This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsPreview
Unable to display preview. Download preview PDF.
References
U.S. Dep’t of Justice & Federal Trade Comm’n, Horizontal Merger Guidelines § 0.1 (1992) [hereinafter Merger Guidelines], available at http://www.ftc.gov/bc/docs/horizmer.htm.
Id. When a group of sellers combines to exercise market power it is called oligopoly power.
Id.
E.g., In re Schering-Plough Corp., No. 9297, at 16–17 (Dec. 18, 2003) (opinion) (discussing FTC v. Indiana Fed’n of Dentists, 476 U.S. 447, 460–61 (1986), in which the Supreme Court said that “the finding of actual, sustained adverse effects on competition... is legally sufficient to supp ort a finding that the challenged restraint was unreasonable even in the absence of elaborate market analysis.”), available at http://www.ftc.gov/os/adjpro/d9297/031218commissionopinion.pdf. A number of lower court decisions have followed this principle. See, e.g., Todd v. Exxon Corp., 275 F.3d 191, 206 (2d Cir. 2001) (evidence of “an actual adverse effect on competition... arguably is more direct evidence of market power than calculations of elusive market share figures”); Toys R’ Us v. FTC, 221 F.3d 928, 937 (7th Cir. 2000) (market power can be proved “through direct evidence of anticompetitive effects”); United States v. Baker Hughes Inc., 908 F.2d 981, 992 (D.C. Cir. 1990) (“‘[m]arket share is just a way of estimating market power, which is the ultimate consideration,’ and... ‘[w]hen there are better ways to estimate market power, the court should use them’” (quoting Ball Memorial Hospital v. Mutual Hospital Insurance, 784 F.2d 1325, 1336 (7th Cir. 1986)).
See, e.g., FTC v. H.J. Heinz Co., 246 F.3d 708 (D.C. Cir. 2001); Merger Guidelines, supra note 1, § 0.2.
Merger Guidelines, supra note 1, § 1.0.
Id. §§ 1.11, 1.21; Seth Sacher & Louis Silvia, Antitrust Issues in Defining the Product Market for Hospital Services, 5 Int’l J. Econ. Bus. 181, 182 (1998).
See, e.g., Monk 4/23 at 38–49; Ginsburg 4/23 at 24–26; Desmarais 4/23 at 36–38.
See, e.g., Monk 4/23 at 43–49; Ginsburg 4/23 at 25; Desmarais 4/23 at 36–38; Lerner 4/23 at 66; Feldman 4/23 at 52–64.
See, e.g., Monk 4 /23 at 39–40 (until DOJ’s 1999 consent in United States v. Aetna Inc., 1999–2 Trade Cas. (CCH) ¶ 72,730 (N.D. Tex. 1999), the definition of the relevant product and geographic markets for health insurance did not provoke controversy; usually, the relevant geographic market was at least statewide, and the relevant product market included self-and fully-insured products, as well as HMOs, PPOs, and indemnity plans); Ginsburg 4/23 at 26; Desmarais 4/23 at 42; Feldman 4/23 at 61–64.
The following analysis deals with group comprehensive medical insurance and may not be applicable to assessing transactions or practices involving individual comprehensive medical insurance, worker’s compensation, disability, long-term care, or dental insurance. See, e.g., Desmarais 4/23 at 32 (“From our perspective, it’s important to realize that there’s really two distinct markets. There’s a group market for health insurance, as well as an individual market. The two markets vary considerably in terms of the economic, business and regulatory considerations and we need to keep that in mind.”); Feldman 4/23 at 56–57 (medicare health plan market may be distinct from employer health plan market).
Ginsburg 4/23 at 21; 25–26; Desmarais 4/23 at 36–37; Monk 4/23 at 43–45; Lerner 4/23 at 67–68, 70–73. See also supra Chapter 1.
See, e.g., Lerner 4/23 at 66–73; Monk 4/23 at 42–44, 48.
65 F.3d 1406 (7th Cir. 1995) (Posner, C.J.).
784 F.2nd 1325 (7th Cir. 1986) (Easterbrook, J.).
Marshfield Clinic, 65 F.3d at 1407.
Id. at 1409.
Id. at 1410.
Id. at 1411.
Ball Mem’l Hosp.. 784 F.2d at 1330–31.
Id. at 1331, 1339–40.
Id. at 1331, 1338–40 (the hospitals raised issues about cost-shifting and cross-subsidization in this context). See supra Chapter 3 for further discussion of this issue.
Ball Mem’l Hosp.. 784 F.2d at 1331, 1340. The court also stated that the “insurance industry is not like the steel industry, in which a firm must take years to build a costly plant before having anything to sell. The ‘productive asset’ of the insurance business is money, which may be supplied on a moment’s notice, plus the ability to spread risk, which many firms possess and which has no geographic boundary.” Id. at 1335.
In U.S. Healthcare, Inc. v. Healthsource, Inc., 986 F2d 589, 598–99 (1st Cir. 19 93), the First Circuit affirmed the trial court’s rejection of an HMO-only market in favor of one that includes all forms of health care financing. As the court explained: The problem with U.S. Healthcare’s argument is that differences in cost and quality between products create the possibility of a separate market, not the certainty.... [T]he issue... would b whether a sole supplier of HM O services... could raise price far enough over cost, and for a long enough period, to enjoy monopoly profits. Usage patterns, customer surveys, actual profit levels, comparison of features, ease of entry, and many other facts are pertinent in answering the question. See also Cont’l Orthopedic Applicances, Inc. v. Health Ins. Plan of Greater N.Y., Inc., 40 F. Supp. 2d 109, 119 (E.D.N.Y. 1999) (“[N]either of those cases [Marshfield Clinic and U.S. Healthcare], or for that matter, any of the cases cited in the defendants briefs, stand for the proposition that HMOs can never be a separate viable product market.”)
Lerner 4/23 at 67, 73 (noting that all of the litigated cases have defined the market broadly, but that the analysis in many of the cases “is either thin or wrong-headed”). See also Arthur Lerner, Health Insurance Monopoly Issues — Market Definition 13 (4/23) (slides), at http://www.ftc.gov/opp/hc/030423arthurlerner.pdf; Feldman 4/23 at 50–51 (suggesting that the main problem with decision in Marshfield Clinic is it defines a product market using both supply and demand substitution, whereas the Guidelines suggest only demand substitution should be considered in defining a relevant product market), 52 (noting that although supply substitution is relevant to antitrust analysis, its use should be limited to identifying firms that participate in the relevant market and to the analysis of entry); Merger Guidelines, supra note 1, §§ 1.32, 3.
