 60 70 80 90 100

% highly desirable

Hearing Aid Improvements Sought by Current Hearing Aid Owners (n=2,428)

(Desirable scores =4-5 on 5 point scale)

7271

666362

5652

483432

2821

15

Easier to regulate volumeMask tinnitus

Easier to cleanWork better on cell phone

Better sound to musicShould not break down as much

Less visibilityEasier battery change2-5 year payment plan

Should have remoteMore fashionable

ColorLease hearing aid

0 10 20 30 40 50 60 70 80 90 100

% highly desirable

Summary of Consumer Needs – Four Methods

• Factors </= 40% satisfaction.

• Factors most related to overall customer satisfaction.

• Reasons why hearing instruments are in the drawer.

• Improvements sought in hearing instruments.

Factors < / = 40% Satisfaction

• Hearing in noise• Hearing instrument usage in large groups• Hearing instrument usage on telephones &

cell phones• Hearing instrument usage at concerts and

movies• Whistling, feedback and buzzing• Comfort with loud sounds

Factors Most Related to Overall Customer Satisfaction

• Improved benefit at a good value

• Better sound quality

• Better Reliability

• Multiple Environmental Listening Utility (MELU)

Reasons Why Hearing Instruments are in the Drawer

• Poor benefit

• Inability to hear in noise/background noise

• Poor fit and comfort

• Negative side effect of hearing instrument

• Price & cost of repairs

Improvements Sought in Hearing Instruments

• Speech intelligibility in noise

• Better sound quality

• Less whistling & buzzing (feedback)

• Lower price

• More soft sounds audible

What does it take to turn the hearing instrument market around? (Rihs

1997)• The underdeveloped hearing instrument

market can only reach its potential if the hearing instrument becomes a true personal communication device.

• The stigma of hearing instruments will decrease parallel to the increase in hearing performance.

What does it take to turn the hearing instrument market around? (Rihs

1997)• The degree of user satisfaction is

directly related to hearing performance and not the cosmetics.

• The negative image of the hearing instrument will only disappear when hearing comfort and communication in all environments are guaranteed.

The Issue of Price & Value

Is This a Common Societal Perception?

Issues & Agenda

• Customer satisfaction with benefit and value are key drivers of customer satisfaction.

• Without major improvements in these two areas market growth is unlikely.

• Agenda:– Explore the relationship between price, benefit and

satisfaction.– Position our industry relative to other industries on

customer satisfaction.– Explore possibilities of “best practices”

selection/fitting/verification/validation protocol

Customer Satisfaction with Value, Benefit in Noise, Overall Benefit and Likelihood of Repurchasing

(H. I <3 years of age; source MarkeTrak III (1991) – MarkeTrak VI (2000)

3127

32 31

54 53 55 5552 54 54

77 7580 76

010

2030

405060

7080

90100

1991 1994 1997 2000

Per

cent

Sat

isfa

ctio

n

Noise Value Repurchase Likelihood Benefit

Method

• 36 MarkeTrak customer satisfaction studies combined (n=16,519).

• Conducted between 1990-2002.• More than half also administered

Abbreviated Profile of Hearing Aid Benefit (APHAB).

• 26 of the studies have been published.• Price of hearing system adjusted for

consumer price index in CY2002 terms.

Basic Descriptive Data

• 36 studies• Average age of consumer = 69• Median household income = $35,000.• 82% bilateral loss/66% binaural user.• Half programmable• 5% directional• 5% DSP• 28% BTE (higher than US average)• Mean CPI adjusted out of pocket cost of hearing

system was $2,308.

Measurement of Benefit

• Combined scales from APHAB– Ease of communication– Background noise– Reverberation

• Absolute Benefit = Unaided – aided• Percent Disability Improvement =

(Benefit/Unaided) x 100• Consumer value = $$$/Percent disability

improvement.

Histogram of Hearing Disability Improvement as Measured by the APHAB (n=8,654).

Hearing disability improvement =(APHAB Benefit/Unaided APHAB).

0

50100150200

250300

350

400450500550

600

0 10 20 30 40 50 60 70 80 90 100

Hearing disability improvement (%)

Sam

ple

siz

e

Median=44%

Validity of APHAB• Related to market penetration (unaided).• Correlated with customer satisfaction and hearing aid

usage.• Unaided APHAB correlated (.45 - .68) with:

– Pure tone threshold– NU-6 word recognition– Speech in noise test

• Indirect validity:– Absolute benefit of my studies is 28%– Absolute benefit of the JAMA hearing aid efficacy study (n=360):

• 29% on NU-6• 26% on Connected Speech Test (CST)

Hearing Instrument Market Penetration is Highly Related to Recognition of Hearing Disability

