Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 1 of 32
`
`UNITED STATES DISTRICT COURT
`WESTERN DISTRICT OF TEXAS
`SAN ANTONIO DIVISION
`
`)
`)
`)
`)
`)
`)
`)
`)
`)
`)
`)
`)
`)
`)
`)
`
`Civil Action No. 5:21-cv-01068
`
`DOCTORS HOSPITAL OF LAREDO
`AND LAREDO PHYSICIANS GROUP,
`
`
`Plaintiffs,
`
`v.
`
`DR. RICARDO CIGARROA, CIGARROA
`HEART AND VASCULAR INSTITUTE,
`LAREDO TEXAS HOSPITAL
`COMPANY, LP D/B/A LAREDO
`MEDICAL CENTER, AND LAREDO
`PHYSICIAN ASSOCIATES,
`
`
`Defendants.
`
`
`PLAINTIFFS’ ORIGINAL COMPLAINT
`
`Plaintiffs Doctors Hospital of Laredo (“Doctors Hospital”) and Laredo Physicians Group
`
`(“Physicians Group”), by and through their attorneys, file this Original Complaint against
`
`Defendants Dr. Ricardo Cigarroa, Cigarroa Heart and Vascular Institute (“Cigarroa Institute”),
`
`Laredo Texas Hospital Company, LP d/b/a Laredo Medical Center (“LMC”), and Laredo
`
`Physician Associates (“LPA”), and respectfully allege the following:
`
`I.
`
`INTRODUCTION AND SUMMARY OF COMPLAINT
`
`1.
`
`Laredo is a vibrant and growing city with more than 260,000 residents. According
`
`to a recent analysis, a population of that size should have at least 20 cardiologists. But Laredo
`
`currently has eight, and only six of them are interventional cardiologists, the type needed to support
`
`acute-care hospitals and patients with acute cardiology needs.
`
`2.
`
`If a patient with interventional cardiology needs is not treated in Laredo, the patient
`
`must travel to different markets, like San Antonio or Houston. But such out-of-market trips carry
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 2 of 32
`
`
`
`significant patient risk. “Time is muscle,” and the sooner a patient with acute cardiological needs
`
`receives medical care, the better.
`
`3.
`
`To address the lack of interventional cardiologists and ensure that Laredo patients
`
`can receive prompt and high quality cardiological care in Laredo, Plaintiffs started actively
`
`recruiting new interventional cardiologists to Laredo in August 2020.
`
`4.
`
`When Defendant Dr. Cigarroa, a prominent interventional cardiologist in Laredo,
`
`heard of Plaintiffs’ plans, he perceived a threat to his dominant market position. Fancying himself
`
`the “Kingmaker” of cardiology in Laredo, he has personally boasted to others that he controls 90%
`
`of the market. Confronted with increased competition in the interventional cardiology market in
`
`the Laredo, Texas Metropolitan Statistical Area, Dr. Cigarroa entered into a conspiracy with the
`
`Cigarroa Institute (a cardiology outpatient clinic) and LMC (the largest acute-care hospital in
`
`Laredo) to engage in anticompetitive and tortious behavior. Their conspiracy had a simple but
`
`pernicious goal: deprive Doctors Hospital and Physicians Group of the doctors and employees
`
`needed to compete and provide interventional cardiology services to the Laredo market.
`
`5.
`
`Defendants’ conspiracy unfolded in multiple steps. First, Dr. Cigarroa issued
`
`threats to Doctors Hospital, Physicians Group, and prospective interventional cardiologists that
`
`Plaintiffs were recruiting to not move to Laredo and compete with Dr. Cigarroa. Defendants’
`
`coercion and threats worked: multiple qualified interventional cardiologists who were interested
`
`in joining Physicians Group, and to whom Physicians Group extended employment offers, decided
`
`not to join because of Defendants’ acts.
`
`6.
`
`Next, Dr. Cigarroa, his son, and his nephew – representing more than half of the
`
`interventional cardiologists in Laredo – gave notice that they would no longer respond to
`
`emergency calls at Doctors Hospital, and the son and nephew downgraded their medical staff
`
`- 2 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 3 of 32
`
`
`
`privileges to “Courtesy.” Instead, Dr. Cigarroa’s group would be responding to emergency calls
`
`from and referring their patients to Doctors Hospital’s only competitor in Laredo: LMC.
