## F I LED United States C ourt of Appeals Tenth Circuit 

### September 6,200 6 Elisab eth A. Shumaker C l erk of C ourt PU BL I SH UNI TED S TATES CO URT O F AP PEALS

T E N T H C IR C U IT J AM E S M . AB RA HAM, ADVAN T AGE EYE CARE; TE RRY H. BERNER; BE RN ER EY E C LI N I C; BL A I N E F. BI RD; ROBER T S . BRI GGS; P ARK CI T Y VI S I ON C E NT E R; T RA E R G . CA YW OO D; BI LL G. CO DN ER; OR EM EYE CLI NI C; CRAI G J . CUTL ER; W A SA TC H V I SI O N CL I N I C; D A N E F. D A N SI E; LA N N Y F. D U CL O S; L I NC OL N J . DYGE RT ; BR ADL E Y V. F E L L OWS ; M AT HE W G. F I NDL AY; M U R R A Y V IS IO N C E N T E R ; K E V IN J . FRO M M ; O PTO M ETR I C PH Y SI CI A N S; J AM E S L . F RO S T ; OP T I CA L ASS OCI ATE S ; P AUL D. GEL LE R; AP P L E CO NT AC T L E NS CE NT E R; RO Y R. GI BSON ; RO BERT F. GR AY ; DA LE F . H A R D Y ; R IC H A R D W . H A R T ; KENNET H H. HOO TON; RI CH HEM PHERY S; FAM I LY V I SI ON CA RE; J OD I E J OH NSO N; RI VER TON FAM I LY EY E C A RE ; M I CH A EL JUD K I N S; RO BERT W . KELLER; TOD D E. KI M BA L L ; S UGAR HOUS E VI S I ON CLI NI C; SHA UN D. LAR SEN; M OB I LE EY E C A RE O F U TA H ; TO D D J . LEW I S; KEI TH W. LI NFORD; DAV I D R. M A S I H D A S , d o i n g b u s i n e s s a s U t a h E ye As s o c i a t e s ; RO L AND K. M ONS ON; E YE CLI NI C A ND CO NTA CT LENS CEN TER OF U TAH VA LLEY; CH ELLE NI CK LE; OAKR I DGE OP T OM E T RY ; KE RR Y A. OKE L BE RR Y; HAR AL D E . OL AF S S ON; DANI E L W. P AC E ; P AUL A. P AXMAN; N o. 05- 4043-2-

M OU NTA I N V I EW EYE C AR E; SCOTT D. P E T E RS ON; WALT E R G . PETE RSON ; GR EG M . PI CK ETT; P H I L L I P A . P L O T H O W; R U S S E L L W. P URDY; DAV I S EYE CARE C ENT ER; ALA N T. REES; J AM ES D. SARG ENT; J EFF REY H. SEEHOLZER; SEEHOLZER VI S I ON C E NT E R; F RA NK A. S I DDOWAY; GAR Y C . S L AUGH; OGDE N VI S I ON C E NT E R; DAVI D A. S M I TH; S OUTH VA LL EY E YECARE CE NT E R; DOUGL AS R. S M I T H; BOUNTI F UL VI S I ON PL AZA; ROBER T M . W I LKES; BO UN TI FUL EYE C AR E; RO BERT P. W OO LDR I DG E; S T ANDAR D OP T I CA L ; UT AH C OUNT Y O P T O M E T R IC P H Y S IC IA N S ,

P l ai nti ffs - A pp el l ants , v. I NTE RM OUN TAI N HEALT H CARE IN C .; I H C H E A L T H S E R V IC E S , IN C .; I HC HE AL T H P L ANS , I NC . ; I HC BE NE F I T AS S UR ANC E CO M P ANY, I NC . ; CO REY A. M I LLER; DA VI D E. BR ODS T E I N; CO UNT RY HI L L S E YE CENT ER, D efen dan t s - A pp el l ees. AP P EA L F ROM THE UNI TE D S TA TE S DI S TR I CT COURT

F OR THE DI S TR I CT OF UT AH ( D . C t . N o. 2: 01- C V - 919- J) D ani el L . B erm an, B erm an & Savage, Sal tL ake Ci ty , U t ah ( PeggyA . T om s i c,T he H onor abl e W i l l i am P . J ohns on, D i s tr i ctJ udge of the U ni t ed St at es * D i s t r i ctC our tfort he D i s t r i ctof N ew M exi co, s i t t i ng bydes i gnat i on. -3- T om s i c Law Fi r m , L L C , Sal tL ake Ci ty , U t ah, w i th hi m on the br i efs ) , appea r i ng fo r A p p e llan t. R i char d W . C as ey , H ow r ey , L . L . P. , Sal tL ake Ci ty , U t ah ( G aryF. B endi ngerand J ohn H . B ogar t , H ow r ey , L . L . P. , Sal tL ake Ci ty , U t ah; J ames S. J ar di ne and J ohn M ac k ay , R ay , Q u inn ey& N eb ek er, Sa ltL ak e C ity , U tah; T h o m as R . K arren b erg and N athan B . W i l cox, A nder s on & K arr enber g; and W i l l i am G . K opi tand Pat r i ci a W agner , E ps t ei n, B ecke r& G r een, P. C . , W as hi ngt on, D C , w i th hi m on t he b ri ef) appeari ng for A pp el l ees. B efor e T AC HA , C h ie f C ir c u it J u d g e , P O R F IL IO , C i r cui tJ udge, and J OHN S ON , D i s t r i ctJ udge. * T AC HA , C hi ef Ci r cui tJ udge. T h is a p p e a l is th e re su lt o f c e rta in U tah o p to m e trists’ d e c a d e -lo n g e ffo rt to b e c o m e p a n e l p ro v id e rs fo r t h e la rg e s t m a n a g e d h e a lth c a re c o m p a n yin th e s ta te . I n 2001, t he opt om etr i s t s ul t i m at el yfi l ed s ui tagai ns tI nt erm ount ai n H eal th C ar e, In c . (“I H C ” ) a n d o th e rs, a lleg in g th a t IH C ’s e x c lu sio n o f o p to m e trists f

ro m its n etw o rk o f p rov iders v iolates § § 1 an d 2 o f th e S h erm an A ct. T h e D istri ct C o u rt gr ant ed s um m aryj udgm enti n favorof the D efe ndant s on al l cl ai m s . W e t ake ju ri s d ic tio n u n d e r 2 8 U .S .C . § 1 2 9 1 a n d A F F IR M . I . BA CKGROUND A . T h e P arti es a n d P lay ersT he W as at ch Fr ontr efe r s t o Sal tL ake, D avi s , W eber , C ache , U t ah, and 1 w e s te rn S u m m it c o u n tie s . -4- 1 . Th e P la in tif

fs T h e P lai n ti ffs are fo rty -nin e o p tom etri sts w h o p rac ti ce alon g U tah’s W asa tch F ron t an d their affil iat ed p rofessio n al org an izati o n s, as w ell as S tand ard 1 O p tic a l C o m p a n y , a n e y e c lin ic o n th e W a s a tc h F ro n t th a t e m p lo y s o p to m e tr is ts . O pt om etr i s t s s el l opt i cal har dw ar e, s uch as gl as s es and cont actl ens es , and have b ee n p erm itted u n d er U tah law to p erfo rm the f u ll sco p e o f n o n -surg ical ey e c are (“ N S E C ” ) sin c e 1 9 9 1 . A ll o p to m e trists w h o a re p a rties to th is s u it are th e ra p e u tic o p to m e trists, w h ich m e a n s th e ya re a u th o riz e d to p re sc rib e p re sc rip tio n d ru g s in addi t i on t o per form i ng N SE C and s el l i ng har dw ar e. 2. The D ef

end an ts W e begi n w i t h I H C , t he l ar ges tm anage d car e companyi n U t ah. I H C began a s a n n o n p ro fit as so c iatio n o f h o sp itals in 1 9 7 5 . In th e m id -1 9 8 0 s IH C v e rtica lly i n t e g r a t e d i t s h o s p i t a l s a n d b e g a n t o o ffe rp r e p a i d h e a l th s e r v i c e s f r o m I HC fa c ili ties a n d p h y sic ian s th ro u g h m a n a g e d c a re o rg a n iza tio n s. IH C ’s h e a lth serv ice p rod u cts— also ca ll ed m an ag ed ca re p lans

— are p rov ided thro u g h IH C ’s w hol l y - ow ned s ubs i di ary , I H C H eal th Pl ans , I nc. I n the mi d- 1990s , I H C added a phy s i ci ans ’ di vi s i on and form ed I H C H eal th Ser vi ces , I nc. T hatent i tyoper at es h ea lth ca re fac il it ies an d d ir ec tl yem p loy s p h y sici an s an d o ther h ea lth ca reFort he s ake of cl ar i t y , w e w i l l col l ect i vel yr efe rt o the I H C - aff i l i at ed 2 e n tit ies a s “ IH C .” W e w ill re fe r to D rs. M ill e r a n d B ro d ste in a n d th e ir pr ofes s i onal corpor at i ons as “defendantopthal m ol ogi s t s . ” W e w i l l r efe rt o the c o llec tiv e g ro u p o f

d e fe n d a n ts— IH C , IH C H e a lth P lan s, In c ., a n d IH C H e a lth Ser vi ces , I nc. , and the defendantophthal m ol ogi s t s — as “D efe ndant s . ” -5- p rov iders. IH C an d it s affil iat es n o w o w n an d o p era te nin etee n ac u te ca re hos pi t al s and s i x s ur gi cal cent er s i n U t ah. N i ne of thes e hos pi t al s and fi ve of th e s e s u rg ic a l c e n te rs a re lo c a te d o n th e W a s a tc h F ro n t. T h e De fe n d a n t s a l s o i n c l u d e two o p h th a l mo l o g i s t s — Co r e yA. M i l l e r , M . D. a n d D a v id A . B ro d s te in , M .D .— a n d th e irre s p e c tiv e p ro fe s s io n a l c o rp o ra tio n s . L ik e o p to m e trists, o p h th a lm o lo g ists s e ll o p tica l h a rd w a re a n d p e rfo rm th e f u ll scope o f N S E C . T heyt herefore com pete w i th o ptom et ri st s for the sal e of these goods and s ervi ces . U nl i ke opt om etr i s t s , how ever , ophthal m ol ogi s t s ar e l i cens ed p h y sic ian s a n d a re a u th o riz e d in U tah to p e rfo rm su rg ica l eye c a re (“ S E C ” ) in addi t i on t o N SE C . A ccor di ngl y , ophthal m ol ogi s t s fr equent l yhave s t aff pr i vi l eges a th o s p i t a l s , w h i c h e n a b l e s t h e m t o u s e t h e h o s p i t a l t o p e r fo r m e ye s u r g e ry. 2 T hough nota part yt o t hi s act i on, E y e N etw or k of U t ah ( “EN U ”) fi gur es p ro m in e n tlyin th is c a se . E N U is a n e tw o rk o f v isio n c a re p ro v id e rs; its me mb e r s h i p c o mp r i s e s e x c l u s i v e l yo p h th a l mo l o g i s t s u n d e rc o n tr a c twi th a n I HC m anage d car e pl an. D r . M i l l erand D r . B r ods t ei n w er e manager s of EN U dur i ng the p eriod relev an t t o this ap p ea l. T h e m em b ers o f E N U , as w ell as a ll o f IH C ’s p a n e l o p h th a lm o lo g ists, a re h o riz o n tallyp o sitio n e d c o m p e tit o rs w ith re sp e c t toU ta h la w e x p lic itly p e rm its th is p ra c tic e . See U t ah C ode A nn. § 31A - 8- 3 1 0 5 (2) (stati n g that “o rga n izati o n s m ay. . . fu rnish h ea lth ca re thro u g h p rov iders w h ic h a re u n d e r c o n tr a c t w ith th e o rg a n iz a tio n ” ). -6- eac h ot her( i n t he pr ovi s i on of SE C and N SE C and i n the s al e of opt i cal h a rd w a re ) a n d w ith re sp e c t to o p to m e trists (in th e p ro v isio n o f N S E C a n d th e sa le o f o p tic a l h a rd w a re ). B . B ackg round F act s IH C adm i nis t ers fou r m anag ed care plans that furni sh health care services , in c lu d in g S E C a n d N S E C , to a n e n ro llee in e x c h a n g e fo r p e rio d ic p re p a id pr emi um s . T he pl ans s eek t o l i m i tcos t s ( and ther efor e pr emi um s ) by : ( 1) des i gnat i ng t he i ndi vi dual heal t h car e pr ovi der s ( “pane l pr ovi der s ”) fr om w hom en roll ee s m aysee k tr ea tm en t; an d (2) m an ag ing ac ce ss to a n d the typ e o f c are enr ol l ees m ayobt ai n. I H C t hen r ei m bur s es panel pr ovi der s fors ervi ces pr ovi ded to e n ro llee s. B e c a u se p a n e l p ro v id e rs a c c e p t lo w e r p a ym e n ts fo r th e ir se rv ice s to IH C enrol l ees i n ex chan ge fo r i ncreased pati ent vol um es di rect ed to them as a panel pr ovi der , cos t s m aydecl i ne and pr emi um s m aydecr eas e w hen pr ovi der panel s become s m al l erand more excl us i ve. T her efor e, I H C l i m i t s the numberof heal t h car e pr ovi der s w i t h w hom i t contr act s . T hes e contr act s ar e governed by 3 w r i t t en agr eement s , and al l I H C ’ s panel pr ovi der s — w hetherphy s i ci ans l i ke opht hal m ol ogi s t s ors o- cal l ed “a nci l l arypr ovi der s ” l i ke opt om etr i s t s — s i gn the s a m e a g re e m e n t.-7-

