The health care industry continues to undergo unprecedented consolidation. Health care providers and payors alike have pursued a wide variety of integrative strategies to achieve efficiencies or other business advantages. The Health Care Mergers and Acquisitions Handbook is designed to educate the practitioner about the antitrust analysis of mergers and acquisitions within the health care industry. Over the past two decades there has been an extraordinary amount of litigation related to challenges of hospital mergers. Each chapter identifies and analyzes important antitrust issues governing such consolidations. Accordingly, the first several chapters are devoted to a detailed treatment of substantive issues peculiar to such mergers: an introduction to hospital merger litigation, describing trends in litigation and the way in which such mergers are analyzed; issues unique to market definition, including product market definition and geographic market definition; the competitive effects of hospital mergers, assessing the evidence necessary to establish a prima facie case in a merger challenge and the rebuttal arguments offered by merging parties; a unique rebuttal argument offered by merging hospitals that is treated separately due to its prominent role in hospital merger litigation - the role and significance of efficiencies in determining the competitive merits of such mergers; the potential applicability of the state action doctrine to hospital mergers. In addition to a substantive treatment of hospital mergers, the Handbook also addresses; combinations of health care management organizations (HMOs) and physician practice groups; the analysis used by the enforcement agencies when reviewing mergers of HMOs; antitrust issues posed by physician practice consolidations. The appendix contains a chart summarizing litigated hospital mergers.--

Consolidation via merger both from hospital-to-hospital mergers and from hospital acquisitions of physician groups is changing the competitive landscape of the provision of health care delivery in the United States. This Article undertakes a legal and economic examination of a recent Ninth Circuit case examining the hospital acquisition of a physician group. This Article explores the Saint Alphonsus Medical Center-Nampa Inc. v. St. Luke's Health System, Ltd. (St. Luke's) decision -- proposing a type of analysis that the district court and Ninth Circuit should have undertaken and that we hope future courts undertake when analyzing mergers in the health care sector. First, the Article addresses the question of how best to frame the acquisition of a physician group by a hospital -- is the merger horizontal, vertical, or potentially both? In undertaking this analysis the Article examines the broader issue of the treatment of Accountable Care Organizations (ACOs) in antitrust law. ACOs are short of full integration and as such, a potential contractual alternative for hospitals and physician groups to an acquisition. A hospital acquisition of a physician practice also has implications for how to view competitive effects in the context of ACOs. Indeed, in St. Luke's the Ninth Circuit suggests that integration short of full merger was a possible alternative. Second, the Article examines the justification for integration as a way to address countervailing power in health care, the reduction of transaction costs, and potential cost and quality efficiencies. Third, the Article applies the economics of these issues to merger case law generally and specifically to the St. Luke's decision. Ultimately, the Article finds the economic analysis of the Ninth Circuit lacking. Finally, the Article offers policy implications of the decision and concludes with some suggestions to improve health care antitrust analysis in practice for litigated cases to make such analysis better follow economic principles.

The appropriate role of merger efficiencies remains unresolved in US antitrust law and policy. The Patient Protection and Affordable Care Act (ACA) has led to a significant shift in health care delivery. The ACA promises that increased integration and a shift from quantity of performance through increased competition will create a system in which quality will go up and prices will go down. Increasingly, due to the economic trends that respond to the ACA, including considerable consolidation both horizontally and vertically, it is imperative that the antitrust agencies provide an economically sound and administrable legal approach to efficiency enhancing mergers. In this regard, horizontal hospital mergers present particularly challenges for antitrust. Most hospital merger cases focus on cost based efficiencies, as does most of the academic empirical literature. Yet, government policy seems out of synch with quality analysis. This essay proceeds as follows. First, it provides a discussion of the welfare effects on quality and its implications for antitrust analysis. In the next part, the article explores quality analysis both in the 2010 Horizontal Merger Guidelines and in antitrust case law. In doing so, the essay identifies areas both of clarity and ambiguity regarding quality enhancing efficiencies policy. In the subsequent part, the essay draws parallels to an efficiency analysis of quality under rule of reason analysis, in which the essay offers examples of resale price maintenance and tying of franchising contracts. Thereafter, in the next part, the essay addresses how agencies and courts should treat quality efficiencies in mergers. In doing so, the essay draws upon the existing academic literature in empirical industrial organization economics and public health on measurements of what is hospital quality in a consolidating healthcare marketplace. In its concluding section, the essay advocates a more robust use of quality measurements as a guiding principle of merger law and policy that is flexible enough for case by case analysis and that will provide for ease of adminstrability and outcomes more in line with sound economic analysis than the current system.