Arizona v. Maricopa County Medical Society
Opinion of the Court
delivered the opinion of the Court.
. The question presented is whether § 1 of the Sherman Act, 26 Stat. 209, as amended, 15 U. S. C. § 1, has been violated by agreements among competing physicians setting, by majority vote, the maximum fees that they may claim in full
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In October 1978 the State of Arizona filed a civil complaint against two county medical societies and two “foundations for medical care” that the medical societies had organized. The complaint alleged that the defendants were engaged in illegal price-fixing conspiracies.
The Court of Appeals, by a divided vote, affirmed the District Court’s order refusing to enter partial summary judgment, but each of the three judges on the panel had a different view of the case. Judge Sneed was persuaded that “the challenged practice is not a per se violation.” 643 F. 2d, at
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The Maricopa Foundation for Medical Care is a nonprofit Arizona corporation composed of licensed doctors of medicine, osteopathy, and podiatry engaged in private practice. Approximately 1,750 doctors, representing about 70% of the practitioners in Maricopa County, are members.
The Maricopa Foundation was organized in 1969 for the purpose of promoting fee-for-service medicine and to provide the community with a competitive alternative to existing health insurance plans.
The Pima Foundation for Medical Care, which includes about 400 member doctors,
At the time this lawsuit was filed,
The fee schedules limit the amount that the member doctors may recover for services performed for patients insured under plans approved by the foundations. To obtain this approval the insurers — including self-insured employers as well as insurance companies
The impact of the foundation fee schedules on medical fees and on insurance premiums is a matter of dispute. The State of Arizona contends that the periodic upward revisions of the maximum-fee schedules have the effect of stabilizing and enhancing the level of actual charges by physicians, and
This assumption presents, but does not answer, the question whether the Sherman Act prohibits the competing doctors from adopting, revising, and agreeing to use a maximum-fee schedule in implementation of the insurance plans.
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The respondents recognize that our decisions establish that price-fixing agreements are unlawful on their face. But they argue that the per se rule does not govern this case because the agreements at issue are horizontal and fix maximum prices, are among members of a profession, are in an industry with which the judiciary has little antitrust experience, and are alleged to have procompetitive justifications. Before we examine each of these arguments, we pause to consider the history and the meaning of the per se rule against price-fixing agreements.
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Section 1 of the Sherman Act of 1890 literally prohibits every agreement “in restraint of trade.”
The elaborate inquiry into the reasonableness of a challenged business practice entails significant costs. Litigation of the effect or purpose of a practice often is extensive and complex. Northern Pacific R. Co. v. United States, 356 U. S. 1, 5 (1958). Judges often lack the expert understanding of industrial market structures and behavior to determine with any confidence a practice’s effect on competition. United States v. Topco Associates, Inc., 405 U. S. 596, 609-610 (1972). And the result of the process in any given case may provide little certainty or guidance about the legality of a practice in another context. Id., at 609, n. 10; Northern Pacific R. Co. v. United States, supra, at 5.
The costs of judging business practices under the rule of reason, however, have been reduced by the recognition of per
Thus the Court in Standard Oil recognized that inquiry under its rule of reason ended once a price-fixing agreement was proved, for there was "a conclusive presumption which
“The aim and result of every price-fixing agreement, if effective, is the elimination of one form of competition. The power to fix prices, whether reasonably exercised or not, involves power to control the market and to fix arbitrary and unreasonable prices. The reasonable price fixed today may through economic and business changes become the unreasonable price of tomorrow. Once established, it may be maintained unchanged because of the absence of competition secured by the agreement for a price reasonable when fixed. Agreements which create such potential power may well be held to be in themselves unreasonable or unlawful restraints, without the necessity of minute inquiry whether a particular price is reasonable or unreasonable as fixed and without placing on the government in enforcing the Sherman Law the burden of ascertaining from day to day whether it has become unreasonable through the mere variation of economic conditions.” Id., at 397-398.