I H C ’ s pr es ence i n t he mar ketform anage d car e— thati s , the mar ketfor m anage d car e pl ans — i s s i gni fi cant , es t i m at ed bys om e t o cons i s tof s i xtyper cent o f to tal m an ag ed ca re p lan e n roll ee s o n the W asa tch F ron t. A lth o u g h IH C ’s en roll ee s m ayp atron ize a h ea lth ca re p rov ider w h o is no t an IH C p an el pro v ider, pl an bene fi t s w i l l gener al l ynotbe pai d w hen the enr ol l ee doe s s o. A s s uch, IH C ’s pa n el pro v iders o n lytheo reti ca ll yco m p ete w ith n o n -pa n el pro v iders beca us e the pr act i cal i t i es of l i fe di s s uade mostI H C enr ol l ees fr om obt ai ni ng h e a lth s e rv ic e s f

ro m n o n -p a n e l p ro v id e rs . S e e A b ra h a m v . In ter m o u n ta in He a lth C ar e, Inc. , 3 9 4 F . S u p p . 2 d 1 3 1 2 , 1 3 1 8 (D . U ta h 2 0 0 5 ). B esi des IH C ’s presence i n the m arketfor m anag ed care plans, i tal so has a s i gni fi cantpr es ence i n t he mar ketforhos pi t al and s ur gi cal fac i l i t i es on the W as at ch Fr ont . I tcontr ol s appr oxi m at el y51% t o 55% of thatm arket . A l though IH C h a s e m p lo y e d so m e p h y sic ian s d ire c tly , fo r th e m o st p a rt h e a lth c a re is provided o nlyt hroug h it s m anag ed care subsi diar i es. W i t h one exc ept i on, al l of I H C ’ s panel pr ovi der s of ey e ca r e on the W asa tch F ron t are o p h thalm o log ist s. In c o n tr ast, all co m p eti n g m an ag ed ca re compani es on t he W as at ch Fr onthave both ophthal m ol ogi s t s and opt om etr i s t s on t he li stof av ai l able pr ov i ders of N S E C . Indeed , al l the o ptom et ri st s i n thi s case s erve on I H C ’ s compet i t or s ’ panel s . N ots urpr i s i ngl y , then, opt om etr i s t s on the W as at ch Fr onthave form or e than a de cade entr eat ed I H C t o l i s tthem as-8-

pr ovi der s on i t s m anage d car e pl ans . I n fac t , i n 1995 ther e w er e s ever al i ndi cat i ons t hatI H C i nt ended t o i ncl ude opt om etr i s t s on i t s pr ovi derpanel s , as t heyt ypi cal l ychar ge appr oxi m at el ytw entyper centl es s forN SE C than do o p h thalm o log ist s. U lt im ately , h o w ev er, no o p tom etri sts w ere p an eled . IH C ’s di r ect orof pr ovi derr el at i ons expl ai ned thatw heneve rI H C tr i es t o add o p tom etri sts t o it s p rov ider p an els, the o p h thalm o log ist s “w ri te all k ind s o f lett ers and [make] phone ca l l s and r ai s e s uch a s t i nk” thatI H C deci des nott o do i teac h tim e it is p ro p o s e d . T he crux of the Pl ai nt i ffs ’ cl ai m s i s the exi s t ence of an a gr eementbetw een I H C and i t s panel opht hal m ol ogi s t s des i gned t o pr es erve forophthal m ol ogi s t s t he ex clus ive a b il ityto p rov ide N S E C to an esti m ated sixtyp erc en t of the re g ion ’s m anage d car e enr ol l ees w hi l e s i m ul t aneous l yi ncr eas i ng I H C ’ s dom i nance i n the m arketfort he pr ovi s i on of hos pi t al and s ur gi cal fac i l i t i es . M or e s peci fi cal l y , t he P l ai nti ffs cl ai m t hat i n ex chan ge fo r I H C ’s agreem ent nott o p anel opt om et ri st s, I H C ’ s panel opht hal m ol ogi s t s agr eed t o r efe rthei rpat i ent s t o I H C hos pi t al s and su rgica l fac il it ies— as o p p o sed to fac il it ies o w n ed an d o p era ted b yIH C ’s compet i t or s — w hen thos e pat i ent s neede d SE C . N eedl es s t o s ay , I H C and the defe ndantopht hal m ol ogi s t s denythe exi s t ence of anys uch qui d pr o quo . M o re fac t s w i l l come as neede d. C . P roc ed u ral H ist o rySect i on 4 pr ovi des t hat“anyper s on w ho s hal l be i nj ur ed i n hi s bus i nes s or 4 pr oper t ybyr eas on of anyt hi ng forbi dden i n the ant i trus tl aw s m ays ue t her efor. . . and s hal l r ecove rt hr eefol d the damages byhi m s us t ai ned, and the co st of su it , inclu d ing a re aso n ab le att o rne y ’s fe e.” 1 5 U . S . C . § 1 5 (a). Sect i on 16 pr ovi des t hat“[a ] nyper s on . . . s hal l be ent i t l ed t o s ue forand 5 have i nj unct i ve r el i ef . . . agai ns tt hr eat ened l os s ordamage bya vi ol at i on of the ant i t rus tl aw s . . . undert he s ame condi t i ons and pr i nci pl es . . . [us ual l yempl oy ed by ] cour t s of equi t y . ” 15 U . S. C . § 26. -9- T he Pl ai nt i ffs fi l ed s ui tagai ns tthe D efe ndant s i n N ovember2001, al l egi ng v io la tio n s o f

§ § 1 a n d 2 o f

th e S h e rm a n A c t, s ee 15 U . S. C . §§ 1, 2. T heys ought d a m a g e s u n d e r § 4 o f

th e C la yto n A c t, s ee 15 U . S. C . § 15( a) , as w el l as 4 inju n c tiv e re lie f

u n d e r § 1 6 o f

th e C la yto n A c t, s ee 15 U . S. C . § 26. A l l of the 5 Pl ai nt i ffs ’ cl ai m s ar e bas ed on the s ame gener al conduct . A s expl ai ned above , t heyfi r s tal l ege thatI H C and the defendantophthal m ol ogi s t s cons pi r ed t o excl ude o p to m e trists a s a c las s f ro m IH C ’s p ro v id e r p a n e ls— c o n d u c t th a t, ac c o rd in g to th e P la in tiffs , c o n s titu te s a n ille g a l h o ri z o n ta l g ro u p b o y c o tt in v io la tio n o f § 1 . T heyal s o al l ege thatI H C unl aw ful l yt i ed the s al e of i t s m anage d car e pl ans t o t he p r o v i s i o n o f

S E C a n d NS E C i n v i o l a t i o n o f § 1 . F i n a l l y , t h e P l a i n t i ffs a l l e g e I HC and the defendantopht hal m ol ogi s t s cons pi r ed and a t t empt ed t o m onopol i ze the m a rk e t fo r s u rg ic a l fa c iliti e s in v io la tio n o f § 2 . T h e D is tr ic t C o u rt g ra n te d s u m m a ry ju d g m e n t in fa v o r o f a ll D e fe n d a n ts . W ith re g a rd to th e g ro u p b o y c o tt cla im , the c o u rt h e ld th a t th e P lain tiffs fa iled to e sta b lish th e e x iste n c e o f a c o n sp ira c ya n d th a t th e yh a d sh o w n n o “ d isc re te-10-

‘ ant i t rus ti nj ur y ’ t o t hemsel ves fl ow i ng fr om anyadver s e i m pactupon compet i t i on r es ul t i ng fr om t he defendant s ’ al l eged mi s conduct . ” A br aham , 394 F . S u p p . 2 d at 13 2 6 (em p h asis o m itted). A s to the ty ing claim , the D istri ct C o u rt hel d t hatt he Pl ai nt i ffs fai l ed t o es t abl i s h thattw o s epar at e pr oduct s exi s t ed s uch t hatt he s al e of one coul d be t i ed t o the s al e of the other . M or e s peci fi cal l y , the D i stri ctC ou rtcon cl ud ed thatIH C m arket s onlya si ng l e produ ct

— nam el y , “access to h e a lth c a re ”

— a n d th a t th e P lain tiffs’ a ttem p t to c a rv e th a t p ro d u c t in to its in d iv id u a l s e rv ic e c o m p o n e n ts (e .g ., S E C a n d N S E C ) w a s u n a v a ilin g . See i d. at 1 3 1 9

– 2 0 . F inally , w ith reg ard to the m o n o p o li za ti o n claim s, the D istri ct C o u rt concl uded thatt he Pl ai nt i ffs l acke d s t andi ng beca us e theynei thercompet ed nor s oughtt o compet e i n t he s ur gi cal fac i l i t i es m arketand thatanyi nj urythey s uffe r ed w as t her efor e onl yan i ndi r ectr es ul tof the al l egedl yant i compet i t i ve c o n d u c t o n th e p a rt o f th e D e fe n d a n ts . See i d. a t 1 3 1 8 . I I . S E C T I O N 1 C L A I M S A . G ro u p B o y c o tt Sect i on 1 of the Sherm an A ctpr ovi des t hat“[e ] verycontr act , combi nat i on i n t he form of trus torot herw i s e, orcons pi r acy , i n r es tr ai ntof tr ade orcomm er ce a m o n g th e s e v e ra l S ta te s . . . is d e c la re d to b e ille g a l.” 1 5 U .S .C . § 1 . A c o n s p i r a c yi n v o l v e s “ t wo o rmo r e e n t i t i e s t h a tp r e v i o u s l yp u r s u e d t h e i ro wn i nt er es t s s epar at el y. . . combi ni ng t o actas one fort hei rcomm on benef i t . ”-11-

C opper w eld C or

p. v. Independe nce Tube Corp. , 467 U . S. 752, 769 ( 1984) . W hen tw o fo rm e rlyse p a ra te e n tit ies c o m b in e fo r th e ir c o m m o n b e n e fit, th e ir a c tiv ityis “fr aughtw i t h ant i - compet i t i ve r i s k” bec aus e i t“depr i ves the mar ketpl ace of the i ndepende ntcent er s of dec i s i onm aki ng thatcompet i t i on as s um es and demands . ” Id . a t 7 6 8

– 6 9 . O n th e o th e r h a n d , “u n ilate ra l co n d u c t, reg a rd les s o f its a n tic o m p e titiv e e ffe c ts , is n o t p ro h ib ite d ” b y§ 1 o f th e S h e rm a n A c t. Mo tive P a rts Wareho use v. Facet En t er. , 7 7 4 F . 2 d 3 8 0 , 3 8 6 (10 th C ir . 1 9 8 5 ). Itis th ere fo re cr i t i cal t o di s t i ngui s h betw een uni l at er al and conc er t ed ac t i on i n pr ovi ng a v io la tio n o f

