Opinion ID: 552264
Heading Depth: 3
Heading Rank: 1

Heading: Anticompetitive Acts

Text: 22 As with any antitrust case, this one turns on whether certain acts committed by the defendant were anticompetitive or tended to prevent competition on the merits. As noted above, VCA asserted that the defendants violated the antitrust laws in a variety of ways and cited a number of legal theories to support their arguments. The jury found the facts to be as claimed by the plaintiff on every count. Given the importance of the defendants' anticompetitive acts to the outcome of this case, it is useful to summarize those acts here before we discuss at length each of VCA's legal claims: (1) Venice Hospital, MPAC and the Sammett Corporation entered into a reciprocal agreement with the home health care nurses whereby the nurses would preferentially recommend MPAC in exchange for continued access to the hospital's patients; (2) The hospital changed its policy which previously allowed no DME vendors access to patients, to one which allows only one DME vendor, Bowers, access to discuss DME with patients, and the hospital could offer no efficiency justification for this change; (3) Bowers acting on behalf of the hospital and MPAC held himself out as having a position of expertise and authority in the hospital; (4) The Sammett Corporation pursued the joint venture because it wanted to eliminate a potential competitor and exclude other competitors from access to captive referrals; (5) The hospital maintained different standing order rules for home health care nurses as compared to DME suppliers and could offer no legitimate reason for the distinction; (6) The hospital and MPAC through Bowers used a default rule which automatically selected MPAC if the patient did not make a choice of DME supplier, (the home health care nurses were selected on a rotating basis); (7) The hospital used its monopoly power in the acute care field to leverage itself into the DME market with the intent to avoid competition in the DME market on the merits. 23 The fact that the hospital gave Bowers access to the patients and how that contributed to channeling patient choice requires additional clarification. The district court reviewed the evidence and concluded that the defendants had committed no actionable anticompetitive acts. Much has been said about patient choice in this case. The district court noted that the parties stipulated that the patients had the freedom to choose any DME vendor. However, a patient's freedom to choose under these circumstances may be illusory. The evidence presented in this case shows that patients rarely have a preference for a DME vendor. 5 The patients know very little about the equipment or the companies that rent the equipment. Thus, they are very susceptible to recommendations made by anyone who appears to be knowledgeable on the subject. It therefore becomes very easy to channel patient choice by limiting the patient's exposure to the competition. This the hospital accomplished principally in two ways. First, by changing its policy, it limited the home health care nurses' ability to discuss DME vendors with the patients prior to their discharge. The initial policy change following Bowers' arrival in the hospital was that he would discuss the patient's DME needs with the patient, make the DME assessment, and order the equipment. After several nurses complained, the hospital changed its policy and nurses were again allowed to make the DME assessment for their patients. The nurses were encouraged to recommend MPAC which they did because of the political climate at the hospital. 24 The hospital's second policy change was to allow one DME vendor in to solicit business from the patients. Previously it had denied vendors access to the hospital. The district court noted that the no solicitation rule was in effect before the joint venture and concluded that the rule could not constitute evidence that the defendants behaved improperly after the joint venture. 703 F.Supp. at 1518. We disagree. The change was that the hospital now allowed an exception to the rule, but only in the case of its affiliate. The evidence was uncontroverted that MPAC is a for profit business and that Bowers is an MPAC employee. Bowers has experience as a DME salesman and supervisor of salesmen. It is obvious that he was allowed to solicit business in the hospital as an MPAC salesman. The fact that the hospital made him the DME coordinator for the hospital and allowed him to wear a lab coat obscured his role insofar as patients were concerned, but highlighted the change in policy insofar as the jury was concerned. 25 Appellees claim that the antitrust laws do not compel them to grant other DME vendors access to their patients and that they have a right to deal with whomever they choose. As the Supreme Court has stated: We do not dispute that general right. 'But the word right is one of the most deceptive of pitfalls; it is so easy to slip from a qualified meaning in the premise to an unqualified one in the conclusion. Most rights are qualified.'  