Who pays the price when cochlear implants go obsolete?(sapiens.org)
sapiens.org
Who pays the price when cochlear implants go obsolete?
https://www.sapiens.org/culture/planned-obsolescence-cochlear-implants/
51 comments
The so called "Cochlear implant" by vendors is really a system with an actual implant and an external sound processor and a transmitter.
https://media.arkansasonline.com/img/photos/2015/07/13/cochl...
The "external sound processor and transmitter" is an electronic appliance, like a phone, which the patient removes and puts on, like glasses. It can be lost or damaged.
The reason that the external device is abandoned by the manufacturer is the same for abandoning phone software and batteries: market strategy.
My personal opinion is that the most basic product line must guarantee quality and two or three decades of support. Part of the product is INSIDE of the patient. State of the art devices for people who can afford them are another matter entirely.
However, sometimes the difference between Basic and "State of the art" in medicine is non existent, and the patient only pays for it because they don't know better. Most of them don't like it when they get the full story.
https://media.arkansasonline.com/img/photos/2015/07/13/cochl...
The "external sound processor and transmitter" is an electronic appliance, like a phone, which the patient removes and puts on, like glasses. It can be lost or damaged.
The reason that the external device is abandoned by the manufacturer is the same for abandoning phone software and batteries: market strategy.
My personal opinion is that the most basic product line must guarantee quality and two or three decades of support. Part of the product is INSIDE of the patient. State of the art devices for people who can afford them are another matter entirely.
However, sometimes the difference between Basic and "State of the art" in medicine is non existent, and the patient only pays for it because they don't know better. Most of them don't like it when they get the full story.
I believe the "cocleah system" is guaranteed to function for that long, yes. The part inside of you is very simplistic and doesn't do much (or anything) besides translating data into electrical signals. It's the unit on the outside that gets replaced frequently.
> Or is there some supposed medical reason you need to adjust the parameters of the device on a regular basis?
Folks with cochlear implants regularly (i.e. once a year) meet with audiologists to tweak the parameters of the device that feeds the implant, called a "processor." The tweaking process is referred to as "mapping."
The processor is a very small, delicate piece of equipment. Over time, various parts wear out and have to be replaced. Rechargeable batteries stop holding charge, microphone elements putter out from exposure to sweat and dead skin, etc. If the company no longer offers parts/service, then when something stops working, there's not much to be done.
In defense of the manufacturers: a cochlear implant and accompanying processor are very specialized pieces of electronic equipment. The hardware, algorithms, etc. are all being improved over time. So it's not totally unreasonable to try to move folks unto the newer models.
Folks with cochlear implants regularly (i.e. once a year) meet with audiologists to tweak the parameters of the device that feeds the implant, called a "processor." The tweaking process is referred to as "mapping."
The processor is a very small, delicate piece of equipment. Over time, various parts wear out and have to be replaced. Rechargeable batteries stop holding charge, microphone elements putter out from exposure to sweat and dead skin, etc. If the company no longer offers parts/service, then when something stops working, there's not much to be done.
In defense of the manufacturers: a cochlear implant and accompanying processor are very specialized pieces of electronic equipment. The hardware, algorithms, etc. are all being improved over time. So it's not totally unreasonable to try to move folks unto the newer models.
> So it's not totally unreasonable to try to move folks unto the newer models.
I think the issue is the period of support. I think these need to be designed to last 10 or even 20 years. And this needs to be clear before the surgery like informed consent.
The other issue is optionality. It’s nice that there’s a new model and that businesses want to move people on to it. It’s not nice that the old model is unnecessarily, from an ops standpoint, turned off to require patients to upgrade.
If I had to choose for my 4 year old between deafness and an implant that worked for 4 years and then cost my family 10x my annual pay every four years, although I’d be heartbroken, I’d have to choose deafness.
I also think the initial price must include the price of surgical extraction so this kid isn’t stuck with a non-functioning implant in his head for life.
For comparison, a pacemaker battery lasts 5 years and can be replaced in an outpatient clinic [0]. But pacemaker recipients typically only live 5-15 years so it’s quite different than putting this in a kid who will have it for 70-80 years.
