Court Opinion

ID: 72647
Source: CourtListenerOpinion
Date Created: 2010-04-26 07:38:21+00
Date Added: 2024-06-11T14:58:43.108395
License: Public Domain

United States Court of Appeals,

                                        Eleventh Circuit.

                                     Nos. 95-4714, 95-5218.

 ALL CARE NURSING SERVICE, INC., Benson Health Care Services, Inc., et. al., Plaintiffs-
Appellees,

                                                v.

               HIGH TECH STAFFING SERVICES, INC., Defendant-Appellant.

                  ALL CARE NURSING SERVICE, INC., Plaintiff-Appellant,

A Complete Health Service, Inc., Quality Professional Nursing, Inc., et al., Plaintiffs-Appellants,

                         Julie Monahan, Counter-Defendant-Appellant,

                                                v.

   BETHESDA MEMORIAL HOSPITAL, INC., NME Hospitals, Inc., et. al., Defendants-
Appellees,

            High Tech Staffing Services, Inc., Defendant-Appellant-Cross-Appellee.

                                          Feb. 18, 1998.

Appeals from the United States District Court for the Southern District of Florida. (No. 88-8568-
CIV-JCP), James C. Paine, Judge.

Before EDMONDSON and BARKETT, Circuit Judges, and WELLFORD*, Senior Circuit Judge.

       EDMONDSON, Circuit Judge:

       Two separate actions (with different plaintiffs) against the same defendants for alleged

antitrust violations have been consolidated and are treated as one appeal. Plaintiffs appeal a jury

verdict for defendants on antitrust claims. They also appeal the jury verdict against them on

counterclaims for state and federal RICO violations. Many issues were raised on appeal. But we

   *
    Honorable Harry W. Wellford, Senior U.S. Circuit Judge Sixth Circuit, sitting by
designation.
conclude that most of the challenges obviously lack merit, and we do not discuss them in this

opinion. We do discuss a couple of issues in some detail, and we affirm the district courts'

judgments.

                                             Background

       Beginning in the mid-1980's the United States experienced a severe nursing shortage.

Southern Florida was hit especially hard due to its increased demand for nurses in winter months

to accommodate the high influx of people to the area at that time of year. This shortage, along with

other market considerations, caused an increase in prices for nursing services and a difficulty in

staffing hospitals (and other facilities) with sufficiently licensed nurses.1

       Hospitals use full or part-time hospital nurses, contract nurses (nurses hired for a specified

period of time), travel nurses (contract nurses hired from different areas of the country), and

temporary nurses (nurses employed by agencies and hired by hospitals for a shift at a time).2

Temporary nursing agencies send their nurses to hospitals, nursing homes, clinics, doctors' offices,

and patients' homes. They have the choice to provide services for any facility or person in need of

such care. They are not limited to providing nurses to hospitals.

       During the pertinent period, hospitals were faced with quality concerns, as well as rising

prices. No efficient means existed to share information with other hospitals about agency nurses.

This lack of information resulted in problems with some agencies, including plaintiff-appellant All

   1
   Nurse qualifications fall into at least three different licensing categories: Registered Nurse
(RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA).
   2
   These temporary nursing agencies are also providers of travel and contract nurses to
hospitals.
Care Nursing Services, Inc. ("All Care").3 These problems included "phantom booking"—where

a hospital requests a specific nurse with whom it has dealt in the past, only to be sent a different

nurse; "blind booking"—where a hospital sets up to receive the services of a nurse from an agency

only to have the agency cancel at the last minute; fraudulent billing—billing hospitals for services

of an RN when actually a less qualified LPN or CNA performed the services; cheating on

certification exams; and altering certification documents.

       In response to the problems the South Florida Hospital Association ("SFHA") approached

hospitals in Palm Beach County about a potential purchasing arrangement. In 1988, twelve (12)

Palm Beach County hospitals set up an arrangement whereby they would solicit bids from temporary

nursing agencies and would then select agencies to be preferred providers of such services, the

Preferred Provider Program ("PPP"). The selection of the preferred agencies was to be made based

upon competence, services provided, quality, and bid price. Under this joint-buying arrangement

all the participating hospitals agreed to seek first nurses from preferred providers before going to

nonpreferred agencies for nurses on each occasion.

