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Special Report |
1 From the American College of Radiology (ACR), Reston, Va. A complete list of the participants in the Second Annual ACR FORUM appears at the end of this article. Received August 26, 2002; accepted August 29. Address correspondence to B.J.H., Department of Radiology, University of Virginia Health System, PO Box 800170, Charlottesville, VA 22908 (e-mail: bjh8a@virginia.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE MARKET FOR IMAGING...UNCERTAINTIES AND CHANGES IN...MARKET FORCESRECOMMENDATIONSSUMMARYREFERENCES |
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© RSNA, 2003
Index terms: American College of Radiology • Economics, medical • Radiology and radiologists • Radiology and radiologists, socioeconomic issues
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INTRODUCTION |
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To accomplish these objectives, the ACR invites a small group of noted individuals from both within and outside the specialty to a 2-day meeting to discuss the selected subject. In preparation for the meeting, participants read pertinent materials sent to them by the FORUM co-chairs. The co-chairs also sent information about the goals of the FORUM, an agenda, and discussion questions that were based on the readings and that were intended to both stimulate thought about the readings and initiate discussion at the meeting. The first FORUM, held in 2001, resulted in the white paper, "Translating Molecular Imaging Research into Radiological Practice" (1).
In May 2002, the ACR held its second annual FORUM in Dulles, Virginia, on the topic, "Radiology 2012: Radiology and Radiologists a Decade Hence." Participants included radiologists, economists, experts in information technology (IT), individuals who have written extensively on departmental organization and administration, third party payers, health services researchers, and representatives of imaging companies. The following presentation represents a synthesis of the discussion that occurred and the conclusions and recommendations derived from discussions on the following aspects of the topic: (a) the health care environment, financing, and cost; (b) imaging technology and the scope of imaging in the future; (c) manpower; (d) the future effect of IT; (e) turf and competition; and (f) quality and outcomes of care.
We have chosen to present the outcomes of the FORUM as a strategic analysis for the specialty.
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THE MARKET FOR IMAGING SERVICES |
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For third party payers like Medicare—and for employers who pay the majority of the private sector premiums on health insurance—this is the undesirable continuation of a trend of increasing costs and health insurance premiums that began in the late 1990s and that is expected to continue through at least the next decade. The combination of patient backlash to the restrictions of managed care, and the inability of insurers to continue to offer lower-than-cost rates to employers in an effort to gain market share has led to double digit premium increases that employers will find difficult to sustain. Increasingly over the next decade, insurance programs will be developed that provide greater flexibility for patients but that also shift greater responsibility to the insured for sharing the costs of care. In short, employers and insurers are trading in the paternalism of managed care for an approach that attacks the root of the problem, so-called moral hazard. The moral hazard of heath care is that patients tend not to know what their health care costs, nor do they bear the financial consequences of their decisions to seek care; thus, there is an incentive to seek more care. Initiatives such as defined contribution plans are gaining attention. These approaches attack moral hazard by insuring against catastrophic illness and injury, but require the patient to pay for routine costs beyond the defined contribution of the employer.
Innovative concepts such as defined contribution plans should become more prevalent over the next decade, as companies once again have to tighten down on their health care expenditures and employment markets loosen. These types of plans incentivize patients to seek value—that is to make decisions about their health care purchases based on the balance of cost and their perceptions of quality. More information will become available on the quality of care, although, at least for the next decade, true measurements of quality based on health outcomes are likely to remain elusive. Instead, input measures of quality, such as training and certification, access, and the availability of state-of-the-art technology will continue to dominate. That there is a dearth of true quality measures presents an opportunity for organizations such as the ACR to design methods to measure aspects of quality—such as accuracy and variability—implement them across the range of radiology practices, and report the results to a public eager for this sort of information.
In the absence of such definitive data, patients will continue to rely on sources of information they currently trust—such as their personal physicians—to advise them on their health care purchases. However, in the near future, other, more public, entities will vie to provide advice on health care in a for-profit environment. These sources will expand in number and scope as more and more patients turn to the Internet for health care information. Direct-to-consumer health care marketing, now so evident for pharmaceuticals, will expand to other technologies, including imaging. The end result is likely to be a greater stratification of health care: the wealthy will spend increasingly more for noncovered services and others who are less fortunate will think more carefully about the value of seeking care.