Thirteen years later, the Court could report that “for over forty years this Court has consistently and without deviation adhered to the principle that price-fixing agreements are unlawful per se under the Sherman Act and that no showing of so-called competitive abuses or evils which those agreements were designed to eliminate or alleviate may be interposed as a defense.” United States v. Socony-Vacuum Oil Co., 310 U. S. 150, 218 (1940). In that case a glut in the spot market for gasoline had prompted the major oil refiners to engage in a concerted effort to purchase and store surplus gasoline in order to maintain stable prices. Absent the agreement, the
“Any combination which tampers with price structures is engaged in an unlawful activity. Even though the members of the price-fixing group were in no position to control the market, to the extent that they raised, lowered, or stabilized prices they would be directly interfering with the free play of market forces. The Act places all such schemes beyond the pale and protects that vital part of our economy against any degree of interference. Congress has not left with us the determination of whether or not particular price-fixing schemes are wise or unwise, healthy or destructive. It has not permitted the age-old cry of ruinous competition and competitive evils to be a defense to price-fixing conspiracies. It has no more allowed genuine or fancied competitive abuses as a legal justification for such schemes than it has the good intentions of the members of the combination. If such a shift is to be made, it must be done by the Congress. Certainly Congress has not left us with any such choice. Nor has the Act created or authorized the creation of any special exception in favor of the oil industry. Whatever may be its peculiar problems and characteristics, the Sherman Act, so far as price-fixing agreements are concerned, establishes one uniform rule applicable to all industries alike.” Id., at 221-222.
The application of the per se rule to maximum-price-fixing agreements in Kiefer-Stewart Co. v. Joseph E. Seagram & Sons, Inc., 340 U. S. 211 (1951), followed ineluctably from Socony-Vacuum:
“For such agreements, no less than those to fix minimum prices, cripple the freedom of traders and thereby restrain their ability to sell in accordance with their own judgment. We reaffirm what we said in United States v. Socony-Vacuum Oil Co., 310 U. S. 150, 223: ‘Under*347 the Sherman Act a combination formed for the purpose and with the effect of raising, depressing, fixing, pegging, or stabilizing the price of a commodity in interstate or foreign commerce is illegal per se.’” 340 U. S., at 213.
Over the objection that maximum-price-fixing agreements were not the “economic equivalent” of minimum-price-fixing agreements,
“Maximum and minimum price fixing may have different consequences in many situations. But schemes to fix maximum prices, by substituting the perhaps erroneous judgment of a seller for the forces of the competitive market, may severely intrude upon the ability of buyers to compete and survive in that market. Competition, even in a single product, is not cast in a single mold. Maximum prices may be fixed too low for the dealer to furnish services essential to the value which goods have for the consumer or to furnish services and conveniences which consumers desire and for which they are willing to pay. Maximum price fixing may channel distribution through a few large or specifically advantaged dealers who otherwise would be subject to significant nonprice competition. Moreover, if the actual price charged under a maximum price scheme is nearly always the fixed maximum price, which is increasingly likely as the maximum price approaches the actual cost of the dealer, the scheme tends to acquire all the attributes of an arrangement fixing minimum prices.” Id., at 152-153 (footnote omitted).
We have not wavered in our enforcement of the per se rule against price fixing. Indeed, in our most recent price-fixing case we summarily reversed the decision of another Ninth
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Our decisions foreclose the argument that the agreements at issue escape per se condemnation because they are horizontal and fix maximum prices. Kiefer-Stewart and Albrecht place horizontal agreements to fix maximum prices on the same legal — even if not economic — footing as agreements to fix minimum or uniform prices.
Nor does the fact that doctors — rather than nonprofessionals — are the parties to the price-fixing agreements support the respondents’ position. In Goldfarb v. Virginia State Bar, 421 U. S. 773, 788, n. 17 (1975), we stated that the “public service aspect, and other features of the professions, may
We are equally unpersuaded by the argument that we should not apply the per se rule in this case because the judiciary has little antitrust experience in the health care industry.
The respondents’ principal argument is that the per se rule is inapplicable because their agreements are alleged to have procompetitive justifications. The argument indicates a misunderstanding of the per se concept. The anticompet-itive potential inherent in all price-fixing agreements justifies their facial invalidation even if procompetitive justifications are offered for some.
The respondents contend that their fee schedules are pro-competitive because they make it possible to provide consumers of health care with a uniquely desirable form of insurance coverage that could not otherwise exist. The features of the foundation-endorsed insurance plans that they stress are a choice of doctors, complete insurance coverage, and lower premiums. The first two characteristics, however, are hardly unique to these plans. Since only about 70% of
It is true that a binding assurance of complete insurance coverage — as well as most of the respondents’ potential for lower insurance premiums
The most that can be said for having doctors fix the maximum prices is that doctors may be able to do it more efficiently than insurers. The validity of that assumption is far from obvious,
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Our adherence to the per se rule is grounded not only on economic prediction, judicial convenience, and business certainty, but also on a recognition of the respective roles of the Judiciary and the Congress in regulating the economy. United States v. Topco Associates, Inc., 405 U. S., at fill-612. Given its generality, our enforcement of the Sherman Act has required the Court to provide much of its substantive content. By articulating the rules of law with some clarity and by adhering to rules that are justified in their general application, however, we enhance the legislative prerogative to amend the law. The respondents’ arguments against application of the per se rule in this case therefore are
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Having declined the respondents invitation to cut back on the per se rule against price fixing, we are left with the respondents’ argument that their fee schedules involve price fixing in only a literal sense. For this argument, the respondents rely upon Broadcast Music, Inc. v. Columbia Broadcasting System, Inc., 441 U. S. 1 (1979).