       All agencies were invited, either by letter or by advertisement in the Palm Beach newspaper

(Palm Beach Post ), to participate in the bidding. Sixteen (16) agencies presented bids and eight (8)

were selected as preferred.4

   3
    The problems described formed the basis of the counterclaim against All Care and Monahan
for federal and state RICO violations.
   4
    Some of the appellant agencies participated in the bidding process, others did not. Following
the submission of the initial bids four (4) agencies were eliminated based on their bid prices,
which in some instances were 50% higher than other agencies' bids. The remaining twelve (12)
rebid and were considered using the established criteria. Which agencies actually resubmitted
bids is unclear. But, all of the accepted agencies bid prices higher than the price ranges
suggested by the SFHA in its invitation to bid. None of the appellants was selected as preferred
providers.
       In November 1988, the PPP began operation. Each hospital entered into individual contracts

with each of the preferred agencies. All the agencies selected as preferred providers were required

to agree to things like treating their nurses as employees by providing workers' compensation,

paying taxes, and providing necessary insurance. Before the PPP, agencies had treated their nurses

as independent contractors, not employees; and the higher costs associated with unprotected

workers were borne by the hospitals.5

       The preferred agencies did not contract with the hospitals at the same prices, but instead at

the prices that each particular agency had bid. Agencies were also required to agree in the contracts

not to change their prices for one year—the length of each contract—and, thus, were somewhat tied

into their bid prices. But to allow for shifts due to market changes, each agency could terminate its

contract with a particular hospital upon 30 days notice (the "escape clause").

       After the creation of the PPP, plaintiffs-appellants filed suit against the participating

hospitals, preferred agencies, and the SFHA6 alleging antitrust violations under sections 1 and 2 of

the Sherman Act, 15 U.S.C. §§ 1, 2, and under Florida Statutes §§ 542.18 and 542.19. Defendants

then filed a counterclaim against All Care, and its operator Monahan, for violations of federal and

state RICO statutes by billing fraudulently, aiding cheating on certification exams, and aiding

   5
    The hospitals felt the need to place some of the financial burden on the agencies because
after the bidding, agency services were actually costing more than before the PPP. These
contract provisions were a way to shift some of the cost back to the agencies.
   6
   Plaintiffs-appellants include: All Care Nursing Services, Inc.; A Complete Health Care
Services, Inc.; Benson's Health Care Services, Inc.; Critical Health Care, Inc.; Quality
Professional Nursing of Florida, Inc.; and P.D.Q. Nurse, Inc.

               Defendants-appellees include the SFHA, twelve (12) Palm Beach County
       hospitals, and four (4) remaining agency defendants (four (4) agencies settled with
       plaintiffs before final disposition in the district court).
persons to obtain false certification.7

       Awaiting trial, plaintiffs-appellants sought and received a preliminary injunction, which

halted implementation of the PPP. That preliminary injunction, however, was vacated by this court

because of the district court's failure to hold the necessary evidentiary hearing. All Care Nursing

Serv., Inc. v. Bethesda Memorial Hosp., Inc., 887 F.2d 1535 (11th Cir.1989). The request for an

injunction was never reinstated.

       After a four-week jury trial, a verdict was entered in favor of defendants on all relevant

claims. Plaintiffs filed motions for new trial, for judgment as a matter of law, and for amendment

of the pleadings to conform with the evidence. All these motions were denied by the district court;

and we now affirm those denials.8 Plaintiffs-appellants also appeal the antitrust and RICO

counterclaim verdicts against them; but we affirm those judgments, too.

                                            Discussion

I. Federal and State RICO Claims

        Plaintiffs-appellants All Care and Monahan argue that the Florida and Federal RICO claims

against them are barred by the economic-loss rule. That rule provides that "parties to a contract can

only seek tort damages if conduct occurs that establishes a tort distinguishable from or independent

of [the] breach of contract." Jones v. Childers, 18 F.3d 899, 904 (11th Cir.1994) (citations and

quotations omitted). The rule is based upon the idea that "contract principles are more appropriate

than tort principles for resolving economic loss claims."         Florida Power & Light Co. v.

