Case Name: Judith NELSON and Darci Anne Bowman, Plaintiff-Appellants, Cross-Appellees, v. MONROE REGIONAL MEDICAL CENTER, formerly known as the Monroe Clinic, Defendant-Appellee, Cross-Appellant
Court: United States Court of Appeals for the Seventh Circuit
Jurisdiction: United States
Decision Date: 1991-02-19
Citations: 925 F.2d 1555
Docket Number: Nos. 89-3110, 89-3234
Parties: Judith NELSON and Darci Anne Bowman, Plaintiff-Appellants, Cross-Appellees, v. MONROE REGIONAL MEDICAL CENTER, formerly known as the Monroe Clinic, Defendant-Appellee, Cross-Appellant.
Judges: Before CUDAHY and FLAUM, Circuit Judges, and PELL, Senior Circuit Judge.
Reporter: Federal Reporter 2d Series
Volume: 925
Pages: 1555–1579

Head Matter:
Judith NELSON and Darci Anne Bowman, Plaintiff-Appellants, Cross-Appellees, v. MONROE REGIONAL MEDICAL CENTER, formerly known as the Monroe Clinic, Defendant-Appellee, Cross-Appellant.
Nos. 89-3110, 89-3234.
United States Court of Appeals, Seventh Circuit.
Argued Sept. 25, 1990.
Decided Feb. 19, 1991.
Rehearing and Rehearing En Banc Denied April 10, 1991.
Peter E. Hans, Schrank & Schultz, Madison, Wis., Raymond E. Schrank, II, Cannon & Dunphy, Milwaukee, Wis., for plaintiffs-appellants, cross-appellees.
James R. Troupis, Michael, Best & Fried-rich, Madison, Wis., for defendant-appellee, cross-appellant.
Pamela J. Schmelzer, Monona, Wis., for Association for Retarded Citizens of Wisconsin, amicus curiae.
Before CUDAHY and FLAUM, Circuit Judges, and PELL, Senior Circuit Judge.

Opinion:
FLAUM, Circuit Judge.
Plaintiffs Judith Nelson and Darci Anne Bowman brought suit against defendant Monroe Clinic, alleging constitutional, antitrust, and state-law tort claims arising from defendant's refusal to continue to treat them. The district court dismissed all but the antitrust claims for failure to state a claim. Following the close of discovery, the district court granted summary judgment to defendant on the antitrust claims, ruling that plaintiffs had not demonstrated antitrust injury. Plaintiffs appeal the dismissal of their claims for intentional and negligent infliction of emotional distress and the grant of summary judgment to defendant on their antitrust claims. Defendant cross-appeals the district court's refusal to dismiss on the pleadings plain tiffs' antitrust claims for failure to allege facts showing that defendant's acquisition of Monroe Medical Center had a not insubstantial effect on interstate commerce. We affirm the district court's dismissal of the emotional distress claims but reverse its grant of summary judgment on the antitrust claim. In addition, we affirm but modify the district court's conclusion with respect to defendant's effect on interstate commerce. Recognizing, however, that the district court based its grant of summary judgment exclusively on the question of antitrust injury, we remand for renewed summary judgment motions concerning the relevant product and geographic markets and defendant's power in those markets, as well as the nexus between defendant's alleged antitrust violation and interstate commerce.
I. FACTS AND PRIOR PROCEEDINGS
Darci Bowman is a mildly retarded eighteen year-old. She lives with her mother, plaintiff Judith Nelson, in Monroe, a city of approximately 10,000 inhabitants located in south central Wisconsin. Because of her handicap, Bowman is in need of frequent medical attention. In 1984 and 1985, she received this treatment from, among others, Doctor James Raettig of the Monroe Clinic, a partnership of over 60 physicians providing health care from eight locations in Monroe and surrounding areas of Wisconsin and Illinois. In April, 1985, Bowman brought a malpractice suit against Raettig in Wisconsin state court. After filing the malpractice action, Bowman ceased patronizing Dr. Raettig, instead consulting with Dr. Erie Anderson, a physician at Monroe Medical Center, a clinic employing five physicians located in Monroe. In late 1986 Monroe Clinic acquired Monroe Medical Center. Monroe Medical Center became one of Monroe Clinic's branches and Monroe Medical Center physicians, including Dr. Anderson, joined Monroe Clinic. Bowman withdrew her malpractice claim against Raettig in mid-1987. On January 22, 1988, Nelson and Bowman received a letter from the Monroe Clinic informing them that it would no longer treat either of them on a non-emergency basis and offering to assist them to find alternate care and to transfer records to the providers they selected.
Plaintiffs allege that this letter was intended to, and did, cause both of them severe emotional distress. Alternatively, they allege that the Monroe Clinic acted negligently because it should have known that the letter would cause extreme emotional distress. Plaintiffs also allege that the merger between Monroe Clinic and Monroe Medical Center has increased concentration in the market for health care in Monroe, with the consequence that the denial of access to any branch of Monroe Clinic is equivalent to the complete denial of access to non-emergency medical care in Monroe and other parts of Green County, Wisconsin. Plaintiffs now obtain medical care in Madison, Wisconsin, some 40 miles north of Monroe. Another consequence of the Clinic's decision to deny them care is to prevent Bowman from obtaining medical care by herself; because she must travel outside Monroe, she must be driven by Nelson. According to Nelson and her employer, the City of Monroe, the need to accompany her daughter on her periodic visits to doctors in Madison has disrupted Nelson's work schedule and caused her to lose wages.