In Broadcast Music we were confronted with an antitrust challenge to the marketing of the right to use copyrighted compositions derived from the entire membership of the American Society of Composers, Authors and Publishers (ASCAP). The so-called “blanket license” was entirely different from the product that any one composer was able to sell by himself.
This case is fundamentally different. Each of the foundations is composed of individual practitioners who compete with one another for patients. Neither the foundations nor the doctors sell insurance, and they derive no profits from the sale of health insurance policies. The members of the foundations sell medical services. Their combination in the form of the foundation does not permit them to sell any different product.
The foundations are not analogous to partnerships or other joint arrangements in which persons who would otherwise be competitors pool their capital and share the risks of loss as well as the opportunities for profit. In such joint ventures, the partnership is regarded as a single firm competing with other sellers in the market. The agreement under attack is
The judgment of the Court of Appeals is reversed.
It is so ordered.
Justice Blackmun and Justice O’Connor took no part in the consideration or decision of this case.
The complaint alleged a violation of § 1 of the Sherman Act as well as of the Arizona antitrust statute. The state statute is interpreted in conformity with the federal statute. 643 F. 2d 533, 554, n. 1 (CA9 1980). The State of Arizona prayed for an injunction but did not ask for damages.
The District Court offered three reasons for its decision. First, citing Continental T. V., Inc. v. GTE Sylvania Inc., 433 U. S. 36 (1977), the court stated that “a recent antitrust trend appears to be emerging where the Rule of Reason is the preferred method of determining whether a particular practice is in violation of the antitrust law.” App. to Pet. for Cert. 43. Second, “the two Supreme Court cases invalidating maximum price-
The District Court also denied the defendants’ motion to dismiss based on the ground that they were engaged in the business of insurance within the meaning of the McCarran-Ferguson Act, 15 U. S. C. § 1011 et seq. See App. to Pet. for Cert. 39-41. The defendants did not appeal that portion of the District Court order. 643 F. 2d, at 559, and n. 7.
The quoted language is the Court of Appeals’ phrasing of the question. Id., at 554. The District Court had entered an order on June 5,1979, providing, in relevant part:
“The plaintiff’s motion for partial summary judgment on the issue of liability is denied with leave to file a similar motion based on additional evidence if appropriate.” App. to Pet. for Cert. 48.
On August 8, 1979, the District Court entered a further order providing:
“The Order of this Court entered June 5, 1979 is amended by addition of the following: This Court’s determination that the Rule of Reason approach should be used in analyzing the challenged conduct in the instant case to determine whether a violation of Section 1 of the Sherman Act has occurred involves a question of law as to which there is substantial ground for difference of opinion and an immediate appeal from the Order denying plaintiff’s motion for partial summary judgment on the issue of liability may materially advance the ultimate determination of the litigation. Therefore, the foregoing Order and determination of the Court is certified for interlocutory appeal pursuant to 28 U. S. C. § 1292(b).” Id., at 50-51.
Judge Sneed explained his reluctance to apply the per se rule substantially as follows: The record did not indicate the actual purpose of the maximum-fee arrangements or their effect on competition in the health care industry. It was not clear whether the assumptions made about typical price restraints could be carried over to that industry. Only recently had this Court applied the antitrust laws to the professions. Moreover, there already were such significant obstacles to pure competition in the industry that a court must compare the prices that obtain under the maximum-fee arrangements with those that would otherwise prevail rather than with those that would prevail under ideal competitive conditions. Furthermore, the Ninth Circuit had not applied Keifer-Stewart Co. v. Joseph E. Seagram & Sons, Inc., 340 U. S. 211 (1951), and Albrecht v. Herald Co., 390 U. S. 145 (1968), to horizontal agreements that establish maximum prices; some of the economic assumptions underlying the rule against maximum price fixing were not sound.
Judge Kennedy’s concurring opinion concluded as follows:
“There does not now appear to be a controlling or definitive analysis of the market impact caused by the arrangements under scrutiny in this case, but trial may reveal that the arrangements are, at least in their essentials, not peculiar to the medical industry and that they should be condemned.” 643 F. 2d, at 560.
Judge Larson stated, in part:
“Defendants formulated and dispersed relative value guides and conversion factor lists which together were used to set an upper limit on fees received from third-party payors. It is clear that these activities constituted maximum price-fixing by competitors. Disregarding any ‘special industry’ facts, this conduct is per se illegal. Precedent alone would mandate application of the per se standard.