Lorain Journal Co. v. United States, 342 U.S. 143, 72 S.Ct. 181, 187, 96 L.Ed. 162 (1951). In Aspen Skiing Co. v. Aspen Highlands Skiing Corp., 472 U.S. 585, 105 S.Ct. 2847, 2858, 86 L.Ed.2d 467 (1985), the Supreme Court upheld liability in part because the monopolist elected to make an important change in a pattern of distribution that had originated in a competitive market and had persisted for several years. Id. Thus, Venice Hospital's decision to allow an MPAC salesman access to patients and initially limit the home health care nurses' authority to discuss patients' DME needs was a decision by a monopolist to make an important change in the character of the market. Id. The outcome in Aspen Skiing turned on whether the record supported the jury's conclusion that there were no valid business reasons for Ski Co.'s refusal to deal with a competitor. In analyzing the record, the Court noted that Ski Co. was unable to produce any efficiency justification whatever for its pattern of conduct. Id. 105 S.Ct. at 2860. Additionally, the Court found that Ski Co. had engaged in economically irrational behavior by foregoing short-run benefits and consumer goodwill in exchange for a perceived long-run impact on its smaller rival. Id. at 2861. The district court incorrectly concluded that economically irrational behavior, i.e., behavior which results in lost profits, was a necessary condition to the Court's holding. This demonstrates an unjustifiably narrow view of Aspen Skiing. The presence of economically irrational behavior made the record in that case comfortably support[ ] an inference that the monopolist made a deliberate effort to discourage its customers from doing business with its smaller rival. Id. (emphasis added). The operative question is whether the hospital can offer any efficiency reason for its behavior. Id. at 2860-61. We can find no efficiency justification in the record. We also note that as we above summarized the hospital's refusal to allow other DME vendors access is but one of several identifiable anticompetitive acts which when viewed together support the jury's findings that the defendants' actions have impaired competition in an unnecessarily restrictive way. 26 Appellees argue that since the joint venture was legitimate, any benefits that Venice Hospital, MPAC and Sammett derive from the integration is likewise legitimate. We think appellees err in leaping to this conclusion. VCA has not challenged the joint venture as such and, therefore, we have assumed the joint venture is legitimate. 6 VCA's complaint relates to the manner in which the defendants implemented the joint venture and to their intent in forming the joint venture. Our discussion here extends no further than the case presented.B. Antitrust Injury 27 Appellees claim and the district court found that VCA had failed to demonstrate that it had suffered any antitrust injury. The district court observed that the underlying policy and purpose of the antitrust laws is to protect competition and not competitors. 703 F.Supp. at 1513 (citing Cargill, Inc. v. Monfort of Colorado, Inc., 479 U.S. 104, 110, 107 S.Ct. 484, 489, 93 L.Ed.2d 427 (1986)). The district court's failure to recognize antitrust injury in this case stems from its failure to recognize the defendants' anticompetitive acts as such. As we explained above, defendants engaged in a number of anticompetitive acts which, if causally related to VCA's alleged injury, support a finding of antitrust injury. Recently the Supreme Court reaffirmed its holding in Cargill and concluded that a plaintiff must prove the existence of '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.'  Atlantic Richfield Co. v. USA Petroleum Co., --- U.S. ----, ----, 110 S.Ct. 1884, 1889, 109 L.Ed.2d 333 (1990) (quoting Brunswick Corp. v. Pueblo Bowl-O-Mat, Inc., 429 U.S. 477, 489, 97 S.Ct. 690, 698, 50 L.Ed.2d 701 (1977) (emphasis in original)). In Atlantic Richfield, a competitor sought to challenge a vertical maximum price-fixing arrangement. The Supreme Court noted that it is impossible for such a scheme to do injury to the competitor. The danger in price fixing arrangements identified in Albrecht v. Herald, 390 U.S. 145, 152-53, 88 S.Ct. 869, 873, 19 L.Ed.2d 998 (1968), is that they tend to stifle a small distributor's ability to compete with a larger distributor because the small distributor may, at the low maximum price, be unable to provide the services demanded in a competitive market. A competitor not bound by the price ceiling, the Court reasoned, could not be harmed by the price-fixing agreement. Additionally, the court noted that a competitor could not be injured by a conspiracy to fix minimum prices. A competitor can only stand to gain from a conspiracy to raise a market price. Matsushita Elec. Industrial Corp. v. Zenith Radio Corp., 475 U.S. 574, 582-83, 106 S.Ct. 1348, 1353-54, 89 L.Ed.2d 538 (1986). 28 VCA's claim suffers from none of these infirmities. VCA claims that defendants' practices have unreasonably restricted competition by channeling patient choice to defendants and by excluding all competing DME vendors' access to Venice Hospital's patients. The antitrust laws were intended to prevent unreasonably exclusionary practices. VCA's injury flows directly from that which makes the defendants' acts unlawful. Appellees claim and the district court agreed that VCA failed to show that the patients as the consumers, suffered any injury. As we discussed above, the channeling of patient choice is sufficient to show injury to consumers. The antitrust laws do not require the consumer to suffer some form of monetary damage before a defendant's anticompetitive conduct is actionable. See Aspen Skiing, 105 S.Ct. at 2859-60 (consumers injured by not having easy access to all four mountains). See also Association of General Contractors of Cal. v. California St. Council of Carpenters, 459 U.S. 519, 103 S.Ct. 897, 903, 74 L.Ed.2d 723 (1983) (Coercive activity that prevents its victims from making free choices between market alternatives is inherently destructive of competitive conditions and may be condemned even without proof of its actual market effect.). Injury to competition may be shown even though injury to the consumer is practically nonexistent. Cf. Otter Tail Power Co. v. United States, 410 U.S. 366, 93 S.Ct. 1022, 1029, 35 L.Ed.2d 359 (1973) (electric utility that dominates transmission