II. CLAIMS FOR INFLICTION OF EMOTIONAL DISTRESS
A. Intentional Infliction of Emotional Distress.
Plaintiffs first challenge the district court's dismissal of their claim for intentional infliction of emotional distress. On appeal from a dismissal of a claim under Federal Rule of Civil Procedure 12(b)(6),
we must accept as true all the plaintiff's well-pleaded factual allegations and the inferences reasonably drawn from them. Zinser v. Rose, 868 F.2d 938, 939 (7th Cir.1989); Gillman v. Burlington N.R.R., 878 F.2d 1020, 1022 (7th Cir.1989). We shall affirm the dismissal only if the plaintiff has failed to allege any set of facts upon which relief can be granted. Zinser, 868 F.2d at 939.
Yeksigian v. Nappi, 900 F.2d 101, 102 (7th Cir.1990). "In giving the pleadings a liberal construction, however, we are not required to accept legal conclusions either alleged or inferred from the pleaded facts." Mescall v. Burrus, 603 F.2d 1266, 1269 (7th Cir.1979); see 5 C. Wright & A. Miller, Federal Practice & Procedure (Civil) § 1357 at 595-96 (1969 & Supp.1989).
Under Wisconsin law, "one who by extreme and outrageous conduct intentionally causes severe emotional distress to another is subject to liability for such emotional distress_" Alsteen v. Gehl, 21 Wis.2d 349, 358, 124 N.W.2d 312, 317 (1963); see Estate of Drab v. Anderson, 143 Wis.2d 568, 572, 422 N.W.2d 144, 146 (Wis.App.1988).
"Four factors must be established to prove a claim of intentional infliction of emotional distress: (1) the conduct was intended to cause emotional distress; (2) the conduct was extreme and outrageous; (3) the conduct was the cause of the person's emotional distress, and (4) the emotional distress must be extreme and disabling."
Stoll v. Adriansen, 122 Wis.2d 503, 516, 362 N.W.2d 182, 189 (Wis.App.1984), rev. den. 122 Wis.2d 782, 367 N.W.2d 222 (1985); see Alsteen, 21 Wis.2d at 359-61, 312 N.W.2d at 318; Laska v. Steinpreis, 69 Wis.2d 307, 322, 231 N.W.2d 196, 204 (1975). According to the district court, plaintiffs' complaint failed to establish that defendant's decision to terminate its relationships with Bowman and Nelson was sufficiently extreme and outrageous to satisfy the second part of this four-part test. We agree.
Since Wisconsin explicitly recognized the tort of intentional infliction of emotional distress in Alsteen, its courts have required plaintiffs asserting intentional infliction claims to show that defendant's conduct was so egregious that "the average member of the community" would regard the acts forming the basis for the claim "as being a complete denial of the plaintiff's dignity as a person." Alsteen, 21 Wis.2d at 359-60, 124 N.W.2d at 318.
Wisconsin courts have been reluctant to find that liability existed even where plaintiffs alleged that defendants conducted themselves in a manner far more egregious than the Monroe Clinic did when it ended its relationship with Darci Bowman and Judith Nelson. In Alsteen, the first case in which the Wisconsin Supreme Court recognized the tort of intentional infliction of emotional distress, it refused to find that the defendant in that case, a building contractor, had acted in a sufficiently outrageous fashion despite the fact that he had left a job half-done, exposing his elderly client to the elements; when Alsteen complained, he told her that she made him sick. 21 Wis.2d at 353, 124 N.W.2d at 314. Similarly, in Laska v. Steinpreis, the Supreme Court affirmed a trial court's decision to sustain a defendant's demurrer to a complaint alleging that the defendant, a landlord, was liable for intentionally inflicting emotional distress on his tenant by spying on the tenant's domestic activities and driving his car at high speed onto the lawn of the leased property, scattering the tenant's children. 69 Wis.2d at 319, 231 N.W.2d at 203.x`
The three Wisconsin Supreme Court cases in which intentional infliction claims have been upheld also show the extreme nature of the conduct required to state a claim for intentional infliction of emotional distress. In McKissick v. Schroeder, 70 Wis.2d 825, 235 N.W.2d 686 (1975), the Wisconsin Supreme Court reversed an or der of a trial court sustaining defendant Schroeder's demurrer to plaintiff McKis-sick's intentional infliction claim. Mrs. McKissick alleged that she had seen defendant Schroeder, a policeman, shoot her son and that after the shooting, as her son lay bleeding to death, the policeman questioned Mrs. McKissick rather than calling for medical assistance. In Slawek v. Stroh, 62 Wis.2d 295, 215 N.W.2d 9 (1974), the Supreme Court reversed the order of a trial court sustaining a demurrer to a complaint, in which plaintiff alleged that a former paramour had sought to continue their relationship "by his intentional physical acts in repeatedly telephoning her and her family at all hours of the day and night, interrupting her sleep and other activities . [and] by wild and false ruses, stories, and the use of false names...." Id. at 314, 215 N.W.2d at 20. And in Scarpaci v. Milwaukee County, 96 Wis.2d 663, 292 N.W.2d 816 (1980), the Supreme Court reversed the order of the trial court sustaining defendants' demurrer to the Scarpacis' complaint, which alleged that the defendants, county coroners and their employer, had performed an unauthorized autopsy on the body of plaintiffs' daughter after having been told by plaintiffs that they did not wish this procedure to be performed. Id. at 666, 292 N.W.2d at 818.