“I find nothing in the nature of either the medical profession or the*339 health care industry that would warrant their exemption from per se rules for price-fixing.” Id., at 563-564 (citations omitted).
Most health insurance plans are of the fee-for-service type. Under the typical insurance plan, the insurer agrees with the insured to reimburse the insured for “usual, customary, and reasonable” medical charges. The third-party insurer, and the insured to the extent of any excess charges, bears the economic risk that the insured will require medical treatment. An alternative to the. fee-for-service type of insurance plan is illustrated by the health maintenance organizations authorized under the Health Maintenance Organization Act of 1973, 42 U. S. C. § 300e et seq. Under this form of prepaid health plan, the consumer pays a fixed periodic fee to a functionally integrated group of doctors in exchange for the group’s agreement to provide any medical treatment that the subscriber might need. The economic risk is thus borne by the doctors.
The record contains divergent figures on the percentage of Pima County doctors that belong to the foundation. A 1975 publication of the foundation reported 80%; a 1978 affidavit by the executive director of the foundation reported 30%.
In 1980, after the District Court and the Court of Appeals had rendered judgment, both foundations apparently discontinued the use of relative values and conversion factors in formulating the fee schedules. Moreover, the Maricopa Foundation that year amended its bylaws to provide that the fee schedule would be adopted by majority vote of its board of trustees and not by vote of its members. The challenge to the foundation activities as we have described them in the text, however, is not mooted by these changes. See United States v. W. T. Grant Co., 345 U. S. 629 (1953).
The parties disagree over whether the increases in the fee schedules are the cause or the result of the increases in the prevailing rate for medical services in the relevant markets. There appears to be agreement, however, that 85-95% of physicians in Maricopa County bill at or above the maximum reimbursement levels set by the Maricopa Foundation.
Seven different insurance companies underwrite health insurance plans that have been approved by the Maricopa Foundation, and three companies underwrite the plans approved by the Pima Foundation. The record contains no firm data on the portion of the health care market that is covered by these plans. The State relies upon a 1974 analysis indicating that the insurance plans endorsed by the Maricopa Foundation had about 63% of the prepaid health care market, but the respondents contest the accuracy of this analysis.
“Every contract, combination in the form of trust or otherwise, or conspiracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal. . . .” 15 U. S. C. § 1.
Justice Brandéis provided the classic statement of the rule of reason in Chicago Bd. of Trade v. United States, 246 U. S. 231, 238 (1918):
“The true test of legality is whether the restraint imposed is such as merely regulates and perhaps thereby promotes competition or whether it is such as may suppress or even destroy competition. To determine that question the court must ordinarily consider the facts peculiar to the business to which the restraint is applied; its condition before and after the restraint was imposed; the nature of the restraint and its effect, actual or probable. The history of the restraint, the evil believed to exist, the reason for adopting the particular remedy, the purpose or end sought to be attained, are all relevant facts. This is not because a good intention will save an otherwise objectionable regulation or the reverse; but because knowledge of intent may help the court to interpret facts and to predict consequences.”
For a thoughtful and brief discussion of the costs and benefits of rule-of-reason versus per se rule analysis of price-fixing agreements, see F. Scherer, Industrial Market Structure and Economic Performance 438-443 (1970). Professor Scherer’s “opinion, shared by a majority of American economists concerned with antitrust policy, is that in the present legal framework the costs of implementing a rule of reason would exceed the benefits derived from considering each restrictive agreement on its merits and prohibiting only those which appear unreasonable.” Id., at 440.
“Among the practices which the courts have heretofore deemed to be unlawful in and of themselves are price fixing, division of markets, group boycotts, and tying arrangements.” Northern Pacific R. Co. v. United States, 356 U. S., at 5 (citations omitted). See United States v. Columbia Steel Co., 334 U. S. 495, 522-523 (1948).
Thus, in applying the per se rule to invalidate the restrictive practice in United States v. Topco Associates, Inc., 405 U. S. 596 (1972), we stated that “[w]hether or not we would decide this case the same way under the rule of reason used by the District Court is irrelevant to the issue before us.” Id., at 609. The Court made the same point in Continental T. V., Inc. v. GTE Sylvania Inc., 433 U. S., at 50, n. 16:
“Per se rules thus require the Court to make broad generalizations about the social utility of particular commercial practices. The probability that anticompetitive consequences will result from a practice and the severity of those consequences must be balanced against its procompetitive consequences. Cases that do not fit the generalization may arise, but a per se rule reflects the judgment that such cases are not sufficiently common or important to justify the time and expense necessary to identify them.”