of power in most of its service area may not use that dominance to foreclose potential entrants into the retail area from obtaining electric power from outside sources of supply); Fishman v. Estate of Wirtz, 807 F.2d 520, 536 (7th Cir.1986) (The antitrust laws are concerned with the competitive process, and their application does not depend in each particular case upon the ultimate demonstrable consumer effect.) (emphasis added). We recognize that Otter Tail Power was a civil antitrust suit brought by the government and not a private plaintiff. This does not alter the Court's conclusion that Otter Tail's exclusionary practices foreclose[d] competition. Id. This case is significant because in selecting which power company will serve an area, the consumer plays a minor, if not nonexistent, role. 29 Thus, a court must consider the effect on competition and not simply the effect on the ultimate consumer. 7 In the DME industry, because of the regulated nature of Medicare and Medicaid reimbursements, the primary means of competition is quality and service. The defendants here have knowingly and purposefully set in place a scheme which insulates the unknowing patient from learning of these nuances. Competition has been injured because there is no effective means by which competing DME vendors can reach those patients who require DME when they are discharged from the hospital. The Supreme Court has aptly stated: 30 A refusal to compete with respect to the package of services offered to customers, no less than a refusal to compete with respect to the price term of an agreement, impairs the ability of the market to advance social welfare.... Absent some countervailing procompetitive virtue--such as, for example, the creation of efficiencies in the operation of a market or the provision of goods and services--such an agreement limiting consumer choice by limiting the ordinary give and take of the market place, cannot be sustained.... 31 Federal Trade Commission v. Indiana Federation of Dentists, 476 U.S. 447, 106 S.Ct. 2009, 2018, 90 L.Ed.2d 445 (1986) (federation of dentists refused to forward certain information (X-rays) to their patients' insurance companies) (emphasis added). The Court then stated that even if the desired information were in fact completely useless to the insurers and their patients in making an informed choice ... the Federation would still not be justified in deciding on behalf of its members' customers that they did not need the information. Id. 106 S.Ct. at 2020. Elsewhere the Court has stated even if the customer is indifferent among brands of the second product and therefore loses nothing by agreeing to use the seller's brand of the second in order to get his brand of the first, such tying agreement may work significant restraints on competition in the tied product. Jefferson Parish Hosp. v. Hyde, 466 U.S. 2, 104 S.Ct. 1551, 1558 n. 19, 80 L.Ed.2d 2 (1984). Finally, we note that in Association of General Contractors, the Supreme Court concluded that the Union did not suffer antitrust injury because the Union was neither a consumer nor a competitor in the market in which trade was restrained. 103 S.Ct. at 909. The Court expressed some doubt as to whether the Union's goal was robust competition. Id. In the instant case, the plaintiff is a competitor in the market in which trade was restrained and VCA's injury is inextricably intertwined with the injury which the conspirators imposed on the DME consumers. Blue Shield of Virginia v. McCready, 457 U.S. 465, 484, 102 S.Ct. 2540, 2551, 73 L.Ed.2d 149 (1982). We have no difficulty concluding as did the jury that VCA suffered an injury of the type the antitrust laws were intended to prevent and that flows from that which makes the defendants' acts unlawful. --- U.S. at ----, 110 S.Ct. at 1889. We now turn to VCA's claims under Sections 1 and 2 of the Sherman Act and under state law for tortious interference with VCA's business relations. C. Section 1 Conspiracy 32 VCA argues that the jury verdict on its Section 1 claim was proper because it presented substantial evidence in support of its contention that the defendants entered into a reciprocal agreement with one or more of the home health agencies whereby the home health care nurses would continue to have access to patients prior to discharge in exchange for the nurses preferentially referring their patients to MPAC. The district court analyzed this reciprocal agreement as a tying case and concluded that VCA had failed to prove that Venice Hospital's condition for continued access to the hospital reached the level of a mandatory requirement. 703 F.Supp. at 1517. The court relied on Bob Maxfield, Inc. v. American Motors Corp., 637 F.2d 1033 (5th Cir.), cert. denied, 454 U.S. 860, 102 S.Ct. 315, 70 L.Ed.2d 158 (1981), a former Fifth Circuit tying case and held that defendant's behavior, as a matter of law, was not unlawfully coercive. Id. While reciprocal dealing as an antitrust violation has significant conceptual similarity to tying, we conclude that the district court erred by applying the strict tying standard for coercion to this reciprocal dealing case. 33 Reciprocal dealing has received little attention in the courts; however, when the subject has arisen, courts have not hesitated to condemn the practice. In a tying arrangement, a seller uses its power in the market for product A to coerce the buyer of product A to purchase product B. But [a] reciprocal dealing arrangement exists when the two parties face each other as both buyer and seller. Spartan Grain & Mill Co. v. Ayers, 581 F.2d 419, 424 (5th Cir.1978). The buyer of product A offers to buy from the other party, but only if that second party will buy product B from the first party. A typical example is where a producer of aluminum ingot sells to a manufacturer who uses the ingot to manufacture equipment used to produce the ingot. See L. Sullivan, Antitrust Sec. 170 at 490 (1977). In Spartan Mills, the court noted that reciprocal dealing cases were similar to tying cases since [i]n each case one side of a transaction has special power in the market place, and observed that [i]n reciprocal dealings a buyer with economic power forces a seller to buy something from it to sell its goods. 