[0] https://www.hopkinsmedicine.org/health/treatment-tests-and-t...
I think the issue is the period of support. I think these need to be designed to last 10 or even 20 years. And this needs to be clear before the surgery like informed consent.
The other issue is optionality. It’s nice that there’s a new model and that businesses want to move people on to it. It’s not nice that the old model is unnecessarily, from an ops standpoint, turned off to require patients to upgrade.
If I had to choose for my 4 year old between deafness and an implant that worked for 4 years and then cost my family 10x my annual pay every four years, although I’d be heartbroken, I’d have to choose deafness.
I also think the initial price must include the price of surgical extraction so this kid isn’t stuck with a non-functioning implant in his head for life.
For comparison, a pacemaker battery lasts 5 years and can be replaced in an outpatient clinic [0]. But pacemaker recipients typically only live 5-15 years so it’s quite different than putting this in a kid who will have it for 70-80 years.
[0] https://www.hopkinsmedicine.org/health/treatment-tests-and-t...
I think it could be something as simple as the rechargeable batteries no longer hold a charge and they don't manufacture the receiver unit anymore.
If you clicked the link [1] in the article, it sounds like designing them to survive regular day-to-day usage is important. Components will wear down over time and replacing them is inevitable.
[1] https://www.indiamart.com/proddetail/cp-802-sound-processor-...
If you clicked the link [1] in the article, it sounds like designing them to survive regular day-to-day usage is important. Components will wear down over time and replacing them is inevitable.
[1] https://www.indiamart.com/proddetail/cp-802-sound-processor-...
>I think it could be something as simple as the rechargeable batteries no longer hold a charge and they don't manufacture the receiver unit anymore.
If that was the case, then the author missed a big opportunity use this one sentence to spell this out and lend a whole lot of credibility to the article (that the article is currently missing).
If that was the case, then the author missed a big opportunity use this one sentence to spell this out and lend a whole lot of credibility to the article (that the article is currently missing).
It seems that it is "just" a matter of dropping service support for devices
> Companies like Cochlear Americas stop providing parts or service for old processors, essentially forcing people with cochlear implants to upgrade to newer versions. A new processor isn't covered by the Saskatchewan health plan.[1]
> The typical replacement timeframe is once every five to seven years, or the lifespan of the sound processor. [2]
> After March 31, 2023, you will no longer be able to purchase parts and accessories for all Nucleus 6 Sound Processors and Cochlear will no longer be able to repair them.[3]
[1]https://www.cbc.ca/news/canada/saskatchewan/costs-to-maintai...
[2]https://www.saskhealthauthority.ca/your-health/conditions-di...
[3]https://www.cochlear.com/us/en/campaign/product-retirement-2...
> Companies like Cochlear Americas stop providing parts or service for old processors, essentially forcing people with cochlear implants to upgrade to newer versions. A new processor isn't covered by the Saskatchewan health plan.[1]
> The typical replacement timeframe is once every five to seven years, or the lifespan of the sound processor. [2]
> After March 31, 2023, you will no longer be able to purchase parts and accessories for all Nucleus 6 Sound Processors and Cochlear will no longer be able to repair them.[3]
[1]https://www.cbc.ca/news/canada/saskatchewan/costs-to-maintai...
[2]https://www.saskhealthauthority.ca/your-health/conditions-di...
[3]https://www.cochlear.com/us/en/campaign/product-retirement-2...
The iPhone 5 could stay out of obsolescence if Apple were to continue offering replacement parts and repair services for its current owners. It's not that the device would stop working on a pre-programmed day - it's that the iPhone 5's out there would all eventually need parts and/or repairst, and would have no way of getting them.
How often to these hearing aid type devices wear out? It seems like that is something that could last 10-20 years.
Here's the thing about cochlear implants that the article at first glance does not tell the reader:
* you undergo a VERY expensive surgery.
* in the surgery you get installed the actual cochlear implant.
* the implant itself is VERY basic and is designed to work with future models of the hearing aid (the one behind the ear).