§ 1 . T he hea r tof the Pl ai nt i ffs ’ § 1 cl ai m i s thatI H C , atthe behe s tof s ever al of its p a n e l o p h th a lm o lo g ists— in c lu d in g D rs. M ill e r a n d B ro d ste in

— u n law f u lly excl uded opt om etr i s t s fr om i t s pr ovi derpanel s , and thatthi s excl us i on i nj ur ed b o t h c o mp e t i t i o n , g e n e r a l l y , a n d th e P l a i n t i ffs , s p e c i fi c a l l y . Of c o u r s e , i f

I HC a c te d in d e p e n d e n tly in e x c lu d in g o p to m e tr is ts , IH C w o u ld n o t b e lia b le u n d e r § 1 . See Mons ant o C o. v. Spr ay- R i t e Ser v. C or p. , 465 U . S. 752, 761 ( 1984) ( “A m a n u fa c tu re r . . . g e n e ra llyh a s a rig h t to d e a l, or re f u se to d e a l, w ith w h o m e v e r it li k es, as lon g as itd o es so ind ep en d en tl y . ”); Uni t ed Stat es v. C olgat e & C o. , 250 U .S . 3 0 0 , 3 0 7 (1 9 1 9 ). S u c h is th e c a se “ [ e ]v e n w h e re a sin g le firm ’s r e stra in ts di r ect l yaffectpr i ces and have t he s ame economi c effec tas conce r t ed ac t i on m i ghthave. ” F is herv. C i t y of B erkeley , 47 5 U . S . 26 0, 26 6 (198 6). T here i s al so-12-

n o d isp u te th a t if p a n e l o p h th a lm o lo g ists c o n sp ire d w ith e a c h o th e r a n d th e n w ith IH C to re s tr a in tr a d e , th e n s u c h c o n d u c t is a c tio n a b le u n d e r § 1 . See Todor ov v. D CHHeal thcar e Aut h. , 921 F. 2d 1438, 1455 ( 11th C i r . 1995) ( hos pi t al and m ed ical st aff a re se p ara te l eg al en ti ti es c ap ab le of co n sp ir ing w ith ea ch o ther); C ooperv. Forsyth C ount y Hos p. A uth. , Inc. , 789 F. 2d 278, 282 ( 4th C i r . 1986) (M o tz, J. , co n cu rri n g ) (“S ec ti o n 1 o f th e S h erm an A ct clearlyp roh ibit s m em b ers o f a m ed ical-de n tal staff fro m ag ree ing w ith o n e a n o ther to c o erc e a h o sp it al’s t rust ees t o d enypri vil eges t o m em bers of a com peti ng professi on for the p urpose o f f u rth e rin g th e ir e c o n o m ic s e lf-in ter e st.” ). In th is w a y , “[ l]iab ili tyw ill o n ly at t ach t o a g re e m e n ts des i gned unr eas onabl yt o r es tr ai n tr ade. ” Todorov , 921 F. 2d at1455. T he ques t i on befor e us i s w hetherther e i s s uffi ci entevi dence of s uch an ag ree m en t betw ee n IH C an d it s p an el op h thalm o log ist s to su rviv e su m m ary ju d g m e n t. A l t ho ug h the tradi t i on al sum m aryj ud gm ent s t and ard app l i es t o an t i trust cas es , t he ana l y s i s i s al t er ed s om ew hatw hen— as i s the s i tuat i on her e— the p la in tiff re lie s s o le ly o n c ir c u m s ta n tia l e v id e n c e to p ro v e c o n c e rt e d a c tio n . See R os s i v. Standar d R oof i ng, Inc. , 156 F. 3d 452, 465 ( 3d C i r . 1998) . I n thatcas e, “ant i t rus tl aw l i m i t s t he r ange of perm i s s i bl e i nfer ence s fr om ambi guous evi dence i n a § 1 ca s e. ” Mats us hi ta E l ec. Indus . C o. v. Zeni th R adi o C or p. , 475 U . S. 574, 588 ( 1986) . “[C]onduc tas cons i s t entw i th perm i s s i bl e compet i t i on as w i th i l l egal-13-

cons pi r acydoes not , s t andi ng al one, s uppor tan i nfer ence of ant i trus tcons pi r acy . ” Id. A ccor di ngl y , t o s ur vi ve s um m aryj udgm ent , a pl ai nt i ff mustpr es ent“evi dence

‘ t hatt ends t o excl ude the pos s i bi l i ty ’ thatthe al l eged c ons pi r at or s act ed i ndepende nt l y . ” Id . ( quot i ng Mo n sa n to , 4 6 5 U .S . at 7 6 4 ); R e a zin v. B l ue C ross & B l ue Shi eld of

Kan. , 89 9 F . 2d 95 1, 96 3 (10th C i r. 19 90 ). T hat i s, the an t i trust pl ai nt i ff mustpr es entevi dence t hatthe al l eged c ons pi r at or s “had a cons ci ous comm i t m entt o a comm on s cheme des i gned t o achi eve a n unl aw ful obj ect i ve. ” Mo n sa n to , 4 6 5 U .S . a t 7 6 4 (q u o ta tio n o m itte d ). A s th e T h ird C irc u it h a s e x p lain e d : T he Supr eme C our t ’ s conce rns aboutperm i tt i ng the i nfer ence of a con spi racyfrom am biguou s ci rcum st anti al evidence in the an t i trust cont exts t em from i t s concl us i on thatm i s t akes byan over zea l ous j udi ci aryw oul d be “e s peci al l ycos t l y. . . chi l l [i ng] the veryconduct t he ant i t rus tl aw s ar e des i gned t o pr ot ect . ” Ma tsu sh ita , 475 U . S. at 5 9 4 ; Mo n sa n to , 4 6 5 U .S . at 7 6 3 ; B igAp p l e B MW, 9 7 4 F .2 d [ 1 3 5 8 ,] 1363 ( “C ar e mustbe t aken t o ens ur e thati nfer ence s of unl aw ful act i vi t ydr aw n fr om ambi guous evi dence do noti nfr i nge upon d e fe n d a n t’s f

re e d o m , so lo n g a s it a c ts in d e p e n d e n tly , to r e f u se to deal . ”) ( ci t i ng C olgat e & C o. , 2 5 0 U .S . 3 0 0 (1 9 1 9 )). F o r th is re a so n , the p lau sib ili tyo f a n a n titru st p lain tiff ’s c laim is im p o rta n t. “ [ I]f th e fa c tu a l co n tex t re n d e rs [ th e p lain tiff ’s] c laim im p lau sib le— if

th e c laim is o n e th a t sim p lym a k e s n o e c o n o m ic s ens e— [a pl ai nt i ff] m us tcome for w ar d w i th m or e per s uas i ve evi dence t o s uppor t[i t s ] cl ai m than w oul d otherw i s e be ne ces s ary . ” Ma tsu sh ita , 4 7 5 U .S . at 5 8 7 (c itatio n s o m itt e d ). R e late d ly , in evaluat i ng w hethera gen uine i ssue for tri al exis t s, the an t i trust defe ndant s ’ economi c mot i ve i s hi ghl yr el evant . “[I ] f[ the d e fe n d a n ts] h a d n o ra tio n a l ec o n o m ic m o tiv e to c o n sp ire , an d if th e ir conducti s cons i s t entw i t h other , equal l ypl aus i bl e expl anat i ons , the conductdoes notgi ve r i s e t o an i nfer ence of cons pi r acy . ” Id . a t 5 9 6 . M or eover , even w i t h a pl aus i bl e mot i ve t o cons pi r e, ambi guous-14-

conductw i l l notcr eat e a tr i abl e i s s ue of factw i th r es pectt o the e x is te n c e o f

a c o n s p ir a c y . S e e id . at597 n. 21. R ossi , 1 5 6 F .3 d a t 4 6 6 . T o est abli sh a con spi racybetw een IH C and the d efen dan top hthal m ologi st s, t he Pl ai nt i ffs i n t hi s cas e make t he fol l ow i ng al l egat i ons i n l i ghtof the undi s put ed fact s: O pht hal m ol ogi s t s have a l ong hi s t or yof try i ng t o l i m i tcompet i t i on betw een t hemsel ves and i ndepende ntopt om etr i s t s . T hi s t ens i on i ncr eas ed i n 1991, w hen U t ah pas s ed new l egi s l at i on author i zi ng opt om etr i s t s t o engage i n the ful l s cope of N SE C . T he onl ygr oup t o oppos e the l egi s l at i on w as the U t ah O phthal m ol ogy Soci ety( “U O S”) ; D r . M i l l erw as the cha i r m an of U O S’ s l egi s l at i ve comm i t t ee a t th a t tim e . D u e in p a rt to th e 1 9 9 1 leg isla tio n , in 1 9 9 5 IH C b e g a n stu d y in g w h e th e r to add opt om etr i s t s t o i t s pr ovi derpanel s . D r s . M i l l erand B r ods t ei n— both of w hom w er e al r eadyI H C pr ovi der s — w or ked vi gor ous l yw i th eac h otherand w i th other panel opht hal m ol ogi s t s t o di s cour age I H C fr om panel i ng opt om etr i s t s . I ndeed, th e re c o rd is re p lete w ith e v id e n c e o f th e ir e ffo rts, w h ich th e o p h th a lm o lo g ists fel tw er e nec es s aryi n or dert o r et ai n thei rs har e of N SE C pat i ent s and opt i cal h a rd w a re p u rc h a s e rs . O f cour s e, a cons pi r acyamong t he ophthal m ol ogi s t s al one coul d not e ffe c tu a te th e irp la n to h o rd e th e p ro v is io n o f N S E C a n d o p tic a l h a rd w a re .E N U ’s in ter n a l m e m o ra n d a , h o w e v e r, re v e a l les s c o n c e rn o v e r th e q u a lity 6 of ca r e than conc ern aboutt he pos s i bi l i tyt hati ndepende ntopt om etr i s t s m i ght d ilu te th e v o lu m e o f

b u s in e s s c o n d u c te d b yth e o p h th a lm o lo g is ts .

-15- P a n e lin g d e c isio n s a t IH C a re m a d e b yIH C ’s P re fe rre d P ro v id e r S tra teg ic C om m i t t ee— no m ember s of w hi ch ar e ophthal m ol ogi s t s . T her efor e, the o p h th a lm o lo g ists h a d to d e v ise so m e w a yto c o n v in c e IH C n o t to p a n e l th e ir compet i t or s . T o es t abl i s h t hi s i ndi s pens abl e partof the al l eged c ons pi r acy , the P l a i n t i ffs e mp h a s i z e t h a to p h t h a l mo l o g i s t s h a d r e p e a t e d d i s c u s s i o n s wi th I HC ur gi ng i tt o panel onl yopht hal m ol ogi s t s . Forexampl e, i n N ovember1995, T odd K i m bal l , one of the pl ai nt i ff opt om etr i s t s i n thi s cas e, m etw i th I H C t o di s cus s t he p o ss ib ili tyo f

p a n e lin g o p to m e trists. S e v e ra l o p h th a lm o lo g ists w e re a lso in a tten d a n c e , an d th e yw e re o p e n lyh o stile to D r. K im b a ll. T w o m o n th s la ter , in J anuary1996, D r . B r ods t ei n w r ot e a l et t eron behal f of EN U t o I H C . T he l et t er n o ted IH C ’s in ter e st in p a n e lin g o p to m e trists b u t w e n t o n to e x p lain th a t in E N U ’ s vi ew an ophthal m ol ogi s t - l ed netw or k of pr ovi der s thatonl yi ncl uded opt om etr i s t s i ns ofaras t heyw er e empl oy ed byand ac t ed underthe s upervi s i on of opht hal m ol ogi s t s w as “es s ent i al t o m ai nt ai n the hi gh qual i tyof ca r e pr ovi ded by IH C .” In o th e r w o rd s , it d id n o t w a n t in d e p e n d e n t o p to m e tr is ts o n IH C ’s p a n e ls .

