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Case 1:21-cv-01693-JMS-MG Document 1 Filed 06/11/21 Page 1 of 40 PageID #: 1
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`UNITED STATES DISTRICT COURT
`FOR THE SOUTHERN DISTRICT OF INDIANA
`INDIANAPOLIS DIVISION
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`DR. RICARDO VASQUEZ,
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`Plaintiff,
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`vs.
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`INDIANA UNIVERSITY HEALTH, INC., )
`INDIANA UNIVERSITY HEALTH
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`BLOOMINGTON, INC., d/b/a
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`IU HEALTH BLOOMINGTON
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`HOSPITAL, and DR. DANIEL HANDEL
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`Defendant.
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`Case No. 21-CV-1693
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`COMPLAINT FOR DAMAGES AND INJUNCTIVE RELIEF
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`This is a monopolization case about a health system—Indiana University Health, Inc.—
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`and its subsidiary hospital in Bloomington, Indiana, Indiana University Health Bloomington, Inc.
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`(collectively, “IU Health”) building a monopoly in primary care services through a series of
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`anticompetitive acquisitions, and using that monopoly to secure and enhance monopolies over
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`specialist services, including vascular surgery. As a result, healthcare costs to patients and health
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`insurance companies (“payors”) in Bloomington have increased, quality of care has decreased,
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`and some patients are unable to receive care, because the monopolist IU Health sends those
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`patients to its higher cost sister facilities in Indianapolis or has made the decision not to perform
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`certain procedures at all.
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`INTRODUCTION
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`1.
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`IU Health is a monopolist with over 92.5 percent market share of inpatient
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`discharges in the Bloomington area. In addition, it employs and controls 35 of the 36 family
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`practice physicians and internists (collectively, “Primary Care Physicians”)—over 97% of the
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`total—who have a primary practice location in Bloomington.1 These Primary Care Physicians
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`refer patients to specialist surgeons who rely on their referrals to receive patients.
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`2.
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`IU Health’s largest facility in Southern Indiana is Indiana University Health
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`Bloomington, Inc. d/b/a IU Health Bloomington Hospital (“Bloomington Hospital”), located in
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`Bloomington, Indiana. IU Health also owns two critical access hospitals in Southern Indiana—
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`Indiana University Health Bedford (“IU Health Bedford”) and Indiana University Health Paoli
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`(“IU Health Paoli”)—and the vast majority of the area physician practices. Finally, IU Health
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`holds a 45% share in the largest of two area outpatient surgery centers.
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`3.
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`Not happy with its high profits and already dominant position in healthcare in
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`Bloomington, in approximately 2017, IU Health instituted an increasingly aggressive scheme to
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`acquire nearly all of the Primary Care Physicians in Bloomington. In doing so, it both cemented
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`its monopoly in primary care services, and it used that monopoly to secure and maintain
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`monopolies in specialty services. Now, because it controls the physicians who refer to
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`specialists, and controls many of the specialists as well, IU Health decides where surgeries are
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`performed and which surgeries are available to area patients, payors, and other healthcare
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`providers.
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`4.
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`As one example, IU Health leveraged its monopoly in primary care services to
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`monopolize vascular surgery services, a specialty service area. In the past two years, the
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`percentage of vascular surgeons in the Bloomington area that were employed by IU Health rose
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`from 50 percent (1 out of 2) to 75 percent (3 out of 4). IU Health’s control over primary care
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`services forces patients to see the IU Health employed vascular surgeons to their detriment, and
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`1 In the Greater Bloomington Metropolitan Area consisting of the three counties of Greene, Monroe, and Owen, IU
`Health employs approximately 83% of the family practice physicians and internists. It also has a monopoly for nurse
`practitioners, controlling 80% of the nurse practitioners.
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`2
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`sacrifices patients’ continuity of care. IU Health charges more for patients to see these unfamiliar
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`vascular surgeons—raising prices to consumers and payors—patients receive lower quality care,
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`and patients cannot receive certain vascular surgery services altogether from the IU Health
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`vascular surgeons.
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`5.
