PHILADELPHIA — David Decker had all the signs.

He often missed things that actors said on TV. Hearing in crowds was a challenge. And when he came home each day from work in a noisy data center, where cooling fans whirred nonstop, his wife would tell him he talked too loudly.

Why not get hearing aids? A big reason: the cost.

Decker, 70, of Philadelphia, learned what millions of aging baby boomers are starting to discover. High-end devices can cost $6,000 a pair, and most insurance plans cover a fraction of the cost at best. Medicare, to the astonishment of many, covers none of it.

"It’s costly," Decker said. "Insurance companies basically pay diddly-squat."

Lower-cost options have started to emerge in recent years, but some entail less in-person service. And for the uninitiated, the menu of choices may seem daunting.

Large retailers such as Costco sell lower-cost hearing aids. One insurer, UnitedHealthcare, sells the devices through a sister company, both to insured members and others, who pay slightly more. And like most other things, hearing aids can now be bought online.

Yet consumer frustration remains rampant, said Carolyn Meyer, outreach coordinator for the Pennsylvania Office of the Hearing Loss Association of America, a consumer group.

Meyer, 71, who has worn a hearing aid for decades, estimates that she gets three calls a week from people dismayed by the price tag. She provides information about financial assistance for low-income people with hearing loss, but options are limited.

"It breaks my heart," the Jenkintown, Pa., resident said.

The technology has undergone great changes in the past two decades. Virtually all hearing aids now are digital, meaning they can be programmed to amplify sounds of various frequencies by differing amounts, depending on the person’s hearing loss.

Able to hear the rumble of a garbage truck but have trouble understanding the high-pitched voices of children? A digital aid can help.

Other newer developments include custom settings for listening to music and talking on cellphones via wireless Bluetooth technology.

It all costs money, but customers wonder why a hearing aid should cost more than other sophisticated devices, such as a laptop computer.

Industry officials cite multiple reasons, among them that the products are medical devices sold in lower numbers than computers. But the biggest is that the price includes much more than just the device.

Audiologists, who have traditionally sold most hearing aids, usually include an array of follow-up care in a unit’s price. The tab includes fitting, programming, adjustments, and training, among other services.

Providers also teach strategies so that new hearing-aid wearers can make sense of the sudden influx of sound. After years of living without amplification, their brains are likely to need help, said Lynda Wayne, treasurer of the Pennsylvania Academy of Audiology, a professional group. And everyone’s brain is different, so the sound-processing algorithms that work for one person may not work as well for another.

"It’s not like you slap them on your ears and you’re good to go," said Wayne, of Cadence Hearing Services in Langhorne, Pa. "You’re not buying a washer and dryer."

The cost of the device alone is hard to find out. When The Inquirer asked six major manufacturers for the wholesale prices they charge to audiologists, all declined to answer.

Ross Porter, the chief executive officer of Embrace Hearing, estimates that it costs a manufacturer $400 or $500 to make a good-quality pair of hearing aids, which are then sold to an audiologist for $1,000 and to the end-user for $5,000 or more.

Carole Rogin, president of the Hearing Industries Association, a manufacturers’ group, said that at a typical audiology practice, one-third of the consumer’s total price is for the device, and two-thirds for the professional services.

Some audiologists say they need to do better in explaining the cost, and have begun to "unbundle" their services, letting patients pay for a hearing aid and follow-up care separately.

That is what eventually happened with Decker, the Northeast Philadelphia man. He recently bought a pair of hearing aids from audiologist Elizabeth Gray-Karagrigoriou, who engages in what she calls "partial unbundling" at Ascent Audiology & Hearing in Holland, Pa.

She charges one fee for a hearing aid, fitting, programming, and the initial 30 days of training. That’s $2,000 for a high-end model, or $4,000 a pair, which she said would cost $6,000 at a traditional audiology practice. She then charges a separate fee for optional service plans of one, two or three years — a fee that most audiologists fold into their higher up-front cost.

Decker bought a pair of high-end hearing aids made by the Starkey company. Although he opted to add on a three-year service plan, his total was less than $5,500 for what would have typically cost $6,000.

The audiologist said her goal in charging less upfront was to get patients to start wearing devices sooner, while their brains are more "plastic" — adaptable.

"I’m hoping that people will say ‘Yes, I’m going to go in and do this a decade earlier than I would have before,’" Gray-Karagrigoriou said.

In a 2012 survey by the American Academy of Audiology, one-third of audiologists reported that they charged separate fees for follow-up care, said Debbie Abel, senior specialist in practice management at the professional group.

Many audiologists say they are loath to unbundle their prices, fearing that if customers have to pay a fee every time they need a follow-up, they will choose not to come at all, and stop wearing their aids.

"We want people to come in to see us at no extra charge so we can fix any problems they have," said Kathy Landau Goodman, president of Narberth, Pa.-based Main Line Audiology. It allows customers to make unlimited visits for three years, she said.

Then there is Costco. The membership-based warehouse chain has been selling hearing aids at lower cost than independent audiology practices for years.

The chain offers its high-end aids for about half the going rate at typical audiology practices — about $1,400 for a behind-the-ear model. Sold under Costco’s Kirkland brand, the store’s devices always have been made by major manufacturers, now Denmark’s GN ReSound, said Costco senior vice president Richard Chavez.