The implications of all of this for imaging are somewhat unpredictable. On the one hand, the penchant of boomers for more information and more control may further enhance their already evident acceleration in the use of medical imaging. For example, should Americans decide to pay out of pocket for screening (including nonimaging screening tests that will become popularized over the next 10 years) on a large scale, there doubtlessly would be a considerable multiplier effect that dramatically increases the volume of downstream imaging diagnostic studies. However, if under these insurance plans, which shift the financial burden to patients, the patients must also pay out of pocket for these diagnostic examinations, there may be a lesser desire to pursue screening examinations in the future.
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UNCERTAINTIES AND CHANGES IN THE IMAGING ENVIRONMENT |
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Manpower
Even under the best of circumstances, it has proven difficult in the past to correctly predict physician manpower needs (2,3). Nonetheless, there is an acknowledged shortage of trained radiologists currently and this situation is likely to worsen. The key factors likely to exacerbate the manpower shortage are the development of new technologies and the introduction of new uses for existing technology. With regard to new technologies, molecular imaging figures most prominently; although it is likely to be a long-term transition to molecular imaging from current imaging approaches, this process is already underway. Imaging screening examinations are examples of new uses for existing technologies that bear the greatest potential for expanding imaging volumes and putting still greater pressure on radiology manpower. Screening facilities continue to open despite organizational and other expert warnings that the presumed benefits of screening are still unproven. The aging of the population and the new consumerism, detailed earlier, are additional factors that are expected to increase the amount of imaging work.
The ACR already has made proposals for increasing the radiology work force that, if enacted, may help the specialty respond to the expected increased demand for imaging services (4,5). The broad adoption of IT innovations, such as picture archiving and communications systems and computer-aided detection and diagnosis may improve productivity, such that the expected additional workload could be better handled by the available work force. Improvements in the electronic flow of information (detailed later) will facilitate the reentry into the work force of part-time workers. The ACR has preliminarily supported the concept of developing radiologist assistants, who would be able to work under radiologist supervision in a number of different support roles.
Finally, as will be detailed in a later section, a greater share of medical imaging may done by other specialists tied to specific technologies.
Imaging Screening Examinations
The fate of imaging screening examinations is uncertain. Given the difficulties and expense of mounting large scale screening trials (a trial of CT screening for lung cancer that is about to open will involve 50,000 subjects and cost nearly $200 million), acceptably rigorous evidence of the value of screening may be a long time in coming. Thus, the fate of screening examinations will be determined in the marketplace. As noted earlier, to the extent patients have discretionary income they wish to expend on health care and to the degree they are protected from the downstream costs engendered by positive examinations, screening may thrive. Nonimaging molecular testing for some diseases that should appear over the next 10 years may improve risk stratification and better determine who should undergo imaging screening, such that imaging screening can become more cost-effective.
The Future of IT
IT will become less costly and more widely available. Wide-bandwidth technology—hence higher speed access and more utility—will be universally available within the next decade (with the possible exception, in some cases, of "the last mile" to personal residences). The integration of imaging into comprehensive health systems, or even regional systems, will make obsolete the concept of picture archiving and communications systems. Interconnectivity will be facilitated by the completion of image and data communication standards. Departments will have to redesign their workflow so as to achieve maximum efficiencies from their IT investments.
The connectivity of radiology groups with centralized service providers will improve the efficiency of operations and provide access to any number of diagnostic aids. Computer-aided detection and diagnosis and access to on-line educational resources may improve detection and diagnosis, as may feedback systems, such as neural nets, that will provide diagnostic probabilities based on clinical and imaging inputs and improve as information about outcomes is fed back to them. This means that, to survive, all imaging practices will necessarily be on the grid that will electronically interconnect all of health care (and much of the rest of society). As a result, geographic barriers that previously constrained image interpretation to the locale where the image was captured will likely disappear. Greater pressures than in the past will be brought to bear to legislate limited licensure or even federal licensure to practice electronic medicine across state borders and to overcome institutional credentialing requirements. As will be described in an ensuing section, the upshot of all of this will be greater competition over imaging.