Guided by these cases, we cannot say that the actions of the Monroe Clinic in terminating its relationship with Darci Bowman or Judith Nelson were sufficiently "extreme and outrageous," Alsteen, 21 Wis.2d at 359,124 N.W.2d at 317, to state a claim under Wisconsin law. The Clinic's letter did not completely deny the personal dignity of Bowman or Nelson. See id. at 359-60, 124 N.W.2d at 318. In recognition of their continued medical needs, the Clinic offered to assist them in finding an alternate provider of medical care and allowed them ten days in which to find this provider. The Clinic also implied that it would continue to provide emergency services to Bowman and Nelson, which may have been of some comfort given the geographical proximity of their home to two of the Clinic's branches and the alleged lack of alternate medical facilities in their immediate vicinity. Moreover, the tone of the letter was dispassionate, and no reasonable juror could read it as calculated to insult or belittle Bowman or Nelson, much less completely to deny their basic human dignity. While the letter undoubtedly upset Bowman and Nelson, so did the landlord's conduct in Steinpreis and the contractor's actions in Alsteen. As the district court correctly held, Wisconsin law requires more than upset or irritation to state a claim for intentional infliction of emotional distress. The Clinic's termination of its relationship with Bowman, a mentally handicapped young adult, was surely not a generous response to a malpractice suit whose filing Bowman likely did nothing to bring about. Nonetheless, we agree with the district court that it did not create a cause of action for intentional infliction of emotional distress under Wisconsin law.
B. Negligent Infliction of Emotional Distress.
We turn next to plaintiffs' claim for negligent infliction of emotional distress. Plaintiffs allege that defendant breached a duty it owed to them when it terminated its relationship with both Bowman and Nelson, causing foreseeable and extreme emotional distress. Defendant counters with the well-known legal principle that a physician owes no duty to continue to treat particular patients. It argues that since it was under no duty to continue to treat Bowman or Nelson, it breached no duty when it chose to discontinue the relationship. We disagree with defendant's reasoning. "[RJeliance upon a no duty-no liability theory is misplaced in Wisconsin: a 'duty' exists when it is established that it was foreseeable that an act or omission to act may cause harm to someone." Schus- ter v. Altenberg, 144 Wis.2d 223, 237-38, 424 N.W.2d 159, 165 (1988). While Alten-berg was a malpractice case, we read the discussion in that case as applicable to all negligence actions. See id. at 238, 424 N.W.2d at 165. As applied to this case, Altenberg suggests that the law's understandable hesitance to impose a duty on a physician to continue to treat a patient is not relevant to the question of whether a physician might terminate a patient in such a callous fashion as to give rise to a claim for negligent infliction of emotional distress.
W'e do, however, agree that plaintiff has failed to state a claim for negligent infliction of emotional distress. "The general rule in Wisconsin is that, to recover for the negligent infliction of emotional distress, the 'plaintiff's emotional, distress must be manifested by physical injury.' " Meracle v. Children's Serv. Soc'y, 149 Wis.2d 19, 28, 437 N.W.2d 532, 535 (1989) (quoting Garrett v. City of New Berlin, 122 Wis.2d 223, 231, 362 N.W.2d 137, 142 (1985)). The policy underlying the "reluctance" to allow recovery for negligent infliction of emotional distress without accompanying physical injury "is the fear of flooding the courts with fraudulent claims and exposing defendants to potentially unlimited liability for every type of mental disturbance." LaFleur v. Mosher, 109 Wis.2d 112, 115, 325 N.W.2d 314, 316 (1982). In LaFleur, the Wisconsin Supreme Court grafted a narrow exception onto this rule, recognizing that certain circumstances of negligent confinement could give rise to a claim for negligent infliction of emotional distress. 109 Wis.2d at 119, 325 N.W.2d at 317. The Court created this exception because it determined that an extended period of confinement caused by the negligent act of another "by its very nature has the special likelihood of causing real and severe emotional distress." Id. at 119, 325 N.W.2d at 317. Three years later in Meracle, the Court observed that "La-Fleur involved unique facts and the decision emphasized the narrowness of its holding." 149 Wis.2d at 29, 437 N.W.2d at 536. In deciding this pendent state claim, we are unwilling "to speculate on any trends in state law," Shaw v. Republic Drill Corp., 810 F.2d 149, 150 (7th Cir.1987), that would lead the Wisconsin Supreme Court to expand the narrow exception recognized in LaFleur to cover the facts of this case, which present no "similar guarantee of the genuineness and severity of the injury," Meracle, 149 Wis.2d at 29, 437 N.W.2d at 536, that Nelson and Bowman suffered when Monroe Clinic terminated its relationship with them.
