State sued Sutter Health, the largest hospital system in northern California, alleging that Sutter engaged in anticompetitive behavior in violation of the Cartwright Act by 1) establishing, increasing and maintaining Sutter’s power to control prices and exclude competition; 2) foreclosing price competition by Sutter’s competitors; and 3) enabling Sutter to impose prices for hospital healthcare services and ancillary products that far exceed the prices it would have been able to charge in an unconstrained, competitive market. The complaint alleges that Sutter did this by: Preventing insurance companies from negotiating with it on anything other than “all or nothingâ€ system-wide basis, requiring health insurers under the terms of contract with Sutter Health to negotiate with all the Sutter Health system or face termination of their contract; Preventing insurance companies from giving consumers more low-cost health plan options, for example, charging a $200 out-of-pocket cost for an outpatient surgery performed by a facility outside of the preferred group and $100 for outpatient surgery performed by a facility inside the preferred group; Setting excessively high out-of-network rates for patients who must seek care outside of their provider network; Restricting publication of provider cost information and rates. The complaint alleged three causes of action under the Cartwright Act: price tampering and fixing; unreasonable restraint of trade; and combination to monopolize. The state sought injunctive relief, disgorgement and attroneys fees.
Commonwealth v. Beth Israel Lahey Health, Inc. No. 2018-3703, Sussex Super. Ct., Mass Nov. 29, 2018)
Beth Israel Deaconess Medical Center and Lahey Health System sought to merger to form the Beth Israel Lahey Health system (BILH). After a lengthy investigation, the Massachusetts Attorney General reached a settlement that permitted the merger while imposing a seven-year price cap and $71.6 million in financial commitments to support health care services for low-income and underserved communities in Massachusetts. In an assurance of discontinuance, filed in Suffolk Superior Court, the parties agreed to a series of enforceable conditions that also require BILH to strengthen its commitment to MassHealth; engage in joint business planning with its safety net hospital affiliates, including Lawrence General Hospital, Cambridge Health Alliance, and Signature Brockton Hospital; and enhance access to mental health and substance use disorder treatment across the system, as well as requiring BILH to retain a third-party monitor to ensure compliance with the terms. The settlement resulted after a referral from the state Health Policy Commission (HPC), which asked the AG’s Office to determine whether it could negotiate terms to address potential cost increases and barriers to access to care raised by the HPC’s own review of the transaction.
United States and North Carolina v. Charlotte-Mecklenburg Hospital Authority d/b/a Carolinas Healthcare System
North Carolina and USDOJ filed suit alleging that Atrium Health, formerly known as Carolinas HealthCare System illegally reduced competition in the health care market in Charlotte and limited consumers’ ability to shop around for better deals on health care. Atrium is based in Charlotte and operates Carolinas Medical Center and nine other hospitals in the Charlotte area. It dominates the hospital market in the Charlotte region with a 50 percent share of the market and approximately $8.7 billion in annual revenues. The state alleged that Atrium acted unlawfully to preserve its dominance in the Charlotte health care market by using its market power to require steering restrictions in its contracts with every major insurer. These provisions have prevented insurers from, among other things, introducing health plans that encourage patients to use medical providers that offer lower priced, higher-quality services. The plaintiffs sought injunctive relief and attorneys fees. After the court denied defendants’ motion to dismiss, the parties settled. Under the terms of the settlement, Atrium is prohibited from using anticompetitive steering restrictions in contracts between commercial health insurers and its providers in the Charlotte, North Carolina metropolitan area. These steering restrictions prevented health insurers from promoting innovative health benefit plans and more cost-effective healthcare services to consumers.
United States and Michigan v. Hillsdale Community Health Center et al., No. 2:15-cv-12311 (E.D. Mich. June 25, 2015)
The United States and Michigan filed suit in federal court against four Michigan hospital systems, alleging that for years they unlawfully agreed to allocate territories for marketing. The complaint alleged Hillsdale, Allegiance, Branch and ProMedica’s Bixby and Herrick Hospitals, the only hospitals in their respective counties, each competed through marketing to attract patients, including advertising, direct mailings to patients, outreach to physicians and employers, conducting health fairs and offering free health screenings. The complaint alleges that Hillsdale curtailed this competition for years by entering into agreements with Allegiance, Branch and ProMedica to limit the marketing of competing healthcare services. Three of the systems, Hillsdale Community Health Center, Community Health Center of Branch County, Michigan, and ProMedica Health System Inc., agreed to settle the charges in 2015. The settlement prohibits Hillsdale, Branch and ProMedica from agreeing with other healthcare providers, including hospitals and physicians, to limit marketing or to divide any geographic market or territory, prohibits communications among the defendants about their marketing activities and requires the hospitals to implement compliance measures tailored to prevent the recurrence of these types of anticompetitive practices in the future. The parties paid $5,000 each to Michigan for costs and attorneys’ fees. W.A. Foote Memorial Hospital, doing business as Allegiance Health, settled in 2018. The Allegiance settlement expands on the terms of the previous settlements, specifically, the proposed settlement prevents Allegiance from engaging in improper communications with competing providers regarding their respective marketing activities and entering into any improper agreement to allocate customers or to limit marketing. It explicitly prevents Allegiance from continuing to carve out Hillsdale County from its marketing and business development activities. Allegiance must report any violations and must annually certify compliance with the terms of the final judgment. Allegiance must also submit to compliance inspections at the Department’s request. Allegiance must also pay $40,000 to the state and the US to reimburse costs.