IT will make possible the accumulation and storage of large amounts of data on a nationwide basis. This may permit, for the first time, the accrual and organization of information about the effect of using imaging technologies for specific disease states on the outcomes of treatment at the grass roots level. To the extent this is possible, data mining and decision analysis may, in the future, at least partially supplant more expensive and time-consuming traditional technology assessment as the standard mechanisms for defining appropriate practice. However, for this to occur, the specialty will have to adopt lexicons of uniformly accepted definitions and structured reporting formats.
The Uninsured
New coverage of this population of individuals doubtlessly would further increase imaging utilization. There have been several extensive efforts during the past quarter century to legislate universal health insurance—most recently the Clinton health plan of the mid-1990s—however, all of these have failed. Current efforts in some states to legislate single-payer insurance systems that would both simplify health care reimbursement and cover the uninsured are unlikely to succeed, as they will be perceived as "take aways" by the largest segment of the American population, the middle class. It is unlikely that anything comprehensive will be done about uninsured Americans over the next decade.
Tort Reform
Estimates of the cost of defensive medicine vary widely, however, defensive medicine certainly increases testing of all sorts. The FORUM participants felt that this was unlikely to change significantly over the next decade for two reasons: powerful lobbies that benefit from the current system; and a perception on the part of Americans that the legalistic climate results in more careful, better care. The recent Institute of Medicine report on the frequency and outcomes of mistakes in medical practice has sharpened this perception. Nonetheless, the panel did offer one disclaimer to their belief that little would change: the cost of physician malpractice insurance is currently increasing at an accelerating rate; should this continue to the extent that physicians could no longer afford to practice and access to health care were to seriously diminish for patients, important change might occur.
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MARKET FORCES |
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Competition and Risk of New Entrants
The FORUM participants cited both competition among radiologists and between radiologists and other specialists as the critical market force for the next decade.
Radiologists, by their extensive training and certification, have the advantage as the "name brand." That radiologists largely control hospital imaging infrastructures (eg, technologists, image archives, reporting systems) was also seen as an advantage, particularly at a time when hospitals are seeking to incorporate imaging IT systems into comprehensive informatics and need to avoid expensive duplication. To the extent radiologists can use their first-mover advantage in IT to lever a centralized role in the integration of patient information, they can use that new role to maintain dominance in imaging, at least in the hospital setting.
However, participants believed that there will be even more self-referral than has been the case in the past. Despite direct-to-consumer advertising and the rise of screening examinations, radiology will remain a largely referral-based specialty. Nonradiologist physicians, who control patient utilization of imaging examinations, will become increasingly attached to specific technologies related to their specialties and in which they will receive greater training during residency and fellowship. Self-referral will be facilitated by the development of disruptive technologies—smaller, task-specific versions of key technologies—and the associated lowering of their acquisition costs, such that they can be implemented in office practice (or perhaps even by patients in their homes). One potential major exception to this projection is in the field of interventional radiology, where, increasingly, interventional radiologists expect to take their services directly to patients, providing clinical evaluation, procedural services, and follow-up similar to other clinicians.
Certain aspects of imaging are at particular risk. The refinement of image-guided surgery and the dependence of radiation oncologists on imaging will promote a greater degree of self-referral by these specialists. Molecular imaging is particularly at risk, since it will attract physician specialists who are more physiologically and metabolically oriented than radiologists have been in the past. Interdisciplinary groups of non-radiology physicians will band together to develop specialized clinics and boutique hospitals that will attempt to attract higher paying patients to facilities that will specialize in specific organ systems and diseases where reimbursement tends to be high. This phenomenon is already evident in the development of so-called heart hospitals in numerous locales. This has the potential to "skim the cream" from radiology practices.