Albrecht v. Herald Co., 390 U. S., at 156 (Harlan, J., dissenting).
It is true that in Kiefer-Stewart, as in Albrecht, the agreement involved a vertical arrangement in which maximum resale prices were fixed. But the case also involved an agreement among competitors to impose the resale price restraint. In any event, horizontal restraints are generally less defensible than vertical restraints. See Continental T. V., Inc. v. GTE Sylvania Inc., 433 U. S. 36 (1977); Easterbrook, Maximum Price Fixing, 48 U. Chi. L. Rev. 886, 890, n. 20 (1981).
The argument should not be confused with the established position that a new per se rule is not justified until the judiciary obtains considerable rule-of-reason experience with the particular type of restraint challenged. See White Motor Co. v. United States, 372 U. S. 253 (1963). Nor is our unwillingness to examine the economic justification of this particular application of the per se rule against price fixing inconsistent with our reexamination of the general validity of the per se rule rejected in Continental T. V., Inc. v. GTE Sylvania Inc., supra.
“The health care industry, moreover, presents a particularly difficult area. The first step to understanding is to recognize that not only is access to the medical profession very time consuming and expensive both for the applicant and society generally, but also that numerous government subventions of the costs of medical care have created both a demand and supply function for medical services that is artificially high. The present supply and demand functions of medical services in no way approximate those which would exist in a purely private competitive order. An accurate description of those functions moreover is not available. Thus, we lack baselines by which could be measured the distance between the present supply and demand functions and those which would exist under ideal competitive conditions.” 643 F. 2d, at 556.
“Perforce we must take industry as it exists, absent the challenged feature, as our baseline for measuring anticompetitive impact. The relevant inquiry becomes whether fees paid to doctors under that system would be less than those payable under the FMC maximum fee agreement. Put differently, confronted with an industry widely deviant from a reasonably free competitive model, such as agriculture, the proper inquiry is whether the practice enhances the prices charged for the services. In simplified economic terms, the issue is whether the maximum fee arrangement better permits the attainment of the monopolist’s goal, viz., the matching of marginal cost to marginal revenue, or in fact obstructs that end.” Ibid.
In the first price-fixing case arising under the Sherman Act, the Court was required to pass on the sufficiency of the defendants’ plea that they had established rates that were actually beneficial to consumers. Assuming the factual validity of the plea, the Court rejected the defense as a matter of law. United States v. Trans-Missouri Freight Assn., 166 U. S. 290 (1897). In National Society of Professional Engineers v. United States, 435 U. S. 679, 689 (1978), we referred to Judge Taft’s “classic rejection of the argument that competitors may lawfully agree to sell their goods at the same price as long as the agreed-upon price is reasonable.” See United States v. Addyston Pipe & Steel Co., 85 F. 271 (CA6 1898), aff'd, 175 U. S. 211 (1899). In our latest price-fixing case, we reiterated the point: “It is no excuse that the prices fixed are themselves reasonable.” Catalano, Inc. v. Target Sales, Inc., 446 U. S. 643, 647 (1980).
“Whatever economic justification particular price-fixing agreements may be thought to have, the law does not permit an inquiry into their reasonableness. They are all banned because of their actual or potential threat to the central nervous system of the economy.” United States v. Socony-Vacuum Oil Co., 310 U. S. 150, 226, n. 59 (1940).
According to the respondents’ figures, this presumption is well founded. See Brief for Respondents 42, n. 120.
We do not perceive the respondents’ claim of procompetitive justification for their fee schedules to rest on the premise that the fee schedules actually reduce medical fees and accordingly reduce insurance premiums, thereby enhancing competition in the health insurance industry. Such an argument would merely restate the long-rejected position that fixed prices are reasonable if they are lower than free competition would yield. It is arguable, however, that the existence of a fee schedule, whether fixed by the doctors or by the insurers, makes it easier — and to that extent less expensive — for insurers to calculate the risks that they underwrite and to arrive at the appropriate reimbursement on insured claims.
According to a Federal Trade Commission staff report: “Until the mid-1960’s, most Blue Shield plans determined in advance how much to pay for particular procedures and prepared fee schedules reflecting their determinations. Fee schedules are still used in approximately 25 percent of Blue Shield contracts.” Bureau of Competition, Federal Trade Commission, Medical Participation in Control of Blue Shield and Certain Other Open-Panel Medical Prepayment Plans 128 (1979). We do not suggest
In that program the foundation performs the peer review function as well as the administrative function of paying the doctors’ claims.