Westinghouse Elec. Corp., 510 So.2d 899, 901 (Fla.1987).

   7
   Claims of fraud, civil theft, and false representation against All Care and Monahan were
dismissed before trial.
   8
   Also affirmed is the district court's decision in the bench trial of Defendant High Tech's
Lanham Act counterclaim.
        Neither All Care nor Monahan can use the economic-loss rule to escape liability under the

federal RICO statutes.9 We have already ruled that Florida's economic-loss rule does not bar a

plaintiff from "bringing a [federal] RICO action where a breach of contract claim also exists ....

many RICO cases involve contract disputes." Arabian American Oil Co. v. Scarfone, 939 F.2d

1472, 1478 (11th Cir.1991).

        About the state RICO claims, Florida's RICO statutes have consistently been interpreted

using federal RICO claims cases. No reason has been presented to us to justify applying the

economic-loss rule differently to RICO claims made under state and federal RICO statutes.10 Thus,

the economic-loss rule does not bar these claims.

II. Antitrust Claims

        Plaintiffs-appellants argue that the formation and operation of the Palm Beach County PPP

is a violation of the antitrust laws of the Sherman Act and Florida Statutes §§ 542.18 and 542.19,11

   9
    Defendants argue that Monahan cannot be afforded the benefit of the economic-loss rule
because she, individually, entered into no contract with the defendant hospitals: she lacked
privity of contract. All contracts were between her agency, All Care, and the hospitals. Because
we conclude that the economic-loss rule does not bar RICO claims, state or federal, we need not
decide this question. But, the Florida Supreme Court has held, at least under one set of facts,
that privity is not required for the economic-loss rule to apply. See Casa Clara Condominium
Ass'n v. Charley Toppino and Sons, Inc., 620 So.2d 1244 (Fla.1993); see also Hoseline, Inc. v.
U.S.A. Diversified Products, Inc., 40 F.3d 1198, 1200 (11th Cir.1994) (where this court applied
Casa Clara to make "meritless" a claim that the rule does not bar tort claims between parties
who lack contractual privity).
   10
     Plaintiffs-appellants also challenged the RICO counterclaims on another ground: that
reliance on the alleged misrepresentations made by All Care and Monahan was not proved by
defendants. Reliance is only an element of a RICO claim to the extent that a RICO plaintiff must
prove he was injured by reason of the RICO defendant's deception and fraud. Pelletier v.
Zweifel, 921 F.2d 1465, 1499 (11th Cir.1991). But, no argument is made by the
plaintiffs-appellants that injury was inadequately shown. So, lack of reliance does not require
reversal on this claim.
   11
    Federal and Florida antitrust laws are analyzed under the same rules and case law. Fla. Stat.
§ 542.32 ("It is the intent of the Legislature that, in construing this chapter, due consideration
prohibiting restraints on trade. The Sherman Act, in relevant part, sets out these rules:

       Section 1: Every contract, combination in the form oftrust or otherwise, or conspiracy, in
       restraint of trade or commerce among the several States, or with foreign nations, is hereby
       declared to be illegal....

       Section 2: Every person who shall monopolize, or attempt to monopolize, or combine or
       conspire ... to monopolize ... shall be deemed guilty of a felony.

15 U.S.C. § 1; 15 U.S.C. § 2.

        Despite the expansive language of the statute, the Supreme Court has interpreted this statute

to prohibit only "unreasonable" restraints on trade. "A restraint may be violative of the Sherman Act

because it is solely a naked restraint of trade so offensive to competition as to be unreasonable per

se, or because it runs afoul of the more detailed rule of reason inquiry." Retina Assocs., P.A. v.

Southern Baptist Hosp. of Florida, Inc., 105 F.3d 1376, 1380 (11th Cir.1997).

        Some acts have been said to be so facially anticompetitive that by their very nature they are

deemed unreasonable and, thus, per se violative of antitrust laws. These "practices are "so plainly

anticompetitive,' and so often "lack ... any redeeming virtue,' that they are conclusively presumed

illegal without further examination under the rule of reason...." Broadcast Music, Inc. v. Columbia

Broadcasting System, Inc., 441 U.S. 1, 7-8, 99 S.Ct. 1551, 1556, 60 L.Ed.2d 1 (1979) (internal

citations omitted) ("BMI "). Price fixing, horizontal market divisions, tying arrangements, and group

boycotts have emerged as practices that are generally illegal per se. See National Bancard Corp.