Competition among radiologists will be based on the electronic grid services detailed earlier. To date, state licensure laws, institutional credentialing, and the cultural credo that referring physicians need face-to-face consultation with their own radiologist have limited interregional competition over imaging services. However, the advances in IT described in a preceding section will eventually supersede these considerations and promote a much higher level of competition based on availability, timeliness, and price. The new consumerism, with its emphasis on quality, discussed earlier, will mandate around-the-clock real-time practice. International reading sites—some organized by U.S. practices—already are being established to facilitate night coverage for groups that otherwise could not provide 24-by-7 service. These operations may provide footholds for increasing international competition over imaging. By using these or other innovations, small groups will agglomerate or form networks to provide expected levels of service and subspecialty expertise. The upshot of all of this will be greater price and quality competition among radiology and other specialist groups for imaging contracts that ensure a flow of patients. Groups will use the sophistication of their IT and their access to patients to attract scarce manpower. Thus, the effect of the manpower shortage may be felt quite differently by different groups and in different regions.
Competition with other radiologists and with other medical specialists may redefine radiologist roles. FORUM participants envisioned three niches for radiologists of the future: (a) service-oriented traditionalists who will be much like today’s radiologists but who will necessarily depend more on the new IT capabilities to be much more responsive to cost and timeliness pressures; (b) technocrats, who would be specialists in a specific technology and who would be consulted for the most difficult or complex cases; and (c) disease-oriented imaging physicians who will be attached to interdisciplinary groups as the imaging expert for the team. Successful groups—or networks of smaller groups—will employ all of these types of radiologists to fulfill the demands of the new consumerism for higher quality care. The development of these roles, and how they differ, has important implications for considering the future training of radiologists.
Customers
Radiologists’ customers are both patients and referring physicians. Both sets of customers will have increased expectations—and market power—as they gain greater access to information and competition increases over the next decade. Even allowing for the expected consolidation in imaging, customers will have available to them expanded choices of their supplier of imaging services as a result of the IT-engendered diminution in geographic barriers. Customers, focused on receiving value in return for being at risk for a greater share of the cost, will leverage this advantage into greater availability and demand that imagers show them evidence of quality. This will include, at a minimum, offering 24-by-7 real-time interpretation of images on demand, developing and disseminating input measures of quality, and ensuring security and safety. Groups that cannot respond to these requirements will eventually fail or be subsumed into larger groups or networks.
Regulators and Payers
The renewed acceleration in the rate of rise in health care costs signals the certainty that both regulators and payers will again emphasize cost reduction as the first priority on their agendas. However, it is unlikely that they will be able to again successfully use the mechanisms of managed care so evident in the 1990s. Patients have bridled at the restrictions and abuses of managed care and used their market power with employers to dictate the reduction of these restrictions to the point that they are largely ineffective. As this trend continues, it will more greatly empower providers to negotiate higher payment levels than during the most draconian days of managed care. In response, regulation will increase, including the possibility of limitations on direct-to-consumer advertising and requirements to provide more quality-related information to patients. There will be renewed focus on what payers see as a primary progenitor of higher costs, the diffusion of new technology that increases cost but with unsubstantiated benefit. Payers will develop more stringent requirements as to what constitutes proof of benefit and cost-effectiveness and apply them to technologic innovations before approving reimbursement for the use of a new technology. They will be particularly attuned to "indication creep"—requests for payment for indications similar to but not exactly the same as indications for which reimbursement is approved—in rejecting claims.
Despite the expected increased emphasis on proof of benefit before reimbursement, it is unlikely that payers will significantly contribute to the cost of technology assessment. The payers’ view is that the developers of technology will eventually reap the benefits, so they should bear the risk and cost of demonstrating efficacy. Conditional reimbursement has been talked about for many years, but it may finally come to fruition in the next decade. Recent efforts by multiple federal agencies (eg, National Cancer Institute, Food and Drug Administration) working jointly with industry are directed at increasing the rapidity of diffusion of promising technology into practice. The possibility of incentivizing acquisition of a promising innovation—while still restraining broad diffusion and its associated costs—by providing reimbursement for use in clinical trials (conditional reimbursement) is one mechanism that will receive consideration.