581 F.2d at 425. It is clear that such coercive conduct is sufficient to run afoul of the Sherman Act; however, it is equally clear that [r]eciprocal trading may ensue not from bludgeoning or coercion but from more subtle arrangements. A threatened withdrawal of orders if products of an affiliate cease being bought, as well as a conditioning of future purchases on the receipt of orders for products of that affiliate is an anti-competitive practice. Federal Trade Commission v. Consolidated Foods Corp., 380 U.S. 592, 85 S.Ct. 1220, 1222, 14 L.Ed.2d 95 (1965) (concerning potential for reciprocal dealing as basis to challenge merger). In the context of an alleged tying claim, the Supreme Court has stated: 34 This type of market power has sometimes been referred to as leverage. Professors Areeda and Turner provide a definition that suits present purposes. Leverage is loosely defined here as a supplier's power to induce his customer for one product to buy a second product from him that would not otherwise be purchased solely on the merit of that second product. 5 P. Areeda & D. Turner, Antitrust Law p 1134a, p. 202 (1980). 35 Jefferson Parish Hosp. v. Hyde, 466 U.S. 2, 104 S.Ct. 1551, 1559 n. 20, 80 L.Ed.2d 2 (1984) (emphasis added). The word induce clearly contemplates conduct short of an absolute command. The commentators take this a step further. One has concluded that, [w]e ought to have no compunction about inhibiting a firm from buying from a customer if it does so not because it regards the customer's offering as best, but because it sees this transaction as a way to bind the customer to it as a customer. L. Sullivan, supra at 494. Sullivan observes: 36 it may in some cases be possible to identify reciprocity as the motive for a transaction with considerable assurance ... and if [a] firm then begins systematically switching its purchases from sellers who could not also be buyers from it to firms which could, we ought not to hesitate to label the purchases as being made from a reciprocal motive. 37 Id. at 494-95. See Betaseed, Inc. v. U and I, Inc., 681 F.2d 1203, 1216-17 (9th Cir.1982) (applying per se rule to coercive reciprocity, but recognizing that [t]he spectrum of the practice ... extends from the use of overt coercion to the use of a mutual patronage arrangement); United States v. General Dynamics Corp., 258 F.Supp. 36, 57 (S.D.N.Y.1966) (reciprocity, whether mutual or coercive, serves to exclude competitors). 38 In the instant case VCA has relied on a theory of coercive reciprocity to support its Section 1 conspiracy claim. The arrangement in this case does not fit precisely the contours of either a classic tying or a reciprocal arrangement; however, the court instructed the jury on the basis of VCA's reciprocal dealing claim and no party objected. Since we find that the arrangement between defendants and the home health agencies has sufficient elements of a reciprocal arrangement, we analyze the evidence VCA presented to support its claim under the law governing such arrangements. Additionally, we do not think it necessary to divide reciprocity cases into two categories; i.e. coercive and mutual. An antitrust plaintiff may succeed on a claim of coerced reciprocity even if the coercion involved in the case does not rise to the level required for per se treatment. See Spartan Grain, 581 F.2d at 425; Betaseed, 681 F.2d at 1217. If the element of coercion necessary for per se treatment is not present, a court will analyze the case under the rule of reason. 581 F.2d at 425 n. 6. Therefore, we conclude that where a plaintiff's evidence shows that one party has sufficient market power to unduly influence a second party to treat the first more favorably than the free market would otherwise dictate, and the second party acts in conformity with the reciprocal arrangement, the plaintiff has proved the existence of an arrangement which unreasonably restrains trade. Cf. Spartan Grain & Mill Co. v. Ayers, 735 F.2d 1284, 1288 (11th Cir.1984) (appeal after remand) (jury must find that defendant had an economic advantage in the tying product market which could be used to induce or coerce the victim to accept the tied product). Heightened scrutiny is justified in the instant case since we are confronted with a conspiracy. 39 Section 1 of the Sherman Act, in contrast, reaches unreasonable restraints of trade.... Concerted activity subject to Sec. 1 is judged more sternly than unilateral activity under Sec. 2.... Whatever form the inquiry takes, however, it is not necessary to prove that concerted activity threatens monopolization. 40 The reason Congress treated concerted behavior more strictly than unilateral behavior is readily appreciated. Concerted activity inherently is fraught with anticompetitive risk. It deprives the marketplace of the independent centers of decisionmaking that competition assumes and demands.... Of course, such mergings of resources may well lead to efficiencies that benefit consumers, but their anticompetitive potential is sufficient to warrant scrutiny even in the absence of incipient monopoly. 