United States v. Aetna Inc., No. 3–99CV 1398-H ¶¶ 17–18 (June 21, 1999) (complaint) [hereinafter Aetna Complaint], available at http://www.usdoj.gov/atr/cases/f2500/2501.pdf; see also United States v. Aetna Inc., No. 3-99 CV1398-H, at 5-6 (Aug. 3, 1999) (revised competitive impact statement) [hereinafter Aetna Impact Statement], available at http://www.usdoj.gov/atr/cases/f2600/2648.pdf.
Monk 4 /23 at 49; see also id. (“[F]rom the evidence that I’ve been able to analyze... HMOs and PPOs generally do compete in the same relevant market”).
Feldman 4/23 at 60–61.
Roger Feldman, Health Insurance Monopoly Issues — Market Definition 7 (4/23) (slides), at http://www.ftc.gov/ogc/healthcarehearings/docs/030423feldman.pdf; Feldman 4/23 at 52, 53–64 (discussing studies and demand elasticities that support his belief that there are separate product markets and noting that consumer price sensitivity appears to be significant among comparable plans, i.e., is across plans where non-price attributes such as provider network and utilization controls are held constant).
See, e.g., Desmarais 4/23 at 37 (“Obviously, if I’m an insurer and I have an employer customer, I have to be mindful of the fact that that customer, at any time, can decide to become self-insured and to assume the responsibility and hire a TPA, not necessarily my insurance company, and that certainly has to color the relationships between the employer customers and the insurers and TPAs in which they do business.”).
Monk 4/23 at 42–43. See also id. at 45 (noting that bidding documents and broker spreadsheets also provided useful insights); Feldman 4/23 at 96 (citing Portland, Oregon as an example of why the assessment of self-insurance in the product market has to be geographically specific: “[W]e found that even large employers in the Portland market just do n’t want anything to do with self-insurance. It’s virtually a fully-insured city for reasons that are not entirely obvious to me.”). But see Lerner 4/23 at 98 (suggesting that although employers in Portland do not self-insure now, they might change their minds if the price of other insurance products went up); Monk 4/23 at 98–99 (noting that perhaps employers in Portland do not self-insure because the other available products are great, but if that were to change, employers might choose to self-insure).
See Monk 4/23 at 42, 43 (noting that perhaps self-insurance should not be included in the relevant product market for small employers because such employers may not find it “advantageous to switch to a self-insured plan”). Obviously self-insurance can only be part of the relevant product market if employers view it as a substitute for products offered by commercial insurers.
Merger Guidelines, supra note 1, § 1.21. The Division, in some recent cases, has used the United States Department of Commerce Metropolitan Statistical Areas (MSAs) as a starting point for defining geographic markets for insurance company mergers.
Id. See also Feldman 4/23 at 90 (“[I]f an HMO... raises its price, would buyers switch to products produced outside the region?... [T]he answer is quite clear, geography matters.”).
Aetna Complaint, supra note 26, ¶ 19. But see Monk 4/23 at 41 (arguing that although the Merger Guidelines do not use supply substitution to define markets, in his view “the ease and speed with which these [health] plans can move from one part of a state to another make insurance markets an exception”).
Aetna Complaint, supra note 26, ¶ 20; Aetna Impact Statement, supra note 26, at 7. See also Monk 4/23 at 40 (“[M]y experience on more recent mergers suggests that an MSA-based, fully insured HMO market is still the Department of Justice’s starting point.”); News Release, Dep’t of Justice Antitrust Division, Statement on the Closing of its Investigation of Anthem, Inc.’s Acquisition of Wellpoint Health Networks, Inc. (Mar. 9, 2004), at http://www.usdoj.gov/atr/public/press_releases/2004/202738.pdf.
SeeMerger Guidelines, supra note 1, §§ 2.1, 2.2.
Id. § 2.21 (“Substantial unilateral price elevation in a market for differentiated products requires that there be a significant share o f sales in the market accounted for by consumers who regard the products of the merging firms as their first and second choices, and that repositioning of the nonparties’ product lines to replace the localized competition lost through the merger be unlikely.”)
Aetna Complaint, supra note 26, ¶ 21; Aetna Impact Statement, supra note 26, at 8.
Mazzeo 4/23 at 133–34, 139–42.
Id. at 142–143. Of course, a health plan merger does not necessarily have adverse unilateral effects just because it is “big.” In the D ivision’s recent investigation of the Anthem/WellPoint merger, for instance, the Division learned from employers and other market participants that, in addition to one of the merging parties’ market shares being very small in each of the nine states in which they competed, neither of the WellPoint products was a close competitor to Anthem in any of these states. Given these facts, the Division concluded that this transaction would not enhance Anthem’s ability to increase prices, reduce quality, or otherwise reduce consumer welfare in any of these markets. Dep’t of Justice Antitrust Division, supra note 36.
Fred Dodson, Health Insurance Monopoly Issues — Competitive Effects 3 (4/23) [hereinafter Dodson (stmt)], at http://www.ftc.gov/ogc/healthcarehearings/docs/030423freddodson.pdf. See also Dodson 4/23 at 172; Darling 4/23 at 183–84; Helen Darling, Health Insurance Monopoly Issues — Competitive Effects 1 (4/23) [hereinafter Darling (stmt)], at http://www.ftc.gov/ogc/healthcarehearings/docs/030423darling.pdf; Wu 4/23 at 117; Lawrence Wu, Economic Issues in Analyzing Competitive Effects in Health Insurance Markets 4–14 (4/23) (slides) [hereinafter W u Presentation], at http://www.ftc.gov/ogc/healthcarehearings/docs/030423wucompetitve.pdf.
Dodson (stmt), supra note 42, at 3. See also Dodson 4/23 at 172; Darling 4/23 at 186.
Darling (stmt), supra note 42, at 1. See also Darling 4/23 at 183–86.
Darling 4/23 at 183, 185; Darling (stmt), supra note 42, at 1.
Darling (stmt), supra note 42, at 1.
Id.; see also Darling 4/23 at 185–87.
Stephen Foreman & Dennis Olmstead, Written Comments of the Pennsylvania Medical Society 3 (9/9/02), at http://www.ftc.gov/ogc/healthcare/pms.pdf. See also Gabel 4/23 at 159 (in last few years, “the insurance industry has become less competitive”); Foreman 4/24 at 69–70; Hall 4/25 at 74–75, 78 (stating that Blue Cross is dominant in Alabama).
