Examining exclusionary conduct of HMOs and PPOs: a case comment on Northwest Medical Laboratories v. Blue Cross and Blue Shield of Oregon.

As the climate of the health care industry has changed to one of cost-containment and competition through the growth of HMOs and PPOs, health care providers have become the subjects of antitrust litigation. One such case, Northwest Medical Laboratories v. Blue Cross and Blue Shield of Oregon, involved a medical laboratory and a radiology center who claimed that they were victims of an illegal group boycott after defendant's pre-paid health plan denied them preferred provider status. The Oregon Court of Appeals, using the traditional antitrust analysis applied to other industries for decades, failed to consider the intricacies that exist within the health care industry. This result led to an inaccurate market share computation and an inadequate rule of reason analysis. This Comment examines the shortcomings of the Northwest Medical opinion and argues that, in applying the antitrust laws to the health care industry, courts in future cases must recognize and respect the unique features of the business of providing health care.     

Ball Memorial Hospital: Section 2 Sherman Act analysis in the alternative health care delivery market

In 1986, the Seventh Circuit Court of Appeals in Ball Memorial Hospital v. Mutual Hospital Insurance denied an injunction sought under the antitrust laws by the plaintiffs, eighty acute care hospitals, which would have precluded Blue Cross and Blue Shield of Indiana from implementing a Preferred Provider Organization. The Ball court used a conservative economic analysis to deny the injunction and failed to consider many industry-specific factors. This Note examines these factors and challenges the Ball court's position by arguing that antitrust scrutiny of alternative health care delivery markets must go beyond the court's narrow approach.     

Blue Cross/Blue Shield-sponsored prepaid individual practice

The HMO is no longer a fledgling idea in the Blue Cross/Blue Shield System. There are 45 Blue Cross/Blue Shield Plans throughout the country which sponsor a total of 54 HMO programs with about 1,040,000 members. Among those 54 programs are staff models, group models, Individual Practice Associations (IPAs), and other structures. This analysis is confined to the Minnesota affiliate corporation, "HMO Minnesota."     

管制行业反垄断执法权配置分析——以管制度为视角

管制行业在不同程度上存在着反垄断执法问题,其执法权配置有多种模式可供选择,但从管制度的角度看,这一执法权配置应是从行业管制机构向反垄断专门执法机关逐步移转的过程,这也是大多数国家或地区立法与实践的发展趋向,因此,我国相关立法也应作相应完善.     

City of Revere v. Massachusetts General Hospital: government responsibility for an arrestee's medical care

City of Revere v. Massachusetts General Hospital presented the United States Supreme Court with its first opportunity to consider whether a state or municipality has a constitutional duty to pay for medical treatment received by an individual in police custody. The Supreme Judicial Court of Massachusetts had held that the city had an eighth amendment duty to pay for an arrestee's treatment. The U.S. Supreme Court reversed, observing that eighth amendment rights and duties are not implicated prior to conviction and that fourteenth amendment due process concerns were met once the arrestee received adequate medical care. No obligation to pay arises, the Court held, absent a specific state law provision requiring such payment. Because arrestees are subject to physical restraints similar to those imposed on convicted prisoners, this Case Comment argues that courts undertaking to determine the scope of a state's duty to provide treatment to arrestees should apply a due process standard which draws upon eighth amendment analysis. The Comment concludes that under such an eighth amendment equivalence approach, no duty to pay arises because the state's failure to pay the health care provider does not reflect "deliberate indifference" towards the recipient of the treatment.     

A cure for the Blues: resolving nonprofit Blue Cross conversions

This Article analyzes the issues involved in converting nonprofit Blue Cross organizations to for-profit status. These issues have arisen in the context of litigation regarding the "reorganization" of Blue Cross and Blue Shield of Missouri ("BCBSMo"). BCBSMo had reorganized by creating and transferring a majority of its business to a new for-profit subsidiary. Missouri consumer groups and state regulators characterized the "reorganization" as a conversion requiring BCBSMo to transfer its assets to a foundation dedicated to charitable health purposes. BCBSMo, however, denied that it had any obligation to leave behind its assets in the nonprofit sector. The BCBSMo litigation raises issues common to most conversions of nonprofit healthcare organizations, particularly conversions of nonprofit Blue Cross plans. This Article provides a road map for state regulators and the public to follow in ensuring that the public interest is fully protected in such conversions.     

Capture and culture: organizational identity in New York Blue Cross.

This article explores the changing corporate culture of New York's Blue Cross and Blue Shield plan in its first fifty years. As the plan grew, corporate culture evolved over four sequential phases: the plan first had the character of an experiment, then that of a movement, a business, and, most recently, a corporate agglomerate. Accompanying this evolution has been an identity crisis, as the need to adapt to a turbulent environment has challenged the plan's settled understanding of its core values, namely, voluntarism, community, and cooperation.     