III. ANTITRUST CLAIM
A. Antitrust Injury.
In their complaint, plaintiffs alleged two antitrust claims, both related to the merger between the Monroe Clinic and Monroe Medical Center. The first claim alleged that the merger was a contract or combination in restraint of trade in violation of § 1 of the Sherman Act, 15 U.S.C. §• 1. The second claim alleged that, through the merger, the Monroe Clinic sought to monopolize the provision of medical services in Monroe and its environs, in violation of § 2 of the Sherman Act, 15 U.S.C. § 2. Unlike plaintiffs' emotional distress claims, these two antitrust claims survived defendant's Rule 12(b)(6) motion to dismiss.
Discovery concerning the antitrust claims proceeded, and at the close of discovery defendant filed a motion for summary judgment. The district court granted summary judgment to defendant because of what it viewed as plaintiffs' failure "to demonstrate any relationship between any anticompetitive conduct and the denial of care to plaintiffs and their resulting injuries." August 29,1989 Memorandum Opinion ("Mem. Op.") at 7. Specifically, the district court observed that the plaintiffs had "been unable to provide evidence to support" the antitrust violations they alleged, "such as evidence that other former patients have been denied care because of filing lawsuits against the defendant." Id. The district court concluded that "[wjhile defendant may have caused plaintiff[s] some unfortunate concerns, any loss suffered by them simply cannot be considered an antitrust injury which flows from the public injury to competition which the antitrust laws regulate, 'which means injury from higher prices or lower output, the principal vices prescribed by the antitrust laws.' " Id. at 8-9 (quoting Ball Memorial Hosp. v. Mutual Hosp. Ins., 784 F.2d 1325, 1334 (7th Cir.1986)).
We respectfully disagree with the district court's conclusion that plaintiffs have failed to demonstrate that the injury they suffered when the Clinic terminated its relationship with them is not an injury cognizable under the antitrust laws. Private civil actions to enforce the Sherman Act are allowed under § 4 of the Clayton Act, 15 U.S.C. § 15. That section provides that "any person who shall be injured in his business or property by reason of anything forbidden in the antitrust laws may sue therefore_" Despite the "comprehensive" language of § 4, Mandeville Island Farms, Inc. v. American Crystal Sugar, 334 U.S. 219, 236, 68 S.Ct. 996, 1006, 92 L.Ed. 1328 (1948), the Supreme Court has recognized that " 'Congress did not intend the antitrust laws to provide a remedy in damages for all injuries that might conceivably be traced to an antitrust violation.' " Associated General Contractors of California v. California State Council of Carpenters, 459 U.S. 519, 534, 103 S.Ct. 897, 906, 74 L.Ed.2d 723 (1983) (quoting Hawaii v. Standard Oil Co., 405 U.S. 251, 263 n. 14, 92 S.Ct. 885, 891-92 n. 14, 31 L.Ed.2d 184 (1972)); see also Illinois Brick Co. v. Illinois, 431 U.S. 720, 761, 97 S.Ct. 2061, 2082-83 n. 14, 52 L.Ed.2d 707 (1977) (Brennan, J., dissenting) ("I concede that despite the broad wording of § 4 there is a point beyond which the wrongdoer should not be held liable."); Southwest Suburban Bd. of Realtors v. Beverly Area Planning Auth., 830 F.2d 1374, 1377 (7th Cir.1987); Repp v. F.E.L. Publications, 688 F.2d 441, 444 (7th Cir.1982).
In Blue Shield of Virginia v. McCready, the Supreme Court, reviewing its past decisions, identified "two types of limitation on the availability of the § 4 remedy to particular classes of persons and for redress of particular forms of injury." 457 U.S. 465, 473, 102 S.Ct. 2540, 2545, 73 L.Ed.2d 149 (1982). The concern animating the first limitation, announced in Standard Oil, supra, and Illinois Brick, supra, was "the risk of duplicative recovery engendered by allowing every person along a chain of distribution to claim damages arising from a single transaction that violated the antitrust laws." McCready, 457 U.S. at 474-75, 102 S.Ct. at 2545-46. The second limitation identified in McCready concerned "the conceptually more difficult question 'of which persons have sustained injuries too remote [from an antitrust violation] to give them standing to sue for damages under § 4.' Illinois Brick Co. v. Illinois, 431 U.S., at 728, n. 7 [97 S.Ct. at 2065-66, n. 7] (emphasis added)." McCready, 457 U.S. at 476, 102 S.Ct. at 2546.
A year after McCready, the Supreme Court revisited the limitations on the reach of § 4 identified in that case. In Associated General Contractors, supra, the Court recognized that, in light of "the infinite variety of claims" that might arise under § 4, it was "virtually impossible to announce a black-letter rule that will dictate the result in every case." 459 U.S. at 536, 103 S.Ct. at 908. Instead of promulgating such a rule, the Court pointed to various "factors that circumscribe and guide the exercise of judgment in deciding whether the law affords a remedy in specific circumstances." Id. at 537, 103 S.Ct. at 908. The first of these factors was the causal connection between the damages claimed by the antitrust plaintiff and the harm to the plaintiff; the second was the nature of the injury suffered by the plaintiff and the relationship between that injury and the type of conduct sought to be redressed by providing a private remedy for antitrust violations; the third was the directness of the asserted injury and, closely related, the risk of duplicate recoveries or (conversely) the difficulties of apportioning damages among various classes of plaintiffs. See id,., 459 U.S. at 537-45, 103 S.Ct. at 908-12.