6 T he ophthal m ol ogi s t s w er e s ucce s s ful ; i ndepende ntopt om etr i s t s w er e not p a n e le d . C .D . R ic h a rd s , th e M e d ic a l D ir e c to r fo r I H C ’s H e a lth P la n s , In c ., expl ai ned t o D r . K i m bal l t hatt he dec i s i on w as m ade be caus e “[ t ] he phy s i ci ans do-16-

notw anty ou on t he pane l att hi s t i m e. ” A m emo bet w een M r . R i char ds and anotherempl oy ee f

ur t herel uci dat es I H C ’ s deci s i on: P O L IT IC S S H O U L D N O T C O N T R O L P A N E L D E C IS IO N : T h ere ar e manypr ovi der s w ho do notgetadded t o ourpanel s beca us e of th e p o litic s a s s o c ia te d w ith h o s p ita ls a n d p ro v id e r r e la tio n s h ip s . A good exampl e i s opt om etr i s t s . O urm ember s w antt o s ee them; they do notcr eat e anyant i - s el ect i on; theyar e cos teffect i ve; and y etthey are n o t add ed b ec au se th e o p h thalm o log ist s at th e h o sp it als d o n ’t w antt he compet i t i on. A t first b lu sh , itm ig h t ap p e a r a s th o u g h IH C a n d its p a n e l o p h th a lm o lo g ists act ed i n conce r tt o excl ude opt om etr i s t s fr om I H C ’ s pr ovi derpanel s — ther eby es t abl i s hi ng t hatel ementof a § 1 c l ai m . I ndeed, i ti s cl earthatI H C excl uded o p to m e trists b e c a u se o f th e a c tio n s o f

its p a n e l o p h th a lm o lo g ists. B u t sim p ly b e c a u se IH C a c ted in re sp o n se to o p h th a lm o lo g ists’ c o m p lain ts is n o t en o u g h to es t abl i s h t he conc ert ed ac t i on r equi r ement . T o the contr ary , i ti s w el l - es t abl i s hed in a n titru st c a se s th a t a m a n u fa c tu re r’s e x c lu sio n o f a b u y e r-d istrib u to r in r es pons e t o anotherbuy er - di s t r i but or ’ s compl ai nt s i s i ns uffi ci entas a mat t erof la w to e s ta b lis h c o n s p ir a c y , se e Mo n sa n to , 4 6 5 U. S . a t7 6 3 ; a c c o r d i n g l y , th a tI HC chos e nott o panel opt om etr i s t s beca us e i t s opht hal m ol ogi s t s l obbi ed I H C forthat d ec isi o n d o es n o t i n d icate tha t I H C an d the o p h thalm o log ist s ac ted in co n ce rt w ith in th e m e a n in g o f § 1 . T h e S u p re m e C o u rt e x p lain e d th e ra tio n a le b e h in d th is rul e i n Mo n sa n to :

Per m i t t i ng an agr eementt o be i nferr ed mer el yfr om the exi s t ence of compl ai nt s , oreven f r om the fa ctthat-17- t erm i nati on cam e abo ut “i n respon se t o” co m plai nts , c o u l d d e t e ro rp e n a l i z e p e r fe c t l yl e g i t i ma t e c o n d u c t . As M ons ant o poi nt s out , compl ai nt s aboutpr i ce- cutt er s ar e natur al

— and fr om t he manufactur er ’ s per s pect i ve, unavoi dabl e— r eac t i ons bydi s tr i but or s t o the ac t i vi t i es of thei rr i val s . Such compl ai nt s , part i cul ar l yw her e the m anufa ctur erhas i m pos ed a c os t l ys etof nonpr i ce r es t r i ct i ons , ar i s e i n the norm al cour s e of bus i nes s and d o n o t i n d icate il lega l con ce rt ed ac ti o n . M o reo v er, di s t r i but or s ar e an i m por t ants our ce of i nform at i on for m anufa ctur er s . I n or dert o as s ur e an e ffi ci ent d istri b u ti o n sy stem , m an u fa cture rs an d d istri b u tors cons t ant l ym us tcoor di nat e thei ract i vi t i es t o as s ur e that t hei rpr oductw i l l r eac h the cons um erper s uas i vel yand e fficie n tly . T o b a r a m a n u fa c tu re r f ro m a c tin g so lely beca us e the i nform at i on upon w hi ch i tact s or i gi nat ed as a pr i ce c om pl ai ntw oul d cr eat e an i rr at i onal di s l ocat i on i n t he mar ket . I n s um , t o perm i tthe i nfer ence of c o n c e rte d a c tio n o n th e b a sis o f re c e iv in g c o m p lain ts al one and thus t o expos e the defendantt o tr ebl e damage l i abi l i t yw oul d bot h i nhi bi tm anage m ent ’ s exer ci s e of i n d e p e n d e n tb u s i n e s s j u d g me n ta n d e ma s c u l a t e th e t e r ms of the s t atut e. 4 6 5 U . S . at 76 3

– 6 4 (qu o tat ion m ark s, cit ati o n s, an d alt era ti o n o m itted). A ccor di ngl y , t he Pl ai nt i ffs m us tpr es entaddi t i onal evi dence

— evi dence t hat t ends t o excl ude the pos s i bi l i t yt hatI H C w as act i ng i ndepende nt l yand not pur s uantt o an agr eementw i t h t he ophthal m ol ogi s t s . T o thi s end, the Pl ai nt i ffs a ss e rt th a t o p to m e trists a re a lo w e r-c o st a ltern a tiv e to o p h th a lm o lo g ists w h e n it comes t o N SE C beca us e opt om etr i s t s gener al l ychar ge tw entyper centl es s than opht hal m ol ogi s t s fort he s ame N SE C and, acc or di ng t o a 1999 s tudyconduct ed by IH C , IH C m ig h t sa v e $ 3 0 0 ,0 0 0 to $ 4 0 0 ,0 0 0 p e r y e a r o n th e p ro v isio n o f N S E C if itad d ed o p tom etri sts t o it s p an els. S p ec ifi ca ll y , the s tud yn o ted th at i n d u stry-18-

expert s es t i m at e thatfi ftyper centof r out i ne ey e exa m s ar e per form ed by o p tom etri sts; that IH C ’s pa n el op h thalm o log ist s em p loyo p tom etri sts t o p erfo rm N SE C fort hem; and thatI H C pay s opht hal m ol ogi s t s ( fors ervi ces per form ed by t hei rempl oy ee- opt om etr i s t s ) ata hi gherr at e than i tw oul d have t o pay opt om etr i s t s fort he s ame se r vi ce i f the opt om etr i s t s w er e di r ect l yi ncl uded on the p ro v id e r p a n e l. A c c o rd in g ly , the stu d yre c o m m e n d e d th a t IH C list o p to m e trists o n its p ro v id e r p a n e ls if th e yw e re w ill in g to a c c e p t re im b u rse m e n t at a ra te tw e n ty p e rc e n t le s s th a n th e ra te IH C p a y s to o p h th a lm o lo g is ts . In a d d iti o n , the P lain tiffs c o n ten d th a t IH C h a d a m o tiv e to c o n sp ire w ith t h e p a n e l o p h t h a l mo l o g i s t s . I HC, a s a v e r t i c a l l yi n t e g r a t e d h e a l th c a r e s y s t e m, s eeks t o m axi m i ze the us e of i t s hos pi t al s and s ur gi cal fac i l i t i es . T he Pl ai nt i ffs cont end thatt he pane l opht hal m ol ogi s t s w er e abl e t o coer ce I H C t o excl ude opt om etr i s t s fr om i t s pr ovi derpanel s bypr om i s i ng thatthey( the opht hal m ol ogi s t s ) w oul d us e I H C ’ s hos pi t al and s ur gi cal fac i l i t i es t o s erve a s ubs t ant i al por t i on of thei rdi s cr et i onarypat i ent s ( i . e. , thos e pat i ent s w ho ar e not IH C e n ro llee s). In th is w a y , b o th IH C a n d th e p a n e l o p h th a lm o lo g ists w o u ld b e n e fi t : I H C w o u l d p r o fi tb y i n c r e a s i n g th e u t i l i z a t i o n o f ( a n d , a c c o r d i n g l y, paym entfor ) i t s fac i l i t i es , and the ophthal m ol ogi s t s w oul d pr ofi tbypr event i ng l o we r - c o s to p t o me t r i s t s f r o m c o mp e t i n g wi th th e m fo rNSE C. T her e i s no di r ectevi dence of s uch col l us i on; I H C ’ s pr ovi deragr eementW hen gr ant i ng hos pi t al pr i vi l eges t o phy s i ci ans , t he hos pi t al s ver i fyt he 7 (c o n tin u e d ...) -19- d o e s n o t lim it w h e re a p a n e l p ro v id e r r e fe rs h is o r h e r n o n -I H C p a tie n ts . N evert hel es s , t he Pl ai nt i ffs ar gue thats uch qui d pr o quo i s i m pl i ci ti n the fo llo w in g p a ra g ra p h o f th e p ro v id e r a g re e m e n t: T erm i nat i on i n C onnect i on w i th R eappoi nt m ent . Pr ovi der under s t ands and agr ees t hatH PI oran A ffi l i at ed M anage d C ar e Pl an m ayt erm i nat e Pr ovi derfr om part i ci pat i on w i th i t s M ember s atthe t i m e of ori n connec t i on w i th the r ecr edent i al i ng/r eappoi nt m ent pr oces s . Such t erm i nat i on m aybe bas ed on ( i ) bus i nes s or co m p eti ti v e re aso n s relati n g to H P I’s or an yA ffil iat ed M an ag ed C are P lans ’ bu sine ss, ( ii ) P rov ider’s a d h ere n ce to efficien t m an ag ed ca re p ri n ciples a n d p rac ti ce s, (i ii ) ut i l iz at i on of I H Cr elat ed pr ovi ders and f aci l i t i es , ( i v) aff

i l i at i on w i th compet i ng or gani zat i ons , or( v) other re a so n s, w h e th e r sp e c ified in th is A g re e m e n t o r n o t. ( emphasi s added) . Fur t her , t he r ecor d r evea l s thatpanel opht hal m ol ogi s t s , al l of wh o m h a v e h o s p i t a l p r i v i l e g e s a tr e g i o n a l h o s p i t a l s n o ta s s o c i a t e d wi th I HC, o f te n u tiliz e IH C ’s h o s p ita l a n d s u rg ic a l fa c iliti e s fo r t h e ird is c re tio n a ry p a tie n ts . A n d w h en o n e o p h thalm o log istfa il ed to ad eq u atelyd ir ec t his discreti o n ary pat i ent s t o I H C ’ s s ur gi cal fac i l i t i es , I H C r efus ed t o r eappoi nthi m t o i t s panel of providers . Fori t s par t , I H C count er s thati tuni l at er al l yi m pl ement ed a pol i cy pr efe r r i ng phy s i ci ans overot herheal th car e pr ovi der s beca us e phy s i ci ans have h o sp ital sta ff

p riv ileg e s. A c c o rd in g to IH C , this is a c o st-e ffe c tiv e m e a n s to i m pl ement r egul ar peer r evi ew , qual i ty contr ol , and bas i c cr edent i al i ng. O n the 7( . . . cont i nued) 7 appl i cant ’ s heal t h car e tr ai ni ng, educa t i on, m al pr act i ce i ns ur ance , as w el l as i nves t i gat e the appl i cant ’ s backgr ound. B ypr efe rr i ng pr ovi der s w i th s t aff pr i vi l eges , I H C s ugges t s t hati tavoi ds unnece s s arycr edent i al i ng cos t s and du pli cat i ve effort s. -20- ot herhand, i ti s undi s put ed thatI H C has r ecogni zed a need t o panel othertypes of a n c illa ry p ro v id e rs w h o d o n o t p o s s e s s h o s p ita l p ri v ile g e s a t I H C h o s p ita ls . I ndeed, I H C has panel ed ps y chol ogi s t s , s oci al w or ker s , phy s i cal ther api s t s , and podi atr i s t s des pi t e thei rl ack of hos pi t al pr i vi l eges . B utI H C cont ends thati thas n o t nee d ed to p an el op tom etri sts i n u rba n are as, suc h as th e W asa tch F ron t, w h ere t here are s uffi ci ent panel ophthal m ologi st s t o fu l fi l l al l enrol l ees’ ey e care needs, i ncl udi ng N SE C . A s s uppor tforthi s cont ent i on, I H C poi nt s t o the fa ctthati thas panel ed opt om etr i s t s i n ot hergeogr aphi c mar ket s w her e ophthal m ol ogi s t s cannot m eett he nee ds of i t s enr ol l ees . Forexampl e, though no opt om etr i s t s ar e pane l ed t o s erve enr ol l ees on t he W as at ch Fr onts peci fi cal l y , thr oughoutU t ah I H C has pan el ed thi rtyop t om et ri st s. I H C al s o not es t hatal l i t s panel pr ovi der s ar e s ubj ectt o the t erm i nat i on of p riv ileg e s p ro v isio n c ited a b o v e — it i s n o t a p ro v isio n sp e c ific to opht hal m ol ogi s t s . I n ot herw or ds , I H C coul d t erm i nat e pr i vi l eges of anypanel p ro v id e r if