A major opportunity exists to reduce the administrative cost of the American health system. Currently 20%–30% of the cost of care is consumed in the "front-end" and "back-end" costs of registration, billing, and collecting. These are believed to be the highest administrative costs in the world. There is a major opportunity for savings that could be returned to the system to make provider payments more equitable and lower the cost of care. Over the next decade, approaches will be proposed to lower managerial costs.
Potential Substitutes
Several kinds of potential procedures that might substitute for imaging were offered by participants. Most significantly, there is the possibility that as the long transition of molecular imaging into clinical practice proceeds, earlier molecular diagnosis and treatment would eventually obviate much of the gross anatomic diagnosis, staging, and follow-up of treatment that currently constitutes radiology practice. This will occur slowly, the speed of the transition determined by numerous factors, including funding for research and the regulatory apparatus. Just as significant is the role that may be played by nonimaging molecular-based diagnostic tests that will be developed over the next decade. To the extent that these develop as screening tests, their introduction may provide improved risk stratification that will inform patients and practitioners who should undergo imaging screening examinations. However, some of these tests may prove to be diagnostic, encouraging early systemic treatment that may obviate pretreatment imaging for disease localization or posttreatment follow-up.
Suppliers
Traditionally, the revenue growth for corporations in the medical imaging business has been 3%–7%. However, as consolidation has occurred in the industry, and medical imaging has become a division or subsidiary of larger enterprises, expectations for growth have outstripped traditional performance. From outside the imaging industry, new managers have been brought in who are less attached to the traditional customer base (ie, radiologists) and are more attuned to searching out new opportunities.
There are a number of approaches companies will take to expand their revenues: (a) gain a broader share of the market within a region in which they already compete through marketing, expanding their sales force, or other means; (b) horizontal expansion—develop new products of the sort they already sell (in essence, traditional technological innovation); (c) cost leadership—develop low cost variations of established technologies to appeal to potential acquirers who have previously been priced out of the market, and task-specific miniaturized technologies, such as portable ultrasonography or limb magnetic resonance imagers typify this approach; (d) add services that improve the effectiveness of their products; (e) open new geographic markets; (f) vertical expansion—add to their product line consumables or other products that are required to fully use or enhance the use of their core products; and (g) identify new customers, particularly nonradiologist physicians, who are eager to take on medical imaging as part of their practice.
Imaging corporations may design products to separately target the radiologist and nonradiologist markets, based on specific criteria that they believe typify these markets, as reflected in the Figure.
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RECOMMENDATIONS |
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TOPABSTRACTINTRODUCTIONTHE MARKET FOR IMAGING...UNCERTAINTIES AND CHANGES IN...MARKET FORCESRECOMMENDATIONSSUMMARYREFERENCES |
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General
1. The ACR should commence a continuous, dynamic long-range planning process for the specialty that establishes what constitutes the core of radiology and how that core can be protected and expanded; the core should be constantly reviewed, revised, and communicated to the specialty.
2. The ACR must use the planning process recommended earlier, and its communications with its members, to overcome a common conception among radiologists that all is well now and that it will remain so in the future.
Quality
1. Radiologists must define the various aspects of quality (eg, access, timeliness, technical quality, appropriateness), or others will—perhaps to the detriment of the specialty.
2. The ACR and other radiology organizations should work with national medical organizations interested in quality (eg, the Leapfrog group, Joint Commission on Accreditation of Healthcare Organizations) to reach an agreement on what constitutes imaging quality.
3. The ACR should establish mechanisms, based on electronic connectivity to radiology practices, to collect analyze, and disseminate data on the quality of radiologic practice. One mechanism to accomplish this might be to establish a "Patterns of Care" project for diagnostic imaging similar to what has been so successful for radiation oncology.
4. Radiology should develop common data elements with specific, universally accepted definitions (lexicons) and use them in structured reports as a means of both making radiology reporting more intelligible to physicians and patients and facilitating the development of databases that could be used to evaluate quality.