In order to create an insurance plan under which the doctor would agree to accept as full payment a fee prescribed in a fixed schedule, someone must canvass the doctors to determine what maximum prices would be high enough to attract sufficient numbers of individual doctors to sign up
In this case it appears that the fees are set by a group with substantial power in the market for medical services, and that there is competition among insurance companies in the sale of medical insurance. Under these circumstances the insurance companies are not likely to have significantly greater bargaining power against a monopoly of doctors than would individual consumers of medical services.
“[Congress] can, of course, make per se rules inapplicable in some or all cases, and leave courts free to ramble through the wilds of economic theory in order to maintain a flexible approach.” United States v. Topco Associates, Inc., 405 U. S., at 610, n. 10. Indeed, it has exempted certain industries from the full reach of the Sherman Act. See, e. g., 7 U. S. C. §§ 291, 292 (Capper-Volstead Act, agricultural cooperatives); 15 U. S. C. §§ 1011-1013 (McCarran-Ferguson Act, insurance); 49 U. S. C. § 5b (Reed-Bulwinkle Act, rail and motor carrier rate-fixing bureaus); 15 U. S. C. § 1801 (newspaper joint operating agreements).
"Thus, to the extent the blanket license is a different product, ASCAP is not really a joint sales agency offering the individual goods of many sellers, but is a separate seller offering its blanket license, of which the individual compositions are raw material.” 441 U. S., at 22 (footnote omitted).
“Here, the blanket-license fee is not set by competition among individual copyright owners, and it is a fee for the use of any of the compositions
It may be true that by becoming a member of the foundation the individual practitioner obtains a competitive advantage in'the market for medical services that he could not unilaterally obtain. That competitive advantage is the ability to attract as customers people who value both the guarantee of full health coverage and a choice of doctors. But, as we have indicated, the setting of the price by doctors is not a “necessary consequence” of an arrangement with an insurer in which the doctor agrees not to charge certain insured customers more than a fixed price.
Dissenting Opinion
with whom The Chief Justice and Justice Rehnquist join, dissenting.
The medical care plan condemned by the Court today is a comparatively new method of providing insured medical services at predetermined maximum costs. It involves no coercion. Medical insurance companies, physicians, and patients alike are free to participate or not as they choose. On its face, the plan seems to be in the public interest.
The State of Arizona challenged the plan on a per se antitrust theory. The District Court denied the State’s summary judgment motion, and — because of the novelty of the issue — certified the question of per se liability for an interlocutory appeal. On summary judgment, the record and all inferences therefrom must be viewed in the light most favorable to the respondents. Nevertheless, rather than identifying clearly the controlling principles and remanding for decision on a completed record, this Court makes its own per se judgment of invalidity. The respondents’ contention that
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The Maricopa and Pima Foundations for Medical Care are professional associations of physicians organized by the medical societies in their respective counties.
An insured under a foundation-sponsored plan is free to go to any physician. The physician then bills the foundation directly for services performed.
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This case comes to us on a plaintiff’s motion for summary judgment after only limited discovery. Therefore, as noted above, the inferences to be drawn from the record must be viewed in the light most favorable to the respondents. United States v. Diebold, Inc., 369 U. S. 654, 655 (1962).
Several other aspects of the record are of key significance but are not stressed by the Court. First, the foundation arrangement forecloses no competition. Unlike the classic cartel agreement, the foundation plan does not instruct potential competitors: “Deal with consumers on the following terms and no others.” Rather, physicians who participate in the foundation plan are free both to associate with other medical insurance plans — at any fee level, high or low — and directly to serve uninsured patients — at any fee level, high or low. Similarly, insurers that participate in the foundation plan also remain at liberty to do business outside the plan with any physician — foundation member or not — at any fee level. Nor are physicians locked into a plan for more than one year’s membership. See n. 1, supra. Thus freedom to compete, as well as freedom to withdraw, is preserved. The Court cites no case in which a remotely comparable plan or agreement is condemned on a per se basis.
Second, on this record we must find that insurers represent consumer interests. Normally consumers search for high quality at low prices. But once a consumer is insured
The insurer, however, is not indifferent. To keep insurance premiums at a competitive level and to remain profitable, insurers — including those who have contracts with the foundations — step into the consumer’s shoes with his incentive to contain medical costs. Indeed, insurers may be the only parties who have the effective power to restrain medical costs, given the difficulty that patients experience in comparing price and quality for a professional service such as medical care.
On the record before us, there is no evidence of opposition to the foundation plan by insurance companies — or, for that matter, by members of the public. Rather seven insurers willingly have chosen to contract out to the foundations the task of developing maximum-fee schedules.