(NaBanco) v. VISA U.S.A., Inc., 779 F.2d 592, 598 (11th Cir.1986) (citing United States v. Parke,

and great weight be given to the interpretations of the federal courts relating to comparable
federal antitrust statutes."); see also St. Petersburg Yacht Charters, Inc. v. Morgan Yacht, Inc.,
457 So.2d 1028, 1032 (Fla.Dist.Ct.App.1984) ("[T]he Florida legislature has, in effect, adopted
as the law of Florida the body of antitrust law developed by the federal courts under the Sherman
Act."); Fla. Stat. §§ 542.16 (Florida antitrust laws complement federal antitrust laws), 542.18
(analogous to § 1 of the Sherman Act). So, for purposes of this opinion discussion of the law
under the Sherman Act is equally applicable to the plaintiffs-appellants' state antitrust claims.
Davis & Co., 362 U.S. 29, 80 S.Ct. 503, 4 L.Ed.2d 505 [1960] ); State Oil Co. v. Khan, --- U.S. ----,

118 S.Ct. 275, 139 L.Ed.2d 199 (1997); International Salt Co. v. United States, 332 U.S. 392, 68

S.Ct. 12, 92 L.Ed. 20 (1947); Fashion Originators' Guild of America v. FTC, 312 U.S. 457, 61 S.Ct.

703, 85 L.Ed. 949 (1941).

       "But easy labels do not always supply ready answers." BMI, 441 U.S. at 8, 99 S.Ct. at 1556.

Since the emergence of these per se categories, we have stressed that "whether the ultimate finding

is the product of a presumption or actual market analysis, the essential inquiry remains the

same—whether or not the challenged restraint enhances competition." National Bancard Corp., 779

F.2d at 598 (citation and quotation omitted). The Supreme Court, as well, has refused to force

various practices into "pigeonhole[s] and [to invoke] the per se rule." FTC v. Indiana Federation

of Dentists, 476 U.S. 447, 458, 106 S.Ct. 2009, 2018, 90 L.Ed.2d 445 (1986).

        A "rule of reason" is generally applied to determine what acts are permissible. Standard Oil

Co. of New Jersey v. United States, 221 U.S. 1, 60, 31 S.Ct. 502, 515-16, 55 L.Ed. 619 (1911).

Thus, a presumption exists that the circumstances of a case will be looked at in the light of the rule

of reason standard and will not be deemed per se unreasonable. Business Electronics Corp. v. Sharp

Electronics Corp., 485 U.S. 717, 723, 726, 108 S.Ct. 1515, 1518-19, 1520-21, 99 L.Ed.2d 808

(1988). But, there are no bright lines. "The decision to apply the per se rule [instead of the rule of

reason] turns on "whether the practice facially appears to be one that would always or almost always

tend to restrict competition and decrease output ... or instead one designed to "increase economic

efficiency and render markets more, rather than less, competitive.' " Northwest Wholesale

Stationers, Inc. v. Pacific Stationery and Printing Co., 472 U.S. 284, 289-90, 105 S.Ct. 2613, 2617,

86 L.Ed.2d 202 (1985).

       In Northwest, the Supreme Court observed that what activities might fall into a per se
category is "far from certain." Id. at 294, 105 S.Ct. at 2619. Considerable inquiry into the market

conditions and market power of the defendant is often necessary before conduct can be presumed

to be anticompetitive. Id. at 296, 105 S.Ct. at 2620-21 (addressing group boycotts).

        Plaintiffs-appellants claim that the PPP's arrangement is per se illegal as both price fixing

and as a group boycott. Thus, plaintiffs-appellants have the burden to make a threshold showing that

the PPP falls into one of these forbidden categories. See Id. at 298, 105 S.Ct. at 2621. In this case,

plaintiffs-appellants allege that, because price bids were a consideration in determining which

temporary nurse agencies would become preferred providers, this conduct falls into the forbidden

category of price fixing. They also claim that the exclusion of the nonpreferred agencies from the

PPP amounts to a group boycott.

