On 28 August 1996, the U.S. Federal Trade Commission and the U.S. Department of Justice issued new guidelines that will give physicians greater leeway to form networks and to integrate their practices under the antitrust laws [1]. By making it easier for physicians to band together, these guidelines address many of the concerns outlined by Dr. Duvall.

The guidelines were originally published in 1993 by the federal antitrust enforcement agencies to help physicians, hospitals, and other health providers understand the application of the antitrust laws to the health care market. In December 1995, the agencies announced that they would rewrite their guidelines to account for changes in the health care delivery system. Representatives of the American College of Physicians had several discussions with agency staff to educate them about the impact of the antitrust laws-and their enforcement-on physician activities in the marketplace.

College representatives argued that the agencies' reliance on financial risk sharing as proof of pro-competitive activities by physicians was unfair and stifled innovative delivery systems. They noted that, in some instances, an integrated group of physicians could provide high-quality and cost-effective care in a pro-competitive manner without sharing substantial financial risk. For example, the physicians could develop a management structure and make a commitment to gather and analyze clinical data, perform utilization review, implement quality improvement methods, and eventually change practice patterns.

The new guidelines specifically recognize that clinical integration can provide the same efficiencies as financial risk sharing [1]. Groups of physicians will not run afoul of the antitrust laws simply because they do not share financial risk. Moreover, if a physician network adopts a financial risk-sharing approach, the guidelines make it clear that a variety of models-in addition to capitation and withholds-will be allowed [1].

The guidelines also reiterate that physicians are not limited to only 20% or 30% of market share. These percentages represent "safety zones"-arrangements that will not be challenged under the antitrust laws unless extraordinary circumstances are present. The guidelines specifically state, however, that "merely because a physician network joint venture does not come within a safety zone in no way indicates that it is unlawful under the antitrust laws" (emphasis added) [1]. Consequently, a physician network that produces market efficiencies is legal even if the member physicians comprise a greater share of the market.

Organized medicine has praised the new guidelines as helpful to physicians [2]. The changes in antitrust enforcement policy detailed by the guidelines will give physicians greater flexibility as they proceed with their integration efforts across the country. This approach will benefit patients by opening the market to new products that have the potential to provide high-quality and affordable care.