Taking the last of the three factors identified in Associated General Contractors first, we note that this case raises no concerns of duplicative recoveries or difficulties in apportioning the damages plaintiffs claim between them or others injured by defendant's merger. The damages Nelson and Bowman claim were directly caused by the Clinic's exercise of its market power. There was no intervening party that passed along the harm caused by its refusal to continue to treat the plaintiffs. Compare Illinois Brick, 431 U.S. at 737-43, 97 S.Ct. at 2070-73; Standard Oil, 405 U.S. at 261-64, 92 S.Ct. at 890-92.
Plaintiffs have satisfied the first of the three factors set out in Associated General Contractors as well: while their pleadings and motions in the district court and their briefs before this court have been less than models of clarity, their complaint nevertheless sufficiently alleges that the merger of the Monroe Clinic and Monroe Medical Center served to monopolize the provision of health care in Monroe and its environs, with the effect of restraining commerce. Second Amended Complaint, ¶ 129. We are mindful of the Supreme Court's statement in Associated General Contractors that "the mere fact that the claim is literally encompassed by the Clayton Act does not end the inquiry." 459 U.S. at 537, 103 S.Ct. at 908. Here, however, the causal connection between the merger and the plaintiffs' diminished access to health care is more direct and obvious than was the causal connection between the defendant Associated General Contractors' exhortation of its members and others to hire non-union workers and the damage allegedly suffered by the plaintiff union. See 459 U.S. at 526-28, 103 S.Ct. at 902-03.
Throughout its brief, defendant argues that plaintiff has failed to show that the injury it suffered was causally related to the merger because the denial of medical care is not the kind of injury that normally flows from the absence of competition in a market. This argument fails to recognize that, but for the merger, plaintiffs might still be enjoying the services of Doctor Anderson and the Monroe Medical Center rather than travelling to Madison because the Monroe Medical Center, now part of Monroe Clinic, refuses to see them. As the Supreme Court observed in Associated General Contractors, "[tjhere is a similarity between the struggle of common-law judges to articulate a precise definition of 'proximate cause' and the struggle of federal judges to articulate a precise test to determine whether a party injured by an antitrust violation may recover treble damages." 459 U.S. at 535, 103 S.Ct. at 907 (footnote omitted). Similarly, in McCready the Court observed that, "[i]n the absence of direct guidance from Congress, and faced with the claim that a particular injury is too remote from the alleged violation to warrant § 4 standing, the courts are thus forced to resort to an analysis no less elusive than that employed traditionally by courts at common law with respect to the matter of 'proximate cause.' " 457 U.S. at 465, 102 S.Ct. at 2540. In the law of torts, the fact that damage would not have occurred but for defendant's tortious conduct is, as a rule, sufficient to establish causation in fact. See 4 F. Harper, F. James & O. Gray, The Law of Torts § 20.1 at 91-92 (2d ed. 1986). And applying the test of proximate cause "currently prevailing in this country," id., § 20.5 at 138, it was arguably foreseeable to defendant that, in view of its alleged market power in the community following the merger, their re fusal to continue to treat plaintiffs would cause harm to them arising from the paucity or complete absence of nearby alternate providers of medical services to whom plaintiffs could turn.
We come to the second of the three Associated General Contractors factors, the presence or absence of an injury " 'of a type that Congress sought to redress in providing a private remedy for violations of the antitrust laws.' " 459 U.S. at 538, 103 S.Ct. at 909, quoting McCready, 457 U.S. at 483, 102 S.Ct. at 2550; see Atlantic Richfield Co. v. USA Petroleum, — U.S. —, 110 S.Ct. 1884, 1889, 109 L.Ed.2d 333 (1990) ("[Ijnjury, although causally related to an antitrust violation, nevertheless will not qualify as 'antitrust injury' unless it is attributable to an anti-competitive aspect of the practice under scrutiny_"); Brunswick Corp. v. Pueblo Bowl-O-Mat, 429 U.S. 477, 489, 97 S.Ct. 690, 697-98, 50 L.Ed.2d 701 (1977) ("Plaintiffs must prove antitrust injury, which is to say injury of the type the antitrust laws were intended to prevent and that flows from that which makes defendants' acts unlawful."); Wilk v. American Medical Ass'n, 895 F.2d 352, 364 (7th Cir.), cert. denied, — U.S. —, 110 S.Ct. 2621, 110 L.Ed.2d 642 (1990); Southwest Suburban Bd. of Realtors v. Beverly Area Planning Ass'n, 830 F.2d 1374, 1377 (7th Cir.1987). The injury Nelson and Bowman allege is that the merger between Monroe Clinic and Monroe Medical Center increased the Clinic's market power and limited plaintiffs' opportunity to obtain medical care in Monroe once the Clinic chose to terminate its relationship with them.