It is therefore, unlike what the article seems to suggest at first glance, not the case that families spend money (a lot of it - upwards $50,000 per ear iirc), only to be told later that they have to go through it all again. I bet what this family experience is a sales department telling them the very real situation that hearing aids - just like smart phones - improve over time and that old models reach an end of life date eventually. There's nothing new here although hearing aids are arguable much more expensive than smartphones - not that they had to be, Hearing Care Professionals make a lot of money per hearing aid.
But that's a story for another time.
* you undergo a VERY expensive surgery.
* in the surgery you get installed the actual cochlear implant.
* the implant itself is VERY basic and is designed to work with future models of the hearing aid (the one behind the ear).
It is therefore, unlike what the article seems to suggest at first glance, not the case that families spend money (a lot of it - upwards $50,000 per ear iirc), only to be told later that they have to go through it all again. I bet what this family experience is a sales department telling them the very real situation that hearing aids - just like smart phones - improve over time and that old models reach an end of life date eventually. There's nothing new here although hearing aids are arguable much more expensive than smartphones - not that they had to be, Hearing Care Professionals make a lot of money per hearing aid.
But that's a story for another time.
To be clear, if I understand this correctly, then the invasive implant that is almost universal and it's the external proprietary apparatuses and components thereof that have product lifecycles that end and end parts support.
This seems like something that ought to have a reasonable social venture develop an open source model with a very long lifecycle and good repairability.
This seems like something that ought to have a reasonable social venture develop an open source model with a very long lifecycle and good repairability.
> families spend money (a lot of it - upwards $50,000 per ear iirc), only to be told later that they have to go through it all again
You make it sound like the surgery is the expensive bit, but as you pointed out, the implant is very basic electronics. The medical procedure is certainly expensive, but the processors are the truly expensive physical product.
You make it sound like the surgery is the expensive bit, but as you pointed out, the implant is very basic electronics. The medical procedure is certainly expensive, but the processors are the truly expensive physical product.
Do you have a link to a processor with the price? It doesn't sound that complicated to make tbh. It might just all be FDA approvals.
NZD50k per side including sound processors. NZD86k-ish if done bilaterally at the same time.
Sound processors are around NZD7-8k a pop and have an expected replacement cycle of 5-7 years.
Sound processors are around NZD7-8k a pop and have an expected replacement cycle of 5-7 years.
The surgery is the expensive bit. It's a 10-to-1* kind of expense compared to the hearing device you attach to the head.
* Rough guess based on the price of regular, high-end "in-the-ear-canal" hearing aids.
* Rough guess based on the price of regular, high-end "in-the-ear-canal" hearing aids.
> Rough guess based on the price of regular, high-end "in-the-ear-canal" hearing aids.
This guess completely missed the point. Cochlear implants are not audio amplifiers like hearing aids are. They must convert sound into electrical impulses which are sent more or less directly at the user's sense organ, via a relatively dumb implant. Now, on the one hand you could say, "yeah well that's just a Fourier transform" but that would also miss the point. A cochlear implant only creates impulses at a limited discrete set of points, and the way those points map to frequencies is not going to obey a nice consistent function. This means the processor must be programmable to adjust the mapping of desired frequency (which may not be the input frequency) to electrodes, which already puts us into needing a rather fancier microprocessor than a hearing aid needs.
Moreover, the limited set of frequencies causes a massive loss of signal-to-noise ratio. The processor has to compensate for this intelligently filtering the sound to make the result useful. For example, it may need to detect and filter background noise. It is not really even attempting to replicate natural hearing because that's impossible; it may be more helpful to think of it hijacking the user's aural sense to do something almost totally different with it, but staying just close enough to natural hearing that the brain has a fighting chance of making sense of the inputs.
This guess completely missed the point. Cochlear implants are not audio amplifiers like hearing aids are. They must convert sound into electrical impulses which are sent more or less directly at the user's sense organ, via a relatively dumb implant. Now, on the one hand you could say, "yeah well that's just a Fourier transform" but that would also miss the point. A cochlear implant only creates impulses at a limited discrete set of points, and the way those points map to frequencies is not going to obey a nice consistent function. This means the processor must be programmable to adjust the mapping of desired frequency (which may not be the input frequency) to electrodes, which already puts us into needing a rather fancier microprocessor than a hearing aid needs.