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`Plaintiff Dr. Ricardo Vasquez is the only independent vascular surgeon left in
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`Southern Indiana, and the sole obstacle to IU Health obtaining a complete monopoly over
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`vascular surgery services. Until April 2019, Dr. Vasquez held privileges (allowing him to
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`perform surgeries) at Bloomington Hospital. Simultaneously, he held privileges at the only other
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`hospital in town—the much smaller Monroe Hospital—and the Indiana Specialty Surgery
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`Center, which competes directly with the IU Health-affiliated surgery center. IU Health targeted
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`Dr. Vasquez because he chose to remain an independent physician, threatening IU Health’s
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`monopoly over vascular surgery services and its ability to reap monopoly profits. Bloomington
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`Hospital improperly revoked Dr. Vasquez’s privileges because he threatened IU Health’s
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`monopoly by competing directly with IU Health: for example, by (1) performing hospital-based
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`procedures at Monroe; (2) performing procedures at IU Health’s only competitor outpatient
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`surgery center; and (3) opening an office-based laboratory to compete directly with IU Health in
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`outpatient vascular surgery services.
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`6.
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`IU Health revoked Dr. Vasquez’s privileges in April 2019. In January 2020, IU
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`Health took a further step in revoking Dr. Vasquez’s credentialing as an IU Health Plan2
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`participating provider, meaning that IU Health Plan covered patients are forced to pay out of
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`pocket, at increased cost, to see Dr. Vasquez. Without privileges, Dr. Vasquez cannot perform
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`surgeries at any IU Health facility, cannot treat any IU Health Plan insured as an in-network
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`2 IU Health Plan is IU Health’s vertically integrated health insurance plan.
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`3
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`patient, and, critically, cannot receive referrals from IU Health employed or affiliated physicians
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`without the physicians facing retribution and retaliation from IU Health.3
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`7.
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`In addition, and all in an effort to destroy his reputation and practice, IU Health
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`and its Chief Medical Officer (“CMO”), Dr. Daniel Handel, have maliciously publicized false
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`statements about Dr. Vasquez, and filed meritless complaints against Dr. Vasquez with the
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`Indiana Professional Licensing Agency and the Indiana Attorney General in 2020. Neither
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`agency has determined it proper to pursue an investigation against Dr. Vasquez based on those
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`complaints.
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`8.
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`On information and belief, IU Health and Dr. Handel also are directing the IU
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`Health employed vascular surgeons to wrongfully and falsely blame any and all missteps in care
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`on Dr. Vasquez. Because Bloomington Hospital is the only area Level III Trauma Center and the
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`only area Stroke Center, patients under Dr. Vasquez’s care may end up in the Bloomington
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`Hospital emergency room and, therefore, be seen by IU Health vascular surgeons. In one recent
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`instance, Dr. Vasquez had determined to treat a patient medically (i.e., without surgery) because
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`she had not responded well to surgery in the past. The patient had been stable under Dr.
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`Vasquez’s care for years. She went to the Bloomington Hospital emergency room with a toe
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`ulcer. The IU Health vascular surgeons performed two unnecessary surgeries and ultimately had
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`to amputate her leg. The IU Health vascular surgeons then falsely blamed their poor care on Dr.
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`Vasquez, in an attempt to harm Dr. Vasquez’s reputation and harm him financially.
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`9.
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`Patients have suffered from reduced choice because Dr. Vasquez is well-known as
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`the most skilled vascular surgeon in the area. He is the only area vascular surgeon performing the
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`3 Surgeons have been retaliated against for referring patients to Dr. Vasquez, as described in more detail below.
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`4
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`cutting edge and revolutionary vascular procedure, transcarotid stenting (TCAR).4 He also
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`performs arteriovenous (AV) fistula procedures—a necessary procedure for many dialysis
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`patients—in significantly less time than the other three vascular surgeons in Bloomington and
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`with excellent results. Patients in need of these procedures are high risk, with preexisting heart
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`and lung conditions that make anesthesia problematic. Dr. Vasquez’s ability to perform
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`procedures quickly greatly increases the likelihood of success and decreases the risk of patient
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`morbidity.
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`10.