Ill
It is settled law that once an arrangement has been labeled as “price fixing” it is to be condemned per se. . But it is equally well settled that this characterization is not to be ap
Before characterizing an arrangement as a per se price-fixing agreement meriting condemnation, a court should determine whether it is a “ ‘naked restraint] of trade with no purpose except stifling of competition.’” United States v. Topco Associates, Inc., 405 U. S. 596, 608 (1972), quoting White Motor Co. v. United States, 372 U. S. 253, 263 (1963). See also Continental T. V., Inc. v. GTE Sylvania Inc., 433 U. S. 36, 49-50 (1977). Such a determination is necessary because “departure from the rule-of-reason standard must be based upon demonstrable economic effect rather than . . . upon formalistic line drawing.” Id., at 58-59. As part of this inquiry, a court must determine whether the procom-petitive economies that the arrangement purportedly makes possible are substantial and realizable in the absence of such an agreement.
For example, in National Society of Professional Engineers v. United States, 435 U. S. 679 (1978), we held unlawful as a per se violation an engineering association’s canon of ethics that prohibited competitive bidding by its members. After the parties had “compiled a voluminous discovery and trial record,” id., at 685, we carefully considered — rather than rejected out of hand — the engineers’ “affirmative defense” of their agreement: that competitive bidding would tempt engineers to do inferior work that would threaten pub-
In Broadcast Music, Inc. v. Columbia Broadcasting System, Inc., supra, there was minimum price fixing in the most “literal sense.” Id., at 8. We nevertheless agreed, unanimously,
In sum, the fact that a foundation-sponsored health insurance plan literally involves the setting of ceiling prices among competing physicians does not, of itself, justify condemning the plan as per se illegal. Only if it is clear from the record that the agreement among physicians is “so plainly
IV
The Court acknowledges that the per se ban against price fixing is not to be invoked every time potential competitors literally fix prices. Ante, at 355-357. One also would have expected it to acknowledge that per se characterization is inappropriate if the challenged agreement or plan achieves for the public procompetitive benefits that otherwise are not attainable. The Court does not do this. And neither does it provide alternative criteria by which the per se characterization is to be determined. It is content simply to brand this type of plan as “price fixing” and describe the agreement in Broadcast Music — which also literally involved the fixing of prices — as “fundamentally different.” Ante, at 356.
In fact, however, the two agreements are similar in important respects. Each involved competitors and resulted in cooperative pricing.
As in Broadcast Music, the plaintiff here has not yet discharged its burden of proving that respondents have entered a plainly anticompetitive combination without a substantial and procompetitive efficiency justification. In my view, the District Court therefore correctly refused to grant the State’s motion for summary judgment.
I believe the Court’s action today loses sight of the basic purposes of the Sherman Act. As we have noted, the antitrust laws are a “consumer welfare prescription.” Reiter v. Sonotone Corp., 442 U. S. 330, 343 (1979). In its rush to condemn a novel plan about which it knows very little, the Court suggests that this end is achieved only by invalidating activities that may have some potential for harm. But the little that the record does show about the effect of the plan suggests that it is a means of providing medical services that in fact benefits rather than injures persons who need them.
In a complex economy, complex economic arrangements are commonplace. It is unwise for the Court, in a case as novel and important as this one, to make a final judgment in the absence of a complete record and where mandatory inferences create critical issues of fact.
The Pima Foundation is open to any Pima County area physician licensed in Arizona. It has a renewable 5-year membership term. A voluntary resignation provision permits earlier exit on the January 1 following announcement of an intent to resign.
The Maricopa Foundation admits physicians who are members of their county medical society. The Maricopa Foundation has a renewable 1-year term of membership. Initial membership may be for a term of less than a year so that a uniform annual termination date for all members can be maintained.
The medical societies are professional associations of physicians practicing in the particular county. The Pima County Medical Society, but not the Pima Foundation, has been dismissed from the case pursuant to a consent decree.
Three private carriers underwrite various Pima Foundation-sponsored plans: Arizona Blue Cross-Blue Shield, Pacific Mutual Life Insurance Co'.,
The foundations act as the insurance companies’ claims agents on a contract basis. They administer the claims and, to some extent, review the medical necessity and propriety of the treatment for which a claim is entered. The foundations charge insurers a fee for their various services. In recent years, this fee has been set at 4% of the insurers’ premiums.
This agreement provides in part that the physician agrees “to be bound . . . with respect to maximum fees ... by any fee determination by the [foundation consistent with the schedule adopted by the [foundation physician] membership .. . .” App. 31-32. The agreement also provides that foundation members “understand and agree that participating membership in the [foundation shall not affect the method of computation or amount of fees billed by me with respect to any medical care for any patient.” Ibid.