5. The ACR should enhance and better market its "brand" as the arbiter of quality in medical imaging as a means of better establishing radiologists as the high quality practitioners of imaging.
6. The ACR should support research endeavors and the establishment of clinical databases that bear the potential for better defining the risks and benefits of radiology, incorporate the results into their standards, certification, and appropriateness criteria, and then disseminate this information to patients and referring physicians.
Manpower
1. The ACR must continue to work with other radiology organizations and the federal government to seek means for increasing the number of radiologists nationally.
2. Radiologists should adopt IT and optimize the efficiencies offered by it to respond to expected increases in demand for imaging services.
3. Radiologists should adopt innovative solutions to manpower shortages, such as computer-aided detection and diagnosis and employing radiologist assistants to keep pace with the demand for imaging services.
4. Through its standards process, the ACR should participate in ratifying and promoting IT standards to radiologists to hasten the successful deployment of IT and reap its efficiencies.
5. The ACR should promote federal telemedicine licensure and other initiatives that will help even out the effects of the manpower shortage across the United States and ensure a higher level of care for all regional populations.
Turf and Competition
On the basis of what radiology determines to be its core during its long-range planning process, the specialty should expend its resources on defending and expanding the core and consider a policy of graceful withdrawal with respect to noncore aspects of imaging practice. How this should be accomplished should be an important part of the dynamic long-range planning process recommended earlier.
Changes in the Scope of Practice
1. The introduction of molecular imaging is driven by the progression towards molecular medicine. Radiologists must lead the research that leads to clinical molecular imaging and introduce molecular imaging into practice or risk losing it to other specialties.
2. The ACR must encourage the development of molecular imaging, the training of molecular imagers, and the introduction of molecular imaging into radiologic practice through its Commission on Molecular Imaging.
3. The ACR should take a stronger stand on appropriate activity surrounding screening and other direct-to-consumer imaging offerings. This should include determinations of what constitutes fair and accurate marketing and better dissemination of the risks and benefits associated with these procedures.
Regulation and Reimbursement
1. The ACR should expand its support of clinical research through its research offices, with the goals of better defining the value of imaging technologies and hastening regulatory approval and reimbursement for new technologies that promise to benefit patients.
2. The ACR should develop registries and databases, based on electronic connectivity with large numbers of radiologic practices, that could be mined for information on the effect of using imaging technologies on patient health and cost-effectiveness.
3. The ACR should join with developing consortia of government agencies and industry to promote mechanisms for the more rapid dissemination of promising new technologies.
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SUMMARY |
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TOPABSTRACTINTRODUCTIONTHE MARKET FOR IMAGING...UNCERTAINTIES AND CHANGES IN...MARKET FORCESRECOMMENDATIONSSUMMARYREFERENCES |
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Participants in the Second Annual ACR FORUM: E. Stephen Amis, MD, Albert Einstein College of Medicine, New York, NY; Joseph Antos, PhD, American Enterprise Institute, Washington, DC; Wade Aubrey, MD, Health Technology Center, San Francisco, Calif; William G. Bradley, MD, University of California San Diego; David S. Channin, MD, Northwestern University, Chicago, Ill; Paul Deeringer, BA, Health Technology Center, San Francisco, Calif; James Hartert, MD, Cobalt Corporation, Waukesha, Wis; Bruce J. Hillman, MD, University of Virginia, Charlottesville; Thomas McCausland, Siemens Medical Systems, Iselin, NJ; Thomas Miller, MBA, LightLab Imaging, Waltham, Mass; Scott A. Mirowitz, MD, University of Pittsburgh, Pittsburgh, Pa; Harvey L. Neiman, MD, Western Pennsylvania Hospital, Pittsburgh; Sanford Schwartz, MD, Leonard Davis Institute, University of Pennsylvania, Philadelphia; Edward V. Staab, MD, National Cancer Institute, Rockville, Md; Jonathan Sunshine, PhD, American College of Radiology, Reston, Va; and James H. Thrall, MD, Massachusetts General Hospital, Boston.
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FOOTNOTES |
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