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`Examples abound of IU Health’s employed vascular surgeons failing to recognize
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`and/or sending patients home with life-threatening, severe aneurysms and other life-threatening
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`vascular conditions. Some of these patients have died. The IU Health vascular surgeons have
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`been directed not to perform certain procedures altogether, and instead have been instructed to
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`send patients needing more complicated procedures, including TCAR, to another IU Health
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`facility outside of Southern Indiana. IU Health even sends most patients with aneurysms—a
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`common, but life-threatening condition—to IU Health’s Methodist Hospital an hour away in
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`Indianapolis. IU Health is forcing patients to travel further to seek care they could—but for IU
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`Health’s conduct against Dr. Vasquez—receive closer to home, cheaper, and with good
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`outcomes. This policy and practice increases prices and reduces quality of care in the following
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`ways: (1) Methodist’s prices are higher; (2) the increased patient load overburdens the physician
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`and nursing staff at Methodist, reducing quality of care; and (3) transferring patients
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`4 TCAR is revolutionary because it replaces the traditional carotid endarterectomy, which is a procedure to remove
`plaque buildup in the carotid artery to reduce the risk of strokes. A common side effect of the carotid
`endarterectomy is that calcium deposits get back into the patient’s blood stream, putting the patient at risk for stroke
`again. With TCAR, the patient’s blood is shunted away and filtered—resulting in no calcium deposits and no side
`effects.
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`5
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`unnecessarily increases the patient’s time before obtaining (often life-saving) surgery, increasing
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`morbidity.
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`11.
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`IU Health specifically refers and/or transfers patients formerly operated on by
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`Dr. Vasquez to Indianapolis for treatment, instead of referring those patients to local vascular
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`surgeons. IU Health is further compromising patient health by targeting these patients for
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`retaliatory gains against Dr. Vasquez.
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`12.
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`IU Health has specifically instructed employees and other physicians with
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`privileges at IU Health not to refer patients to Dr. Vasquez—retaliating against those who
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`continue to refer patients to him or who defend him against baseless attacks. Primary care
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`physicians prefer to refer to Dr. Vasquez, and a few have continued to refer to him despite IU
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`Health’s directive not to do so because they value patient quality of care over IU Health’s profits.
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`IU Health’s actions have no procompetitive justification, and are done solely to exclude Dr.
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`Vasquez for economic reasons.
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`13.
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`The Bloomington area has suffered beyond the monopoly in vascular surgery. The
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`area has lost several skilled physicians in other specialties who wanted to stay in Bloomington as
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`independents but who have left because noncompete provisions with IU Health, and IU Health’s
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`internal referral policies prohibited them from continuing to practice in Bloomington. IU
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`Health’s vice hold over primary care services must be dismantled before Bloomington loses
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`more specialists and quality of care declines even further.
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`THE PARTIES
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`14.
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`Plaintiff Dr. Vasquez is a Board Certified Vascular Surgeon who has practiced in
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`Bloomington since 2006. He resides in Bloomington, Indiana.
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`15.
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`Defendant Indiana University Health, Inc. (“IU Health, Inc.”) is a health system
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`with a principal place of business in Indianapolis, Indiana. It is a 14 hospital system with several
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`locations in the state. IU Health owns and operates three hospital facilities in Southern Indiana:
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`Bloomington Hospital, and two critical access hospital hospitals, each with 25 beds—IU Health
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`Bedford and IU Health Paoli.
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`16.
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`Defendant Indiana University Health Bloomington, Inc. is an Indiana not-for-
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`profit domestic corporation doing business in Indiana under the registered assumed name, IU
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`Health Bloomington Hospital. In 2018, Bloomington Hospital had 282 staffed beds, 12,552
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`inpatient admissions, and over 225,000 outpatient visits.
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`17.
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`Defendant Dr. Daniel Handel is Chief Medical Officer of Bloomington Hospital,
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`and, on information and belief, is a resident of Monroe County, Indiana.
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`JURISDICTION AND VENUE
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`18.
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`Dr. Vasquez alleges federal antitrust claims against the Defendants pursuant to
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`Section 2 of the Sherman Act, 15 U.S.C. § 2 and Section 7 of the Clayton Act, 15 U.S.C. § 18.
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`19.
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`Dr. Vasquez seeks damages pursuant to 15 U.S.C. § 15 (“any person who shall be
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`injured in his business or property by reason of anything forbidden in the antitrust laws may sue
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`therefor in any district court of the United States in the district in which the defendant resides or
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`is found or has an agent, without respect to the amount in controversy, and shall recover
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`threefold the damages by him sustained, and the cost of suit, including a reasonable attorney’s
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`fee”).
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`20.