41 Copperweld Corp. v. Independence Tube Corp., 467 U.S. 752, 104 S.Ct. 2731, 2740, 81 L.Ed.2d 628 (1984). To recover on its Section 1 claim, a plaintiff must also show that it suffered an antitrust injury which is causally related to the challenged conduct. This aspect has already been addressed. 42 The district court concluded that the home health care nurses lost none of their autonomy to select any DME supplier. 703 F.Supp. at 1517. We disagree and have no difficulty concluding that VCA presented sufficient evidence to support the jury's finding that a reciprocal arrangement existed between those defendants checked on the interrogatory and at least one home health care agency. While only one of the home health care nurses admitted she felt leveraged, several others stated that they thought it best to cooperate. All nurses who testified stated that they were aware that the hospital was considering an exclusive arrangement with one of the home health agencies. The testimony of all the home health care nurses indicated that VCA was superior to MPAC in quality and service and that they recommended VCA to most of their patients. VCA's superiority did not change, yet the nurses started recommending MPAC in lieu of VCA. Plaintiff placed in evidence a memo from a former senior vice president of the hospital to the social services director instructing her to refer all patients to these hospital affiliated organizations unless the attending physician specifically refers the patient to a different supplier. Following the joint venture, the hospital initially instituted a policy which substantially curtailed the nurses' opportunity to discuss with a patient his or her DME needs; i.e., perform a DME assessment. However, after several of the nurses complained, the nurses were again allowed to perform a patient's assessment. The plaintiffs presented uncontroverted evidence that VCA's business started to decline immediately after the joint venture went into effect. It bears noting that MPAC had been in the Venice market for some time prior to that, during which time VCA suffered no appreciable change in market share. 43 While no individual piece of the evidence presented may be sufficient to support the jury's finding, when viewed as a whole the evidence reasonably supports the inference that because of a possible threat to their job security and in response to the hospital's solicitations, the home health care nurses preferentially recommended MPAC over other competing DME vendors. That the nurses did not testify that they were coerced is not essential to VCA's claim, nor is it surprising as many of these nurses must have access to the hospital to survive. We do not here attempt to guess what the jury may have relied upon to reach its decision, we merely note that the element of coercion which the district court found so lacking in this case may have been apparent to the jury. Contrary to the district court, we find supportive of the jury's finding a reciprocal arrangement that the home health care nurses were in part motivated by their own self interest. 44 In its opinion, the district court did not discuss the jury's finding that defendants Venice Hospital, MPAC and the Sammett Corporation were participants in the conspiracy; however, since appellees here contend that the evidence was insufficient on this element, we will address their concern. We are aware of the Supreme Court's recent admonition that the plaintiff must show that the conspiracy is economically reasonable and must present evidence which tends to exclude the possibility that the manufacturer and nonterminated distributor[ ] [were] acting independently. Matsushita Elec. v. Zenith Radio Corp., 475 U.S. 574, 106 S.Ct. 1348, 1356, 89 L.Ed.2d 538 (1986); Delong Equip. v. Washington Mills Abrasive Co., 887 F.2d 1499, 1508 (11th Cir.1989). We conclude that the evidence of each defendant's participation in the conspiracy meets that test and is sufficient to support the jury's verdict. The actions taken by the conspirators was to their mutual benefit. Direct evidence of each defendant's knowing participation is not required, instead it may be established through proof of surrounding circumstances. United States v. Socony-Vacuum Oil Co., 310 U.S. 150, 252-54, 60 S.Ct. 811, 858, 84 L.Ed. 1129 (1940); Bolt v. Halifax Hosp. Medical Center, 891 F.2d 810 (11th Cir.1990). Additionally, a conspiracy need not be express or formally agreed upon. Halifax Hosp., 891 F.2d at 810; Gainesville Utilities v. Florida Power & Light, 573 F.2d 292, 301 (5th Cir.1978). The result in Gainesville Utilities was supported by the finding that concerted action was contemplated and invited. 573 F.2d at 301 (quoting Interstate Circuit v. United States, 306 U.S. 208, 226, 59 S.Ct. 467, 474, 83 L.Ed. 610 (1939)). 45 The hospital made it known to the home health care nurses that they were to recommend MPAC. The hospital was responsible for creating a climate where the nurses felt it necessary because of the political climate to ingratiate themselves to the hospital. The hospital invited concerted action and the home health care nurses cooperated. The hospital, predictably, graciously accepted the nurses' cooperation. MPAC was involved through the participation of its agent Bowers who was positioned to receive the orders from the patients or nurses which in the absence of the reciprocal arrangement would have been placed in a competitive market. He was aware of the hospital's policies regarding the home health care nurses and of the change in policy which allowed him, a representative and employee of MPAC, to solicit business in the hospital when no other DME representative was allowed such access. The Sammett Corporation entered this arrangement intent on eliminating competition. The trial court instructed the jury on the requirements for a finding of knowing participation in a conspiracy. In closing argument, attorneys for MPAC and Sammett argued that the plaintiffs had failed to prove knowing participation in a conspiracy with the home health care nurses. Nevertheless, the jury found that the above named defendants participated in the conspiracy with the nurses and each other. 