Physician-Run Health Plans and Antitrust

Abstract

As the health care system changes and large managed care entities gain greater control in some markets, proponents of antitrust reform have expressed concern that physicians could lose their autonomy.To respond to this concern, the American College of Physicians has consistently argued that physicians should be allowed to establish their own health plans and networks to provide high-quality and cost-effective care. Moreover, the College has advocated utilization review reform and due process protections to empower physicians in their dealings with insurers.

Under current antitrust law, as interpreted by the federal enforcement agencies, physicians already have the legal authority to form their own health plans and networks, and many state medical societies are sponsoring such plans.The law also allows physicians to operate the clinical components of a health plan, regardless of who owns it. Moreover, physicians can share information about quality, utilization, and, in some circumstances, fees. An examination of federal enforcement agency actions since the mid-1970s shows that physician networks have rarely been challenged. In light of market developments, however, the College has urged the federal antitrust agencies to analyze the effect of their current enforcement policies on physician activities and adopt a more flexible approach. Further monitoring and analysis of the changing health care marketplace are necessary to ensure that physicians are being treated fairly and to determine which factors spur or inhibit the development of physician-run health plans and networks.