Merger Guidelines, supra note 1, § 3.
Ginsburg 4/23 at 10–12; Paul Ginsburg, Competition in Health Insurance 6–7 (4/23) (slides) (noting that the underwriting cycle was leading to wider margins but that “exits from unprofitable markets” continued) [hereinafter Ginsburg Presentation], at http://www.ftc.gov/ogc/healthcarehearings/docs/030423ginsburg.pdf.
Aetna Complaint, supra note 26, ¶ 23. See also Aetna Impact Statement, supra note 26, at 8 n.4 (“Indeed, Aetna has acknowledged that on average it costs between $600 and $1000 per enrollee to build membership in a HMO.”); Aetna Complaint, supra note 26, ¶ 23 (further noting that these costs are substantially higher than those required for setting up a PPO or indemnity plan). On the other hand, the Division also noted in Congressional testimony that “there has been new entry into various local [health plan] markets” and that “[b]etween 1994 and 1997 over 150 new HMOs were licensed across the country.” Statement: Hearing on H.R. 1304, The Quality Health-Care Coalition Act of 1999, Before the House Comm. on the Judiciary, 106th Cong. 8 (1999) (Statement of Joel I. Klein, Assistant Attorney General, Department of Justice Antitrust Division), available at http://www.usdoj.gov/atr/public/testimony/2502.pdf.
Gabel 4/23 at 159.
Gabel 4/23 at 163–64; Jon Gabel, Competition Among Health Plans 11 (4/23) (slides) [hereinafter Gabel Presentation], at http://www.ftc.gov/opp/hc/030423jongabel.pdf (suggesting that entry should have begun to increase for at least three reasons: (1) four years of underwriting profits, (2) growing profitability among publicly traded managed care companies, and (3) a limited number of competitors in many local markets). See also Ginsburg 4/23 at 20 (noting that “during the stage of the underwriting cycle when premium trends are exceeding cost trends, you expect to see exits from markets rather than entry, and from our on-the-ground sense at 12 sites, we are still seeing some exits, we’re not seeing any entry”); Ginsburg Presentation, supra note 50, at 13.
Gabel 4/23 at 168–69; Gabel Presentation, supra note 53, at 15.
See, e.g., Desmarais 4/23 at 33, 35 (suggesting that in order “[t]o understand the current insurance marketplace, it’s important to recognize that insurers are subject to intense government scrutiny of their business practices” and that state policies sometimes reduce the number of insurers willing to do business in a particular state); Stephen Foreman, Competition Among Health Plans 11 (4/24) [hereinafter Foreman (stmt)], at http://www.ftc.gov/opp/hc/030423forman.pdf (noting that entry barriers include costs of regulatory approval, including capitalization). See also, Senkewicz 4/24 at 8–17 (outlining state regulatory procedures for insurers, but no ting that state regulators do not view the requirements as barriers, but as good, sound regulation of an industry where the transactions are no t at arms-length).
See Lerner 4/23 at 106–107 (suggesting employer community could set up own HMO if monopolist managed care plan unreasonably raised rates, absent the monopolist “tying up the provider community with exclusive contracts or something”); Wu 4/23 at 118–19. But see Foreman (stmt), supra note 55, at 9.
Angoff 4/24 at 39–45.
Id. See also American Bar Ass’n, Comments Regarding the Federal Trade Commission’s Workshop on Health Care and Competition Law and Policy 8–9 (Public Comment).
Angoff 4/24 at 43–45.
Id. at 46–49. See also Foreman (stmt), supra note 55, at 7–8 (arguing that “mergers may have the effect of increasing brand name loyalty even though there has been no change in quality”); Angoff 4/24 at 52 (suggesting that perhaps the Guidelines should be revised to state that “even when a merger does not meet the H erfindahl thresho lds, in a market, where entry is particularly difficult, and efficiencies are clearly not going to be created,” the merger should be challenged). But see Lerner 4/24 at 119–20 (noting that the antitrust laws should not be used to challenge inefficient mergers that do not raise competitive concerns).
See Ruth S. Given, Economies Of Scale And Scope As An Explanation Of Merger And Output Diversification Activities In The Health Maintenance Organization Industry, 15 J. Health Econ. 685 (1996); Douglas Wholey et al., Scale And Scope Economies Among Health Maintenance Organizations, 15 J. HEALTH ECON. 657 (1996).
See, e.g., Ginsburg 4/23 at 19 (noting that one of the stated reasons for many of the recent health insurance mergers is “to achieve scale economies which presumably could come from the use of information technology and marketing and the same promotional programs and in-care management and how to do it”); Given 4/24 at 30–31, 33–37 (suggesting that the need for larger economies of scale and efficiencies, resulting in larger HMO size, also may create greater barriers to entry).
See generally Ginsburg 4/23 at 18 (“Disease management and case management, these are new areas and some companies are pursing it in a more sophisticated way.”); Given 4/24 at 33.
Ginsburg 4/23 at 28–29. See also Foreman (stmt), supra note 55, at 8 (arguing that “developing credibility with employer-purchasers” is an entry barrier).
Wu 4/23 at 119; Wu Presentation, supra note 42, at 5; Wu 4/24 at 53–62 (discussing studies of entry, expansion, and customer switching. between health plans), 62 (concluding that, based on the studies he has reviewed, entry and expansion have been sufficient to take share away from the leading firm and have reduced HMO concentration over time, and that this evidence, along with facts about the percentage of employees who have a choice of plans, suggest that although there are switching costs, they do not rise to the level of being a barrier to entry).
Wu 4/23 at 120–23; Wu Presentation, supra note 42, at 6–11; Wu 4/24 at 57–62.
Wu 4/23 at 118.
Id. at 123–24; Wu Presentation, supra note 42, at 11 (showing that from January 1994 through December 1998, new entrants captured 47 percent of the HMO/POS market from six incumbent firms and that the largest incumbent, Blue Cross & Blue Shield of New Jersey, went from having 38 percent of the market to 21 percent). But see Foreman 4/24 at 69 (arguing that more recent data suggests that there are only two insurers left in the Atlantic City, New Jersey market).
Id. at 41. See also Id. (“In the late 1990s, there were many examples in many states where insurers rapidly expanded services from one part of the state to the next and the data showed that this expansion came at a very low price.”).