Moreover, the limited set of frequencies causes a massive loss of signal-to-noise ratio. The processor has to compensate for this intelligently filtering the sound to make the result useful. For example, it may need to detect and filter background noise. It is not really even attempting to replicate natural hearing because that's impossible; it may be more helpful to think of it hijacking the user's aural sense to do something almost totally different with it, but staying just close enough to natural hearing that the brain has a fighting chance of making sense of the inputs.
I'm aware it's a different product and that the price is not the same, as was stated. An example of a price was given elsewhere of roughly NZD $8000, which isn't too far off the price of a pair of high-end in ear hearing aids.
Perhaps medical implants should be legally required to have open-source hardware and software.
"security" by obscurity is the golden standard here. You don't want to see the massive incompetence at play if everything was open.
I think, as a society, we do want to see it, slowly, over time.
Perhaps requiring they be open sourced after a point in time or to be eligible for medicaid, etc. Maybe only new ones - but eventually we need to clean this up; as we're creating a digital superfund site each time, only covered up by people disposing of them or dying.
Perhaps requiring they be open sourced after a point in time or to be eligible for medicaid, etc. Maybe only new ones - but eventually we need to clean this up; as we're creating a digital superfund site each time, only covered up by people disposing of them or dying.
Allowing/affording society some ability to come in, to see, to form opinions seems so elemental to progress in general.
Pay no attention to the man behind thr curtain forever & ever, everywhere, does not seem like a great strategy for keeping & maintaining a society.
Pay no attention to the man behind thr curtain forever & ever, everywhere, does not seem like a great strategy for keeping & maintaining a society.
Gonna go out on a limb and guess that it's enough to send shivers down anyone who's heard the Therac-25 story...
Auditing is a mess more so than security by obscurity.
Source: employee.
confidence through obscurity?
actually a semi interesting argument, which seems likely to be widely accurate in many places.
actually a semi interesting argument, which seems likely to be widely accurate in many places.
It's interesting, because in some fashion the private industry has a practice which is designed to prevent against software obsolescence or the failure of their vendor company: Code Escrow.
I would love to see a nonprofit/NGO/TLA dedicated to getting such defunct tech open sourced. I am sure lots of great stuff gets archived in hopes of selling/licensing the IP later, and then it never sees the light of day again. To the extent such things get archived at all.
This came up in another thread here the other day in fact. And before the same guy chimes in to suggest that governments ruin everything they take on because of corruption: You're still wrong, and you can take that defeatism elsewhere.
I would love to see a nonprofit/NGO/TLA dedicated to getting such defunct tech open sourced. I am sure lots of great stuff gets archived in hopes of selling/licensing the IP later, and then it never sees the light of day again. To the extent such things get archived at all.
This came up in another thread here the other day in fact. And before the same guy chimes in to suggest that governments ruin everything they take on because of corruption: You're still wrong, and you can take that defeatism elsewhere.
And spare parts and built for repairability.
Batteries are practically guaranteed to degrade after a few hundred charge cycles, and totally fail after a few hundred more... with daily charging, that's a timeline of a few years.
And with all the breakthroughs in technology, we've gone from replacable batteries everywhere, even with waterproof devices, to impossible or very-hard-to replace batteries, even in large, non-waterproof stuff such as laptops.
Batteries are practically guaranteed to degrade after a few hundred charge cycles, and totally fail after a few hundred more... with daily charging, that's a timeline of a few years.
And with all the breakthroughs in technology, we've gone from replacable batteries everywhere, even with waterproof devices, to impossible or very-hard-to replace batteries, even in large, non-waterproof stuff such as laptops.
A lot of OSS is used in modern hearing aids, actually. A hearing aid is closer to a small computer these days than you'd think.
They fully are computers. I wear hearing aids, and for example, one setting will glom onto voices in the stereo field and track them so the voice remains clear if they are moving around, while damping everything else.