经济全球化与反垄断立法

随着经济全球化的发展,基于国内因素的考虑而制定的反垄断法不可避免地遇到了各种问题,美国和欧盟等都开始对传统反垄断法进行调整。经济全球化也促进了反垄断国际规范的发展。中国在经济全球化的背景下应该及时制定反垄断法或反限制竞争法;并且在制度安排上应注意:坚持垄断中性的认识,充分体现合理规则,中国反垄断法应以规制限制竞争行为为中心,充分考虑国际市场因素,合理安排责任制度,有克制地赋予域外效力。     

Why don't courts treat hospitals like tanks for liquefied gases? Some reflections on health care antitrust enforcement

In this article, I use the Federal Trade Commission and the Department of Justice 2004 report Improving Health Care: A Dose of Competition as an occasion to comment on two specific issues that have arisen in health care antitrust: the recent string of losses by the enforcement agencies in hospital merger cases and an antitrust exemption for physicians to bargain collectively with health insurers. One of the more salient facts about health care antitrust enforcement is the notable recent lack of success of the enforcement agencies in hospital merger cases. This may be due to judges and juries holding views of hospital markets as being different from markets for other goods and services. My conclusion is that hospitals are an industry with unique attributes, but nothing about the specifics of the health care industry suggests that the unregulated use of market power in this industry is socially beneficial. As a consequence, the antitrust laws should be enforced here as in any other industry. Countervailing power is an issue that has come to the fore in health care antitrust. Physicians have explicitly asked for legislative exemption from the antitrust laws in order to bargain collectively with insurance companies, as a means of counteracting insurers' monopsony power. It is not clear that health insurers possess significant monopsony power. Even if they do, bestowing monopoly power on physicians will not necessarily improve matters. Active antitrust enforcement in insurance markets is the correct response, not blanket exemptions for providers.     

中国企业在美国反垄断诉讼中的挑战与应对:基于对相关判决的质疑

中国企业在美国的一系列反垄断诉讼发生在中国加入世界贸易组织后与美国在经贸关系中博弈摩擦不断升级的背景之下,其中涉及了美国反托拉斯法的域外适用、国际礼让原则、外国法查明、外国政府对本国法律解释的效力等一系列焦点问题。在相关案件的判决中,美国法院就上述问题的观点和论述存在诸多漏洞和偏颇之处,包括限缩适用"国际礼让原则"中"真实冲突"的条件、外国法查明中客观性的缺失等。而未来随着中国企业日益成为美国反托拉斯重点关注对象,中国企业会面临更多挑战,需从美国国内法、国际法、中国相关政策法规的制定以及企业自身行为的合规性等方面积极应对。     

Vertical restraints among hospitals, physicians and health insurers that raise rivals' costs. A case study of Reazin v. Blue Cross and Blue Shield of Kansas, Inc. and Ocean State Physicians Health Plan, Inc. v. Blue Cross and Blue Shield of Rhode Island

Two recent district court opinions consider whether affiliations among hospitals, doctors and health insurers--through contract or ownership--violate the antitrust laws. This Article applies a raising rivals' costs framework to the facts of those cases in order to assess whether the practices at issue were unreasonable.     

The conversion and settlement of Georgia Blue: are consumer groups still singing the blues?

As more Blue Cross/Blue Shield Organizations employ various means to convert to for-profit status, myriad issues arise concerning the proper treatment of assets that were accumulated during the not-for-profit years of such organizations. Moreover, state officials face pressure from all sides to assure that the conversion process is "fair." In the following Article, the author examines the conversion of Blue Cross and Blue Shield of Georgia to demonstrate the various conversion issues that arise under traditional legal principles--as well as the means by which that Blue employed newly enacted legislation to avoid many of the requirements that otherwise would have attended its conversion.     

私营标准的反垄断法分析

私营标准具有事实上的强制力,缺乏等效性,且可能成为大型零售商构筑市场准入门槛、实施贸易歧视的工具,这使私营标准可能触发反垄断法上的问题。目前,私营标准的国际协调面临着困境,这势必促使各国国内反垄断法做出相应对策。反垄断法的域外适用机制成为私营标准反垄断法管制的接点,滥用私营标准的反垄断法分析遵循与滥用市场支配地位反垄断法分析一致的思路。同时,应关注私营标准的技术法规化问题,警惕私营标准中知识产权因素可能对市场竞争的影响。     

反垄断法的价值构造

价值问题是反垄断立法和实施中的核心和前置性问题,在当前中国反垄断法实施面临制度分裂、"纸面上的法"与"行动中的法"相背离等背景下,对这一话题的研讨尤为重要。成熟反垄断法律制度的实体价值主要表现在自由、效率和公平等诸方面,在经济理性的作用下,这些价值呈并存、竞争和融合的矛盾运动之势。受制于政治、经济、社会文化以及制度等因素的影响,中国反垄断法表现出来的自由价值和经济理性等先天不足,是该法实施乱象的重要根源,亟待通过制度实践和竞争文化培育凝聚更多价值共识。     

Redressing the imbalanced political market for health policy: a role for the state attorney general?