Merger Guidelines, supra note 1, § 4 (as revised Apr. 8, 1997).
Id. § 4.
Merger-specific efficiencies are “only those efficiencies likely to be accomplished with the proposed merger and unlikely to be accomplished in the absence of either the proposed merger or another means having comparable anticompetitive effects.” Id. Cognizable efficiencies are assessed “net of co sts produced by the merger or incurred in achieving those efficiencies.” Id.
Given 4/24 at 27–34; Ruth Given, National HMO Trends 6 (4/24) (slides) [hereinafter Given Presentation], at http://www.ftc.gov/ogc/healthcarehearings/docs/0304given.pdf. See also Given at 4/24 at 111–12 (“[J]ust because you have economies of scale doesn’t mean you have mergerspecific efficiencies”).
Given 4/24 at 33 (noting that plans may need to be bigger to negotiate with providers who also have gained greater market concentration); Given Presentation, supra note 73, at 6.
Given 4/24 at 32–36; Given Presentation, supra note 73, at 6.
Given Presentation, supra note 73, at 6; Given 4/24 at 32–37; see also Schwartz 4/25 at 9.
Schwartz 4/25 at 9. See also Given 4/24 at 34–37; G iven Presentation, supra note 73, at 6.
Given 4/24 at 34–37; Given Presentation, supra note 73, at 6.
Given 4/24 at 32–33 (noting that an article she wrote discussed maximizing efficiencies at about 115,000 enrollees, but in that case she was discussing the “whole state of California, and it’s about 30-to 40,000 when you adjust for” the number of geographic markets in which HMOs compete in the state; further noting, however, that these numbers may be biased low for current market conditions).
Gabel 4/23 at 165–66; Gabel Presentation, supra note 53, at 9 (summarizing the literature about HMO market structure and performance and noting that local market competition increased between 1994 and 1997 despite national mergers, and that local markets determine the level of competition).
Senkewicz 4/24 at 65–66.
See Foreman 4/24 at 117; Angoff 4/24 at 117–118. See also id. at 122; Lerner 4/24 at 120, 123. Both panelists suggested that the Agencies work more closely with state insurance regulators with respect to health plan mergers.
See, e.g., Feldman 4/23 at 96 (“Unfortunately, I think antitrust cases have to be done one at a time”); Lerner 4/23 at 97–98 (“So, I think a lot of these things, I agree, you have to look at the case you’re dealing with and figure out what makes sense”); Monk 4/23 at 98 (“[W]hen you’re looking at a specific market, you do have to factor in what the characteristics that are in that market at that time and whether the characteristics changed because there was a change in — either the market was currently in balance or out of balance”). See also Ginsburg 04/24 at 7 (“The key to performance by health insurers is really the direction that they get from employers, and I think the problems we have now often stem from the type of directions or absence of it that insurers are getting from employers, their customers”).
Schwartz 4/25 at 8–9; see also Dick 4/25 at 4. When a group of buyers combines to exercise market power it is called oligopsony power.
Schwartz 4/25 at 9–11; Marius Schwartz, Buyer Power Concerns and the Aetna-Prudential Merger, Address Before the 5th Annual Health Care Antitrust Forum at Northwestern University School of Law 4–6 (October 20, 1999) (noting that anticompetitive effects can occur even if the conduct does not adversely affect the ultimate consumers who purchase the end-product), available at http://www.usdoj.gov/atr/public/speeches/3924.wpd.
Schwartz, supra note 85, at 5; see also Schwartz 4/25 at 9 (“If, for example, a merger enables the now bigger buyer to get a lower price because of efficiencies, for example, [when] it buys in bulk, and that saves resources, and that’s what enables a lower wholesale price, then that’s a good thing. That is likely to also increase the amount of the input that’s purchased and, therefore, is a good thing for overall economic performance.”).
The Division defined monopsony markets in both Aetna/Prudential and Cargill/Continental Grain. Aetna Complaint, supra note 26, ¶ 27; Aetna Impact Statement, supra note 26, at 9; United States v. Cargill, Inc., No. 1:99CV01875 ¶¶ 17–19 (July 8, 1999) (complaint), available at http://www.usdoj.gov/atr/cases/f2500/2552.pdf. See also Schwartz 4/25 at 8–22. The Commission defined monopsony markets in several cases, including In re BP Amoco, PLC, Dkt. No. 3938 (Aug. 25, 2000), complaint at ¶¶ 43–48 (complaint alleged that merger would lessen competition in bidding for rights to explore the Alaska North Slope).
United States v. Cargill, Inc., 2000–2 Trade Cas. (CCH) ¶ 72,966 (D.D.C. 2000).
United States v. Aetna, Inc., 1999–2 Trade Cas. (CCH) ¶ 72,730 (N.D. Tex. 1999).
See also supra Chapter 1.
See Miles 4/25 at 44.
See United States v. Med. Mut. of Ohio, 1999–1 T rade Cas. (CCH) ¶ 72,465 (N.D. Ohio v. Delta 1999); United States Dental of R.I., 943 F. Supp. 172 (D.R.I. 1996); United States v. Vision Serv. Plan, 1996–1 Trade Cas. (CCH) ¶ 71,404 (D.D.C. 1996).
See Miles 4/24 at 130–31. This panelist said that the cases that do address monopsony power have not done a good job of analyzing market definition issues, defining the market in terms of the output market rather than the input market. Id. He noted, however, that the Second Circuit’s decision in Todd v. Exxon, 275 F.3d 191 (2d Cir. 2001), which defined the product market by focusing on the interchangeability, from the perspective of plaintiffemployees, of job opportunities in the oil industry and job opportunities in other industries, handled monopsony market definition in a sound manner. Id. at 131–32. He also observed that United States v. Socony-Vacuum Oil Co., 310 U.S. 150 (1940) and Mandeville Island Farms v. American Crystal Sugar Co., 334 U.S. 219 (1948), both involved monopsony power issues in the form of naked price-fixing agreements among buyers with market power. Id. at 127–28.
See id. at 134; Schwartz 4/25 at 11–12.
See McCarthy 4/24 at 202; Blair 4/24 at 204 (noting that when patients need medical services, “whether they’re represented by a commercial health insurer or a government health insurer... [they] contribute to the demand that’s placed on the physician’s time”); but see Foreman 4/24 at 204 (stating that it is a “non-answer” to tell physicians that their “response to a monopsony reduction in prices [should be] to expand your M edicare and Medicaid patient list”).