`
`7.
`
`Then, emboldened by their success in scaring off competitors, and further
`
`cementing their dominant market power and position, Defendants aimed their anticompetitive and
`
`tortious behavior at Laredo’s only cardiovascular surgeon, Dr. Arthur Santos, who was employed
`
`by Physicians Group. Defendants successfully induced Dr. Santos to agree to join Defendant LPA,
`
`breaching his enforceable non-compete contractual provision.
`
`8.
`
`Finally, not content with depriving Doctors Hospital of interventional cardiologists,
`
`Defendants targeted Doctors Hospital’s cardiothoracic surgery technicians to induce them to join
`
`LMC and work with Dr. Cigarroa and Dr. Santos.
`
`9.
`
`The conspiracy to monopolize Laredo’s interventional cardiology market is a win-
`
`win-win for Defendants. Dr. Cigarroa and the clinic avoid competition for interventional
`
`cardiological services, while LMC is left as the only provider of acute cardiology services in
`
`Laredo, gaining additional patients and corresponding increased revenue. Meanwhile, Doctors
`
`Hospital’s acute-care cardiology program will be threatened with extinction and, critically, Laredo
`
`patients are left with higher health care costs and greater health risks and without competitive
`
`market alternatives.
`
`10.
`
`Defendants’ anticompetitive and tortious behavior violates federal and state law.
`
`Unless restrained, their behavior has damaged and will continue to damage Plaintiffs and the
`
`Laredo public. Plaintiffs accordingly seek injunctive relief and damages.
`
`II.
`
`PARTIES
`
`11.
`
`Plaintiff Doctors Hospital of Laredo is a Texas entity with its principal place of
`
`business in Laredo, Texas.
`
`- 3 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 4 of 32
`
`
`
`12.
`
`Plaintiff Laredo Physicians Group is a Texas non-profit physicians group, certified
`
`by the Texas Medical Board. Its sole member is Independence Laredo LLC, which is registered in
`
`Texas with its principal place of business in Laredo, Texas.
`
`13.
`
`Defendant Dr. Ricardo Cigarroa is a resident of Texas. He can be served at 203
`
`Sunset Drive, Laredo, TX 78401.
`
`14.
`
`Defendant Cigarroa Heart and Vascular Institute is a Texas entity with its principal
`
`place of business in Laredo, Texas. It can be served through its registered agent: Ricardo G.
`
`Cigarroa, 1710 E. Saunders Street, Tower B, 5th Floor, Suite 500, Laredo, TX 78041.
`
`15.
`
`Defendant Laredo Texas Hospital Company, LP d/b/a Laredo Medical Center is a
`
`Texas entity with its principal place of business in Laredo, Texas. It can be served through its
`
`registered agent: Corporation Service Company d/b/a CSC – Lawyers Incorporating Service
`
`Company, 211 E. 7th Street, Suite 620, Austin, TX 78701.
`
`16.
`
`Defendant Laredo Physician Associates is a Texas physicians group with its
`
`principal place of business in Laredo, Texas. It is affiliated with LMC and can be served through
`
`its President or Chief Executive at its principal place of business: 1700 E. Saunders Street, Laredo,
`
`TX 78041.
`
`III.
`
`JURISDICTION AND VENUE
`
`17.
`
`This Court has subject matter jurisdiction pursuant to 28 U.S.C. § 1331 and 15
`
`U.S.C. § 26 because Plaintiffs allege violations of Sections 1 and 2 of the Sherman Antitrust Act
`
`and Section 4 of the Clayton Act.
`
`18.
`
`This Court has supplemental jurisdiction over Plaintiffs’ state law claims pursuant
`
`to 28 U.S.C. § 1367(a) because they are “are so related to” the antitrust claims that they “form part
`
`of the same case or controversy under Article III of the United States Constitution.”
`
`- 4 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 5 of 32
`
`
`
`19.
`
`Venue is proper in this District pursuant to 28 U.S.C. § 1391(b)(2) because a
`
`substantial part of the events or omissions giving rise to the claim occurred here. Venue is also
`
`proper in this District pursuant to 15 U.S.C. § 22 because on information and belief Defendant
`
`LMC transacts business here.