46 It is axiomatic that members of a conspiracy need not be aware of, or consent to each act committed in furtherance of the conspiracy to be held liable as a co-conspirator. United States v. Walker, 720 F.2d 1527, 1538-39 (11th Cir.1983) (evidence sufficient to support conviction for conspiracy to distribute narcotics). See Socony-Vacuum, 310 U.S. at 253-54, 60 S.Ct. at 858 (an overt act of one partner may be the overt act of all without any new agreement specifically directed to that act). The evidence recited in preceding paragraphs is but a part of the anti-competitive conduct in which these defendants engaged. We have already discussed other anticompetitive acts, supra. Appellees would have this court analyze each of VCA's claims as if they were completely separate lawsuits. Their suggested approach would be improper. When analyzing the evidence as to whether it supports a finding of conspiracy, the Supreme Court has stated: 47 [P]laintiffs should be given the full benefit of their proof without tightly compartmentalizing the various factual components and wiping the slate clean after scrutiny of each. ... [T]he character and effect of a conspiracy are not to be judged by dismembering it and viewing its separate parts, but only by looking at it as a whole.... [A]nd in a case like the one before us, the duty of the jury was to look at the whole picture and not merely at the individual figures in it. 48 Continental Ore Co. v. Union Carbide & Carbon Corp., 370 U.S. 690, 82 S.Ct. 1404, 1410, 8 L.Ed.2d 777 (1962) (quoting American Tobacco Co. v. United States, 147 F.2d 93, 106 (6th Cir.1944)) (citations omitted). 8 We conclude that VCA has presented sufficient substantial evidence to support the jury's finding that the defendants and at least one home health agency entered into a reciprocal agreement which had the effect of excluding VCA from having access to patients discharged from Venice Hospital. D. Section 2 Conspiracy 49 Conspiracy to monopolize under Section 2 is somewhat different from its Section 1 counterpart and requires: (1) concerted action by knowing participants who have specific intent to achieve a monopoly; and (2) the commission of at least some overt act in furtherance of the conspiracy. L. Sullivan, supra, Sec. 49 at 132. Unlike attempt to monopolize under Section 2, a plaintiff alleging a conspiracy to monopolize need not prove that the conspiracy has a dangerous probability of success. International Distribution Centers, Inc. v. Walsh Trucking, 812 F.2d 786, 795-96 & n. 8 (2nd Cir.1987). See 3 Von Kalinowski, Antitrust Laws and Trade Regulation Sec. 9.02 at 9-35 (1986). Cf. American Tobacco Co. v. United States, 328 U.S. 781, 789, 66 S.Ct. 1125, 1129, 90 L.Ed. 1575 (1946) (conviction for conspiracy to monopolize may stand even if conspirators had not acquired the power to carry out the object of the conspiracy). 50 In Matsushita, the Supreme Court emphasized that conduct as consistent with permissible competition as with illegal conspiracy does not, standing alone, support an inference of antitrust conspiracy. 106 S.Ct. at 1356. The Court also reaffirmed that courts should not permit factfinders to infer conspiracies when such inferences are implausible. 106 S.Ct. at 1359. In Matsushita, the plaintiffs had alleged a conspiracy to engage in predatory pricing; however, the plaintiffs also alleged that the predation period was to have extended over a period of twenty years. Id. Predatory pricing typically involves pricing below some measure of cost which the competition cannot meet for a period of time until the competition is driven out of business. Once the competition is gone, the surviving firm can charge supercompetitive prices, recoup its short term losses and reap monopoly profits. Id. at 1357-59. The Court observed that a conspiracy to engage in predatory pricing is unlikely because of problems in coordination and policing. The Court concluded that it was simply implausible that the firms would sustain losses for two decades in the hope that they may at some future time recoup their losses and reap monopoly profits. Id. 51 In the instant case, the jury found that Venice Hospital, MPAC and Sammett had specific intent to monopolize the DME market in the Venice area. Unlike the scheme in Matsushita, the conspiracy alleged here is most plausible. In its simplest form, the defendants have conspired to monopolize the DME market by adopting policies which exclude competing DME vendors, by unduly influencing the home health care nurses to preferentially recommend MPAC over competing DME vendors, and by using the hospital's market power in the acute care market to gain an unfair advantage in the DME market. Conspirators are unlikely to broadcast their unlawful intent; thus, specific intent to monopolize must often be inferred from a defendant's acts. L. Sullivan, supra, Sec. 51 at 135. In the instant case, we conclude that the defendants' acts when viewed as a whole support an inference that the defendants had specific intent to monopolize. The jury's finding that defendants engaged in a conspiracy to monopolize was supported by substantial evidence. E. Attempt to Monopolize 52 To succeed on its claim that MPAC attempted to monopolize the DME market, VCA's evidence must show that (1) MPAC had specific intent to monopolize the DME market and (2) MPAC had a dangerous probability of success. Lorain Journal Co. v. United States, 