By Doug Aldeen
Bottom of first inning:
Citizens and Plan Sponsors of the State of Wisconsin Antitrust Case (1): vs. Aspirus Health (Regional Monopoly) (0)
1. Sherman Act-price fixing. The court found that Schierl and Heartland adequately alleged price-fixing under Sherman Act Section 1 on the theory that Aspirus and ANI restricted their providers from marketplace activity. Here, the plaintiffs have alleged that Aspirus and ANI prohibit their providers from contracting directly with payers without Aspirus’s consent, and that Aspirus and ANI have pressured their competitors to price healthcare services based upon negotiated prices instead of upon Medicare rates or some other established benchmark
2. The court found that Schierl and Heartland adequately alleged tying under Sherman Act Section 1. Here, the defendants’ controlling market share, notably including the AWH hospital, makes it inevitable that any plan negotiated by a payer would include a network provider. Schierl and Heartland have alleged that the defendants insist upon “all or nothing” arrangements whereby payers cannot pick and choose which network providers they include or exclude from their particular plans.
Team Schierl Co. v. Aspirus, Inc.
Plaintiffs’ claim is based on the following allegations. Defendants have acquired 65 percent of the market for inpatient care in north-central Wisconsin and 75 percent of the market for outpatient care. Defendants have market power in the inpatient market in part because they own the Aspirus Wausau Hospital and that no commercially viable health plan in north-central Wisconsin could exclude that facility. Defendants have power in the outpatient market, through the sheer number of facilities that are in defendants’ network, so payers will “inevitably” need to contract with one of defendants’ outpatient providers. I
Aspirus’s prices are higher than the Wisconsin average. The Wisconsin average for inpatient services is 273 percent of Medicare prices; Aspirus’s average is 336 percent. The Wisconsin average for outpatient services is 337 percent of Medicare; Aspirus’s average is 383 percent.
Aspirus’s prices for specific procedures are higher than the national average. The national average for a lower limb MRI is $1,811; Aspirus’s average is $2,434. The national average for a joint replacement is $20,952; Aspirus’s average is $35,972. The national average for a spinal fusion is $39,000; Aspirus’s average is $71,000. The national average for a Level 5 emergency-room visit is $1,848; Aspirus’s average is $4,196. In recent years, Aspirus’s prices have risen at a significantly greater rate than its costs.