They do quite a lot, actually. They typically have 4 settings that the wearer can opt for. Some are "smarter" than others. The one I described is one of the more advanced functions.
They do quite a lot, actually. They typically have 4 settings that the wearer can opt for. Some are "smarter" than others. The one I described is one of the more advanced functions.
open source doesn’t make modifications free. who is going to take the liability of distributing modifications for other people’s medical devices even with a “no warranty expressed or implied” license?
who is going to load “no warranty expressed or implied” software onto their kids brain implant?
R&D is financed by the profiteering. Having companies legally on the hook for abandoning their clients is a great idea, but demanding that they allow anyone else to manufacture their design is a great way of ensuring vastly fewer designs.
In practice, a lot, and I mean, A LOT of research and development in health is done by universities under government grants from the NIH.
Like this https://twin-cities.umn.edu/news-events/university-minnesota...
Like this https://twin-cities.umn.edu/news-events/university-minnesota...
Universities make good idea guys, but they're not so good at turning them into products. The foundational R is done at universities, and then sold to companies so they can do the specific R and all of the D.
A much better idea is to have the implant part require a standard connector, while the outside part could be upgraded later on.
Medical devices take a TON of money to develop and license, so companies aren't going to open source them.
Medical devices take a TON of money to develop and license, so companies aren't going to open source them.
That is exactly how they work. The implant is incredibly "dumb" and very future proof.
Exactly. The problem is that the processor is absurdly expensive, up to 10 thousand dollars range in the US if you self-pay.
...and the manufacturing price is so low it makes me physically sad to think about.
Nice, thanks for the info!
Yes, it would be convenient to treat prostetic devices as drugs and allow generics to be manufactured.
I wonder how companies go about retiring these sound processors on the technical level. Are those in need of continuous updates to keep working? Do they receive a final update one day which bricks them? Since the consequences seem so heartbreaking I would imagine that unofficial ways of prolonging the life time of this hardware do exist?
The firmware on most modern hearing aid devices can be easily updated. These updates may include updates for the sound processing as well, indeed. However, you can't easily "replace the chip" like you can just swap out an old SSD drive with a new, faster model.
To the best of my knowledge (first hand experience from the industry), they receive a final update one day and will then only be updated in extreme situations, like, say, imagine you plug in your devices one day and suddenly get a max volume high pitched feedback screech in your ears (this should never happen, ever, mind you). But I'm only guessing here.
However, just like my old trusty iPod Touch 1st Generation, they are due an upgrade eventually if you want to use the latest features (my iPod still works, it's just not very fancy anymore...).
To the best of my knowledge (first hand experience from the industry), they receive a final update one day and will then only be updated in extreme situations, like, say, imagine you plug in your devices one day and suddenly get a max volume high pitched feedback screech in your ears (this should never happen, ever, mind you). But I'm only guessing here.
However, just like my old trusty iPod Touch 1st Generation, they are due an upgrade eventually if you want to use the latest features (my iPod still works, it's just not very fancy anymore...).
Probably it will still work but no replacements parts for repair at some point. I know regular hearing aids can be quite moisture sensitive (though new ones are getting much better) so I don't know if these sound processors are the same.
The article barely touches on it but the real threat isn't from the manufacturers producing newer and better processors, but rather from insurers/single payers not covering the cost of new processors. I deliberately use the word "threat" to answer the question that several other comments ask, or rather point out it's the wrong one: "Why does the processor need to be replaced with a newer model?" In ideal circumstances, it doesn't. But if the insurer/single payer has declared they will not pay for a new one for some ridiculous amount of time like 10 or 15 years after the previous are bought, then the user is under the constant threat that the old ones will break but not be replaceable.[0] That is only tangentially related to old models being replaced with new ones, although this may be the excuse that insurers/single payers use not to replace lost or broken processors, e.g. by insisting that the old ones be repaired even though that's no longer an option (granted, this example would be a combined problem with the payers and the manufacturers).
Apparently the upgrade threat is such an issue that the way even exceptional insurance avoids the issue (per my family's experience) is to purchase the user an extra processor at the same time as the processor is first purchased (or, eventually, upgraded): a preemptive replacement/backup unit. This way presumably the payer doesn't have to have on the books a difficult-to-quantify liability from needing to replace a lost/damaged processor with an unknown future model.