Source MarkeTrak IV (n=5,954 individuals with self-admitted hearing loss)

0

10

20

30

40

50

60

70

80

90

100

1-4 5-9 10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90-94

95-99

APHAB Unaided (Hearing Disability)

Per

cent

Hea

ring

Aid

O

wne

rshi

p

Relationship Between Price and Customer Satisfaction for Hearing Instruments

< 3 years of age (n=13,451)The correlation between price and overall satisfaction is low (+.02)

404550556065707580859095

100

0

<250 25

0

500

750

1000

1250

1500

1750

2000

2250

2500

2750

3000

3250

3500

3750

4000

4500

5000

6000

+

Price

Sati

sfac

tion

Overall

Benefit

Value

Poly. (Overall)

Poly. (Benefit)

Poly. (Value)

Relationship Between Improvement in Hearing Disability and Customer Satisfaction (n=8,654)Powerful relationship between disability improvement and satisfaction

253035404550556065707580859095

100

0 10 20 30 40 50 60 70 80 90

% Change in Hearing Disability

Sati

sfac

tion

Overall

Benefit

Value

Poly. (Overall)

Poly. (Benefit)

Poly. (Value)

Customer Satisfaction is Highly Related to $$$ Spent per 1% Improvement in Hearing Disability

253035404550556065707580859095

100

5 15 25 35 45 55 65 75 85 95 125 200 500

Price ($$) spent per 1% disability improvement

Sat

isfa

ctio

n

Overall

Benefit

Value

Poly. (Overall)

Poly. (Benefit)

Poly. (Value)

Development of Underlying Models

• Aggregate consumers into narrow cohorts:– $250 ranges for hearing system (free - $6000+)– %10 hearing improvement range (10% - 100%)

• 110 aggregates• Average consumer per cohort 78 people.• Model weighted based on subjects per cohort after

calculating within each cohort:– Satisfaction– Hearing disability improvement (benefit)– Average price paid (CPI adjusted)

Satisfaction with Benefit and Likelihood of Repurchasing Current Brand of Hearing Aid as a Function of Hearing Disability Improvement.Price is not related to these two

variables. (Statistical model)

253035404550556065707580859095

100

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

Percent Improvement in Hearing Disability

% S

atis

fact

ion/

repu

rcha

se

Benefit-Satisfaction

Brand repurchaselikelihood

Benefit R2=87

Brand repurchase R2 =66

Overall Customer Satisfaction as a Function of Price and Hearing Disability Improvement

(Statistical Model)

PriceHearing disability improvement (%)

Overall Customer Satisfaction (%)

R2=.86

Customer Satisfaction with Value as a Function of Price and Hearing Disability Improvement

(Statistical Model)

PriceHearing disability improvement (%)

Customer Satisfaction (%) with Value

R2=.87

General Conclusions

• Benefit more powerful predictor of customer satisfaction then price.

• Customers are rational and will attempt to maximize their benefit.– Less than perfect benefit will result in significant brand

shifting– Using the models a 50% improvement in hearing disability=

• 86% satisfaction with benefit• 59% repurchase rate• 56% satisfaction with value at $3,000 (binaural)• 75% overall satisfaction at $3,000 (binaural)

Toward a Best Practices Protocol

Benefit is Critical to Market Growth

• High benefit is related to:– High customer satisfaction– High brand retention

• High customer satisfaction :– Leads to positive-word-of-mouth advertising– And therefore market growth

• Important to focus on the dispenser’s role in optimizing consumer benefit.

• Development of equivalent of a ISO9002 program to optimize individual benefit at the point of sale.

Selection/verification/validationSome Considerations

• Convene committee of industry’s brightest to develop/recommend “best practices” hearing instrument selection/verification/validation protocol– Medwetsky found wide variability in protocols in 60

practices.– “might be a great need for a best practices standard that is

widely accepted and used by all hearing care professionals”.

– Standards may be available but not utilized (e.g. ASHA guidelines for hearing aid fitting for adults)

– Washington University School of Medicine Protocol (attached for your review and consideration)


• Fitting formula have become more sophisticated but they are still a starting point. How many dispensers use the default settings versus attempt to optimize individual benefit at the point of sale?

• There will be significant differences in outcome measures both in terms of speech intelligibility and subjective consumer preference depending on which prescriptive formula is used. (See January 2003 Hearing Review)

• May be significant interactions between prescriptive formula, individual hearing loss characteristics, style/circuit of hearing instrument, and perhaps even the personality of the end-user .


• Advanced multivariate research (e.g. use of artificial intelligence software) could lead to the development of a prescriptive decision tree which would assist the hearing care professional in optimizing benefit for the end-user.