In current discussions of "procompetitive" approaches to health policy, the enforcement of antitrust laws in health care markets is a strategy that has attracted increasing attention: the filing of consumer-oriented health suits provides a means to "redress" the typically imbalanced "political market" in health policy. This study examines an important aspect of the antitrust enforcement process, the decision by a state attorney general to undertake an aggressive antitrust enforcement program in the health area. Three variables were found to explain this decision: the political needs of a "politician-supplier," the organizational resources of a strategic institutional position, and the availability of a relatively favorable policy arena. An assessment of the future role of state attorneys general in this area suggests that their health antitrust initiatives will increase, but that various political and resource constraints are likely to inhibit their aggressiveness in pursuing these actions.     

The Economic Problem of Fixed Costs and What Legal Research Can Contribute

The antitrust laws demand competition but, in general, no competitive outcome is possible in markets characterized by substantial fixed costs. Consequently, restrictions on competition may have an efficiency defense, and a prohibition of cartel agreements may entail costs as well as benefits. Giving examples, this essay illustrates the problem that fixed costs pose for competition, long recognized in economics, and discusses implications for real-world industries. The author addresses Wiley's recent criticism of theoretical and empirical work on the fixed cost problem and outlines an agenda for legal research that can help illuminate the underlying economic and antitrust policy issues posed by industries with high fixed costs.     

Special report on liability and insurance. An update on assignment of patient benefits under ERISA

While the holdings in Davidowitz and Arkansas Blue Cross & Blue Shield arose in different contexts, they both reflect the courts' increasing willingness to consider the importance of cost containment in the health insurance arena, even though patient accessibility to health care may be restricted as a result. If the holding in Davidowitz is not successfully appealed, providers may need legislative relief in order to retain their ability to take valid assignments of patient claims for payment from ERISA plans. It is uncertain whether such legislation can be sought at the state level or must instead come from Congress due to ERISA preemption of state legislation. Clearly, the district court decision on remand in Arkansas Blue Cross & Blue Shield will be closely watched for any light it may shed on this question. On a pragmatic note, providers who have not entered into "participation" agreements with insurers or other private payors may now have a greater incentive to do so, and "nonparticipating" providers who continue to obtain assignments from patients in order to collect directly from insurers or other private payors should determine on a case-by-case basis whether the source of the patient's benefits is a group health plan--which is likely to fall under ERISA and may contain nonassignment provisions--or some other form of coverage. For an additional perspective on insurers' responses to copayment waivers, see Newsletter, Vol. 6, No. 10, October 1991, at 7.     

美国反垄断法豁免中的诺尔——本灵顿原则评析

诺尔——本灵顿原则是由美国联邦最高法院通过几个案例确立的联邦反垄断法中的一个原则,其主要含义是:根据《美国宪法第一修正案》的规定,即使竞争者通过游说政府而改变法律将会削弱竞争,其行为也不违反反垄断法。诺尔——本灵顿原则是协调《谢尔曼法》的重要目标与公民请愿权利和各级政府有效决策之间关系的产物。诺尔——本灵顿原则对中国的反垄断法执法也有一定启发意义,在执法过程应当全面协调经营者的竞争利益与其他经营者的宪法权利、与政府行为的关系。     

Certificate-of-need in an antitrust context

Recent cases such as National Gerimedical Hospital and Gerontology Center v. Blue Cross of Kansas City have found that certificate-of-need (CON) legislation did not intend to remove antitrust considerations. This note discusses the exemptions from antitrust provided by the state action doctrine of Parker v. Brown as well as the Noerr-Pennington doctrine, both of which appear to protect provider input into the CON process. Providing information that assists decision-making must be carefully distinguished from providing data that serve the interests of physicians and hospitals.     

Most-favored-nation clauses in commercial contracts: legal and economic analysis and proposal for a guideline

The prevalent use of “most favored nation” (MFN) clauses in commercial agreements has garnered significant attention in the economics and legal literature and by practitioners and enforcement agencies. From an antitrust standpoint, there is a strong consensus that while MFN provisions can lead to procompetitive outcomes or at least play a competitively neutral role, they may also result in competitive harm and a loss of consumer welfare. Therefore, US and EU enforcement agencies and courts have held that MFNs should be reviewed on a case-by-case basis, considering the specific characteristics of both the contractual provision and the industry. While a case-by-case approach is valid, it is not ideal from a variety of standpoints: that of the competition authorities seeking to make best use of their limited resources and that of practitioners seeking to advise their clients. Accordingly, published guidelines on the use of MFNs, containing presumptions and safe harbors, would be both efficient and useful. The paper argues that it would increase the efficiency and accuracy of antitrust enforcement if one of the leading competition authorities issued MFN guidelines. The paper suggests a set of presumptions and safe harbors that should be included in any such guidelines.