See Miles 4/24 at 134.
See discussion of Cargill, infra notes 124–128, and accompanying text.
Aetna Complaint, supra note 26, ¶ 27; Aetna Impact Statement, supra note 26, at 9; see also McCarthy 4/24 at 166–67 (indicating that physician product market definition, in the context of monopsony, should be “basically specialty-specific”).
See, e.g., United States v. Dairy Farmers of Am., Inc., No. 6:03–206 (Apr. 24, 2003) (complaint), available at http://www.usdoj.gov/atr/cases/f200900/200972.pdf.
There was some disagreement among Hearings participants about the extent of price discrimination that actually occurs with resp ect to physician services. Compare Schwartz 4/25 at 16 (noting that there was a good deal of evidence in Aetna that “Aetna and other payors did not set their prices to physicians uniformly on a market wide basis, but rather, negotiated prices separately with individual physicians or individual physician groups”), with Frech 4/24 at 221 (stating that, once one looks past large physician groups, health care insurers do not engage in much price discrimination with respect to physicians).
See Foreman 4/24 at 175–77.
See Schwartz 4/25 at 17; Foreman 4/24 at 175–77. This panelist added that the different billing, quality assurance, and other systems that insurers use can make it difficult for physicians to switch to serving patients covered by another health care insurer. Id. at 176–77.
See Foreman 4/24 at 175–76; Frech 4/24 at 190.
See Foreman 4/24 at 175–76. A related question to the issue of physician mobility is how quickly must provider migration remedy a monopsony situation to make an antitrust remedy inappropriate. See Frech 4/24 at 190.
See McCarthy 4/24 at 163–64, 189.
See id. at 213–214; McCarthy 4/25 at 135; Miles 4/24 at 213.
See Schwartz 4/25 at 17–19.
See id. at 18.
See id. at 19.
See id. at 18–20.
See id. at 21–22.
See Miles 4/25 at 35–36. Some disagree on whether the physician supply curve is upward sloping or inelastic in many markets. Compare McCarthy 4/24 at 217 (indicating that the physician supply curve may be flat in many areas due to excess capacity), with Foreman 4/24 at 218 (stating that there is not “evidence of excess supply” and “depending on the specialty... [there are] some intermediate term concerns about supply.”).
See Miles 4/25 at 43–44.
See Frech 4/25 at 24–25. See also id. at 24–25 (noting that HMOs and PPOs can “improve competition and lower prices” because they “perform search[es] for consumers and they provide stronger incentives for choice of the low-priced sellers”), 28 (also noting that “reducing prices towards the competitive level is one of the general purposes of managed care and... — to the extent it happens — one of the competitive benefits of managed care and efficient health plans”).
749 F.2d 922 (1st Cir. 1984).
Id. at 923. Balance billing refers to the practice whereby a provider bills patients for the difference between what the insurer pays to the provider and the provider’s billed charge for the service. The prohibition on balance billing prohibits the provider from collecting money, other than copayments or deductibles, directly from the patient and requires providers who sign a participating provider agreement with Blue Shield “to accept as payment in full an amount determined by Blue Shield’s ‘usual and customary charge’ method of compensation.” Id.
Id. at 927.
Id. at 927–28, 929. The court also cited to three additional circumstances that argued “against any effort by an antitrust court to supervise the Blue Shield/physician price bargain.... First, the prices at issue are low prices, not high prices.... Second, the subject matter of the present agreement — medical costs — is an area of great complexity where more than solely economic values are at stake.... Third, the price system here at issue is one supervised by state regulators.” Id. at 930–31.
See Brewbaker 9/26 at 50–53 (listing variety of factors indicating that payors lack monopsony power). See also Timothy J. Muris, Everything Old is New Again: Health Care and Competition in the 21st Century, Speech Before the 7th Annual Competition in Health Care Forum 16–18 (Nov. 7, 2002), available at http://www.ftc.gov/speeches/muris/murishealthcarespeech0211.pdf (noting that physicians who entered into consent agreements to settle FTC allegations of anticompetitive conduct were not located in areas with high payor concentration — indicating that the driving force behind such conduct was not an attempt to offset monopsony power).
See McCarthy 4/25 at 65–69. See also discussion of entry, supra notes 49–69, and accompanying text.
See Foreman 4/25 at 122–23.
See Frech at 25. See also Kartell, 749 F.2d at 927–28 (noting the difficulty of determining what is a reasonable or competitive price) and infra Chapter 7 (discussing the difficulties of using price controls to reflect competitive prices).
See Frech 4/25 at 25–27.
See Schwartz 4/25 at 11–12; Frech 4/25 at 29–30.
See Schwartz 4/25 at 11–12.
See id.
See id.
See id. at 12.
Miles 4/25 at 35.
Frech 4/24 at 31–32.
Overstreet 5/7 at 146 (noting that “[t]here’s a fair consensus among economists that have looked at these things that they can be procompetitive or anticompetitive depending on the factual circumstances”); Kopit 5/7 at 126, 132–35; Baker 5/7 at 139–43; Snow 5/7 at 154–55.
As discussed infra notes 148–?, and accompanying text, MFNs are typically used to eliminate provider discounting if the insurer is controlled by providers.
See Kopit 5/7 at 135–38 (suggesting that MFNs imposed by insurers with market power are likely anticompetitive unless they can be shown to reduce cost, similar to the the Robinson-Patman Act’s requirement that volume discounts be cost-justified ). See also Overstreet 5/7 at 148, 190–92 (noting importance of determining actual impact of MFN in weighing theoretical claims that lower costs to the firm imposing the MFN are offset by higher costs tocompeting firms).
Baker 5/7 at 141–43.
See id. at 142–43.
See generally Snow 5/7 at 156–57 (arguing “that in most cases, the largest buyer is entitled to a quantity discount and to the best price”). See also discussion infra note 153; Kopit 5/7 at 136–37 (suggesting some providers may have the incentive to offer smaller insurers lower rates in order to fill their remaining beds).
United States v. Delta Dental Plan of Ariz., 1995-1 Trade Cas. (CCH) ¶ 71,048 (D. Ariz. 1995); United States v. Or. Dental Ser. 1995-2 Trade Cas. (CCH) ¶ 71,062 (N.D.Cal. 1995); United States v. Vision Serv. Plan, 1996-1 Trade Cas. (CCH) ¶ 71,404 (D.D.C. 1996); United States v. Delta Dental of R.I., 943 F. Supp. 172 (D.R.I. 1996); United States v. Med. Mut. of Ohio, 1999-1 Trade Cas. (CCH) ¶ 72,465 (N.D. Ohio 1999); In re RxCare of Tenn., Inc., 121 F.T.C. 762 (1996).
e.g., Baker 5/7 at 143–45.