As this Court recognized in Ball Memorial Hosp. v. Mutual Hosp. Ins., "[wjhe-never the plaintiff and consumers have divergent rather than congruent interests, there is a potential problem in finding 'antitrust injury'.... When the plaintiff is a poor champion of consumers, a court must be especially careful not to grant relief that may undercut the proper functions of antitrust." 784 F.2d 1325, 1334 (7th Cir.1986). In this case, plaintiffs are not "poor champions" of the consumer interest in vigorous competition in the market for medical services in Monroe. As defendant concedes, "antitrust injury 'means injury from higher prices or lower output, the principal vices proscribed by the antitrust laws.' " Brief at 35, quoting Ball Memorial, 784 F.2d at 1334. The facts show that one possible effect of the merger between Monroe Medical Center and Monroe Clinic — perhaps the only one that has manifested itself thus far — has been a reduction in the output of the merged entity relative to its parents: the Clinic no longer treats Nelson and Bowman. Defendant argues that this injury, the denial of non-emergency medical services, is not the type the antitrust laws are intended to remedy. We are unable to agree. Monopolists are more likely to turn away prospective clients because they do not feel the same competitive pressure to serve all comers. This explains why we recognized in Ball Memorial that "injury from . lower output" was one of the "principal vices proscribed by the antitrust laws." 784 F.2d at 1334. A clinic in a more competitive marketplace might have preferred to let bygones be bygones, opting for the insurance payments and other remuneration it would receive for treating Bowman and Nelson and accepting the risk that they would again sue for malpractice. Monroe Clinic's failure to do so in a marketplace rendered non-competitive by its merger with a competitor is an injury that can be said to be directly caused by an absence of competition, the kind of injury the antitrust laws were intended to prevent and redress.
Moreover, even if plaintiffs have suffered an injury of a kind unique to them, they have alleged and introduced facts to support the view that "an injury to the market" has occurred that has claimed them as its first victims. Car Carriers v. Ford Motor Co., 745 F.2d 1101, 1107 (7th Cir.1984), cert. denied, 470 U.S. 1054, 105 S.Ct. 1758, 84 L.Ed.2d 821 (1985). If plaintiffs' allegations and their experts' testimony concerning the dominance the Monroe Clinic has achieved in the provision of medical services in the Monroe area are true, an issue we do not reach, it is not difficult to predict what the future holds: "The higher the aggregate market share of a small number of suppliers, the easier it is for them to increase price above the competitive level without losing so much business to other suppliers as to make the price increase unprofitable; this is the power we call market power." United States v. Rockford Memorial Hosp., 898 F.2d 1278, 1283 (7th Cir.), cert. denied, — U.S. —, 111 S.Ct. 295, 112 L.Ed.2d 249 (1990).
B. Interstate Commerce.
In allowing plaintiffs' antitrust claims to survive defendant's Rule 12(b)(6) motion to dismiss, the district court rejected defendant's argument that plaintiffs had failed to allege facts demonstrating that defendant's activities had a not insubstantial effect on interstate commerce, bringing defendant within the ambit of the antitrust laws. Later in the litigation, in its motion granting summary judgment to defendant on the antitrust claims, the district court explicitly found that plaintiffs had satisfied their burden of showing the nexus between the defendant's activities and interstate commerce, appearing to grant summary judgment on this issue to plaintiffs. The district court based this conclusion on its finding that "defendant has clinics in Illinois and a large percentage of out-of-state patients, thus placing its conduct in interstate commerce." Mem. Op. at 6. In its cross-appeal, defendant challenges the district court's ruling on the motion to dismiss, arguing that plaintiffs failed to allege facts in their complaint sufficient to establish a nexus between defendant's challenged conduct and interstate commerce and that the district court applied the incorrect legal standard in making its determination that defendant acted in interstate commerce. We agree with defendant that the district court erred in looking to the nexus between defendant's business activities as a whole and interstate commerce rather than the relationship between the alleged antitrust violation and interstate commerce, but affirm the district court's conclusion to the extent that we hold that there remains a question of material fact as to whether the merger between Monroe Clinic and Monroe Medical Center had a not insubstantial effect on interstate commerce.
"It is axiomatic that in pleading a cause of action under the Sherman Act § 1, 2, the plaintiff must adequately allege the jurisdictional requirement of interstate commerce." Marrese v. Interqual, Inc., 748 F.2d 373, 379 (7th Cir.1984), cert. denied, 472 U.S. 1027, 105 S.Ct. 3501, 87 L.Ed.2d 632 (1985); see McLain v. Real Estate Board, 444 U.S. 232, 241, 100 S.Ct. 502, 508-09, 62 L.Ed.2d 441 (1980); Seglin v. Esau, 769 F.2d 1274, 1276 (7th Cir.1985). There is "a split in the circuits as to whether a plaintiff must show a nexus between interstate commerce and defendant's general business activities or whether the requisite connection must be between interstate commerce and defendant's challenged (i.e. allegedly unlawful activities)." Anesthesia Advantage v. Metz Group, 912 F.2d 397, 401 (10th Cir.1990). In its decision in Seglin v. Esau, supra, the Seventh Circuit aligned itself with those circuits that require that the plaintiff show the relationship between the challenged conduct and interstate commerce. Seglin, 769 F.2d at 1279 (" '[T]he inquiry must be whether the defendants' activity that has allegedly been infected by unlawful conduct can be shown as a matter of practical economics to have had a not insubstantial effect on the interstate commerce involved.' ") (quoting Furlong v. Long Island College Hospital, 710 F.2d 922, 925-36 (2d Cir.1983)) (internal quotations omitted); see also McLain, 444 U.S. at 246, 100 S.Ct. at 511. In conducting this inquiry, it is not enough to find that the antitrust defendant operates in more than one state, because even a business that operates on a national or global scale may be accused of anti-competitive conduct with a purely local impact. For this reason, it was error for the district court to abbreviate the interstate commerce inquiry it performed in deciding defendant's summary judgment motion upon discovering that the Monroe Clinic operated clinics in both Wisconsin and Illinois.