h e o r sh e fa iled to a d e q u a telyu se IH C ’s fa c ili ties

— it d id n o t n e e d to agr ee t o excl ude opt om etr i s t s i n or dert o br i ng thatpr es s ur e t o bearon opht hal m ol ogi s t s . M or eover , D r . M i l l er , w ho der i ves appr oxi m at el ys i xt een-21-

per centof hi s annual i ncome fr om s ervi ces pr ovi ded t o I H C enr ol l ees , has , s i nce 19 85 , perform ed m ostof h i s sur geri es atthe Int erm ou ntai n S urgi cal C enteras a m at t erof conve ni ence . I H C acqui r ed thatbui l di ng i n 1995. T her efor e, thathe per form s t he maj or i t yof hi s s ur ger i es atan I H C fac i l i tyi s notthe r es ul tof a cons pi r acybetw een I H C and the ophthal m ol ogi s t s , butD r . M i l l er ’ s l ongs t andi ng p ra c tic e . F in a lly , IH C c o n ten d s th a t li m iti n g th e siz e o f th e p a n e l allo w s IH C to n e g o tiate lo w e r p a ym e n ts to th e p a n e l p ro v id e rs s in c e th e ir p a tien t v o lu m e w ill i ncr eas e. I n fac t , t her e i s s ubs t ant i al empi r i cal evi dence thats el ect i ve contr act i ng al l ow s m anage d car e compani es t o cont ai n heal th car e cos t s — the more r es tr i ct i ve th e p a n e l, th e lo w e r t h e c o s t o f th e p re m iu m to th e s u b s c ri b e r. A s not ed above , “ant i t rus tl aw l i m i t s the r ange of perm i s s i bl e i nfer ence s fr om ambi guous evi dence i n a § 1 ca s e, ” Ma tsu sh ita , 4 7 5 U. S . a t5 8 8 , a n d we h o ld tha t th e P lai n ti ffs h av e n o t prese n ted e n o u g h ev iden ce fro m w h ich a jury m ayi nferan ant i t rus tcons pi r acy . T her e i s s i m pl ynothi ng i n the r ecor d t endi ng t o sho w t hat I H C excluded op t om et ri st s i n exc hange foran agr eementbyi t s panel o p h thalm o log ist s to d ir ec t th eir discreti o n aryp ati en ts t o IH C fa cil it ies. R athe r, t he P l ai nti ffs’ ar gu m ent s i m plyassum es the ex i st ence o f con cert ed acti on becau se pan el op hthal m ologi st s com plai ned t o IH C abo ut panel i ng op t om et ri st s, becau se IH C res po nd ed to tho se com plai nts byno tpan el i ng op t om et ri st s, and becau se-22-

panel opht hal m ol ogi s t s r efe rs om e of thei rdi s cr et i onarypat i ent s t o I H C fac i l i t i es i n acc or dance w i th I H C ’ s pr ovi deragr eement . N ot abl yabs enti s evi dence of a lin k b e tw e e n th e s e c o n d a n d th ir d c ir c u m s ta n c e s . T h a t o p to m e tr is ts p ro v id e lo w e r- c o s t N S E C d o e s n o t a lte r t h e a n a lysis . A l t hough t he Pl ai nt i ffs have pr ovi ded evi dence thatI H C m ayhave s aved money in th e p ro v isio n o f

N S E C b yp a n e lin g o p to m e trists, th e P lain tiffs h a v e fa iled to p ro v id e e v id e n c e to sh o w th a t o n th e w h o le, IH C ’s d e c isio n is a g a in st th e ir e c o n o m ic in ter e sts . T h e fin a n c ial c o n se q u e n c e s o f a d d in g o p to m e trists is m u lti d im e n sio n a l g iv e n b o th th e e c o n o m ics o f m a n a g e d c a re a n d th e v e rtica lly i nt egr at ed natur e of I H C ’ s bus i nes s . I H C has pr ovi ded a l egi t i m at e r at i onal e for its d e c isio n , an d , as w e n o ted e a rlier , “c o n d u c t as c o n sis ten t w ith p e rm iss ib le compet i t i on as w i t h i l l egal cons pi r acydoes not , s t andi ng al one, s uppor tan i nfer ence of ant i t rus tcons pi r acy . ” Id. O urhol di ng t odayfi nds s uppor ti n ourcas e l aw as w el l as thatof other ci r cui t s . I n To d o ro v v . D CHHe a lth c a re A u th o rity , forexampl e, the pl ai nt i ff n e u ro lo g ist a rg u e d th a t th e h o sp ital c o n sp ire d w ith th e ra d io lo g ists o n its sta ff to ex clud e the p lai n ti ff

fro m p erfo rm ing serv ices tha t he w as q u ali fied to p erfo rm butt hatw er e tr adi t i onal l yper form ed exc l us i vel ybythe r adi ol ogi s t s . 921 F. 2d 1 4 3 8 , 1 4 4 4

– 4 5 (1 1 th C ir. 1 9 9 1 ). T h e ra d io lo g ists, w h o h a d a n e c o n o m ic i ncen t i ve to l i m i tt he n um ber of h eal th care providers perform i ng such servi ces,-23-

coul d notachi eve thi s obj ect i ve on thei row n. T her efor e, s ever al of the r adi ol ogi s t s r ecomm ended t o t he hos pi t al thatthe pl ai nt i ff’ s r eques tforpr i vi l eges b e d e n ie d . Id. at1443. T he hos pi t al , i n fac t , fol l ow ed s uch r ecomm endat i on and d e n ie d th e p la in tiff

p ri v ile g e s . Id . at 14 4 4 . T h e E leve n th C ir cu ith eld th at th ere w as i ns uffi ci entevi dence of a c ons pi r acybetw een the r adi ol ogi s t s and the ho spi t al t o survi ve sum m aryj ud gm ent, st at i ng that al tho ug h “[t] hese facts sugg est th a t th e h o sp ital m ay h a v e c o n s p ir e d w ith th e p h y s ic ia n s [ ,] . . . t h e yd o n o t . . . e x c l u d e t h e p o s s i b i l i t y t h a tt h e h o s p i t a l a c t e d u n i l a t e r a l l y, a n d p r o c o m p e t i t i v e l y, i n deny i ng hi m t he pr i vi l eges he r eques t ed. ” Id. (em p h asis ad d ed ); see also Wor ld of Sl eep, Inc. v. La- Z- B oy C hai rC o. , 756 F. 2d 1467, 1475 ( 10th C i r . 1985) (d e a ler ’s c o m p lain ts a b o u t a p ric e -c u tti n g c o m p e tit o r a n d se ller’ s a c tio n in resp o n se d o es n o t t en d to ex clud e the p o ssibil ityo f in d ep en d en t con d u ct). I n Virg in ia A c a d e my o f C lin ica l P sy c h o lo g ists v . B lu e Sh ieldo f Virg in ia , t he pl ai nt i ff c l i ni cal ps y chol ogi s t s r ai s ed nea r l yi dent i cal conce rns as the opt om etr i s t s i n t hi s cas e— t he defendanti ns ur er s r efus ed t o payfors ervi ces r ender ed byps y chol ogi s t s , al t hough theypai d fori dent i cal s ervi ces w hen bi l l ed t hr ough a ps y chi atr i s t . 624 F. 2d 476, 478 ( 4th C i r . 1980) . W hi l e ther e w as evi dence t hatcont actbetw een the N eur ops y chi atr i c Soci etyof V i r gi ni a ( “N SV ”) and the defendant s w as “part i cul ar l ycl os e, ” thatthe N SV r ecomm ended t o the defe ndant s t hattheyt erm i nat e di r ectpaym ent s t o ps y chol ogi s t s , and thatB l ue-24-

Shi el d i m pl ement ed thatr ecomm endat i on, the Four th C i r cui thel d thatther e w as n o e v id e n c e o f

a n a g re e m e n t b e tw e e n th e tw o e n titie s . See i d. at478, 483. T he cour tnot ed that“abs ents om e form of coe r ci on, ” i ti s noti l l egal fora s el l erof s ervi ces “t o m ake r ecomm endat i ons ai m ed atper s uadi ng [the buy erof s uch s ervi ces ] t o adopti t s pr opos al . ” Id. I n C ooperv. Forsyth C ount y Hos pi tal , the pl ai nt i ff podi atr i s t s s ought s u rg ic a l p ri v ile g e s a t th e d e fe n d a n t h o s p ita l. 7 8 9 F .2 d 2 7 8 , 2 7 9 (4 th C ir . 1 9 8 6 ). T h e h o s p ita l’ s b y la w s , h o w e v e r, r e s tr ic te d s u rg ic a l p ri v ile g e s to p h y s ic ia n s . Id. N evert hel es s , t he hos pi t al under t ook a r evi ew of the by l aw s t o det erm i ne w hether th e ys h o u ld b e c h a n g e d to a llo w th e p o d ia tr is ts s u rg ic a l p ri v ile g e s . Id . O r t hopedi s t s , w ho per form ed the maj or i tyof foots ur geryatthe hos pi t al , obj ect ed to a m e n d m e n t o f

th e b y la w s . Id . U ltim a te ly, th e p ro p o s a l w a s reje c te d . Id. R el y i ng on Mo n sa n to , t he courtfound thatthe ci r cumst ant i al evi dence of a c o n sp ira c y— c o n tac ts, c o m m u n ica tio n s, a n d th e m e re o p p o rtu n ityto cons pi r e— cons t i tut ed “i ns uffi ci entevi dence fr om w hi ch t o i nferan ant i compet i t i ve cons pi r acy . ” Id. a t 2 8 1 . A concurr i ng opi ni on i n C ooperp ro ffe re d th e fo llo w in g a n a ly sis : Sect i on 1 of the Sherm an A ctcl ear l ypr ohi bi t s m ember s of a m edi cal - dent al s t aff

fr om agr eei ng w i th one anothert o coer ce a hos pi t al ’ s t rus t ees t o denypr i vi l eges t o m ember s of a c om pet i ng p ro fe s s io n fo r t h e p u rp o s e o f f u rt h e ri n g th e ire c o n o m ic s e lf-i n te re s t. A j ur ycoul d pr oper l yi nferthe exi s t ence of s uch an unl aw ful a g r e e me n tf

r o m evi den ce of threats m ad e t o the trust ees of m ass-25-

resign ati on s byt he mem ber s of the medi cal - dent al s t aff and the abs ence of demonstr abl ys ound r eas ons r el at i ng t o the qual i tyof pati ent car e un derl y i ng t he d efen dan t s’ act i on s. Id. at 28 2 (M o tz, J. , co n cu rri n g ) (em p h asis ad d ed ). O u r ow n ca se law also reflects a c o n ce rn th at so m ethin g m o re tha n m ere acqui es cenc e t o a compet i t or ’ s compl ai nt s abouta pr i ce- cutt erbe pr es entt o i nfer a cons pi r acy . I n R eaz i n v. B l ue C r os s & Bl ue Shi eld of Kans as , Inc. , forexampl e, t he d efen dan t s t erm i nated a rel at i on shi p w i th a h ospit al regar ded as a l ow -cost p ro v id e r o f

q u a lityh e a lth c a re w h e n o th e r re g io n a l h o sp itals a g re e d to re d u c e th e ir m axi m um al l ow abl e paym ent s ( “M A Ps” ) . 899 F. 2d 951. I n fi ndi ng s uffi ci ent e v id e n c e o f