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`Dr. Vasquez seeks injunctive relief pursuant to 15 U.S.C.§ 26 (“[a]ny person,
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`firm, corporation, or association shall be entitled to sue for and have injunctive relief, in any
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`court of the United States having jurisdiction over the parties, against threatened loss or damage
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`by a violation of the antitrust laws . . . .”).
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`21.
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`This Court has original jurisdiction over Plaintiff’s federal antitrust claims
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`pursuant to 15 U.S.C. §§ 4, 15 and 26, and 28 U.S.C. §§ 1331 and 1337.
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`22.
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`Venue is proper in this Court under 28 U.S.C. §1391 because: (i) Defendants
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`reside in this District and conduct a substantial amount of business in this District; and (ii) a
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`substantial part of the events or omissions giving rise to the claim occurred, and continue to
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`occur, in this District.
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`23.
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`Dr. Vasquez alleges state antitrust claims pursuant to Ind. Code § 24-1-2-2 and
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`Ind. Code § 24-1-2-7 and common law claims under Indiana law against Defendants. This Court
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`has supplemental jurisdiction over the Plaintiff’s state law claims under 28 U.S.C. § 1367
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`because they are directly related to the Plaintiff’s federal antitrust claims and form part of the
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`same case or controversy.
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`DR. VASQUEZ BUILT A SUCCESSFUL, INDEPENDENT VASCULAR SURGERY
`PRACTICE IN BLOOMINGTON
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`24.
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`Dr. Vasquez graduated with a Doctor of Medicine from the University of Iowa in
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`1996. In 2001, Dr. Vasquez completed his General Surgery residency at Mount Sinai School of
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`Medicine-Cabrini Medical Center in New York, New York. He was Chief Resident in General
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`Surgery at that time.
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`25.
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`From 2001 to 2003, Dr. Vasquez completed a Vascular Surgery Fellowship at the
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`Boston University Medical Center in Boston, Massachusetts. From 2003 to 2006, Dr. Vasquez
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`was a Vascular Surgery Clinical Instructor at the University of Illinois College of Medicine in
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`Champaign-Urbana, Illinois and practiced vascular surgery at the Carle Clinic in Urbana,
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`Illinois.
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`26.
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`In 2006, Dr. Vasquez moved to Bloomington and joined Dr. Virginia Newman’s
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`practice, Vascular Surgery and Technology PC. Another vascular surgeon, Dr. John Hamelink,
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`joined Dr. Newman’s practice around the same time in approximately 2006.
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`27.
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`Beginning in 2006, Drs. Newman, Hamelink, and Vasquez were the only
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`practicing vascular surgeons in Southern Indiana. All three vascular surgeons held privileges at
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`Bloomington Hospital.
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`28.
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`After practicing with Vascular Surgery and Technology for approximately one
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`year, Dr. Vasquez decided to open his own practice, the Vascular Center and Vein Clinic of
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`Southern Indiana. Dr. Newman relocated to Northern Indiana and sold her interest in Vascular
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`Surgery and Technology to Dr. Hamelink. Dr. Hamelink renamed his practice Vascular Premier
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`Care, and continued to operate it until 2012 when he closed the practice and became an
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`employee of Internal Medical Associates, which later became known as Premier Healthcare. IU
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`Health acquired Premier Healthcare in 2017 and its physicians, including Dr. Hamelink, became
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`IU Health employees.
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`29.
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`From 2006 until his privileges were revoked under retaliatory pretext in 2019, Dr.
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`Vasquez was a respected member of the Bloomington Hospital staff. He was on the
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`Credentialing Committee between 2007 and 2010. And from approximately 2010 to 2012, Dr.
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`Vasquez served as Chairman of the vascular subsection of the cardiovascular service line.
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`30.
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`Dr. Vasquez preferred to remain independent. Since 2006, he maintained
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`privileges at two other facilities in addition to Bloomington Hospital: Monroe Hospital—a
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`32-bed facility located 10 minutes from Bloomington Hospital and the closest competitor
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`hospital to Bloomington Hospital—and the Indiana Specialty Surgery Center. Dr. Vasquez was
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`Chief of Staff at Monroe Hospital from approximately 2010 to 2015, and a member of the
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`Medical Executive Committee and the Credentialing Committee for several years. He remains in
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`good standing at both Monroe Hospital and Indiana Specialty Surgery Center.
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`31.