At least seven insurance companies are competing in the relevant market. See n. 2, supra. At this stage of the case we must infer that they are competing vigorously and successfully.
The term “consumer” — commonly used in antitrust cases and literature — is used herein to mean persons who need or may need medical services from a physician.
The State introduced no evidence on its summary judgment motion supporting its apparent view that insurers effectively can perform this function themselves, without physician participation. It is clear, however, that price and quality of professional services — unlike commercial products — are difficult to compare. Cf. Bates v. State Bar of Arizona, 433 U. S. 350, 391-395 (1977) (opinion of Powell, J.). This is particularly true of medical service. Presumably this is a reason participating insurers wish to utilize the foundations’ services.
See Broadcast Music, Inc. v. Columbia, Broadcasting System, Inc., 441 U. S., at 25 (Stevens, J., dissenting in part) (“The Court holds that ASCAP’s blanket license is not a species of price fixing categorically forbidden by the Sherman Act. I agree with that holding”).
Cf. Continental T. V., Inc. v. GTE Sylvania Inc., 433 U. S. 36, 54 (1977) (identifying achievement of efficiencies as “redeeming virtue” in decision sustaining an agreement against per se challenge); L. Sullivan, Law of Antitrust § 74, p. 200 (1977) (per se characterization inappropriate if price agreement achieves great economies of scale and thereby improves economic performance); id., §66, p. 180 (higher burden might reasonably be placed on plaintiff where agreement may involve efficiencies).
In this case the physicians in effect vote on foundation maximum-fee schedules. In Broadcast Music, the copyright owners aggregated their copyrights into a group package, sold rights to the package at a group price, and distributed the proceeds among themselves according to an agreed-upon formula. See Columbia Broadcasting System, Inc. v. American Society of Composers, Authors and Publishers, 562 F. 2d 130, 135-136 (CA2 1977).
In this case, the foundations’ maximum-fee schedules attempt to rectify the inflationary consequence of patients’ indifference to the size of physicians’ bills and insurers’ commitment to reimburse whatever “usual, customary, and reasonable” charges physicians may submit. In Broadcast Music, the market defect inhered in the fact that “those who performed copyrighted music for profit were so numerous and widespread, and most performances so fleeting, that as a practical matter it was impossible for the many individual copyright owners to negotiate with and license the users and to detect unauthorized uses.” 441 U. S., at 4-5.
In this case, the record before us indicates that insurers — those best situated to decide and best motivated to inspire trust in their judgment— believe that the foundations are the most efficient providers of the maximum-fee scheduling service. In Broadcast Music, we found that the blanket copyright clearinghouse system “reduce[d] costs absolutely . . . .” Id., at 21.
The Court states that in Broadcast Music “there was little competition among individual composers for their separate compositions.” Ante, at 355. This is an irrational ground for distinction. Competition could have existed, 441 U. S., at 6; see also 562 F. 2d, at 134-135, 138, but did not because of the cooperative agreement. That competition yet persists among physicians is not a sensible reason to invalidate their agreement while refusing similarly to condemn the Broadcast Music agreements that were completely effective in eliminating competition.
The Court also offers as a distinction that the foundations do not permit the creation of “any different product.” Ante, at 356. But the foundations provide a “different product” to precisely the same extent as did Broadcast Music’s clearinghouses. The clearinghouses provided only what copyright holders offered as individual sellers — the rights to use individual compositions. The clearinghouses were able to obtain these same rights more efficiently, however, because they eliminated the need to engage in individual bargaining with each individual copyright owner. See 441 U. S., at 21-22.
In the same manner, the foundations set up an innovative means to deliver a basic service — insured medical care from a wide range of physicians of one’s choice — in a more economical manner. The foundations’ maximum-fee schedules replace the weak cost containment incentives in typical
Medical services differ from the typical service or commercial product at issue in an antitrust case. The services of physicians, rendered on a patient-by-patient basis, rarely can be compared by the recipient. A person requiring medical service or advice has no ready way of comparing physicians or of “shopping” for quality medical service at a lesser price. Primarily for this reason, the foundations — operating the plan at issue— perform a function that neither physicians nor prospective patients can perform individually. On a collective — and average — basis, the physicians themselves express a willingness to render certain identifiable services for not more than specified fees, leaving patients free to choose the physician. We thus have a case in which we derive little guidance from the conventional “perfect market” analysis of antitrust law. I would give greater weight than the Court to the uniqueness of medical services, and certainly would not invalidate on a per se basis a plan that may in fact perform a uniquely useful service.
Reference
- Full Case Name
- ARIZONA v. MARICOPA COUNTY MEDICAL SOCIETY Et Al.
- Cited By
- 522 cases
- Status
- Published