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Patient referrals: could nurses be violating federal and state antitrust laws?

A recent Florida court case has clearly signaled that nurses may be increasingly involved in activities that may result in violation of state and federal antitrust laws. Nurses must review their referral practices for patterns similar to the Florida case and modify their practices to reflect the recent court decision.

Antitrust Laws↗
PubMed1980

Antitrust law and physician dominance of other health practitioners.

This article surveys recent developments in federal antitrust law regarding the health professions and the delivery of medical care. In the last four years there has been a steady erosion of the affirmative defenses traditionally available to health care providers, both institutional and individual. The article surveys these developments in terms of their implications for mounting antitrust attacks against the domination of nonphysician health care providers by physicians and other sectors of the health care industry. Three specific practices are discussed in light of their susceptibility to antitrust remedy: the denial of admitting privileges, third-party reimbursement, and physician backup to nonphysician practitioners. The article concludes with some caveats and admonitions to judges presiding over any cases which arise in this area.

Delivery of Health Care↗
PubMed1993

The physician self-referral dilemma: enforcing antitrust law as a solution.

As health care reform pervades the United States, lawmakers have subjected physician self-referrals to heightened scrutiny. Recent evidence indicates that sending patients to facilities in which a physician has an ownership interest often causes overutilization, overpricing, and lower quality of care. This Note analyzes how physician self-referral arrangements can have negative effects on competition. To combat the adverse effects, the Note examines how enforcing antitrust laws can ameliorate the self-referral dilemma and aid in restoring competition to the health care market. This solution will maintain the doctor's right to invest while protecting the patient's vulnerability.

Antitrust Laws↗
PubMed1984

How can PPOs control prices without violating antitrust laws?

Preferred provider organizations (PPOs) have caused concern because they raise the question whether providers can establish mechanisms to control the price of medical care without violating antitrust laws. The U.S. Supreme Court recently decided in Arizona v. Maricopa County Medical Society that the practices of a physicians' organization which set fee schedules by majority vote constituted price fixing because "independent competing entrepreneurs" made the agreements. The decision implies that PPOs must carefully structure collective efforts to set prices in order to avoid unlawful agreement among competitors. To avoid antitrust exposure, hospitals may independently determine prices and contract individually with providers, or they may act as brokers for individual physicians, establishing fees and claims-processing procedures and then contracting with physicians who agree to these requirements. Setting fees independently may be difficult, however, since hospitals need to know what payment physicians will accept. Thus some physician involvement is probably inevitable. No antitrust liability results, however, if individual physicians are sampled in an information-gathering process but do not collectively set fees. In addition, a PPO that is structured as a partnership or other joint arrangement involving true risk sharing should withstand antitrust challenge. In recent business review letters, the Department of Justice approved two different PPO structures: A Hospital Corporation of America subsidiary would contract (nonexclusively) with providers, hospitals, and third party payers to treat the third party payers' beneficiaries at discounted rates. The charges would be negotiated individually with each physician and hospital. A management consultant firm would act as an intermediary between providers and third party payers, negotiating patient discounts but not participating in fee setting. A PPO need not be structured in every respect like these programs. Individual situations vary, and with sound antitrust advice, PPOs can avoid legal pitfalls.

Economic Competition↗