`
`IV.
`
`FACTS GIVING RISE TO THIS ACTION
`
`Laredo’s two hospitals and associated physician groups.
`
`The Laredo, Texas Metropolitan Statistical Area (“Laredo”) has approximately
`
`A.
`
`20.
`
`260,000 residents spread across approximately 108 square miles.
`
`21.
`
`To serve its population, Laredo has two hospitals that qualify as adult acute-care
`
`facilities, meaning that they provide inpatient, outpatient, and emergency care for a variety of
`
`ailments, ranging from general surgery to cardiology.
`
`22.
`
`Laredo’s largest hospital is Defendant LMC. According to its website, LMC is “a
`
`326-bed licensed acute care facility offering a range of inpatient and outpatient services.”
`
`23.
`
`Laredo’s second largest hospital, located six miles from LMC, is Plaintiff Doctors
`
`Hospital. It is a 183-bed acute care facility that offers Laredo residents a variety of medical services
`
`and where physicians practice a variety of specialties. Doctors Hospital also houses the Heart and
`
`Vascular Center, which includes a recently renovated cardiac surgery suite.
`
`24.
`
`LMC and Doctors Hospital are the only two hospitals in Laredo that offer inpatient
`
`interventional cardiovascular services. If a patient with interventional cardiovascular needs does
`
`not want to go to LMC or Doctors Hospital, or either hospital is not able to receive that patient,
`
`they would have to travel to a different market, the closest being San Antonio.
`
`25.
`
`Dr. Cigarroa, an independent interventional cardiologist, is an undisputed public
`
`figure in the Laredo community. His family, medical practice, and penchant for media attention
`
`have made him close to a household name, or at least as much of a household name as a cardiologist
`
`- 5 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 6 of 32
`
`
`
`can be. Every practicing physician and hospital administrator in Laredo, as well as most of
`
`southwest Texas, has heard of Dr. Cigarroa.
`
`26.
`
`Historically, Dr. Cigarroa retained privileges at both LMC and Doctors Hospital
`
`and contracted to provide on-call emergency coverage at both hospitals for a certain number of
`
`days each month.
`
`27.
`
`Plaintiff Physicians Group is affiliated with Doctors Hospital. Physicians Group
`
`has been operating in the Laredo community since 2012. Although it employs physicians who
`
`practice a variety of specialties, until October 2021 it did not employ interventional cardiologists.
`
`Instead, Doctors Hospital utilized the services of independent cardiologists like Dr. Cigarroa.
`
`28.
`
`Defendant Laredo Physician Associates (“LPA”) is affiliated with Defendant LMC,
`
`analogous to the relationship between Physicians Group and Doctors Hospital.
`
`29.
`
`As entities and individual physicians engaged in the provision of medical services,
`
`Plaintiffs and Defendants are engaged in interstate commerce by soliciting employees and patients
`
`inside and outside of Texas and using equipment and materials purchased inside and outside of
`
`Texas. Plaintiffs and Defendants also receive federal funding.
`
`B.
`
`30.
`
`Laredo requires additional interventional cardiologists.
`
`Cardiology involves the diagnosis and treatment of diseases and conditions of the
`
`heart and circulatory system. General cardiologists specialize in the diagnosis and treatment of
`
`patients with conditions such as hypertension, high cholesterol, and other conditions that put a
`
`patient at a higher risk of stroke or heart attack.
`
`31.
`
`Interventional cardiology
`
`is a sub-specialty of cardiology. Interventional
`
`cardiologists perform procedures that treat acute heart issues like blockages. Interventional
`
`cardiologists use imaging technologies to route a catheter through a patient’s arteries to the site of
`
`a blockage or other cardiovascular issue where the interventional cardiologist can treat the
`
`- 6 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 7 of 32
`
`
`
`blockage or other issue with a variety of technologies. In short, interventional cardiology provides
`
`less invasive treatment options for cardiovascular issues than surgery. Where more invasive
`
`treatment, such as traditional open-heart surgery, is required, a cardiologist or interventional
`
`cardiologist will refer the patient to a cardiovascular surgeon.
`
`32.