a c o n sp ira c y , w e d id n o t re st o n e v id e n c e o f a m o tiv e o r o p p o rtu n ity to c o n s p ir e . Id . at963. I ns t ead, w e r el i ed on evi dence thatthe dec i s i on t o s eek r educe d M A Ps fr om t he r egi onal hos pi t al s and the dec i s i on t o t erm i nat e the plai nti ff’s cont ractw as “r el at ed, ” as w el l as evi den ce t hat the co m peti t ors’ red u ce d rates w ere co n d it ion ed o n the term ination o f th e p lai n ti ff ’s c o n tr a c t— b o th o f

w h ic h te n d e d to e x c lu d e th e p o s s ib ility o f in d e p e n d e n t c o n d u c t. Id. at964. H ere , the re co rd re flec ts th at IH C p refers to p an el he alth ca re p rov iders w ho have s t aff

pr i vi l eges atI H C hos pi t al s . O phthal m ol ogi s t s , byl aw , can p e rfo rm m o re p ro c e d u re s th a n o p to m e trists. T h e re fo re , ev e n if IH C w e re to i ncl ude opt om etr i s t s on i t s pr ovi derpanel s , i tw oul d s t i l l need t o panel-26-

opht hal m ol ogi s t s . T hi s fac t , coupl ed w i th I H C ’ s pr ocompet i t i ve j us t i fi cat i on for l i m i t i ng t he numberof pane l ed hea l th car e pr ovi der s — thati s , l i m i t i ng the number of pr ovi der s per form i ng a gi ven s ervi ce i ncr eas es the vol um e of pa t i ent s eac h pr ovi ders ees , w hi ch, i n tur n, enabl es I H C t o negot i at e l ow err ei m bur s ementr at es to th e p a n e l p ro v id e rs— su g g e sts th a t IH C m a yh a v e a c ted in d e p e n d e n tlyin deci di ng nott o panel opt om etr i s t s on the W as at ch Fr ont . A l though i ti s t empt i ng t o t r eatt he Pl ai nt i ffs ’ evi dence i n thi s cas e as s uffi ci entevi dence of a c ons pi r acy to su rv iv e su m m a ryju d g m e n t, th e o n lyp e rm iss ib le in fe re n c e to b e d ra w n f ro m it is th a t IH C re sp o n d e d to th e o p h th a lm o lo g ists’ c o m p lain ts b yd e c id in g n o t to p a n e l o p to m e trists. T h e re is n o e v id e n c e to su g g e st th a t th e o p h th a lm o lo g ists th re a te n e d a m a s s re s ig n a tio n , s ee C ooper , 7 8 9 F . 2 d at 28 2 (M o tz, J. , co n cu rri n g ), t hatt he ophthal m ol ogi s t s condi t i oned thei rr at es on the exc l us i on of the o p to m e tr is ts , se e R e a zin , 899 F. 2d at964, orthatthe ophthal m ol ogi s t s i n anyw ay c o e rc e d IH C to e x c lu d e o p to m e tr is ts , se e Va . A c a d . o f C lin ica l P sy c h o lo g ists , 624 F. 2d at483. I n t he abs ence of thes e types of “pl us ” fa ct or s , t o perm i tan in fe re n c e o f

a n titru st c o n sp ira c yo n th e b a sis o f IH C ’s r e sp o n se to c o m p lain ts

“ a n d th u s to e x p o se th e d e fe n d a n t to tre b le d a m a g e liab ili ty [ ,] w o u ld b o th in h ib it m anage m ent ’ s exer ci s e of i ndepende ntbus i nes s j udgm entand emas cul at e the t erm s of the [the Sherm an A ct ] . ” Mo n sa n to , 465 U . S. at764 ( quot at i onsT h e D e fe n d a n ts a lso a rg u e th a t th e P lain tiffs la c k sta n d in g to a ss e rt th e ir 8 g r o u p b o y c o t tc l a i m u n d e r§ 1 . We n e e d n o ta d d r e s s t h a ti s s u e , h o we v e r , a s we c o n c lu d e th a t th e P la in tiffs fa ile d to p re s e n t s u ffic ie n t e v id e n c e o f a c o n s p ir a c y . See Lant ec, Inc. v. Novel l, Inc. , 306 F. 3d 1003, 1030 ( 10th C i r . 2002) ( decl i ni ng t o addr es s w hetherpl ai nt i ffs s uffe r ed an a nt i trus ti nj ur yforpurpos es of s t andi ng w h en claim s w ere reso lved o n o ther g rou n d s). -27- o m itted). 8 B . T y i ng A r r angement T he Pl ai nt i ffs nextar gue thatI H C unl aw ful l yt i ed the s al e of N SE C t o t he sale o f IH C m an ag ed ca re p lans . T h is cl aim str ikes at th e h ea rto f a n en ti re ind u stryd ev o ted to the e ffici en t distri b u ti o n o f h ea lth ca re. A lth o u g h there are m anyconce ptual hur dl es t o hol di ng thats uch an a rr angementamount s t o a vi ol at i on of the ant i t rus tl aw s — i ndeed, as t he Pl ai nt i ffs w oul d have i t , t he arr angementati s s ue amount s t o a per se v io latio n o f th e a n titru st la w s— th e re is not hi ng i n ourj ur i s prudence t o i ndi cat e thatm anage d car e compani es and the p ro d u c ts th e yse ll sh o u ld b e tre a ted a n yd iffe re n tlyth a n p a rticip a n ts a n d p ro d u c ts in o th e r i n d u s tr ie s . “A t y i ng arr angementi s ‘ an agr eementbya partyt o s el l one pr oductbut onl yon t he condi t i on t hatt he buy eral s o pur chas e a di ffe r ent( ort i ed) pr oduct . ’ ” E as tm an Kodak v. Im age Techni calSer vs . , Inc. , 504 U . S. 451, 461 ( 1992) ( quot i ng N. P ac. R . C o. v. Uni t ed Stat es , 356 U . S. 1, 5–6 ( 1958) ) . T y i ng arr angement s ar e unl aw ful “[b] eca us e theydenycompet i t i ve ac ces s t o the t i ed-28-

p ro d u c t m a rk e t o n th e b a sis o f th e se ller’ s le v e ra g e in th e ty in g p ro d u c t m a rk e t, and for ce buy er s t o for ego fr ee c hoi ce be tw een s el l er s . ” O hio- Sea l y Mattress M f g. C o. v. Seal

y, Inc. , 585 F. 2d 821, 834 ( 7th C i r . 1978) . I n thi s cas e, the Pl ai nt i ffs al l ege thatI H C t i ed the s al e of managed c ar e pl ans i n U t ah ( the “ty i ng” pr oduct ) t o t he pr ovi s i on of N SE C ( the “t i ed” pr oduct ) . I n otherw or ds , the Pl ai nt i ffs cont end thatpur chas i ng an I H C m anage d car e pl an al s o r equi r es the buy ert o pur chas e N SE C onl yfr om an I H C panel opht hal m ol ogi s t , r atherthan fr om a di ffe r ents our ce s uch as an opt om etr i s t . T he D i s tr i ctC our tconcl uded that t he P l ai nti ffs fai l ed to est abli sh t he ex i st ence o f t w o separat e produ ct s, w hich i s a n e c e s s a ry p re re q u is ite to a fin d in g o f a n ille g a l tie . See Spor ts R aci ng Ser vs . , Inc. v . S p o r ts Ca r e Clu b o

f A m. , 131 F. 3d 874, 886 ( 1997) ( ci t i ng E as tm an Kodak , 504 U .S . at 4 6 2 ). T h e c o u rt c o n c lu d e d th a t IH C “ o n lym a rk e t[ s] a sin g le p ro d u c t: ac ce ss to h ea lth ca re p ri ce d to su b scribe rs an d p aid to h ea lth ca re p rov iders acc or di ng t o pr i orarr angement s m ade w i th thos e pr ovi der s . ” A br aham , 39 4 F. Supp. 2d at1319–20. W hetherpr oduct s can be cons i der ed di s t i nct“turns noton the func t i onal r e l a t i o n b e t we e n t h e m, b u tr a t h e ro n th e c h a r a c t e ro f th e d e ma n d fo rth e two i t ems. ” Jef

f ers on P ar is h Hos

p. D is t . No. 2 v. H

yde , 4 6 6 U . S . 2 , 1 9 (19 8 4 ), abr ogat ed on othergr ounds by Il l . ToolWorks Inc. v. Indep. Ink , 126 S. C t . 1281 (2 0 0 6 ). T h a t is, “th e m e re fa c t th a t tw o item s a re c o m p lem e n ts, th a t ‘o n e . . . is-29-

us el es s w i t houtt he other ’ does notm ake them a si ngl e ‘ pr oduct ’ forpurpos es of t y i ng l aw . ” Uni t ed Stat es v. Mi cr os of tC or p. , 253 F. 3d 34, 86 ( D . C . C i r . 2001) ( quot i ng Jef

f erson P arish , 466 U . S. at19) ( al t er at i on i n or i gi nal ; i nt ernal ci t at i on o m itt e d ). G iv e n th is b a c k d ro p , the P lain tiffs c o n ten d th a t m a n a g e d c a re p lan s in U t ah and N SE C ar e s epar at e pr oduct s beca us e “ther e i s s epar at e cons um er d e m a n d fo r s u c h e y e c a re s e rv ic e s ” a p a rt f ro m th e s a le o f

m a n a g e d c a re p la n s . In d e e d , IH C a d m its th a t th e re a su b sta n tial c o n su m e r d e m a n d fo r o p to m e tric s ervi ces apartfr om t he s al e of managed c ar e pl ans . T her e i s al s o evi dence that I H C ’ s enr ol l ees w antt o patr oni ze opt om etr i s t s r atherthan I H C panel opht hal m ol ogi s t s forN SE C and thatenr ol l ees s om et i m es vi s i topt om etr i s t s — and payfors ervi ces outof thei row n pocket

— r atherthan vi s i t i ng one of I H C ’ s panel opht hal m ol ogi s t s . T her efor e, t he Pl ai nt i ffs ar gue thatm anage d car e pl ans and N S E C are tw o p roducts . O n t he otherhand, i n t he onl ycas e w i th s i m i l arfac t s t o thos e ati s s ue her e, t he N i nt h C i r cui thel d t o t he contr ary . I n K lam ath- Lake Pharm aceut i calA s s ’ n v. K l am ath Medi calSer vi ce Bure au , 701 F. 2d 1276, 1289 ( 9th C i r . 1983) , the pl ai nt i ff c l ai m ed a t i e betw een a heal th pl an’ s pharm acybenef i t s and r es tr i ct i ons o n th e p h a rm a c ies e n ro llee s c o u ld u se to re a p th e p lan ’s b e n e fits. T h e N in th C i r cui thel d t hatt he bene fi t s and the r es tr i ct i ons w er e one pr oduct , r eas oni ng th a t:-30-