        The decision whether the PPP established by defendants-appellees amounts to either a price

fix or a group boycott, deserving of per se treatment, determines the antitrust issue on appeal.12

A. Per se Violations

                                           1. Price Fixing

        That the PPP has some impact on the prices of obtaining temporary nurses is undisputed.

That price fixing is equally violative of antitrust laws whether it is done by buyers or sellers is also

undisputed. Mandeville Island Farms, Inc. v. American Crystal Sugar Co., 334 U.S. 219, 233-37,

68 S.Ct. 996, 1005-06, 92 L.Ed. 1328 (1948). And, it is no excuse that the price "fixed" is

reasonable. FTC v. Superior Court Trial Lawyers Ass'n, 493 U.S. 411, 423-24, 110 S.Ct. 768, 775,

107 L.Ed.2d 851 (1990). But whether the per se rule should apply "is not a question simply of

   12
     If we decide the PPP is deserving of per se treatment the case ends; plaintiffs-appellants
must win. But if we decide that conduct such as the establishment of the PPP does not rise to the
level of anti-competitiveness necessary to hold it per se illegal, the rule of reason applies; and
we will defer to the determination of the jury—that plaintiffs-appellants failed to establish the
relevant market in which to judge the PPP's reasonableness.
determining whether two or more potential competitors have literally "fixed' a "price.' " BMI, 441

U.S. at 9, 99 S.Ct. at 1556-57.

        Plaintiffs-appellants argue that the intent of the PPP was to stabilize prices and that such

intent makes this practice a per se violation. But anticompetitive effects—not intent—is the focal

point of antitrust legislation. The question is not did defendants intend to fix prices, but instead

whether the PPP did so. In defining "price fixing" the Supreme Court wrote in these terms:

        That price-fixing includes more than the mere establishment of uniform prices is clearly
        evident.... [P]rices are fixed ... if the range within which purchases or sales will be made is
        agreed upon, if the prices paid or charged are to be at a certain level or on ascending or
        descending scales, if they are to be uniform.... They are fixed because they are agreed upon.

United States v. Socony-Vacuum Oil Co., 310 U.S. 150, 222-23, 60 S.Ct. 811, 843-44, 84 L.Ed. 1129

(1940). In forming the PPP, the hospitals, among themselves, never agreed to a uniform price, to

an acceptable price range,13 or to a scale for determining price.

        The PPP has an impact on price; all preferred agencies contracting with the hospitals will,

to some degree, be tied into a set price for their services. But this point of law must be remembered:

"Not all arrangements among actual or potential competitors that have an impact on price are per

se violations of the Sherman Act or even unreasonable restraints." BMI, 441 U.S. at 23, 99 S.Ct. at

1564. And, it cannot be forgotten that market fluctuations could result in a preferred agency's

exercise of the escape clause—allowing that agency to reenter the market free to charge the prices

it chooses. Most important, this case involves lots of distinct contracts. A pricing agreement of

some kind is necessary in the contracting for goods and services; and competitive bidding is an

acceptable way to decide with whom the hospitals wish to contract.

   13
    That the SFHA—when it requested bids—suggested a price range to the participating
agencies does not create an agreement on the prices they would accept. As shown by the
accepted bids, prices outside the range were acceptable.
        Earlier Supreme Court cases were faced with more direct price fixing, which led to the per

se categorization of such schemes. In the context of a blatant agreement to fix prices,

        [i]t makes no difference whether the motives of the participants are good or evil; whether
        the price fixing is accomplished by express contract or by some more subtle means; whether
        the participants possess market control; whether the amount of interstate commerce affected
        is large or small; or whether the effect of the agreement is to raise or to decrease prices.

United States v. McKesson & Robbins, Inc., 351 U.S. 305, 310, 76 S.Ct. 937, 940, 100 L.Ed. 1209

(1956). But we do not have an agreement to fix prices in this case: no prices were preset for nursing

services.