In Seglin, supra, the antitrust plaintiff, a doctor suing his former employer, a psychiatric hospital which had terminated his staff privileges, alleged that the hospital "provide[d] psychiatric services to patients who travel in interstate commerce to receive such services_purchase[d] and receive^] equipment and supplies in interstate commerce_ [and] receive[d] payments in interstate commerce from [ ] government agencies and private insurance carriers_" 769 F.2d at 1275-76. Similarly, in Doe on Behalf of Doe v. St. Joseph's Hosp., 788 F.2d 411 (7th Cir.1986), another case arising from a hospital's decision to revoke a physician's staff privileges, we affirmed the dismissal on the pleadings of the plaintiff's antitrust claims where the complaint alleged only that defendant purchased drugs and medical equipment in interstate commerce, received insurance payments from out-of-state private and public entities, provided medical services to out-of-state patients, and shared information and medical training across state lines. See 788 F.2d at 417.
We. acknowledge that plaintiffs' complaint in this case contains no more factual detail concerning defendant's relationship with interstate commerce than the complaints we found inadequate in Seglin and Doe. Like those complaints, plaintiffs' complaint here alleges defendant's ties to interstate commerce by pointing to the volume of health care services the Monroe Clinic provides to individuals from other states, the employment available to persons from other states at the Clinic's branches, and the flow of medical insurance and loans from out of state to the Clinic.
As in Seglin, however, this is not the end of our inquiry. The dismissal in Seglin was based both on the lack of factual specificity concerning the nexus between defendant's challenged conduct and interstate commerce and the plaintiff's failure to allege a plausible connection between the antitrust violation alleged and a potential impact on interstate commerce. See Seglin, 769 F.2d at 1281-82 (discussing Tarleton v. Meharry Medical College, 717 F.2d 1523 (6th Cir.1983)). In the present case, plaintiffs' complaint is short on factual detail, but it does allege how, " 'as a matter of practical economics,' " the anti-competitive effects of the Monroe Clinic's merger with Monroe Medical Center may lead to concentration, decreased output, and increased prices, causing a reduction in the demand for medical services among the former Monroe Medical Center's interstate clientele, decreasing Monroe Clinic's demand for medical equipment and supplies purchased out-of-state, and lowering the number and value of insurance payments it receives from out of state. See Plaintiffs' Second Amended Complaint, HIT 121-127, 129-35. In this regard, we find this case to be like Marrese, 748 F.2d at 379-80, where we held that an antitrust plaintiff physican denied staff privileges could satisfy the interstate commerce nexus by pointing to the specific effects on interstate commerce his exclusion by the defendant hospital had on interstate commerce. While in Marrese plaintiff supported this allegation with facts concerning the amount of interstate commerce affected by defendant's action, we are reluctant to hold that the inquiry into the sufficiency of an antitrust plaintiff's complaint should turn on the plaintiff's access to statistical information at an early stage of litigation, when this information will likely be in the sole possession of the defendant. Our reluctance is particularly strong in this case, where much of the information concerning the effect of the merger on interstate commerce was, before discovery, completely inaccessible to defendants and was only released by defendants pursuant to a stipulation of confidentiality. See McLain, 444 U.S. at 243, 100 S.Ct. at 509-10 ("Nor is jurisdiction defeated in a case relying on anticompetitive effects by plaintiff's failure to quantify the adverse impact of defendant's conduct."); Hospital Bldg. Co. v. Trustees of Rex Hosp., 425 U.S. 738, 746, 96 S.Ct. 1848, 1853, 48 L.Ed.2d 338 (1976) ("rigorous standard" applied in considering antitrust defendants' motions to dismiss for failure to show nexus with interstate commerce is appropriate, because " 'the proof is largely in the hands of the alleged conspirators.' ") (quoting Poller v. Columbia Broadcasting, 368 U.S. 464, 473, 82 S.Ct. 486, 491, 7 L.Ed.2d 458 (1962)); see also Williams v. St. Joseph Hosp., 629 F.2d 448, 453-454 (7th Cir.1980).
In its brief, defendant directs its interstate commerce challenge to the district court's ruling on its motion to dismiss plaintiff's antitrust claims. Because the district court's application of an incorrect legal standard led it to terminate its interstate commerce inquiry before it reached the question of whether discovery had revealed facts suggesting that defendant's alleged antitrust violations had a not insubstantial nexus with interstate commerce, we remand for renewed summary judgment motions on this question.
IV. CONCLUSION
We have concluded that plaintiffs have cleared two hurdles to the maintenance of an antitrust claim challenging the merger between the Monroe Clinic and the Monroe Medical Center. There remain, however, other obstacles in plaintiffs' path which we do not address, and which nothing in this opinion should be read as prejudging, notably the difficult questions of determining the relevant product and geographic markets and assessing defendant's power in those markets. In resolving this question, the district court should be guided by the burgeoning case law concerning mergers between providers of medical services, including this Circuit's recent decision in Rockford Memorial Hosp., 898 F.2d 1278.