Delta Dental of R.I., 943 F. Sup p. at 176. In a case involving enforcement of an administrative subpoena, the 6th Circuit made a similar observation. h Blue Cross & Blue Shield of Ohio v. Klein, 117 F.3d 1420 (6th Cir. 1997) (unpublished opinion). See also Kopit 5/7 at 127–31; Overstreet 5/7 at 153.
Ocean State Physicians Health Plan, Inc. v. Blue Cross & Blue Shield of R.I., 883 F.2d 1101 (1st Cir. 1989); Kitsap Physician Serv. v. Wash. Dental Serv., 671 F. Supp. 1267 (W.D. W ash. 1987). For a discussion of Ocean State, see Kopit 5/7 at 124–27, 129–30, 134–35 and Snow 5/7 at 154–57.
Ocean State, 883 F.2d 1101 (1989). See also Kopit 5/7 at 125–27. But see Independence Blue Cross, July 23, 2003, Letter re: FTC/DOJ Hearings on Health Care and Competition Law and Policy 1 (Public Comment) (arguing that Independence Blue Cross’s “Prudent Buyer” clause is not an MFN clause).
Marshfield Clinic, 65 F.3d at 1415.
Id. See also Baker 5/7/03 at 144; Jonathan Baker, Competitive Effects of Most Favored Nation Clauses in Health Care Markets 12 (5/7) (slides) [hereinafter Baker Presentation], at http://www.ftc.gov/ogc/healthcarehearings/docs/0305 07baker.pdf; Kopit 5/7 at 119–21 (“One of the interesting things about that is there was no MFN in the case.... So, to say it was gratuitous, I’d say that’s a fair statement.”).
United States v. Eli Lilly, 24 F.R.D. 285 (D.N.J. 1959).
Reazin v. Blue Cross & Blue Shield of Kan., Inc., 899 F.2d 951, 971 n.30 (10th Cir. 1990). The Tenth Circuit noted that it did not need to reach the question addressed in Ocean State of whether an MFN clause could itself violate Section 2. Id. at 971 n.30.
Williamette Dental Group v. Oregon Dental Serv. Corp., 882 P.2d 637 (Or. App. 1994); In re Brand Name Prescription Drugs, 288 F. 3d 1028, 1033 (7th Cir. 2002); Baker 5/7 at 141–45; Baker Presentation, supra note 143, at 8–12.
See, e.g., Baker 5/7 at 139–40.
See Baker 5/7 at 139–40; Overstreet 5/7 at 146–47
See United States v. Delta Dental Plan of Ariz., 1995-1 Trade Cas. (CCH) ¶ 71,048 (D. Ariz. 1995); United States v. O regon Dental Serv., 1995-2 Trade Cas. (CCH) ¶ 71,062 (N.D.Cal. 1995); In re RxCare of Tenn., Inc., 121 F.T.C. 762 (1996).
121 F.T.C. at 763 † 2 (complaint).
Id at 764 † 8.
Baker 5/7 at 140; Overstreet 5/7 at 147–48.
Hospitals, in order to fill their beds, may compete with each other at the margin for the additional patients that smaller insurers can provide them. A hospital, similar to an airline seeking to fill the seats on a flight, may be willing to serve those few additional patients at rates closer to its marginal cost than it would the bulk of its business. Kopit 5/7 at 136–37. The airline analogy may not cap ture the full implications of this competition among hospitals over incremental sales, however, because passengers on an airplane do not compete with each other in a downstream market, whereas insurers compete with each other in the sale of health care insurance. The disparity in hospital rates among competing plans may affect that competition to a significant degree. See Snow 5/7 at 156–57.
Baker 5/7 at 140; Baker Presentation, supra note 143, at 6.
899 F.2d 951, 970 (10th Cir. 1990). For example, Blue Cross had terminated its contract with one hospital that was participating in an HMO. Moreover, it sent a letter to all other hospitals in its service area warning that if they decided to pursue vertical integration arrangements with insurers, Blue Cross would be forced to reassess its relationship with the hospital, and “[h]ospitals that wish to continue their current relationship with Blue Cross and Blue Shield, that do not seek to enroll subscribers in other programs, and that wish to cooperate with Blue Cross and Blue Shield as a major marketing arm of the hospital, will experience no change in the contractual relationship that has historically served Kansans well.” Id. at 959 n.8.
Id. at 972 & n.32 (rejecting Blue Cross’s attempt to rely on Ball Memorial Hosp. Inc. v. Mutual Hospital Insurance, 784 F.2d 1325 (7th Cir. 1986), for the proposition that entry barriers in the health care financing market were always low). The 10th Circuit noted that entry barriers might be low in Indiana, where Blue Cross only had 27 percent of the market and there were 500 insurers currently doing business in the state, but they were not low in Kansas. Interestingly, the plaintiff hospitals in Ball Memorial were attempting to prevent Blue Cross from entering the market with a PPO product that competed with many of their own. 784 F.2d at 1339. In Reazin, Blue Cross was attempting to prevent the hospitals from participating in alternative delivery systems like HMOs and PPOs that might compete with Blue Cross’s traditional indemnity plans. 899 F.2d at 964–65.
See Kopit 5/7 at 132–33, 194–95; Overstreet 5/7 at 147–48.
See Kopit 5/7 at 132–3; Overstreet 5/7 at 147–48.
See, e.g., RxCare of Tenn., 121 F.T.C. 762 (1996); Reazin, 899 F.2d at 971 n.30 (“[T]he most favored nation clause here is no t itself challenged as unlawful monopolization. Rather, it is only considered as evidence of, or as contributing to, Blue Cross’ market or monopoly power”). See also Baker 5/7 at 139 (noting that the cases in which MFNs receive antitrust scrutiny usually involve a dominant health plan); Kopit 5/7 at 131.
See Overstreet 5/7 at 147 (noting that the “concern in the upstream market is most likely to be a competitive one when that market is concentrated, is subject to oligopoly coordination; in the downstream market, the concern is most likely to be a real issue when the firm imposing the MFN has a large share of the market”); Baker 5 /7 at 139–140. But see Snow 5/7 at 156 (arguing that an MFN is “primarily a device to prevent price discrimination....[and] that in most cases, the largest buyer is entitled to a quantity discount and to the best price”).