• Does the lack of wide scale adoption and/or usage of real ear measurement impact benefit?– 50% of HIS own– 75% of audiologists own

• Does the lack of wide scale adoption and/or usage of hearing aid analyzers impact benefit (e.g. measurements on the functionality of the hearing instrument). Is a listening test enough?– 59% of HIS own – 85% of audiologists own

Selection/verification/validationSome Considerations• Assure audibility of important sounds (especially

speech) and loud sounds should be comfortable:– 44% satisfaction with loud sounds comfortable in a custom industry is

unacceptable.

• Measurement of unaided and aided speech intelligibility in quiet and noise. The difference is benefit (see January 2003 Hearing Journal):– Minority of dispensers and audiologists measure benefit routinely.– Subjective (APHAB), or objective (HINT, QuickSIN) tests widely

available.

• Share benefit scores with consumers helping to shape realistic expectations.


• Should we establish contracts with consumers promising certain levels of benefit in quiet and noise based on our knowledge of the consumer’s hearing loss characteristics?

• Does the use of patient focused 360 sound field aided testing (e.g. Beltone Avenue) have a positive impact on maximizing individual benefit?– Preliminary research shows < fitting time– No impact on APHAB benefit scores

• Should consumers be made to pay for hearing instruments with little or no measurable benefit? (e.g. speech intelligibility improvement).


• Measurement of longer term customer satisfaction (3+ months after fitting).– Minority- 18% do any form of formal

follow-up.

• Issue of value assures that the consumer expenditure of energy (time, money) is exceeded by the dispensers energy expenditure (time, service, product).

Consumer

Dispenser


• Industry associations should validate the best practices in order to gain wide scale acceptance of a “golden” or “best practice” protocol:– Customer satisfaction – Consumer benefit – Profitability– Dispenser morale– Practice growth – Referrals– Return rates

• Turn best practices protocol into equivalent “Good Housekeeping Seal of Approval”. Implicit in such a seal is a “benefit guarantee” to the consumer.

Some Methods for Improving Satisfaction 10%-20%

• More counseling time with consumer.• Creating realistic expectations especially given very

high consumer expectations of DSP.• Any form of outcome measure (benefit).• Use of VC especially for experienced user.• Directional hearing aids as standard technique for

improved communication in noisy situations.• More patient focused techniques for optimizing

benefit.• Creating more perceived value for the consumer.

Some Final Considerations

• Measuring performance helps drive success.

• Without effective measurement how can we assure we have optimized the customer’s hearing experience?

• Without effective measurement how can dispenser’s grow in their wisdom on behalf of the consumer?

Sample ProtocolWashington University School of Medicine

• Established appropriate prescriptive REIG (corrected for mixed HL (>20% of A-B gap) and/or binaural summation (<3-5 dB))

• REM for nonlinear hearing aids with input levels of 50, 65 and 80 dB with speech-weighted composite noise (analog) or modulated ANSI noise (DSP) provides appropriate gain and smooth frequency response. Printout placed in chart.

• REM for linear hearing aid with input level of 65 dB with speech-weighted composite noise (analog) or modulated ANSI noise (DSP) provides appropriate gain and smooth frequency response. Printout placed in chart.


• Assessed performance of directional microphone by looking @ differences in REAR @ 00 and at azimuth of greatest null. Printout placed in chart.

• Assess functionality of DSP NR circuitry using appropriate bias signals.

• RESR90 using a pure-tone sweep corresponds to appropriate frequency-specific SPL level for loudness judgment of “loud, but OK.” Printout placed in chart.

• Loudness judgment of 50 dB composite noise is “very soft” or “soft”


• Loudness judgment of 65 dB composite noise is “Comfortable, but slightly soft,” “comfortable,” or “Comfortable, but slightly loud.”

• Loudness judgment of 85 dB composite noise is “loud, but OK.”

• Measure aided thresholds @ 500, 1000, 2000 and 4000 Hz

using FM signals @ 00*

• Measure unaided and aided HINT (dBA) in Quiet with sentences @ 00*

* Currently under consideration


• Measure unaided and aided HINT RTS in Noise with Sentences and Noise @ 00*

• ANSI-96 reveals <10% THD; ANSI-92 reveals smooth coupler response @ 50-80 dB SPL. Printout placed in chart.

• Potentiometer or programmed settings are in the chart.

• Discuss and/or recommended Aural Rehabilitation and/or ALDs.

* Currently under consideration


• APHAB, COSI or Wash U Questionnaire (unaided, aided and benefit) and placed in chart.

• Called patient 2-3 days post-initial fit.

• Customer satisfaction survey (3-6 months after fitting) – Kochkin recommendation.

Documents

MarkeTrak VI: Measurement Drives Success – Consumer Feedback on Needs, Benefit, Satisfaction & Value Sergei Kochkin, Ph.D. Better Hearing Institute