On one hand, the American Academy of Physical Medicine and Rehabilitation recently issued a favorable white paper on neuromusculoskeletal thermography1, confirming and amplifying what chiropractic physicians have known for nearly a century relative to the relationship of surface temperature to underlying biomechanical abnormalities.
Within this same time frame, the Health Care Financing Administration (HCFA) has announced a proposal to withdraw Medicare coverage for thermography2. Certainly, both of these events require further elucidation.
Medicare Coverage for Thermography
The Federal Register of October 9, 1990 contains a proposal by the Health Care Financing Administration (HCFA) to withdraw reimbursement for thermography under the Medicare program. This proposal is based upon a report released in August of 1989 by the Office of Health Technology Assessment (OHTA), which reviewed and quoted much literature on thermography, most of it favorable, but which chose to emphasize the minority of the available data which was negative. Anyone reading this 32-page document, titled "Thermography for Indications Other Than Breast Lesions,"3 can readily discern the negative bias because its conclusions, that "thermography lacks sensitivity, specificity, or predictive value," are unsupported by the actual text of the document itself. Another odd thing is that the author, an individual named Harry O. Handlesman, is a completely unknown osteopath who has never published on thermography and who no one in thermography has ever heard of.
HCFA is currently choosing to depend entirely on this seriously flawed OHTA document, and the proposal by HCFA in the Federal Register therefore lamely asserts that thermography "does not assist in accurately diagnosing an illness," that "there is no evidence to indicate that thermography provides a useful guide in monitoring the effect of treatment of any disease entity," and that "temperature differences in themselves add very little to a physician's assessment based on the patient's history, physical examination, and other studies." HCFA further asserts that "there have been no controlled clinical trials that provide conclusive evidence establishing the usefulness of thermography as a primary diagnostic guide," which is far from true.
The most serious flaw in the OHTA report, as noted above, is that its conclusions are not supported by the data referenced in the report itself; that is, the summary gives undue weight to negative biases against thermography, stressing the few negative papers and de-emphasizing the many positive papers which are listed in the OHTA report's own bibliography. Furthermore, most thinking persons would have difficulty trusting the reliability of a report written by a single individual who has no reputation for research or publication in thermography. It is even more curious that HCFA would rely entirely upon this one document, particularly in the face of literally thousands of scientific papers favorable to thermography, including the favorable AMA Council on Scientific Affairs4 and American Academy of Physical Medicine and Rehabilitation reports, which were compiled by knowledgeable panels and approved by committees and organization memberships.
Normally with federal proposals, there is a comment and evidence gathering period before any decision is published. This comment period concluded on December 10. It would normally be expected that a decision would be announced within a few months, but this varies greatly. At least until then, Medicare does make reimbursement for thermographic studies performed by eligible health care providers, as it has since 1985.
A class action suit has been filed on behalf of aggrieved patients against OHTA and HCFA in the United States District Court for the Eastern District of New York; and three major medical thermography organizations, the American Academy of Thermology, the Academy of Neuromuscular Thermography, and the American Herschel Society, have issued formal complaints to HCFA, as has the American Chiropractic College of Thermology (ACCT). The ACCT response discusses six major points:
- Thermography is a window to the automatic nervous system. Spinal nerves have sensory, motor, and autonomic components. We routinely check the sensory and motor components, but without thermography we ignore the autonomic component.
- Thermography is risk-free and painless.
- Thermography is cost-effective.
- Thermography is scientifically valid. The degree of sensitivity (99.2%), specifically (60%-98%), and predictive value for thermography compare extremely favorably to the other diagnostic procedures, these facts being proven in multiple studies, many of them excellent blinded and prospective studies.1,4
- Thermography is a useful monitoring device for treatment efficacy.
- Thermography is a test of physiology.
The ACCT response concludes with the statement:
Anatomic tests, such as CT, MRI, and myelography do not present the same information as, and cannot replace, the physiological data provided by thermography. Thermography is the somatotopic representation of the cutaneous vascular changes mediated by sympathetic nerve transmission and neurotransmitters, for which CT, MRI, myelography, radionuclide scans, and diagnostic ultrasound have zero sensitivity.
One may question the relevance of this whole matter to chiropractic practice, since Medicare does not pay for any diagnostic services ordered by or performed in chiropractic facilities. Like physical examinations and diagnostic x-rays, thermography has not been subject to Medicare reimbursement when the study is performed in the office of a chiropractor, whereas Medicare does make reimbursement for thermography when ordered and performed by medical and osteopathic physicians. The importance of the new HCFA proposal is that there is a concern that a negative decision on the part of HCFA, resulting in withdrawal of Medicare coverage for thermography, would cast an unfair shadow over the legitimacy of thermography and that it might also serve as a negative precedent to other third-party payers which, except for a few high-profile exceptions, have been routinely paying for justified thermographic studies. The full implication of this possible precedential effect remains to be seen. If a HCFA decision could be considered the ultimate federal edict as to the validity of a procedure, with inviolable trickle-down to other payers, chiropractic practice itself would obviously be in far greater jeopardy than we currently experience!
American Academy of Physical Medicine and Rehabilitation Report
The PM&R white paper titled "Neuromusculoskeletal Thermography," was submitted in June of 1990 and approved by PM&R membership in October 1990. This paper includes a discussion of the history and description of the technology, the physiological basis of the technology, imaging techniques, evidence from blinded and prospective studies, and a discussion on the usefulness of thermography for its most obvious indication, the reflex sympathetic dystrophy syndromes. The report lists 76 references, and its contents are summarized by the abstract, which states:
"Thermography is a safe, non-invasive test which does not involve the use of ionizing radiation. It is a test of physiological function that may aid in the interpretation of the significance of information obtained by other tests. Thermography can be useful in the diagnosis of selected neurological and musculoskeletal conditions. It may facilitate the determination of spinal nerve root, distal peripheral nerve, and soft tissue injuries. Thermography is useful in the diagnosis of reflex sympathetic dystrophy syndromes."
This report, in addition to the AMA Council on Scientific Affairs report, which lists 86 references, stands in sharp contrast to the single-author OHTA report on which HCFA is currently relying. The next few months should provide interesting chapters in the somewhat rocky, but continuing, integration of thermography into general acceptance within health care practice.
References
- "Neuromusculoskeletal Thermography." American Academy of Physical Medicine and Rehabilitation, white paper, Oct 1990, 15p.
- "Medicare Program; Withdrawal of Coverage of Thermography." Health Care Financing Administration, Federal Register, 55; 195 (10-9-90) p. 41140-3.
- "Thermography for Indications Other Than Breast Lesions." Office of Health Care Technology, Public Health Service, Dept. of Health and Human Services, Aug 1989, 32 p.
- "Thermography in Neurological and Musculoskeletal Conditions." AMA Council on Scientific Affairs, Dec 1987, 18 p.
Susan L. Vlasuk, D.C., D.A.C.B.R.
Immediate Past President
American Chiropractic College Of Thermography
Bellevue, Washington