I n s u r e d s , t h e c o n s u me r s , c e r t a i n l yd i d n o tc o n s i d e rth e s e a s two se p a ra te p ro d u c ts. In d e c id in g w h e th e r to b u yth e p h a rm a c yb e n e fit, t heym ade j us tone dec i s i on, compar i ng the expe ct ed cos tof the ben efi tplus copay m ents for drug p urchases agai nstthe ex pected cost of drugs boughtatt he i ndepende ntpharm aci es . T he r i s k i ns ur eds s oughtt o t r ans ferw as t he r i s k of hi gh pharm acybi l l s . T he pr oduct t hes e cons um er s s oughtw as a means byw hi ch theycoul d s at i s fy t hei rdrug needs on favor abl e t erm s . T hei rpur chas e of drugs i n the r equi r ed mannerw as t he cons um m at i on of the pharm acybenef i t , not a n u n w a n te d a n d u n n e c e s s a ry p ro d u c t tie d to th e d e s ir e d p ro d u c t. Id . a t 1 2 9 0 ; s ee als o D e Modena v. Kais erFound. Heal th P lan, Inc. , 743 F. 2d 1388, 1396 ( 9t h C i r . 1984) ( r ej ect i ng the pr emi s e that“a drug pl an and the drugs p rov ided u n d er tha t plan are sep ara te co m m o d it ies. ”). It h a s b e e n su g g e ste d , h o w e v e r, th a t K lam ath- Lake s w e e p s t o o b r o a d l y: T h[e] r eas oni ng [i n K la m a th - Lake ] im p lies th a t any bundl i ng of h e a lth in su ra n c e w ith th e p ro v isio n o f m e d ica l g o o d s a n d se rv ice s is a s i ngl e pr oduct . Foral l s uch i ns ur ance , the cons um erchoos i ng a pl an compar es i t s pr emi um pl us expec t ed copa ym ent s agai ns tthe expec t ed cos tof buy i ng t he cove r ed medi cal goods and s ervi ces fr om i ndepende nts uppl i er s . A nd the pur chas e of the medi cal goods and se rv ice s f

ro m th e p lan is th e c o n su m m a tio n o f th e in su ra n c e b e n e fit. B u t th is l o g ic i s fa r t o o sw ee p ing . F o r any t i e, a r at i onal buy er compar es t he expe ct ed cos tof the bundl e t o the expe ct ed cos tof buy i ng t he i t ems unbundl ed el s ew her e. A nd, havi ng contr act ed for the b u n d le, rec eivin g the b u n d le i s the co n su m m ati o n o f th e b u y er’s c o n tra c t. T h u s, litera llya p p lied , the c o u rts’ lo g ic s u g g e sts th a t all tie s in v o lv e s in g le p ro d u c ts . 1 0 P h illip E . A re e d a & H e rb e rt H o v e n c a m p , A ntr i tr us tLaw ¶ 1745g4 ( 2004) (h e re in a f

te r “ A re e d a & H o v e n c a m p ” ). W e agr ee w i t h t hi s anal y s i s . A l though pow er ful economi c r eas ons m ay j us t i fyt he bundl i ng of m edi cal i ns ur ance w i th the pr ovi s i on of the goods andPr ofes s orA r eeda s ugges t s , forexampl e, t hats uch i nt egr at i on can r educe 9 tra n sa c tio n c o sts , red u c e th e in c e n tiv e to o v e rc o n su m e “ th a t o th e rw ise re su lts w hen the i ns ur ed pat i entorphy s i ci an ca n or deranym edi cal goods and s ervi ces th e yw ish w ith o u t re g a rd fo r c o st b e c a u se th e [ tra d iti o n a l] in su re r re im b u rse s a ll cos t s , ” and i tr educe s ut i l i zat i on of expe ns i ve and e xces s i ve t es t i ng. 10 A r eeda & H ovenca m p, A nt i t rus tL aw ¶ 1745g4. Fur therm or e, s uch bundl i ng can r educe t he c o st to e n ro llee s a s th e m a n a g e d c a re c o m p a n yrig h tlya ss u m e s th a t th o u g h it pr ovi des acc es s t o a hos tof m edi cal s ervi ces , a maj or i tyof enr ol l ees w i l l not u tiliz e th e m a ll. -31- serv ices that fa ll w ith in the p lan’s p ara m eters, su ch b u n d li n g d o es n o t tran sfo rm 9 th e m a n a g e d c a re p lan itse lf a n d th e p ro v isio n o f

its b e n e fits in to a sin g le p ro d u c t. O uranal y s i s , how ever , does notend ther e. I ti s undi s put ed thatI H C does nots el l N SE C and that“the es s ent i al char act er i s t i c of a n i nval i d ty i ng a rra n g e m e n t li e s in th e se ller’ s e x p lo itatio n o f its c o n tro l o v e r th e ty in g p ro d u c t to for ce the buy eri nt o t he pur chas e of the t i ed pr oduct . ” Jef f erson P arish , 46 6 U. S. a t 1 2 . A lth o u g h it i s c ritica l to a ty in g c laim th a t th e se ller fo rc e d a b u y e r to pur chas e the t i ed pr oducti n or dert o gett he ty i ng pr oduct , “i ti s notcr i t i cal t hat th e b u y e r h a v e p u rc h a se d th e tied p ro d u c t dir ect l y f rom the sel l er. ” Spor ts R aci ng Servs. , 131 F. 3d at887. B eca us e the al l eged ty i ng arr angementati s s ue i nvol ves t he s al e of the t i ed pr oductbya thi r d party— namel y , panel o p h th a lm o lo g ists— d istin c t f ro m th e sa le o f

th e ty in g p ro d u c t, w e m u st e v a lu a te IH C ’s e c o n o m ic in ter e st in th e sa le o f th e tied p ro d u c t. W e h a v e e x p lain e d : A n i l l egal t i e maybe found w her e the s el l erof the ty i ng pr oductdoes noti t s el f s el l t he t i ed pr oductbutm er el yr equi r es t he pur chas erof the ty ing p rod u ct t o b u ythe tied p rod u ct fro m a d esig n ated thir d-32-

par t yr athert han fr om anyothercompet i t i ve s our ce thatthe buy er m ig h t p re fe r. H ow ever , w her e a thi r d par tyi s i nvol ved i n s el l i ng the t i ed pr oductt o t he pl ai nt i ff, m os tcour t s have r equi r ed thatthe ty i ng pr oducts el l erhave a di r ecteconomi c i nt er es ti n the s al e of the t i ed p ro d u c t b e fo re a n ille g a l tyin g a rr a n g e m e n t w ill b e fo u n d . C our t s t hathave i m pos ed the ec onom i c i nt er es tr equi r ement w hen the t i ed and ty i ng pr oduct s ar e s ol d bydi ffe r ent , unr el at ed s el l er s have done s o gener al l yon the gr ounds thati f the ty i ng pr oducts el l erdoes nothave a n economi c i nt er es ti n the s al e of the t i ed pr oduct , t he s el l eri s notatt empt i ng t o i nvade the al l eged t i ed pr oductors ervi ce mar keti n a mannerpr os cr i bed bys ect i on 1 of the S h e rm a n A c t. Sp orts R acing Se rvs. , 131 F. 3d at887–88 ( i nt ernal ci t at i ons and quot at i on o m itte d ). U n lik e th e c a se s in w h ich c o u rts h a v e h e ld th e “ e c o n o m ic in ter e st” re q u ire m e n t sa tisfied b e c a u se th e se ller o f th e ty in g p ro d u c t re c e iv e s a n e c o n o m ic b e n e fit f ro m th e s a le o f

th e tie d p ro d u c t, s ee, e. g. , i d. at888 ( s el l erof r aci ng se rv ice s re c e iv e d e c o n o m ic b e n e fit fro m th ird p a rtysa le o f ra c e c a rs) ; Thomps on v. Metr o. Mul t i - Lis t, Inc. , 934 F. 2d 1566, 1570–72 ( 11th C i r . 1991) ( defe ndant m u lti -listin g se rv ice re q u ire d re a l es tate b ro k e rs w a n tin g to u se th e se rv ice to jo in b ra n c h o f

re a lto r o rg a n iz a tio n in w h ic h s e rv ic e m a yh a v e h a d a n in te re s t) , O hi oS e a ly , 585 F. 2d at833–34 ( l i cens orof m at tr es s tr ademar k r equi r ed l i cens eem anufa ctur er s t o pur chas e mat t r es s componentfr om a part i cul ars our ce a nd l i cens orr ece i ved a pe r cent age of components al es ) , i n thi s cas e, I H C r ece i ves no e c o n o m ic b e n e fit fro m th e sa le o f N S E C . T o th e c o n tra ry , IH C re im b u rse s itsT h e P lain tiffs a lso a lleg e th a t IH C u n law f u llytied th e sa le o f

S E C

— in 10 addi t i on t o N SE C

— t o i t s m anage d car e pl ans . T w o types of part i es have s t andi ng t o chal l enge i l l egal t y i ng arr angement s — “the pur chas er s w ho ar e for ced t o buy th e tied p ro d u c t to o b tain th e ty in g p ro d u c t . . . an d th e c o m p e tit o r w h o is r es t r ai ned fr om ent er i ng t he mar ketfort he t i ed pr oduct . ” Sp orts R acing Se rvs. , 131 F. 3d at887. A s t he Pl ai nt i ffs nei therpur chas e norpr ovi de SE C , t heyl ack s ta n d in g to a s s e rt th is c la im . -33- panel opht hal m ol ogi s t s eac h t i m e theypr ovi de N SE C . Farfr om pr ofi t i ng fr om t h e s a l e o f

NSE C, I HC expe nds m o n eyw h en N S E C is sold. W e the refo re con cl ud e t hat I H C has no econ om i c i nter esti n the sal e of N S E C . T he P l ai nti ffs’ t y i ng cl ai m fai l s for t hi s r eas on. See Bear d v. P arkvi ew Hos p. , 912 F. 2d 138, 10 1 4 0

– 4 4 (6 th C ir. 1 9 9 0 ) (n o ty in g a rra n g e m e n t w h e re h o sp ital re q u ire d its p a tien ts t o pur chas e r adi ol ogys ervi ces fr om t hi r d partyfr om w hom hos pi t al r ece i ved no e c o n o m ic b e n e fit); Whi t e v. R ocki ngham R adi ol ogis ts , Ltd. , 8 2 0 F .2 d 9 8 , 1 0 4 (4 th C i r . 1987) ( no t y i ng arr angementw her e hos pi t al r equi r ed C T s cans t o be in terp re ted b ysp e c ific g ro u p o f ra d io lo g ists a n d w h e re h o sp ital d id n o t co m p e te i n t he mar ketfori nt erpr et at i ons of C T s cans and di d notr ece i ve anyof the ra d io lo g ists’ fe e fo r th e ir in terp re tatio n s); R ober t ’s Wai ki kiU- D r i ve, Inc. v. B udgetR ent-A - C arSys . , Inc. , 732 F. 2d 1403, 1407–08 ( 9th C i r . 1984) ( no ty i ng arr ang em ent w here ai rl i ne o ffered l ow er- pri ced ti ckets i f t he p urchaser al so r ent ed a c arfr om a part i cul arcompanybeca us e ther e w as no evi dence t he ai r l i ne h a d a n e c o n o m ic in te re s t in c a r r e n ta ls ). I I I . S E C T I O N 2 C L A I M ST h e P lain tiffs a lso c o n ten d th a t IH C a n d its p a n e l o p h th a lm o lo g ists 11 c o n sp ire d to m o n o p o lize th e m a rk e t fo r su rg ica l fa c ili ties . B e c a u se w e h e ld in s ect i on I I . A t hatt he Pl ai nt i ffs fai l ed t o pr es ents uffi ci entevi dence of a c o n s p ir a c y , th is c la im lik e w is e fa ils . -34- I n contr as tt o § 1 of the Sherm an A ct , w hi ch r eac hes onl yconce r t ed ac t i on, § 2 ex tend s b o th to c o n ce rt ed an d u n il ateral co n d u ct. U n d er tha t secti o n , “[ e]v ery p erso n w h o sh all m o n o p o li ze , o r att em p t t o m o n o p o li ze , o r co m b ine o r co n sp ir e w i t h anyot herper s on orper s ons , t o m onopol i ze a nypartof the tr ade or comm er ce . . . s hal l be dee m ed gui l tyof a fel ony . ” 15 U . S. C . § 2. T he Pl ai nt i ffs al l ege thatI H C at t empt ed t o m onopol i ze the s ur gi cal fac i l i t i es m arketon the W as at ch Fr ont . Speci fi cal l y , t he Pl ai nt i ffs al l ege thatI H C l ever aged i t s pow er 11 in th e m a n a g e d c a re m a rk e t to in c re a se its p o w e r in th e su rg ica l fa c ili ties m a rk e t: beca us e hea l t h car e pr ovi der s des i r e t o be i ncl uded on I H C pr ovi der panel s — w hi ch s erve a s ubs t ant i al por t i on of the popul at i on of the W as at ch F ro n t— th o se p ro v id e rs a re w ill in g to a g re e to se n d a s m a n yp a tien ts a s p o ss ib le to I H C s ur gi cal fac i l i t i es i n excha nge forpanel i ng. T hi s , i n tur n, has t he effec tof i ncr eas i ng I H C ’ s pr es ence i n t he s ur gi cal fac i l i t i es m arket . W e agr ee w i th the D i stri ctC ou rtt hat the P l ai nti ffs l ack st and i ng — w i th respectt o b oth i t s r equ est fordamages under§ 4 of the C l ayt on A ctas w el l as i t s r eques tfori nj unct i ve re lie f u n d e r § 1 6 o f