`
`These sub-specialties are distinct and not fungible. For example, interventional
`
`cardiologists cannot perform open-heart surgery like a cardiovascular surgeon can. Similarly, a
`
`cardiovascular surgeon typically will not treat cardiovascular blockages. And general cardiologists
`
`may not be able to perform the procedures that either an interventional cardiologist or a
`
`cardiovascular surgeon performs.
`
`33.
`
`Interventional cardiologists must be licensed in Texas to practice that specialty.
`
`Because medical specialties are not fungible, there is no available substitute for patients. A patient
`
`with interventional cardiological medical needs requires an interventional cardiologist.
`
`34.
`
`On August 10, 2020, Emma Montes-Ewing started as Doctors Hospital’s new Chief
`
`Executive Officer. Upon arrival, she quickly realized that a population the size of Laredo required
`
`additional interventional cardiologists to meet the cardiology needs of its residents.
`
`35.
`
`Doctors Hospital also required additional interventional cardiologists. In order to
`
`offer acute inpatient cardiological care like Doctors Hospital does, it requires an interventional
`
`cardiologist to be available and on call 24 hours a day, 7 days a week, and 52 weeks a year to
`
`respond to emergency patient needs. These needs typically include a patient with a cardiac event
`
`that may require a surgical intervention to treat or remove a blockage.
`
`36. Without an interventional cardiologist on call, Doctors Hospital would need to turn
`
`away patients with acute cardiological needs because there would be no doctor able to provide the
`
`necessary care.
`
`- 7 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 8 of 32
`
`
`
`37.
`
`To analyze Laredo’s and Doctors Hospital’s shortage of
`
`interventional
`
`cardiologists, Montes-Ewing reviewed a White Paper from Merritt Hawkins titled “Demonstrating
`
`Community Need for Physicians.” That Paper included a methodology that could be used to assess
`
`how many physicians of each specialty were required for populations of various sizes. The
`
`methodology was based on research from the University of Pennsylvania’s Wharton School.
`
`38. Montes-Ewing applied that methodology to Laredo based on a conservative
`
`assessment of 260,000 residents. The results, titled “Demonstrating Community Need for
`
`Physicians in Laredo,” revealed that a city the size of Laredo should have at least 20 cardiologists.
`
`Ideally most, if not all, of these 20 cardiologists would be interventional cardiologists so that they
`
`could provide the full suite of medical procedures to patients, short of invasive heart surgeries.
`
`39.
`
`Laredo, however, had only seven cardiologists and of those, only five were
`
`interventional cardiologists.
`
`40.
`
`Dr. Cigarroa and his family accounted for four of the five interventional
`
`cardiologists: (1) Dr. Cigarroa; (2) his son, Dr. Ricardo Cigarroa II, who started practicing in
`
`Laredo in March 2020; (3) his nephew, Dr. Joaquin Cigarroa; and (4) his brother, Dr. Carlos
`
`Cigarroa, who maintains a separate office practice from the other family members practicing
`
`cardiology.
`
`41.
`
`Dr. Cigarroa, his son, and his nephew are independent physicians, and as of May
`
`2021 had active privileges at both Doctors Hospital and LMC. They also saw patients at the
`
`Cigarroa Institute, an outpatient clinic.
`
`42.
`
`The only additional interventional cardiologist at the time of the study in Laredo
`
`was Dr. Pedro Diaz, also an independent physician. The final two cardiologists of the seven
`
`identified in Montes-Ewing’s analysis were non-interventional “general” cardiologists – they did
`
`- 8 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 9 of 32
`
`
`
`not perform the invasive, catheter procedures required by Doctors Hospital and the Laredo
`
`community. Both non-interventional cardiologists also indicated their intent to retire in the near
`
`future.
`
`43.
`
`Plaintiff Doctors Hospital and Laredo’s patient population were experiencing the
`
`negative effects of too few cardiologists. For example, with a shortage of cardiologists, there was
`
`the potential for longer response times for cariological inpatient consults and procedures at the
`
`hospital, as well as longer wait times for patients at outpatient cardiovascular clinics. Moreover,
`
`patient wait times at outpatient clinics were also lengthening as the interventional cardiologists in
`
`Laredo were being pulled in multiple directions by LMC, Doctors Hospital, and their respective
`
`private practice clinics. Notwithstanding the community need, Cigarroa benefitted from the lack
`
`of cardiologists by further enhancing his market power to be used in pernicious ways to the
`
`detriment of Plaintiffs and the community.