To sum up, we affirm the district court's dismissal of plaintiffs' emotional distress claims but reverse its grant of summary judgment on their antitrust claims. In addition, we modify the district court's conclusion with respect to the nexus between the merger between the Monroe Clinic and Monroe Medical Center and interstate commerce. We remand for renewed summary judgment motions concerning the relevant product markets and defendant's power in those markets, as well as the nexus between the merger and interstate commerce.
. The Wisconsin Supreme Court explained the rationale tor this requirement as follows:
The requirement that the conduct be extreme and outrageous reflects our concern with the difficulties surrounding proof of the existence of severe emotional harm, and proof of a causal relationship between the injury and the defendant's conduct. If the conduct is gross and extreme it is more probable that the plaintiff did, in fact, suffer the emotional distress alleged. Moreover, the requirement of extreme and outrageous conduct as a condition of recovery will avoid litigation "in the field of bad manners, where relatively minor annoyances had better be dealt with by instruments of social control other than law."
Alsteen, 21 Wis.2d at 360, 124 N.W.2d at 318 (quoting Magruder, Mental and Emotional Disturbance in the Law of Torts, 49 Harv.L.Rev. 1033, 1035 (1936)).
. There is some debate between the parties concerning whether plaintiffs' complaint contains a claim for negligent infliction of emotional distress. It is true that the heading of the emotional distress count of plaintiffs' complaint is "CAUSE OF ACTION NUMBER ONE: Intentional Infliction of Emotional Distress." However, throughout the body of the count, plaintiffs allege both intentional and negligent infliction of emotional distress. See, e.g. ¶ 41, 45.
. At a late stage of this litigation in the district court, plaintiffs indicated that they sought relief as well under Section 7 of the Clayton Act, 15 U.S.C. § 18. Defendant argues that this claim was not raised in a timely fashion below and that we are consequently precluded from considering it on appeal. This issue is mooted by this court's decision in United States v. Rockford Memorial Hosp., 898 F.2d 1278 (7th Cir.), cert. denied, — U.S. —, 111 S.Ct. 295, 112 L.Ed.2d 249 (1990). In that case, we observed that, as applied to mergers, the judicial interpretations of § 1 of the Sherman Act (which plaintiffs pleaded and preserved for appeal), and § 7 of the Clayton Act (which defendant argues was not raised below), "have, after three quarters of a century, converged." See id. at 1281-82.
. Nelson and Bowman have supported their allegation that defendant now possesses inordinate market power with evidence presented by an expert witness suggesting that the effect of the merger in the relevant market they propose has been to substantially lessen competition through the elimination of a small but significant competitor. See Affidavit of Harold S. Luft at 24-25 (merger caused Herfindahl indices of competition in market for physician visits in three zip-code area including Monroe to increase by over 1,100 to 4,472); compare Department of Justice Merger Guidelines § 3.11(c), reprinted, 4 Trade Reg.Rep. (CCH) ¶ 13,103 at 20,561 (Department of Justice is likely to challenge mergers resulting in post-merger Herfin-dahl index of over 1,800 where merger increases Herfindahl index by more than 50).
Defendants, as one might expect, describe the relevant market as encompassing a larger area and justify their acquisition by pointing to the low barriers to entry into the medical care market and the presence of larger chains of clinics in urban centers near Monroe such as Madison, Janesville-Beloit, and Rockford. We do not reach the merits of this aspect of the dispute, which the parties are invited to address in the district court through renewed motions for summary judgment.
. Alternatively, one could view the Clinic's refusal to treat Nelson and Bowman as an infinite increase in the price it charges them for treatment. This characterization may be particularly relevant in the market for health care, where the price set for treatment is often negotiated not between patient and physician but between patient's insurer and physician. The Clinic may thus have been unable to charge Nelson and Bowman a higher price for the treatment it provided them to reflect the heightened risk (demonstrated by their past behavior) that it would later have to pay to litigate a malpractice case. Unable to bargain for compensation for this increased risk in the form of higher fees, the Clinic chose not to treat Bowman and Nelson at all. In a competitive market this would not be wrongful, at least absent a concerted refusal by unaffiliated doctors to deal with a past malpractice plaintiff. See Williams v. St. Joseph Hosp., 629 F.2d 448, 452 (7th Cir.1980). In a market made non-competitive by a merger, it is the kind of "price increase" that is a central concern of the Sherman Act.
. The Supreme Court has indicated that it may soon resolve this conflict. See Pinhas v. Summit Health, 894 F.2d 1024, 1031-32 (9th Cir.1989), cert. granted, — U.S. —, 110 S.Ct. 3212, 110 L.Ed.2d 660 (1990).
. This does not mean that we will not impose on antitrust plaintiffs the duty to plead all facts likely to be in their possession at the time they initiate litigation or subsequently amend their complaint that show the nexus between the defendant's challenged conduct and interstate commerce. See Seglin, 769 F.2d at 1283 n. 11. Rather, as we anticipated in Seglin, "[t]here may be cases in which all facts supporting the requirement of a nexus with interstate commerce are within the defendant's exclusive knowledge." Id. In those cases, complaints like the one in this case, which do not contain a welter of factual detail but do set out a plausible theory as to how defendant's anti-competitive conduct impacted interstate commerce, may survive a motion to dismiss.