The FTC administratively challenged the combination of Penn State Hershey Medical Center and PinnacleHealth System, alleging that the merger would substantially reduce competition for general acute care inpatient hospital services in the area surrounding Harrisburg, Pennsylvania, leading to higher costs and reduced quality. The FTC and Pennsylvania filed a motion for preliminary injunction in federal court in Pennsylvania. The court denied the motion by the FTC and Pennsylvania in an opinion filed under seal, holding that the plaintiffs did not properly define the relevant geographic market. The FTC and Pennsylvania appealed to the 3rd Circuit, which reversed the district court and granted the preliminary injunction. The Third Circuit rejected the District Court’s reasoning on all counts: market definition, the relevance and persuasiveness of the parties’ 5-year contracts with payers, whether the claimed efficiencies were cognizable and potentially sufficient to overcome the government’s prima facie case, and how the equities should be balanced in an FTC preliminary injunction proceeding. The parties abandoned the merger. The 3d Circuit denied Pennsylvania’s claim for attorneys’ fees on the grounds that the relief was granted under FTC Act Sec. 13(b), which does not authorize attorneys’ fees to prevailing parties.
The FTC administratively challenged the proposed merger of Advocate Health Care Network and NorthShore University HealthSystem, alleging it would create the largest hospital system in the North Shore area of Chicago. According to the complaint, the combined entity would operate a majority of the hospitals in the area and control more than 50 percent of the general acute care inpatient hospital services. The FTC and the State of Illinois filed for a preliminary injunction to prevent the merger before the FTC’s administrative trial. The district court denied the motion for preliminary injunction based on a finding that “plaintiffs ha[d] not shouldered their burden of proving a relevant geographic market.” The state and the FTC appealed. The 7th Circuit reversed and remanded the case. The court of appeals held that the district court’s geographic market finding was clearly erroneous, and approved the hypothetical monopolist test. The court also cited the “silent majority” fallacy, which overlooks the market power of the patients who are not willing to travel for hospital care.
In the Matter of Cabell Huntington Hospital, Inc.’s Acquisition of St. Mary’s Medical Center, No. 15-C-542, Cabell Cty. Ct., WV
The attorney general reached an agreement with two hospitals in the Huntington WV area who were merging. The agreement requires, among other things 1) that St. Mary’s Medical Center will be maintained as a free-standing, general acute care, faith-based organization for the seven-year period;2) Neither hospital will increase its service rates beyond the benchmark rate established by the West Virginia Health Care Authority; 3) If the combined operating margins of the hospitals exceed an average of 4 percent during any three-year period, the hospitals’ rates will be reduced by the amount of excess for the following three years; 4) Both hospitals will release employees from any non-compete agreements following the termination of their employment 5) The hospitals will maintain open staffs and grant privileges to all qualified physicians, and not terminate privileges to those who start offering services in competition to the hospitals (excluding groups that historically have operated under exclusive agreements) 6) The hospitals will not oppose the award of a certificate of need by the state Health Care Authority to any health care provider that seeks to provide services in their market area; 7) the hospitals will establish a fully integrated and interactive medical record system at both facilities so that patient encounters can be readily available to physicians at both hospitals; 8) they will notify the Attorney General’s Office within 90 days of any proposed addition or deletion of any health care service line.
Massachusetts v. Partners Healthcare System Inc. et al., no. 14-2033 (Mass. Super. Ct. June 24 2014)
State challenged by acquisition by Partners of South Shore, alleging that it would substantially lessen competition in portions of Eastern Massachusetts for the provision of general acute care inpatient health services in violation of state law. After extensive hearings, the Attorney General proposed a settlement. The court permitted extensive public comment and the settlement was ultimately rejected. The parties abandoned the transaction.
State and two hospitals agreed that the merged hospitals would, for a period of five years, pass on $100 million of cost savings to consumers, in the form of new or incremental services, including early detection and screening, increasing services to underserved populations, improvements of health care delivery. the hospitals also agreed to freeze hospital list prices for both inpatient and outpatient services for two years. Annual reports are to be submitted to the attorney general.
In the Matter of the Proposed combintion of Faxton-St. Luke’s Healthcare and St. Elizabeth Medical Center, Assurance No. 13-489 (Dec. 11, 2013))
The two acute care hospitals in the city of Utica sought to merge. Both are in a weak financial state and treat needy patients, most of whose care is covered by Medicaid or Medicare. The settlement includes provisions prohibiting the hospitals from requiring independent physicians to work exclusively at the hospitals, and from requiring health plans to reimburse competing hospitals or health care providers at the same or lower rates than the health plans reimburse the hospitals. The hospitals committed to negotiate in good faith with rate payers. If these payors believe that the hospitals are acting unfairly, the settlement gives the payors the right to continue their currently-existing relationships with the hospitals for five years at current prices, subjected to annual increases not to exceed historic levels. The settlement also provides for continued monitoring by the Attorney General to ensure that the hospitals have implemented their promised efficiencies prior to termination of the rate-protection provisions.