`
`C.
`
`Plaintiffs start recruiting new cardiologists, and Defendants immediately
`engage in anticompetitive behavior to interfere.
`
`44.
`
`Confronted with a lack of interventional cardiologists in Laredo, and with no
`
`interventional cardiologists employed by the Physicians Group, Montes-Ewing focused on
`
`recruiting new interventional cardiologists to Laredo. Although they would be employed by the
`
`Physicians Group, because the new cardiologists would be affiliated with and have medical staff
`
`privileges at Doctors Hospital, Montes-Ewing believed it was important to help with the search
`
`and explain her vision for the cardiology program at Doctors Hospital to prospective recruits.
`
`45.
`
`Plaintiffs’ success in recruiting new cardiologists to Laredo would result in multiple
`
`positive effects. As for the Laredo public, it would provide them with additional cardiologists to
`
`help address the gap that Plaintiffs’ study had identified. As for Plaintiffs, it would allow them to
`
`provide quality medical services to additional patients, fill an unmet critical healthcare need in the
`
`- 9 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 10 of 32
`
`
`
`community, and realize additional revenue. It would also provide Plaintiffs with the necessary
`
`stability that is required for successfully maintaining and expanding a top-class cardiology
`
`program at Doctors Hospital. To start her recruitment efforts, Montes-Ewing first spoke with Dr.
`
`Michael Blanc, a qualified interventional cardiologist whom she had known from her prior jobs in
`
`hospital administration and management. She invited him and his family to Laredo to visit the city
`
`and the facilities offered by Doctors Hospital.
`
`46.
`
`Defendants, however, did not view additional cardiologists in Laredo as a public
`
`good. In fact, they viewed Physicians Group’s recruitment of new cardiologists as a threat to their
`
`heretofore unchallenged market power.
`
`47.
`
`This is because any new interventional cardiologists hired by Physicians Group
`
`who would have medical staff privileges at Doctors Hospital would compete with Dr. Cigarroa for
`
`intervention cardiological medical care. As well, those patients would be treated at Doctors
`
`Hospital, not LMC.
`
`48.
`
`On September 10, 2020, Dr. Cigarroa and Montes-Ewing exchanged text messages.
`
`Upon learning that Doctors Hospital and Physicians Group were inviting Dr. Blanc to visit, Dr.
`
`Cigarroa unequivocally stated that he was “against” it for two primary reasons. See Ex. 1 at 4.
`
`49.
`
`First, Dr. Cigarroa stated that his cardiologist son, Dr. Cigarroa II, was “just
`
`beginning” and should be “given . . . a chance to set his feet” and establish his own cardiology
`
`practice without worrying about competition from additional cardiologists. See Ex. 1 at 4. Second,
`
`Dr. Cigarroa stated that he “would have preferred” that Montes-Ewing recruit new cardiologists
`
`“through our practice,” meaning Dr. Cigarroa’s practice. Id.
`
`50.
`
`Dr. Cigarroa went on to write that it was “ridiculous” for Plaintiffs to look for new
`
`cardiologists without first receiving Dr. Cigarroa’s (and his son’s) “serious input,” id. at 7, and
`
`- 10 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 11 of 32
`
`
`
`that Montes-Ewing’s recruitment efforts outside of Dr. Cigarroa’s practice was “a stinging
`
`rebuke,” id. at 11.
`
`51.
`
`To underscore his frustration with Plaintiffs’ intent to challenge Dr. Cigarroa’s
`
`dominant market power, Dr. Cigarroa referred to Montes-Ewing as a “witch CEO” who was falling
`
`into “the usual ceo [sic] pitfall” of not sufficiently consulting with him. Ex. 1 at 12, 10. Dr.
`
`Cigarroa made his opposition to any new cardiologists, including Dr. Blanc, clear to all the
`
`cardiologists in Laredo.
`
`52.