342 U.S. 143, 72 S.Ct. 181, 186, 96 L.Ed. 162 (1951); Sulmeyer v. Coca Cola Co., 515 F.2d 835, 850-51 (5th Cir.1975). Dangerous probability has not always been a separate and distinct element of an attempt to monopolize claim. See American Tobacco Co. v. United States, 328 U.S. 781, 785, 66 S.Ct. 1125, 1127, 90 L.Ed. 1575 (1946); Swift & Co. v. United States, 196 U.S. 375, 396, 25 S.Ct. 276, 279, 49 L.Ed. 518 (1905). However, dangerous probability has come to serve as a sort of protective feature which shields what may be only intensely competitive conduct from liability under the antitrust laws. Handler, Reforming the Antitrust Laws, 82 Colum.L.Rev. 1287, 1352-53 (1982). A dangerous probability of success might be found when the defendant's market strength approaches monopoly power. Other factors to consider are the relative strength of the defendant's competitors and whether significant barriers to entry exist. White & White, Inc. v. American Hosp. Supply Corp., 723 F.2d 495, 506-07 (6th Cir.1983). 53 Dangerous probability of success is the only primary element necessary to this claim which we have not previously discussed. The judge instructed the jury that [a] dangerous probability of success need not mean the success was nearly certain. It means that the chance of success was substantial and real. That is, that there was a reasonable likelihood that the defendant MPAC would ultimately achieve its goal of monopoly power. As noted above, the relevant market and defendant's market share are inter-related to whether the defendant has a dangerous probability of success. To support an attempt to monopolize claim, a plaintiff must present evidence of the relevant product and geographic markets and evidence which shows that the defendant's conduct had an anti-competitive effect in those markets. American Key Corp. v. Cole Nat. Corp., 762 F.2d 1569, 1579 (11th Cir.1985). The plaintiff's expert witness Dr. Blair testified extensively as to the relevant geographic and product markets and as to the defendant's share of the DME referrals from Venice Hospital and from the rest of the relevant market. The defendant's expert also testified at length and offered his version of the market definitions and market shares which differed from plaintiff's expert. The district court did not disturb the jury's explicit and implicit findings as to product and geographic markets and as to market shares. Defendant asserts that Dr. Blair's version is incorrect and cites only its expert's testimony to support its position; MPAC, however, offered no substantive basis for the claim that their expert's testimony was more trustworthy. The jury was correctly instructed on the use of expert testimony and was free to accept or reject any or all of either expert's testimony. Apparently they found Dr. Blair's testimony more convincing. 54 Dr. Blair's testimony supports a finding that MPAC captured 39% of the total area DME market simply by capturing a large percentage of Venice Hospital's referrals. His testimony also supports a finding that Venice Hospital represents at least 46% of the total DME market in the Venice area. The evidence also showed that over a two-year period, starting just before the joint venture went into effect, MPAC's total area market share rose from 9.2% to 61%. Plaintiff also presented evidence that shows that the challenged practices have had an adverse effect on other competitors in the market; one other DME vendor has gone out of business and another's demise appears imminent. The remaining competitors are small in comparison to VCA which in 1987 retained 30% of the market. In a section on vertical mergers, Professor Sullivan has identified another factor we think relevant in this case. He refers to it as the need for integrated entry. L. Sullivan, supra, Sec. 210 at 659. Generally, it involves the notion that the linking of two firms at different levels in the market may reduce the likelihood of independent entry at either level. The instant case provides an excellent example. Venice Hospital and MPAC are currently linked. MPAC has practically guaranteed itself half the DME market in Venice area simply by capturing Venice Hospital's referrals. Any DME vendor contemplating whether to open a business in the Venice area will have difficulty competing with MPAC because MPAC is linked to the largest DME source in the market. This creates circumstances where it is necessary for a new competitor who wishes to enter the market, to be similarly integrated; that is, it must also have a large guaranteed referral source. Notably, one Sarasota DME vendor who attempted to break into the Venice DME market testified that he could not get a toehold in Venice because MPAC had locked up the market by affiliating with the hospital. The evidence recited above is sufficient to support the jury's finding that MPAC attempted to monopolize the Venice DME market because it demonstrates defendant's intent to monopolize and that it had a dangerous probability of success. 