Baker 5/7 at 139–41; Baker Presentation, supra note 143, a t 5. See also RxCare of Tenn., 121 F.T.C. 76 2.
Russell Korobkin, The Efficiency of Managed Care “Patient Protection” Laws: Incomplete Contracts, Bounded Rationality, and Market Failure, 85 Cornell L. Rev. 1, 8 (1999). See also Lawrence H. Summers, Some Simple Economics of Mandated Benefits, 79 Am. Econ. Rev. 177, 178 (May 1989).
Korobkin, supra note 162, at 87–88.
Id.
Id. See also Summers, supra note 162, at 178 (suggesting that individuals may “irrationally underestimate the probability of catastrophic health expenses, or of a child’s illness that would require a sustained leave”); Frank A. Sloan & Mark A. Hall, Market Failures and the Evolution of State Regulation of Managed Care, 65 Law & Contemp. Probs. 169, 173 (Fall 2002) (“[T]he complexity of the contract may make it very costly for the ordinary consumer to make comparisons among the few alternative plans most consumers have.”). In such situations, consumers are likely to adopt choice strategies that have various weaknesses. Herbert A. Simon, Rational Choice and the Structure of the Environment, 63 Psychol. Rev. 129 (1956); James G. March, Bounded Rationality, Ambiguity, and the Engineering of Choice, 9 Bell J. Econ. 587, 590 (1978). For example, the greater the number of plan attributes that must be compared and weighed, the more likely it is that consumers will simply focus on the price of the plan. Korobkin, supra note 162, at 88.
See Gitterman 6/25 at 19; Hyman 6/25 at 85. See also Summers, supra note 162, at 179.
Hyman 6/25 at 85; Greenberg 9/9/02 at 179–180 (noting risk selection problems in the health care market). Cf. Herzlinger 5/27 at 92 (suggesting that providers who treat sicker patients should receive higher payments).
Ibson 6/25 at 19 (noting employers often single out “mental health disorders and impose restrictive limits on care”).
See id. at 22–24.
See id. at 23 (referring to studies performed by PricewaterhouseCoopers and the National Advisory Mental Health Council). But see Knettel 6/25 at 78–79 (arguing that flexible interpretations of parity laws and carve out arrangements have made impact of parity requirements “tolerable”).
Ibson 6/25 at 24 (arguing that untreated depression costs the economy $44 billion per year in lost productivity); Laser 6/25 at 47–48 (noting that “there was no cost increase due to contraceptive coverage... and the savings of contraceptive coverage outweigh the costs” including savings from “fewer pregnancies, fewer deliveries, and healthier newborns”).
See Kanwit 6/25 at 37–39; Gitterman 6/25 at 8 (“[W]hy mandate Cadillac coverage when purchasers just want a Chevy.”); Mark A. Hall, Making Medical Spending Decisions: The Law, Ethics and Economics of Rationing Mechanisms 22, 24 (1997) (identifying mandates as an important source of inefficiency, and observing that “[e]conomists explain that it usually makes no sense to mandate or encourage insurance that many consumers are unwilling to buy.”). Studies suggest twenty to twenty-five percent of uninsured Americans lack coverage because of benefit mandates. Gail Jensen & Michael Morrisey, Mandated Benefit Laws and Employer-Sponsored Health Insurance 1 (1999) (prepared for Health Insurance Ass’n of America), available at http://www.insureusa.org/research/jensen.htm; Frank A. Sloan & Christopher J. Conover, Effects of State Reforms on Health Insurance Coverage of Adults, 35 Inquiry 280 (1998). See also Kanwit 6/25 at 38–39; T. Miller 6/25 at 63.
Richard A. Epstein, Mortal Peril: Our Inalienable Right to Health Care? 429 (1997).
Patricia M. Danzon, Tort Liability: A Minefield for Managed Care?, 26 J. Legal Stud. 491, 509 (1997). See also David A. Hyman, Consumer Protection in a Managed Care World: Should Consumers Call 911?, 43 Vill. L. Rev. 409, 437 (1998) (“Policy sellers must weigh whether broadening coverage... [is] worth doing if [it] price[s] the policy out of the market — or result[s] in a shift in the nature of coverage from that which is most appealing to the covered pool as a whole.”).
Korobkin, supra note 162, at 22. See also Kanwit 6/25 at 28 (arguing that mandates “drive up the costs for employers and consumers”, “may restrict consumer choice”, “discourage competition among providers”, and “stifle innovative medical advances in treatment and diagnosis because they freeze current practice.”).
T. Miller 6/25 at 57.
See, e.g., Kanwit 6/25 at 40 (describing the New England Journal of Medicine study that suggested that the mandated 48 hour maternity stay mandate did not help infant health); Hyman 6/25 at 87 (noting use of “horror stories” to set regulatory agenda); Clark Havighurst, American Health Care and the Law: We Need to Talk!, 19 Health Affairs 84, 105 n.7 (July/Aug. 2000) (“Nothing could be clearer, however, than that the signals that voters (consumers wearing a different hat and having less reason to think rationally or fully inform themselves) send to their representatives do not invite rational consideration of difficult trade-offs.”); David A. Hyman, Regulating Managed Care: What’s Wrong With A Patient Bill of Rights, 73 S. Cal. L. Rev. 221, 237–41 (2000).
Gitterman 6/25 at 9 (“It’s hard for any voter, consumer or worker to know for sure how he or she is being affected by what ends up being a confusing tax. This helps policymakers foster the illusion that benefits can be provided and no one bears the cost.”).
Uwe E. Reinhardt, Health Insurance for the Nation’s Poor, 6 Health Affairs 101, 106 (Spring 1987) (“A pseudo-tax is a government-mandated fiscal transfer among private individuals, institutions, or business firms that can be referred to by a name other than tax and that does not flow through a public budget for which politicians can be held accountable.”); Daniel P. Gitterman & Robert Nordyke, Providing Credible Information and Improving Health Insurance Regulatory Impact Analysis in California: A Report to the California Health Care Foundation 2 (1999).
Jensen & Morrisey, supra note 172, at 5. See also supra note 1 74, and accompanying text.