`
`Although Dr. Blanc had enjoyed his visit and was interested in the opportunity, he
`
`declined Physicians Group’s offer of employment upon learning of Dr. Cigarroa’s vehement and
`
`organized opposition. Dr. Blanc explained his reasoning to Montes-Ewing on multiple occasions
`
`in October and December 2020: Dr. Cigarroa had a monopoly for cardiology in Laredo; Dr. Blanc
`
`knew that Dr. Cigarroa did not want him to move to Laredo; and at this stage of his career, Dr.
`
`Blanc could not “start a war” with the Cigarroa family.
`
`53.
`
`Plaintiffs next invited cardiologist Dr. Michael Bennett to Laredo to visit Plaintiffs’
`
`facilities as part of their recruitment efforts. He enjoyed the visit and expressed his interest and
`
`excitement at the possibility of moving to Laredo and joining Physicians Group’s practice.
`
`54.
`
`But, again, Defendants repeated their pattern and practice of anticompetitive
`
`behavior. As with Dr. Blanc, Defendants made it clear to anyone who would listen, including
`
`Doctors Hospital, Physicians Group, and Dr. Bennett, that they opposed bringing new cardiologists
`
`to Laredo, including Dr. Bennett.
`
`55.
`
`And, again, Defendants’ anticompetitive actions worked. Dr. Bennett declined
`
`Physicians Group’s employment offer on or about April 5, 2021. He learned that Dr. Cigarroa did
`
`- 11 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 12 of 32
`
`
`
`not want him moving to Laredo, and as with Dr. Blanc, was not interested in opposing Dr. Cigarroa
`
`and Defendants’ dominant control of the interventional cardiology market in Laredo.
`
`D.
`
`Defendants continue their anticompetitive and tortious behavior by making
`additional threats.
`
`56. With Defendants having successfully flexed their market power and restrained
`
`trade to prevent Physicians Group from hiring Dr. Blanc and Dr. Bennett, Plaintiffs tried to recruit
`
`two new cardiologists.
`
`57.
`
`The first recruit was Dr. Mehmet Çilingiroğlu, a cardiologist practicing in San
`
`Diego. Physicians Group and Dr. Çilingiroğlu executed a Letter of Intent (“LOI”) on or about July
`
`15, 2021.
`
`58.
`
`Physicians Group’s second recruit was Dr. Marc Feldman, a cardiologist and
`
`Professor of Medicine with an active research laboratory at and corresponding funding from the
`
`University of Texas Health Science Center at San Antonio (“UTSA”). Physicians Group and Dr.
`
`Feldman executed an LOI on or about July 15, 2021. Dr. Feldman has been a resident of San
`
`Antonio at all times relevant to the allegations in this Complaint. Dr. Feldman was also a clinical
`
`instructor to Dr. Çilingiroğlu at UTSA.
`
`59.
`
`Dr. Feldman’s intent was to practice in Laredo part time, likely seven (7) days each
`
`month. This would allow him to continue to live in San Antonio, so that Dr. Feldman could retain
`
`his research laboratory at UTSA, as well as the corresponding university funding. Plaintiffs knew
`
`of and agreed with Dr. Feldman’s intent to remain based in San Antonio.
`
`60. When Dr. Cigarroa learned of Plaintiffs’ recruitment of Dr. Çilingiroğlu and Dr.
`
`Feldman, he and Defendants continued their anticompetitive and tortious behavior to restrain the
`
`interventional cardiology market in Laredo.
`
`- 12 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 13 of 32
`
`
`
`61.
`
`On or about July 14, 2021, Dr. Cigarroa attended a Doctors Hospital General
`
`Medical Staff meeting. Although Dr. Cigarroa had the right to attend because of his privileges at
`
`Doctors Hospital, it was unusual: Dr. Cigarroa had not attended a General Medical Staff meeting
`
`in over a year.
`
`62.
`
`The reason for Dr. Cigarroa’s attendance soon became clear. On the topic of
`
`recruiting Dr. Çilingiroğlu and Dr. Feldman, Dr. Cigarroa stated that “we can’t stand for this”
`
`because these new cardiologists would be competing for patients in Laredo. And Defendants did
`
`not want any new competition.
`
`63.
`
`Dr. Cigarroa doubled down one week later, on or about July 21, 2021, when he
`
`attended a Doctors Hospital Department of Medicine Committee meeting. He stated that Laredo
`
`had enough cardiologists and accordingly urged the Committee to reject Plaintiffs’ recruitment of
`
`Dr. Çilingiroğlu and Dr. Feldman. The Committee declined to do so.