55 F. Monopoly Leveraging as an Attempt to Monopolize 56 In its simplest form, a firm is guilty of monopoly leveraging if it uses market power in one market to gain market share in another market other than by competitive means. Berkey Photo, Inc. v. Eastman Kodak Co., 603 F.2d 263, 276 (2d Cir.1979) (the use of monopoly power attained in one market to gain a competitive advantage in another is a violation of Sec. 2, even if there has not been an attempt to monopolize the second market). This doctrine is limited by the view that a large firm does not violate Sec. 2 simply by reaping the competitive rewards attributable to its efficient size, nor does an integrated business offend the Sherman Act whenever one of its departments benefits from association with a division possessing a monopoly in its own market. Id. 57 This theory has been embraced by the Sixth Circuit in Kerasotes Mich. Theatres v. National Amusements, 854 F.2d 135, 136-37 (6th Cir.1988), and specifically reaffirmed by the Second Circuit in GrandLight & Supply Co. v. Honeywell, Inc., 771 F.2d 672, 681 (2d Cir.1985). Both the D.C. Circuit and the Ninth Circuit have expressly reserved judgment for a case that squarely raises the issue. See Catlin v. Washington Energy Co., 791 F.2d 1343, 1346 (9th Cir.1986); Association for Intercollegiate Athletics for Women v. NCAA, 735 F.2d 577, 586 n. 14 (D.C.Cir.1984). In Grandlight, the court summarized the requirements for liability as follows: monopoly power in one market; the use of that power, however lawfully acquired, to foreclose competition, to gain a competitive advantage, or to destroy a competitor in another distinct market; and injury caused by the challenged conduct. 771 F.2d at 681 (citations and quotations omitted). The Sixth Circuit has concluded that 58 while the alleged agreement between [defendant] and its film distributors is vertical, the effect is exclusively horizontal. The sole purpose for such an agreement is to extend a business' dominance from one market into a second market, without having to achieve that dominance in the second market by developing a superior product or as the result of other legitimate competitive advantages. 59 Kerasotes, 854 F.2d at 137. 60 There exist plausible business reasons for the hospital's desire to enter the DME market and the jury might have concluded that Venice Hospital and MPAC are simply reaping the rewards of integration. The jury, however, concluded otherwise. When we scrutinize the hospital's means of implementation in light of all the circumstances present in this case, we have no difficulty concluding Venice Hospital purposefully abused its monopoly power in the acute care market to exclude MPAC's competitors from a significant and perhaps essential segment of the DME market in the Venice area. 61 Appellees contend that monopoly leveraging is not a separate offense under Section 2. While we harbour some reservation about the Second Circuit's conclusion that no attempt to monopolize the leveraged market need be proved, that aspect of the monopoly leveraging theory is not problematic in this case. The judge charged the jury in part as follows: 62 In order to win on this claim the plaintiff must have proved each of the following elements by a preponderance of the evidence. 63 First, that the defendant Venice Hospital had monopoly power in the primary hospital services market as alleged. Second, that the defendant Venice Hospital willfully used that power to foreclose competition, gain a competitive advantage or destroy a competitor in a different market. And third, that plaintiff was injured in its business or property because of defendant's conduct. 64 In explaining the means by which plaintiff could prove willful use of monopoly power the judge stated that plaintiff 65 may do so by showing that the defendant Venice Hospital's conscious objective was to use its monopoly power in primary hospital services to obtain an unlawful competitive advantage or to injure its competitors and competition in the Durable Medical Equipment market. 66 Second, it may do so by showing that the unlawful competitive advantage or injury to competitors in the Durable Medical Equipment market was the necessary and direct consequence of defendant Venice Hospital's conduct or business arrangements. 67 In effect, the jury was charged on attempted monopolization. See Catlin, 791 F.2d at 1349. The only element arguably missing from this charge is the requisite specific intent to monopolize required under traditional Section 2 attempt claims. We need not now decide whether this would be fatal to plaintiff's monopoly leveraging claim since under the count for conspiracy to monopolize, the jury found that Venice Hospital had specific intent to monopolize the DME market. All the other elements of an attempt to monopolize under Section 2 are present in this case. The key to distinguishing unlawful monopoly leveraging from lawful competitive advantage available as a result of integration is intent. There is ample evidence--other than the mere fact that Venice Hospital through the joint venture expanded into a related field--which shows that this tack was taken with the unlawful intent to monopolize the DME market. In a different context, nevertheless applicable here, the Supreme Court held that [i]n the absence of any purpose to create or maintain a monopoly, the act does not restrict the long recognized right of a party to deal with whomever he chooses. Lorain Journal, 72 S.Ct. at 187. The Court observed that [t]he right claimed by the publisher is neither absolute nor exempt from regulation. Its exercise as a purposeful means of monopolizing interstate commerce is prohibited by the Sherman Act. Id. So it is here. Generally speaking a party with a lawful monopoly may reap the benefits of its size and an integrated firm may reap the benefits of that integration. However, when a party with monopoly power abuses its monopoly power in one market as a means of gaining an unlawful competitive advantage in and monopolizing another market, we have no hesitation to conclude that the Sherman Act prohibits such conduct. See Otter Tail Power, 93 S.Ct. at 1029 (Use of monopoly power to destroy threatened competition is a violation of the attempt to monopolize clause of Sec. 2 of the Sherman Act.). We conclude therefore that there is ample evidence which supports the jury's finding that Venice Hospital engaged in unlawful monopoly leveraging. 68