The chain can sell the devices for less because it does so much volume, and spends nothing on marketing.

Most of the company’s sites are staffed by hearing aid dispensers, who must pass state licensing exams. But unlike audiologists, they do not need an advanced degree. Audiologists caution that their additional years of training allow them to spot problems that need medical attention.

Still, Costco worked for Tasha Turner, 46, of Highland Park, N.J., who in December bought a pair of aids for the first time and has been back to the chain’s Edison, N.J., store for five or six tune-up visits. "They are just absolutely fantastic on follow-up," Turner said.

One point on which all providers agree is that most hearing-impaired people wait too long to buy the devices, if they ever do at all. Studies have found that just 20 to 25 percent of hearing-impaired people wear them.

Studies also suggest that people with hearing loss are more prone to cognitive decline, though it is not clear if one problem causes the other.

If nothing else, a hearing aid helps you communicate rather than drift off into your own world.

What is the proper price for that? The marketplace is still deciding.

(EDITORS: BEGIN OPTIONAL TRIM)

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A PERSONAL ACCOUNT:

Buying hearing aids online has advantages — but it’s not for everyone

I have worn a hearing aid for nearly four decades, and I cannot imagine life without one.

But the pricey devices keep getting more expensive. My current model, bought from a trained professional called an audiologist, cost about $3,000.

Would it make sense to save money by ordering my next one online?

A cardboard box arrived in late November from Wilmington, Del.-based Embrace Hearing, holding what I hoped would be the answer.

Inside was the X-Mini, an aptly named model about the size of a kidney bean. It was packed with electronics and features similar to what I have in my old hearing aid, yet it sells for just $599.

Right away I hit a small roadblock. I was not entirely sure how to put it on.

But 30 minutes after I sent a question via e-mail, the company responded with helpful guidance, and I was on my way.

The X-Mini worked well.

The sound was a bit metallic the first few times I wore it, but a new hearing aid often sounds a bit unnatural, regardless of where it is bought. The brain may need a few days to adjust to a given device.

What’s more, it was the first time I had tried a hearing aid that fits into the ear canal by means of a "dome" — a small, plastic cone that fits any adult-sized ear, rather than the traditional, custom-fit earmold.

Within an hour of turning on the X-Mini for the first time, I put it to the ultimate test: lunch in Philadelphia’s Chinatown.

Anyone with a hearing loss will tell you that restaurants can be a challenge, and this one, a crowded hole-in-the-wall with no carpet or wall hangings to absorb noise, was a killer. Between the clatter of kitchenware and the chatter of fellow diners, I was prepared to miss some of my lunch partner’s conversation.

Not to worry. I simply pressed a button on a remote control, thereby putting the X-Mini into "speech beam" mode.

That did two things. The rear-facing microphone was turned off, so I could focus on the sound coming through the forward-facing microphone. And for that front-facing mike, the frequencies associated with speech were pumped up while other kinds of sounds were tamped down a bit.

Many digital hearing aids, including my old one, have similar features. My version of the X-Mini had five other settings, including one for music.

So should everyone buy online?

In my opinion, no. If the person is fairly tech-savvy and likes to figure things out, then sure.

But if the wearer is older and requires lots of hand-holding, buying a hearing aid online could lead to frustration and ultimately a refusal to wear it. Hearing aids are tricky if you have never worn one, and an audiologist can teach strategies for getting the most out of them.

And some patients, because of the nature of their hearing loss, will need multiple follow-up adjustments to their devices. Embrace Hearing offers to adjust a hearing aid if you mail it back, but that could be a hassle.

Fortunately, my X-Mini did not need any modification. I had sent the company the results of my most recent hearing test in advance, and they programmed the hearing aid to amplify sound at various frequencies by whatever amount I needed.

The company allowed me to wear the X-Mini on a trial basis for a few weeks, and now I’m back to my old one, made by a firm called Oticon, which I got from Main Line Audiology and like very much.

I’m not sure what I’ll do when it’s time to buy a new hearing aid in a few years. Rest assured you will never find me without one.

(END OPTIONAL TRIM)

(EDITORS: STORY CAN END HERE)

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AUDIO OPTIONS

Audiologists have traditionally sold most hearing aids. Some lower-cost options have emerged, though not always with the same level of service. Here are prices for a pair of high-end devices by category.

Traditional audiologist: $6,000

Price includes extensive service, such as programming, training, and upkeep for up to 3 years

Partially "unbundled" audiology practice: $4,000

Provider charges separate fees for service plan, so patients are not daunted by a large up-front price.

Costco: $2,800

The store’s aids are made by major manufacturers, and price includes unlimited follow-up care. But most of its dispensers are not audiologists, and are not required to have nearly as much training.

Embrace Hearing: $1,898

The online retailer mails hearing aids to the patient. Adjustments are free, though the patient has to send the device back. If in-person help is needed, the company will contact audiologists who charge an extra fee.

hi HealthInnovations: $1,998

Product can be ordered by phone or online. Patients insured by UnitedHealthcare, a sister company, pay even less. In-person service available from contracted providers; the nearest is in Emmaus, Pa.

PERSONAL SOUND-AMPLIFICATION DEVICES

These devices are worn in the ear and make sounds louder, but are less sophisticated than hearing aids, and the FDA does not allow them to be marketed as such.