`
`64. While flexing his market power by directly demanding that Plaintiffs cease their
`
`recruitment efforts, Dr. Cigarroa was also working behind the scenes to sabotage the recruitment
`
`of Dr. Feldman.
`
`65.
`
`On or about August 5, 2021, Dr. Feldman texted Doctors Hospital’s CEO, Montes-
`
`Ewing, asking to speak with her. During a subsequent phone call, Dr. Feldman informed Montes-
`
`Ewing that Dr. Cigarroa had threatened UTSA’s Dr. Allen Anderson. Dr. Anderson was the Chair
`
`of UTSA’s Cardiology Department.
`
`66.
`
`Dr. Cigarroa had boasted to Dr. Anderson (who was working in San Antonio at the
`
`time of the call) that he controlled 90% of the Laredo cardiology market, and that he did not want
`
`Dr. Feldman to come to Laredo. To ensure that Dr. Feldman did not come to Laredo, Dr. Cigarroa
`
`threatened Dr. Allen and UTSA, saying that he would stop referring his patients to UTSA for
`
`- 13 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 14 of 32
`
`
`
`cardiac surgeries and would begin referring those patients to UTSA’s competition if Dr. Feldman
`
`joined Physicians Group.
`
`67.
`
`Dr. Cigarroa’s acts were directed at entities and individuals in San Antonio and
`
`were in furtherance of Defendants’ anticompetitive and tortious behavior.
`
`68.
`
`Dr. Cigarroa’s threat was significant to UTSA. Until September 2021, Defendant
`
`Physicians Group’s Dr. Santos was the only cardiovascular surgeon in Laredo. If a patient had
`
`open heart or valve replacement surgery in Laredo, Dr. Santos performed the procedure. And if he
`
`chose not to, was unable to, or if the treating cardiologist referred elsewhere, Laredo residents were
`
`referred to hospitals and cardiovascular surgeons in other locations, chiefly San Antonio.
`
`69.
`
`UTSA was one such hospital for referrals. On information and belief, Dr. Cigarroa
`
`referred his patients who required surgery that Dr. Santos could or would not perform to UTSA,
`
`which was a significant source of revenue for UTSA.
`
`70.
`
`Confronted with Dr. Cigarroa’s threat and the potential for a significant loss of
`
`revenue, Dr. Anderson asked to meet with Dr. Feldman in person at UTSA. During that meeting,
`
`Dr. Anderson instructed Dr. Feldman “not to come to Laredo as that was Dr. Cigarroa’s territory.”
`
`To effectuate that demand, Dr. Anderson informed Dr. Feldman that if he accepted Physicians
`
`Group’s offer (having already signed an LOI at this point), UTSA “will take your lab away from
`
`you,” including the corresponding funding.
`
`71.
`
`Dr. Anderson’s threat to Dr. Feldman was a direct result of and caused by Dr.
`
`Cigarroa’s threat to cease referring patients to UTSA if Dr. Feldman started practicing with
`
`Physicians Group in Laredo. Dr. Anderson’s threat was an additional act in San Antonio in
`
`furtherance of Defendants’ anticompetitive and tortious behavior.
`
`- 14 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 15 of 32
`
`
`
`72.
`
`Later that day (still August 5), Montes-Ewing attended a dinner meeting with
`
`Laredo’s cardiologists to discuss Doctors Hospital’s plans for its cardiology program. Defendant
`
`Dr. Cigarroa and his son were in attendance.
`
`73.
`
`After Montes-Ewing’s short presentation, Dr. Cigarroa II demanded that Montes-
`
`Ewing and Physicians Group terminate any contracts with Dr. Çilingiroğlu and Dr. Feldman and
`
`refuse to hire them. His reasoning echoed his father’s: Dr. Cigarroa II needed time to develop his
`
`practice in Laredo and wanted to do so without any competition from new and well-qualified
`
`cardiologists.
`
`74.
`
`Dr. Cigarroa agreed, stating that “we don’t like it and we will not stand for it,” with
`
`“it” being Physicians Group’s hiring of Dr. Çilingiroğlu and Dr. Feldman. He followed up by
`
`explicitly threatening Montes-Ewing with the statement that she “will learn what it is like to go
`
`against this group.”