        The Supreme Court has recently taken another step away from per se treatment, particularly

in maximum vertical price fixing arrangements.14 See State Oil Co. v. Khan, --- U.S. ----, 118 S.Ct.

275, 139 L.Ed.2d 199 (1997). Vertical price fixing is no longer a per se violation. Id. at ----, 118

S.Ct. at 278.

        The key to per se treatment is whether the conduct is of the kind that can only be

anticompetitive. But, the PPP, arranged by the SFHA and the Palm Beach County hospitals, is not

inherently an anticompetitive practice. No temporary nursing agency was precluded from competing

to become a preferred agency. Also, all agencies are still able to provide nurses to medical facilities

other than hospitals and even to hospitals should the need for nurses not be met by the preferred

agencies. Although the PPP may stabilize prices to some degree, it is not the kind of "stabilization"

that can be viewed as price fixing, especially when the escape clauses in the contracts are taken into

account. These escape clauses allow the market and not the SFHA to be the ultimate decisionmaker

for each hospital and each agency on the issues of price, demand, supply, and terms of dealing.

   14
     The alleged attempt to fix prices by the hospitals' agreement with each other would be
horizontal—an agreement among competitors. The alleged attempt to fix prices by the hospitals'
agreements with the preferred agencies would be vertical.
                                         2. Group Boycotts

       The same principles apply to a consideration of application of the per se rule whether the act

complained of is labeled price fixing or a group boycott. "[T]he recent jurisprudence of the Supreme

Court and of the Court of Appeals of this Circuit cautions against the haphazard expansion of the

"group boycott label' and the concomitant imposition of per se liability." Retina Assocs., 105 F.3d

at 1381. "Not all concerted refusals to deal are predominantly anticompetitive." Northwest, 472

U.S. at 298, 105 S.Ct. at 2621. In cases of group boycotts where the per se rule has been applied,

"the boycott often cut[s] off access to a supply, facility, or market necessary to enable the boycotted

firm to compete, ... and frequently the boycotting firms possessed a dominant position in the relevant

market." Id. at 294, 105 S.Ct. at 2619 (emphasis added).

       In dealing with group boycott situations, market analysis has found its way into the

determination of whether a given practice should be per se illegal. No longer is relevant market a

factor only after it has been decided that the rule of reason applies. "Unless the cooperative

possesses market power or exclusive access to an element essential to effective competition, the

conclusion that [the conduct] is virtually always likely to have an anticompetitive effect is not

warranted." Northwest, 472 U.S. at 296, 105 S.Ct. at 2620-21.

        In this case, no refusal to deal has been shown. All agencies were able to participate in the

bidding to become preferred providers, and generally a hospital will still deal with any nursing

agency when the preferred agencies with which the hospital has contracted for nursing services fail

to meet its needs. The record shows, in fact, that more than a trifling portion of hospital nursing

business in Palm Beach County continued to go to nonpreferred agencies after the PPP was in

operation. Also, due to the rise in HMOs, home care, and similar trends in the medical world,

facilities other than hospitals provide the market, the supply, and the facilities necessary for
nonpreferred agencies to compete with each other and with preferred agencies in the marketplace.

        Per se treatment has been given to those practices which history has shown have only

anticompetitive effects. "[A]nalyzing this case under the per se rubric would remain inappropriate

absent some demonstration that the practice at issue historically leads to anticompetitive effects in

the market." Retina Assocs., 105 F.3d at 1381. No history of this kind seems to exist for health-care

preferred-provider programs materially similar to what we have before us now.

        We conclude, based upon undisputed facts, that the practice of this PPP is not deserving of

per se treatment and was properly evaluated under the rule of reason.