th e C la yto n A c t— to p u rs u e th is c la im . T he conc eptof “a nt i t rus ts t andi ng, ” w hi ch ext ends t o s ui t s ar i s i ng underSi gni fi cant l y , t he Pl ai nt i ffs do notal l ege thatpartof the monopol i zat i on 12 at t empt i nvol ved the qui d pr o quo d is c u s s e d in P a rt I.A . supra . I ns t ead, t he Pl ai nt i ffs s i m pl ycont end thatI H C agr eed t o panel ophthal m ol ogi s t s i n excha nge fo r a n a g re e m e n t to re fe r p a tie n ts n e e d in g s u rg e ry to IH C s u rg ic a l fa c iliti e s . M or eover , t o t he ext entt hatt he Pl ai nt i ffs ’ ar gum entcoul d be cons trued i n s uch a w ay , t hei rcl ai m fai l s beca us e s uch al l egedl yant i compet i t i ve conduc tdoes not r es ul ti n a dange r ous pr obabi l i t yof s ucce s s ful l ym onopol i zi ng the s ur gi cal fa c iliti e s m a rk e t. See Col o. Int ers tat e G as C o. v. Nat ur alG as P i pel i ne C o. of A m. , 885 F. 2d 683, 693 ( 10t h C i r . 1989) ( s t at i ng thatt o s t at e a c l ai m for at t empt ed monopol i zat i on, a pl ai nt i ff musts how t hatt her e i s a dange r ous (c o n tin u e d ...) -35- bot h § 4 and § 16 of the C l ayt on A ct , i s di s t i nctfr om thatof cons t i tut i onal s ta n d in g . See B- S St eelof Kan. , Inc. v. Tex. Indus . , Inc. , 4 3 9 F .3 d 6 5 3 , 6 6 6 (1 0 th C i r . 2006) . T he thr es hol d i nqui r yi n anal y zi ng w hethera pl ai nt i ff maypur s ue an ant i t rus tcl ai m i s t hatof “a nt i t rus ti nj ury . ” Id . a t 6 6 7 ; Todorov , 9 2 1 F .2 d a t 1 4 4 9 . A n a n titru st inju ryis a n “ inju ryo f th e typ e th e a n titru st la w s w e re d e sig n e d to pr eventand thatfl ow s fr om t hatw hi ch makes defe ndant s ’ act s unl aw ful . ” B -S St eel , 4 3 9 F .3 d a t 6 6 7 (q u o tatio n s o m itt e d ). T h e P lain tiffs c a rryth e b u rd e n to m a k e th is d e m o n s tr a tio n . See Hai rs t on v. P ac. 10 C onf er ence , 101 F. 3d 1315, 1 3 2 1 (9th C ir . 1 9 9 6 ). I n t hi s cas e, t he Pl ai nt i ffs m ake no a t t empt t o del i neat e any i nj urythey have s uffe r ed orw i l l s uffe rt hati s as s oci at ed w i th I H C ’ s dom i nance i n the s ur gi cal fac i l i t i es m arket , l etal one expl ai n how thati nj uryi s “of the type the ant i t rus tl aw s w er e des i gned t o pr eventand thatfl ow s fr om thatw hi ch makes d e fe n d a n ts ’ a c ts u n la w f u l.” A s s oci at ed G en. C ontr actors of C al . , Inc. v. 12( . . . cont i nued) 12 pr obabi l i t yt hatt he defendantw oul d achi eve monopol ys t atus i n the r el evant m arketas t he r es ul tof the pr edat or yconductal l eged bythe pl ai nt i ffs ) . D ur i ng t he t i m e per i od i n w hi ch I H C w as al l egedl ycaus i ng ophthal m ol ogi s t s t o r efe r s u b s t a n t i a l l y a l l o f

t h e i rd i s c r e t i o n a ry p a t i e n t s fo rs u r g e ry a tI H C fa c i l i t i e s , e ye s u r g e r i e s a c c o u n t e d fo ro n l ya s ma l l p r o p o r t i o n o f s u r g e r i e s a tI HC hos pi t al s — betw een 6% and 7%

— and amount ed t o l es s than 3% of I H C ’ s s ur gi cal rev en u es. D esp it e the fa ct th at IH C h ad , at th e re leva n t t im e, a 5 1 % to 5 5 % sh are of the s ur gi cal fac i l i t i es m arket , ther e i s no evi dence t o s ugges tthateven c o m p lete su c c e ss in d ire c tin g a ll S E C p a tien ts to IH C ’s h o sp itals w o u ld re su lt i n m o n o p o ly p o w e r i n p ro v is io n o f s u rg ic a l fa c iliti e s . See Bacchus Indus . , Inc. v. A r vi n Indus . , Inc. , 9 3 9 F .2 d 8 8 7 , 8 9 4 (1 0 th C ir. 1 9 9 1 ) (s tatin g th a t m o n o p o ly p o w e r is d e fin e d a s “ th e a b ili tyto c o n tro l p ric e s a n d e x c lu d e c o m p e tit io n ” ); C ol o. Int ers tat e G as C o. , 885 F. 2d at694 n. 18 ( m onopol ypow ergener al l yexi s t s w hen d e fe n d a n t c o n tr o ls 7 0 % to 8 0 % s h a re o f th e re le v a n t m a rk e t) . -36- C arpen t ers , 4 5 9 U .S . 5 1 9 , 5 3 5 n .3 1 (1 9 8 3 ). In d e e d , the P lain tiffs c o m p lete lyfa il t o di s cus s how I H C ’ s purpor t ed pl an t o m onopol i ze the s ur gi cal fac i l i t i es m arket bear s anyr el at i on t o t he pr act i ce of opt om etryoranyotheri nt er es tthe Pl ai nt i ffs cou l d p ossi blyal l ege w as i nv aded as a r esul tof thatplan. R at her, the P l ai nti ffs’ ar gum enton t hi s poi nts i m pl yas s um es the exi s t ence of s t andi ng, as thei rbr i efi ng on t he mat t eri s devot ed exc l us i vel yt o an exa m i nat i on of the el ement s of a § 2 cl ai m . T hi s i s i ns uffi ci entt o m eetthe Pl ai nt i ffs ’ bur den. M or eover , a pl ai nt i ff s eeki ng damages under§ 4 m us tal s o demonstr at e that it is a n e ffic ie n t e n fo rc e r o f th e a n titr u s t la w s . B - S St eel , 439 F. 3d at667; Todorov , 9 2 1 F .2 d a t 1 4 4 9 , 1 4 5 0 . F a c to rs to b e c o n sid e re d in th is a n a ly sis i ncl ude the di r ectnes s orr emot enes s of the i nj urys uffe r ed bythe pl ai nt i ff, w hi ch, in tu rn , d e p e n d s o n th e e x iste n c e o f o th e r m o re d ire c tly -inju re d p o ss ib le-37-

p la in tiffs . See Todor ov , 9 2 1 F .2 d a t 1 4 5 1 ; A ssoci ated G en. C on tract ors , 45 9 U. S. at54 2 (“T he ex i st ence o f an identi fi able cl ass of persons w ho se sel f-i nter est w ou l d n orm al l ym oti vate them t o v i nd i cat e t he p ub l i c i nter esti n an t i trust e n fo rc e m e n t d im in ish e s th e ju stifica tio n fo r a llo w in g a m o re re m o te p a rty[ to b rin g su it]. ” ). T h e P lain tiffs h e re h a v e “ n o n a tu ra l ec o n o m ic s e lf-in ter e st” in p re s e rv in g c o m p e titio n in th e m a rk e t fo r s u rg ic a l fa c iliti e s . D ani elv. A m . B d. of E m ergency Med. , 428 F. 3d 408, 444 ( 2d C i r . 2005) . O n the otherhand, other re g io n a l p ro v id e rs o f

su rg ica l fa c ili ties “ h a v e a d ire c t an d u n d iv id e d e c o n o m ic i nt er es t ” i n obt ai ni ng r efe r r al s t o i t s hos pi t al s and i n ens ur i ng thatI H C i s not a c tin g u n la w f

u lly in o b ta in in g re fe rr a ls to its fa c iliti e s . See i d. T hough notan exhaus t i ve l i s t , i n t hi s cas e i ti s cl earthat

— atm i ni m um — non- I H C s ur gi cal fac i l i t i es on t he W as at ch Fr ontand cons um er s of s ur gi cal fac i l i t i es on the W a sa tch F ro n t w o u ld b e m o re d ire c tlyh a rm e d b yIH C ’s a lleg e d a ttem p t to m onopol i ze the mar ketfors ur gi cal fac i l i t i es . Forthi s addi t i onal r eas on, the Pl ai nt i ffs her e l ack s t andi ng. V. OUTS TA NDI NG M OTI ONS T here are al so t w o o uts t and i ng m oti on s w e m ustbri efl yadd res s. T he fir st mo t i o n r e g a r d s a p r o t e c t i v e o r d e re n t e r e d b yt h e Di s tr i c tCo u r tp u r s u a n tt o F e d . R. C i v. P. 26( c) . T he pr ot ect i ve or derdes i gnat es a partof the r ecor d bel ow as confi dent i al , and i n es s ence , s ubj ectt o r evi ew onl ybycouns el and the courtas-38-

neede d foradj udi cat i on of the ca s e. T he or derexpr es s l ys t at es thati t s pr ot ect i ons “sh all su rviv e the term ination o f th e li ti g ati o n . ” F o ll o w ing the e n tryo f su m m ary j udgm ent , t he D efe ndant s fi l ed a mot i on t o enfor ce the pr ot ect i ve or der , w hi ch a panel of thi s cour tpr ovi s i onal l ygr ant ed, r es ervi ng the i s s ue forr econs i der at i on b yth e m e rits p a n e l. T h e P lain tiffs’ m o tio n fo r re c o n sid e ra tio n o f th a t ru lin g is now befor e us . G ener al l y , “[a ] s l ong as a pr ot ect i ve or derr emai ns i n effect , the cour tt hatent er ed the or derr et ai ns the pow ert o m odi fyi t , even i f the under l y i ng s ui thas been di s m i s s ed. ” Uni t ed Nucl earC or p. v. C r anf

or d Ins . C o. , 905 F. 2d 1 4 2 4 , 1 4 2 7 (1 0 th C ir. 1 9 9 0 ). “[ M ]o d ifica tio n o f a p ro tec tiv e o rd e r, li k e its or i gi nal entr y , i s l eftt o t he di s cr et i on of the di s tr i ctcourt . ” Id. T h e P lain tiffs d id n o t seek m o d ifi ca ti o n o f th e o rde r i n the D istri ct C o u rt , n o r do theyarg u e h ere t hatt he D i s t r i ctC our tabus ed i t s di s cr et i on i n i m pos i ng the pr ot ect i ve or deri n t he fi r s tpl ace . R ather , t heyar gue thatthe pr ot ect i ve or deraut om at i cal l ydi s s ol ved dur i ng t he fi nal s t ages of pr etr i al pr epar at i ons and ac cor di ngl yther e i s nothi ng l eftt o enfor ce. T hi s as s ert i on i s bel i ed bythe or der ’ s ow n t erm s , w hi ch i ndi cat es i tw as i nt ended t o “s ur vi ve the t erm i nat i on of the l i t i gat i on. ” W e ther efor e deny th e m o tio n to re c o n s id e r. T he Pl ai nt i ffs al s o fi l ed a mot i on t o s uppl ementthe r ecor d al ong w i th a s u p p le m e n ta l a p p e n d ix . T h a t m o tio n is g ra n te d . VI . CO NC L US I ON-39-

Fort he for egoi ng r eas ons , w e conc l ude the Pl ai nt i ffs fai l ed t o pr es ent evi dence of a c ons pi r acybetw een the defendantopht hal m ol ogi s t s and I H C that t ends t o excl ude the pos s i bi l i t yof i ndepende ntconduct . W e al s o concl ude that th e P lain tiffs h a v e fa iled to ra ise a g e n u in e iss u e o f fa c t o n th e ir ty in g c laim beca us e theyfai l ed t o s how t hatI H C has an ec onom i c i nt er es ti n the s al e of N S E C . F in a lly , w e c o n c lu d e th a t th e P lain tiffs h a v e fa iled to d e m o n stra te stan d ing to as sert th eir § 2 claim s. W e the refo re A F F IR M the D istri ct C o u rt ’s d ispo sit ion o f th is m att er.