`
`75.
`
`On or about August 9, 2021, Dr. Cigarroa and Dr. Cigarroa II sent a letter to Doctors
`
`Hospital informing it that they would stop providing emergency coverage for the hospital after the
`
`required 90-days’ notice. Moreover, Dr. Cigarroa II would be dropping his privilege status at
`
`Doctors Hospital from “Active” to “Courtesy.”
`
`76.
`
`On or about August 12, 2021, Montes-Ewing spoke with both Dr. Çilingiroğlu and
`
`Dr. Feldman. During that call, Dr. Feldman informed Montes-Ewing that Dr. Cigarroa’s
`
`anticompetitive and tortious act had worked: UTSA pulled its funding from Dr. Feldman’s
`
`research laboratory. Because Dr. Feldman’s plan had been to work part-time in Laredo so that he
`
`could retain his laboratory and funding at UTSA, Dr. Feldman was upset, anxious, and concerned.
`
`As with Dr. Blanc and Dr. Bennett, Defendants’ anticompetitive behavior and threats were scaring
`
`off qualified cardiologists from practicing in Laredo.
`
`- 15 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 16 of 32
`
`
`
`77.
`
`On August 24, 2021, Dr. Çilingiroğlu emailed Montes-Ewing to express his
`
`concern with Dr. Cigarroa’s threat to stop referring patients to UTSA if Dr. Feldman came to
`
`Laredo, and Dr. Allen’s threat in response to withhold funding for Dr. Feldman’s UTSA
`
`laboratory. Dr. Çilingiroğlu made it clear that he was concerned about joining Physicians Group’s
`
`practice in Laredo. Hesitantly, Dr. Çilingiroğlu began practicing with Physicians Group on
`
`October 4, 2021.
`
`78.
`
`Soon thereafter, Dr. Feldman informed Physicians Group that he would not be
`
`joining their practice in Laredo.
`
`79.
`
`Notably, when Dr. Feldman informed UTSA that he would not be joining
`
`Physicians Group’s practice in Laredo, UTSA’s funding of his research laboratory was restored.
`
`80.
`
`Defendants’ threats and barriers to entry were successful. UTSA acceded to Dr.
`
`Cigarroa’s demands and coerced Dr. Feldman to not accept Physicians Group’s employment offer,
`
`eliminating and reducing competition in Laredo’s interventional cardiology market.
`
`81.
`
`Defendants’ anticompetitive and tortious interference with the prospective
`
`employment contract between Physicians Group and Dr. Feldman caused Plaintiffs to suffer
`
`monetary damages.
`
`82.
`
`Plaintiffs’ damages include, but are not limited to, their likely need to hire locum
`
`tenens (“Locum”) cardiologists to serve the patient population if Defendants’ anticompetitive and
`
`tortious behavior continues. These Locum physicians are temporary fixes and do not allow a
`
`hospital to maintain and grow a stable and top-quality cardiology program, nor does this practice
`
`offer the Laredo patient community continuity of care with respect to their caregivers. Moreover,
`
`Locum cardiologists are much more expensive than hiring full or part-time cardiologists,
`
`- 16 -
`
`

`

`Case 5:21-cv-01068 Document 1 Filed 10/29/21 Page 17 of 32
`
`
`
`sometimes as much as two to three times the cost. If Defendants’ anticompetitive and tortious
`
`behavior forces Plaintiffs to use Locum cardiologists, the higher costs will be unsustainable.
`
`83.
`
`Indeed, these costs will raise the costs of care, and will be indirectly passed to
`
`consumers, because higher coverage costs compel the hospital to seek higher reimbursement rates
`
`from commercial payers, like insurers, as an offset. This, in turn, results in higher premiums, co-
`
`pays and deductibles paid by consumers.
`
`84.
`
` Ultimately, Doctors Hospital’s ability to provide care to patients in cardiology and
`
`other specialties will suffer, and its cardiology program may be shuttered, leaving LMC as the only
`
`acute-care hospital offering cardiology care in Laredo. Indeed, that is the object of Defendants’
`
`anticompetitive plan.
`
`85.
`
`Defendants’ anticompetitive and tortious behavior has also had, and will c