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`Despite having privileges elsewhere, Dr. Vasquez performed the vast majority
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`(over 95%) of his inpatient procedures at Bloomington Hospital and hundreds of outpatient
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`procedures there per year until 2018.
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`32.
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`Between 2007 and 2019, Dr. Vasquez and Dr. Hamelink were the only two
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`vascular surgeons practicing in Bloomington. During that time, both physicians held privileges at
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`Bloomington Hospital, and they shared call at the hospital. Despite sharing call equally (50/50),
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`Dr. Vasquez cared for over 70% of the total patients during that time. This is because many
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`physicians prefer to work with Dr. Vasquez due to his skill, competence, and ability to perform
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`procedures quickly and accurately. Meanwhile, Dr. Hamelink did not perform the variety of
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`procedures that Dr. Vasquez did and prefers not to perform more complex procedures.
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`Dr. Vasquez never turned a physician down who called him unless he was out of town.
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`33.
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`This continued as it had for approximately one year after Dr. Hamelink became an
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`IU Health employee in 2017. Thereafter, IU Health became increasingly antagonistic toward Dr.
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`Vasquez because he chose to remain independent, and began a smear campaign to create the
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`pretext to enable IU Health to revoke Dr. Vasquez’s privileges.
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`HOW VASCULAR SURGEONS RECEIVE PATIENT
`REFERRALS AND PAYMENT
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`34.
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`Patients needing vascular surgery services are routed to a vascular surgeon
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`through one of two ways: (1) the patient is referred by their primary care physician (an internist
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`or family medicine physician); or (2) the patient is hospitalized and the treating physician or
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`surgeon (often a general surgeon or hospitalist) calls a vascular surgeon with privileges at that
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`hospital.
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`35.
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`Patients and insurance companies receive two charges for vascular surgery
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`services—a “facility fee,” which is the charge for the use of the operating room or facility, and
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`the “physician fee,” which covers the vascular surgeon’s services. In general, the facility fee is
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`higher in a hospital setting than in an outpatient or office setting. This is true even when patients
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`receive the exact same services. And, the facility fee is higher in hospitals that have the
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`capability to provide higher acuity care than when patients receive the exact same services in
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`lower acuity hospitals, outpatient facilities, or physician offices.
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`SUBSTANTIAL EFFECT ON INTERSTATE COMMERCE
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`36.
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`The interstate commerce requirement is met because Defendants IU Health, Inc.
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`and Bloomington Hospital admit patients from out of state, purchase equipment from out of
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`state, receive reimbursement from insurance companies located out of state, and receive
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`Medicare and Medicaid funding from out of state.
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`THE GEOGRAPHIC AND PRODUCT MARKETS
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`37.
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`Bloomington is a proper geographic market. Patients prefer to stay within
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`Bloomington to receive care, and do not want to travel to Indianapolis or other cities located an
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`hour or further from Bloomington. Physicians who practice in Bloomington also prefer to stay
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`local rather than travel long distances for work or, alternatively, uproot themselves and their
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`families to move their practice. Once a physician has an established practice, it is extremely
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`difficult to leave one city and build a practice in another location because healthcare is local.
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`Physicians lose most if not all of their current patients in doing so and must find another source
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`of referrals. In addition, to be viable, commercial insurance plans need healthcare providers
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`within Bloomington to make available for their insureds. Health insurance plans covering
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`Bloomington would not offer a plan that does not include a provider in Bloomington. Thus, the
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`proper geographic market for healthcare services is local—and, in this case, Bloomington.
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`38.
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`In addition, or in the alternative, Southern Indiana is a proper geographic market.
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`Southern Indiana includes the area extending from Martinsville, Indiana in the north to Paoli,
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`Indiana in the south along IN-37, encompassing Morgan, Owen, Monroe, Brown, Greene,
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`Daviess, Martin, Lawrence, Orange, and Washington counties. These counties comprise the
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`primary and secondary service areas for Bloomington Hospital and its direct competitors.
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`Southern Indiana is a proper geographic market because healthcare providers compete for
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`patients located in the area, healthcare providers prefer to practice locally in the area rather than
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`move their practice, and payors require providers in Southern Indiana.
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`39.