[0] Critical context: Unlike a hearing aid, the process of getting a cochlear implant physically destroys any residual hearing the user may have had. When the processor is not present and functioning, the user is completely deaf. And that's little-d deaf, which is the problem: cochlear implant users have explicitly chosen not to enter the big-D Deaf world (which largely rejects implants anyways), and so are completely dependent upon their devices functioning correctly.
Apparently the upgrade threat is such an issue that the way even exceptional insurance avoids the issue (per my family's experience) is to purchase the user an extra processor at the same time as the processor is first purchased (or, eventually, upgraded): a preemptive replacement/backup unit. This way presumably the payer doesn't have to have on the books a difficult-to-quantify liability from needing to replace a lost/damaged processor with an unknown future model.
[0] Critical context: Unlike a hearing aid, the process of getting a cochlear implant physically destroys any residual hearing the user may have had. When the processor is not present and functioning, the user is completely deaf. And that's little-d deaf, which is the problem: cochlear implant users have explicitly chosen not to enter the big-D Deaf world (which largely rejects implants anyways), and so are completely dependent upon their devices functioning correctly.
Any company that brings a medical implant device to market should be required by law to establish a trust to fund continued support of the device for the natural lifespan of the youngest/longest lived recipient, period.
Also, all designs, software and patents should be open sourced/released to the public domain if the company goes bankrupt or the product line gets sunsetted.
This is surgery, these are peoples lives. These are their organs. People that make executive decisions like this are subhuman scum.
Also, all designs, software and patents should be open sourced/released to the public domain if the company goes bankrupt or the product line gets sunsetted.
This is surgery, these are peoples lives. These are their organs. People that make executive decisions like this are subhuman scum.
Putting a requirement to support a product for another 80+ years will prevent small volume product from ever hitting the market and will increase the cost to the consumer.
What if we decrease the regulation on things that do not harm the patient when they fail, so they can but a device for $100 on Amazon rather than $10k at the hospital?
What if we decrease the regulation on things that do not harm the patient when they fail, so they can but a device for $100 on Amazon rather than $10k at the hospital?
Sure, glasses, hearing aids, that's all fine.
If your product needs to be surgically installed in a patient, if you can't afford to support it for the lifetime of the patient the product isn't viable and shouldn't be brought to market.
If your product needs to be surgically installed in a patient, if you can't afford to support it for the lifetime of the patient the product isn't viable and shouldn't be brought to market.
It should be illegal to implant anything that does not have open documentation and source code available into the human body.
It's not explained in the article how these compulsory upgrades are being forced. These are not net enabled devices. Perhaps the idea is that the receiver is no longer for sale and cannot be replaced once it has eventually broken?
Your old processor needs a new battery. it gets damaged.
But it was EOL'd a few months ago. No spare parts, no servicing. You need a new one.
>Their child’s current processor—a “basic” model designed for the developing market—was becoming “obsolete” and would no longer be serviced by the company. The family would need to purchase another one, said to be a “compulsory upgrade.”
...from the quote above, it doesn't sound like there is anything wrong with their existing hardware. And it doesn't seem like the existing hardware is broken. It sounds like a pushy sales department is trying to scare these people into upgrading to the latest-and-greatest version? Or is there some supposed medical reason you need to adjust the parameters of the device on a regular basis?
>In one especially devastating case, a father lamented that his daughter, who had been doing well with her implant, could no longer hear since her device had become obsolete.
Is there a timer in the existing hardware that is shutting things off after a certain amount of time? Or it phones home somehow, and gets instruction from the mother ship that it should stop working? Is there more than this one case? I guess the article keeps using the term "planned obsolescence", but I need some more evidence to go on here. Could it be that in this one case, the kid dropped the external processor in the river, and now it doesn't work? And the article also keeps mentioning continued maintenance, but seems to be conflating maintenance with upgrades. Maybe these people are showing up at the audiologist for a "check-up", and the audiologists are bricking the devices in the name of upgrades?