B. Rule of Reason

        The rule of reason requires "the factfinder [to weigh] all of the circumstances of the case in

deciding whether a restrictive practice should be prohibited as imposing an unreasonable restraint

on competition." Continental T.V., Inc. v. GTE Sylvania Inc., 433 U.S. 36, 49, 97 S.Ct. 2549, 2557,

53 L.Ed.2d 568 (1977). The rule of reason should be applied to practices designed to "increase

economic efficiency or render markets more, rather than less, competitive." BMI, 441 U.S. at 19-20,

99 S.Ct. at 1562-63; see also Northwest, 472 U.S. at 289-90, 105 S.Ct. at 2616-17.

        "[T]o satisfy the rule of reason, the plaintiff must prove that the [conduct] had an adverse

effect on competition." Coffey v. Healthtrust, Inc., 955 F.2d 1388, 1392 (10th Cir.1992). But,

competition occurs only in a market. Thus, "before we can reach the larger question of whether

[defendants] violated any of the antitrust laws, we must confront the threshold problem of defining

the relevant market." Thompson v. Metropolitan Multi-List, Inc., 934 F.2d 1566, 1572 (11th

Cir.1991).15

   15
    Because this case is subject to the rule of reason and because of the importance of relevant
market and market power in evaluating the reasonableness of a purported restraint, the district
court's jury instructions and interrogatories directing that the jurors must find for defendants if
        Interrogatories went to the jury.16 The jury found that plaintiffs-appellants failed to establish

the relevant market. Because no definable market was proved, plaintiffs could show no adverse

effect on competition. Plaintiffs-appellants try to debate the required showing of market power. But

their argument is based upon per se treatment of the antitrust claim. Because we have decided, as

did the district court, that the PPP triggers no per se analysis, relevant market was critical to

plaintiffs-appellants' claims.

         The jury found that no relevant market was shown; and we will reverse the jury's

determination on this factual issue only if it is clearly erroneous. United States v. E.I. du Pont de

Nemours & Co., 351 U.S. 377, 381, 76 S.Ct. 994, 999, 100 L.Ed. 1264 (1956). We cannot say the

finding that no relevant market was established is clearly erroneous. The failure to establish the

relevant market (either by product or geography) was fatal to plaintiffs-appellants' antitrust claims.

So, we accept the jury verdict against them.

        AFFIRMED.

        WELLFORD, Senior Circuit Judge, concurring:

        I concur in Judge Edmondson's opinion. The antitrust issues were addressed early in this

case through a decision on setting aside a preliminary injunction in and expanded on in a concurring

opinion authored by then Chief Judge Tjoflat, 887 F.2d 1535, 1539 (11th Cir.1989) (Tjoflat, C.J.,

concurring).

        There were contested issues as to whether defendants possessed market power in a relevant

market for temporary nursing services. The jury decided the contested relevant issue on which

plaintiffs failed to establish the relevant market were proper applications of the law governing
this case.
   16
     The interrogatories, among other things, directed the jury to find for the defendants if the
plaintiffs did not establish the necessary relevant market.
plaintiffs had the burden. There were contested issues as to whether defendants had monopoly

"control over access to an essential element of competition" by means of the arrangement. Plaintiffs

had the burden to prove this and they failed in this burden.

       Judge Edmondson points out, as Judge Tjoflat previously did in this case, that Northwest

Wholesale Stationers, Inc. v. Pacific Stationery & Printing Co., 472 U.S. 284, 105 S.Ct. 2613, 86

L.Ed.2d 202 (1985), is key, and it "prohibits the application of the per se rule to cooperative buying

arrangements unless a court has made certain preliminary findings of fact." Id. Northwest held that

"[a]bsent a showing [of market power or exclusive access to an element essential to effective

competition] with respect to a cooperative buying arrangement, courts should apply a rule-of-reason

analysis." Northwest, 472 U.S. at 297, 105 S.Ct. at 2621, quoted in All Care Nursing Service, 887

F.2d at 1539; see also Areeda & Havenkamp, Antitrust Law (1989 Supp.) ¶ 1511 (discussing

Northwest and suggesting that plaintiffs must establish market power of defendant before the court

should finally decide per se or rule of reason application).

       In addition, this circuit has indicated that "[t]he presumption in cases brought under section

1 of the Sherman Act is that the rule-of-reason standard applies." Seagood Trading Corp. v. Jerrico,

Inc., 924 F.2d 1555, 1567 (11th Cir.1991). We observed in that case, moreover, that "[t]he Supreme

Court has made it clear that the per se label should be applied infrequently and with caution." Id.

       The majority opinion has covered all of the questions in this case; I merely emphasize the

application of the rule-of-reason principle under the circumstances.