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`Primary care physician services is a relevant product market. Primary care
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`physicians (which include family practice and internal medicine physicians) provide front-line
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`healthcare to patients. These practitioners provide a broad range of preventive care, manage
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`chronic diseases, and provide referrals and coordination of care with specialists like vascular
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`surgeons. Many health plans require patients to have a designated primary care practitioner, and
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`cover specialist services only if referred by the patient’s designated primary care practitioner.
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`Health plans do not allow patients to assign physicians in other specialties as their primary care
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`practitioner.
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`40.
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`Vascular surgery services is a relevant product market. Vascular surgery is a
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`surgical specialty in which diseases of the vascular system—arteries, veins, and lymphatic
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`circulation—are managed by medical therapy, minimally-invasive catheter procedures (stents),
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`and surgical reconstruction. Vascular surgery is a primary surgery specialty recognized by the
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`American Board of Surgery, and physicians may become Board Certified in Vascular Surgery.
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`Dr. Vasquez is a Board Certified Vascular Surgeon. Only trained vascular surgeons can perform
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`vascular surgery services. A patient needing vascular surgery services cannot substitute other
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`hospital services for vascular surgery services, nor are other specialists like cardiologists or
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`nephrologists substitutes for vascular surgeons.
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`IU HEALTH BUILT ITS MONOPOLY IN PRIMARY CARE SERVICES THROUGH
`ANTICOMPETITIVE ACQUISITIONS
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`41.
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`In January 1997, three Indianapolis hospitals—Methodist Hospital, Riley Hospital
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`for Children, and Indiana University Hospital—merged to form Clarian Health Partners. Since
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`that time, Clarian quickly acquired other facilities in the state, including other hospitals and
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`physician practices. Formerly independent Bloomington Hospital merged with Clarian Health
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`Partners in 2010. In January 2011, Clarian Health Partners rebranded as Indiana University
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`Health, Inc. and Bloomington Hospital became IU Health Bloomington Hospital.
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`42.
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`Today, IU Health, Inc. operates 14 hospitals in the state of Indiana, including
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`three in Southern Indiana—Bloomington Hospital, IU Health Bedford Hospital, and IU Health
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`Paoli Hospital. In Southern Indiana, it also controls IU Health Orthopedics & Sports Medicine
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`Center (an outpatient orthopedic facility), a radiology group, a neurology group, a behavioral
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`health facility, and owns 45% of Southern Indiana Surgery Center, an outpatient surgical facility.
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`43.
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`Controlling nearly all of the facilities in the Bloomington area was not enough. IU
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`Health sought to control physicians as well. In particular, it sought to obtain a monopoly over
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`primary care services because that monopoly allows it to dictate where and how patients receive
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`specialty services. That control has enabled IU Health to secure and maintain its monopoly over
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`a variety of specialty care services, including vascular surgery services, vascular ultrasound lab
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`services, and cardiovascular laboratory studies.
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`44.
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`The turning point for Bloomington occurred in May 2017 when IU Health, Inc.
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`acquired Premier Healthcare, which was one of the largest independent physician groups in the
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`state at that time with 40 primary care and specialty physicians. Premier Healthcare’s physicians
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`became IU Health employees and part of the larger IU Health Southern Indiana Physicians
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`(“Southern Indiana Physicians”) practice group. Southern Indiana Physicians now includes
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`hundreds of primary care practitioners, specialists, and nurse pracitioners operating in 37
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`locations across Southern Indiana. Southern Indiana Physicians refer patients to specialists with
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`IU Health privileges.
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`45. With the Premier Healthcare acquisition, IU Health secured control over Primary
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`Care Physicians in Bloomington. Today, 82 Primary Care Physicians and nurse practitioners are
`
`a part of Southern Indiana Physicians. IU Health controls 97% of the Primary Care Physicians
`
`within Bloomington, and over 80% of the Primary Care Physicians in the larger Southern
`
`Indiana area.
`
`46.
`
`IU Health’s merger with Premier Healthcare gave it the ability to foreclose
`
`competitors because it now controls where patients receive specialty services, like vascular
`
`surgery services. Most patients comply with primary physician recommendations as to who will
`
`perform their surgeries and where they should be performed, and IU Health Primary Care
`
`Physicians refer to IU Health specialists.
`
`47.
`
`IU Health prefers to employ physicians, not because patients or health insurance
`
`companies benefit, but because IU Health makes more money and has greater control over
`
`referrals. When its employees perform procedures, IU Health retains both the facility fee and the
`
`physician fee, reaping a greater profit.