See, e.g., Kanwit 6/25 at 39–40 (describing the mandates for autologous bone marrow transplant (ABMT), a breast cancer treatment for women for which there were no clinical trials, many women died from the treatment, and ABMT was no more effective than the standard treatment); T. Miller 6/25 at 66; Jensen & Morrisey, supra note 172, at 5; Hyman, supra note 177, at 223.
Knettel 6/25 at 76. Of course, these are the very employers that may be best able to avoid the state mandates by self-insuring.
The Employee Retirement Income Security Act (ERISA) largely preempts self-insured plans from state mandates. Thus, an employer may avoid state regulation by pro viding its own insurance. See supra Chapter 5.
Jensen & Morrisey, supra note 172, at 9–10.
Knettel 6/25 at 73–75 (noting that each time a benefit is mandated that mandate “is going to be offset by a benefit reduction of equal or greater cost in some other area”). See also Sloan & Conover, supra note 172.
See T. Miller 6/25 at 64 (noting that mandates “can also have offsetting effects in terms of lower wages, decreased employment, reduced generosity of fringe benefits as well”). See also Gitterman 6/25 at 18; T. Miller 6/25 at 57.
As the costs of mandates rise, more firms seek to self-insure to avoid the added expense of state mandates, but some smaller businesses do not have the necessary capital to do so. See Jensen & Morrisey, supra note 172, at 10. As stop — loss insurance with low attachment points has made self-insurance available on a broader basis, this problem has become less significant.
See Kanwit 6/25 at 37; Gitterman 6/25 at 15 (“One of the things that you have seen in the 1996 mental health parity debate is the incredible wide range of estimates from each of these different consulting groups. I think the costs were somewhere between zero and 8 percent.”).
See generally 6/26 at 6–105; Hyman, supra note 177, at 234–36.
The substantial tax subsidy for employment-based health insurance encourages broader and deeper insurance coverage than would otherwise be the case. Pauly 2/26 at 98; Clark Havighurst, How the Health Care Revolution Fell Short, 65 Law & Contemp. Probs. 55, 69–71 (2002).
See generally Hyman, supra note 177.
Michael Vita, Regulatory Restrictions on Selective Contracting: An Empirical Analysis of ‘Any Willing Provider’ Regulations, 20 J. Health Econ. 955, 956 (2001).
See, e.g., id. (“[F]reedom of choice (FOC) laws... obligate plans to reimburse for care obtained from a qualified provider even if the provider is not a member of the network”)
See, e.g., id. (“By one count, 34 states had enacted some form of FOC or AWP law by 1996”).
See FTC staff comments on proposed legislation that incorporated any willing provider or “freedom of choice” provisions in the following states: Rhode Island (Letter from Office of Policy Planning et al., to Patrick C. Lynch, Attorney General (Apr. 8, 2004)), at http://www.ftc.gov/os/2004/04/ribills.pdf; Massachusetts (Letter from Bureau of Competition, to John C. Bartley, Representative (May 30, 1989)); New Hampshire (Letter from Office of Consumer & Competition Advocacy, to Paul J. Alfano (Mar. 17, 1992)); California (Letter from Office of Consumer & Competition Advocacy, to Patrick Johnston, Senator (June 26, 1992)), at http://www.ftc.gov/opa/predawn /F93/calpharm.htm; Montana (Letter from Office of Consumer and Competition Advocacy, to Joseph P. Mazurek, Attorney General (Feb. 4, 1993)); New Jersey (Letter from Office of Consumer and Competition Advocacy, to E. Scott Garrett, Assemblyman (Mar. 29, 1993)); Pennsylvania (Letter from Office of Consumer and Competition Advocacy, to Roger Madigan, Senator (Apr. 19, 1993)); South Carolina (Letter from Office of Consumer and Competition Advocacy, to Thomas C. Alexander, Representative (May 10, 1993)); and Nevada (Letter from Bureau of Competition, to David A. Gates, Commissioner of Insurance (Nov. 5, 1986)).
See, e.g., FTC Staff letter to Rhode Island, supra note 195, at 6; Greenberg 6/12 at 68–69.
See supra note 196.
FTC Staff letter to Rhode Island, supra note 195. See also Michael A. Morrisey & Robert L. Ohsfeldt, Do State ‘Any Willing Provider’ and ‘Freedom of Choice’ Laws Affect HMO Market Share?, 40 Inquiry 362 (2003/2004).
See, e.g., Gene A. Blumenreich, United States Supreme Court upholds “any willing provider” statutes, 71 AANA J. 259 (Aug. 2003) (Legal Brief of American Ass’n of Nurse Anesthetists), at http://www.aana.com/legal/legbrfs/2003/pdfs/p259–262.pdf; American Medical Ass’n, H-285.984 Any Willing Provider Provisions and Laws (AMA policy re: “Any Willing Provider” laws, including opposing federal preemption of state AWP laws), at http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-285.984.htm (last visited June 25, 2004); National Community Pharmacists Ass’n, High Court Upholds State Any Willing Provider Laws (from America’s Pharmacist, May 2003), at http://www.ncpanet.org/leg_gov/notes_from_capitol_hill/2003/may.shtml
FTC Staff letter to Rhode Island, supra note 195. But see Blumenreich, supra note 199 (noting that the American Association of Nurse Anesthetists (AANA) supports AWP legislation, arguing that these laws prohibit insurance companies from discriminating against them).
Congressional Budget Office, CBO’s Activities under the Unfunded Mandates Reform Act, 1996–2000 (2001), available at ftp://ftp.cbo.gov/28xx/doc2843/UMRA-Paper.pdf; Unfunded Mandates Reform Act (UMRA) of 1995, Pub. L. No. 104–4, 109 Stat. 48. The UMRA requires the Congressional Budget Office (CBO) to prepare an analysis of the direct costs of any mandates and an assessment of whether the bill authorizes or otherwise provides funding to cover the costs of the mandate.
Gitterman & Nordyke, supra note 179.
Gitterman 6/25 at 12–13.
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2005 Springer
About this chapter
Cite this chapter
(2005). Chapter 6: Competition Law: Insurers. In: Hyman, D. (eds) Improving Healthcare. Developments in Health Economics and Public Policy, vol 9. Springer, Boston, MA. https://doi.org/10.1007/0-387-25752-7_7
Download citation
DOI: https://doi.org/10.1007/0-387-25752-7_7
Publisher Name: Springer, Boston, MA
Print ISBN: 978-0-387-25751-8
Online ISBN: 978-0-387-25752-5
eBook Packages: Business and EconomicsEconomics and Finance (R0)