`
`48.
`
`By nature of referrals from Primary Care Physicians to specialists, primary care
`
`services and vascular surgery services are complementary services. IU Health’s acquisition of
`
`Premier Healthcare, and subsequent monopoly over primary care services, gave it power to
`
`diminish competition by excluding rivals. In particular, it can cause rivals to lose significant
`
`14
`
`

`

`Case 1:21-cv-01693-JMS-MG Document 1 Filed 06/11/21 Page 15 of 40 PageID #: 15
`
`
`
`referral sources, which are integral to a specialist’s ability to stay in business. IU Health’s ability
`
`to control the referral sources to Dr. Vasquez means it has the power to reduce his new patient
`
`base significantly, threatening the viability of his independent practice.
`
`49.
`
`IU Health’s control over primary care services increases the barriers to entry for
`
`independent physicians. Because IU Health requires that its physicians refer only to other IU
`
`Health affiliated specialists, specialists must affiliate with IU Health to obtain and keep their
`
`referrals. And non-employed specialists with privileges at IU Health are pressured not to
`
`compete aggressively with IU Health or risk losing their privileges out of retaliation. In the past
`
`three years, numerous specialists have left Bloomington because they did not want to become an
`
`IU Health employee but could not practice in Bloomington without IU Health referrals. This
`
`includes highly skilled specialists in numerous areas, including neurology, general surgery,
`
`pulmonology, critical care, neurosurgery, and nephrology.
`
`IU HEALTH HAS MONOPOLIES OVER PRIMARY CARE SERVICES AND
`VASCULAR SURGERY SERVICES IN BLOOMINGTON AND SOUTHERN INDIANA
`
`50.
`
`IU Health is a monopolist in both primary care services and vascular surgery
`
`services in Bloomington and Southern Indiana. Its ability to maintain high shares while charging
`
`supracompetitive prices demonstrates it is a monopolist.
`
`51.
`
`IU Health has high shares in both primary care services and vascular surgery
`
`services in Bloomington and the rest of Southern Indiana. Its shares of these services are high
`
`enough to raise a presumption of monopoly power. IU Health employs and controls all but one
`
`of the Primary Care Physicians in Bloomington. In other words, it has a near complete monopoly
`
`over all referral sources. In addition, IU Health has high shares in inpatient vascular surgery
`
`services (86%), and outpatient vascular surgery services performed in a hospital setting (95%).
`
`15
`
`

`

`Case 1:21-cv-01693-JMS-MG Document 1 Filed 06/11/21 Page 16 of 40 PageID #: 16
`
`
`
`52.
`
`Bloomington Hospital is a “must have” provider. Bloomington Hospital is the
`
`only Level III Trauma center, the only Level I Heart Attack center, and the only Stroke Center in
`
`Bloomington and the entire Southern Indiana area. Patients are transferred to Bloomington
`
`Hospital from around Southern Indiana because it is the only facility with certain specialties. For
`
`example, no other facility in Southern Indiana has interventional cardiologists. Therefore, if a
`
`patient arrives at any facility in Southern Indiana complaining of chest pain—whether an IU
`
`Health facility or not—the patient must be sent to Bloomington Hospital for further care if the
`
`emergency department physicians determine the patient should see an interventional cardiologist.
`
`53.
`
`IU Health’s ability to charge supracompetitive prices is evidence of its monopoly
`
`power in Bloomington and Southern Indiana. As a result of IU Health’s dominance, prices are
`
`higher because it controls where patients receive services. IU Health’s facilities are more
`
`expensive, and, therefore, the cost of healthcare to both health insurance companies and patients
`
`has increased.
`
`54.
`
`High barriers to entry and IU Health’s control over referral sources limit the
`
`ability of any independent physician or physician practice to enter Bloomington and Southern
`
`Indiana. Because of the difficulty in competing against a monopolist, no hospital has entered the
`
`geographic area since Monroe Hospital opened in 2006. And Monroe Hospital nearly did not
`
`survive—it was on the verge of bankruptcy only a few years after opening. Before then, the last
`
`hospital to open has operated for decades. Nor have there been recent entrants in outpatient
`
`surgery centers.
`
`55.
`
`IU Health’s monopoly over referral sources prohibi

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