476 U.S. 447 (1986), 84-1809, Federal Trade Commission v. Indiana Federation of Dentists

Docket Nº:No. 84-1809
Citation:476 U.S. 447, 106 S.Ct. 2009, 90 L.Ed.2d 445, 54 U.S.L.W. 4531
Party Name:Federal Trade Commission v. Indiana Federation of Dentists
Case Date:June 02, 1986
Court:United States Supreme Court

Page 447

476 U.S. 447 (1986)

106 S.Ct. 2009, 90 L.Ed.2d 445, 54 U.S.L.W. 4531

Federal Trade Commission


Indiana Federation of Dentists

No. 84-1809

United States Supreme Court

June 2, 1986

Argued March 25, 1986




Respondent organization of dentists in Indiana promulgated a policy requiring its members to withhold x-rays from dental insurers in connection with evaluating patients' claims for benefits. The Federal Trade Commission (FTC) issued a cease-and-desist order, ruling that the policy constituted an unfair method of competition in violation of § 5 of the Federal Trade Commission Act, since it amounted to a conspiratorial restraint of trade in violation of § 1 of the Sherman Act. The Court of Appeals vacated the FTC's order on the ground that it was not supported by substantial evidence, holding that the FTC's findings that respondent's x-ray policy was anticompetitive were erroneous; that the findings were inadequate because of the FTC's failure to define the market in which respondent allegedly restrained competition and to establish that respondent had the power to restrain competition in that market; and that the FTC erred in not determining whether the alleged restraint on competition among dentists had actually resulted in higher dental costs to patients and insurers.


1. The FTC's factual findings regarding respondent's x-ray policy are supported by substantial evidence. There is no dispute that respondent's members conspired among themselves to withhold x-rays, and the FTC's finding that competition among dentists with respect to cooperation with insurers' requests for x-rays was diminished where respondent held sway also finds adequate support in the record. Pp. 455-457.

2. Evaluated under the Rule of Reason, the FTC's factual findings are sufficient as a matter of law to establish a violation of § 1 of the Sherman Act, i.e., an unreasonable restraint of trade, and hence a violation of § 5 of the FTC Act. Respondent's x-ray policy takes the form of a horizontal agreement among its members to withhold from their customers a particular service that they desire. Absent some countervailing procompetitive virtue, such an agreement cannot be sustained under the Rule of Reason. This conclusion is not precluded by the absence of specific findings as to the market in which respondent allegedly restrained competition or as to the power of respondent's members in that market, or by the FTC's failure to find that respondent's x-ray policy resulted in

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more costly dental services than the patients and insurers would have chosen if they were able to evaluate x-rays in conjunction with claim forms. Nor do alleged noncompetitive "quality of care" considerations justify respondent's x-ray policy. And whether or not respondent's policy is consistent with Indiana's supposed policy against submission of x-rays to insurers, it is not immunized from antitrust scrutiny. Anticompetitive collusion among private actors, even when consistent with state policy, acquires antitrust immunity only when it is actually supervised by the State, and there is no suggestion of such supervision here. Pp. 457-466.

745 F.2d 1124, reversed.

[106 S.Ct. 2013] WHITE, J., delivered the opinion for a unanimous Court.

WHITE, J., lead opinion

JUSTICE WHITE delivered the opinion of the Court.

This case concerns commercial relations among certain Indiana dentists, their patients, and the patients' dental health care insurers. The question presented is whether the Federal Trade Commission correctly concluded that a conspiracy among dentists to refuse to submit x-rays to dental insurers for use in benefits determinations constituted an

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"unfair method of competition" in violation of § 6 of the Federal Trade Commission Act, 38 Stat. 719, as amended, 15 U.S.C. § 45 (1982 ed. and Supp. II).


Since the 1970's, dental health insurers, responding to the demands of their policyholders, have attempted to contain the cost of dental treatment by, among other devices, limiting payment of benefits to the cost of the "least expensive yet adequate treatment" suitable to the needs of individual patients. Implementation of such cost-containment measures, known as "alternative benefits" plans, requires evaluation by the insurer of the diagnosis and recommendation of the treating dentist, either in advance of or following the provision of care. In order to carry out such evaluation, insurers frequently request dentists to submit, along with insurance claim forms requesting payment of benefits, any dental x-rays that have been used by the dentist in examining the patient, as well as other information concerning their diagnoses and treatment recommendations. Typically, claim forms and accompanying x-rays are reviewed by lay claims examiners, who either approve payment of claims or, if the materials submitted raise a question whether the recommended course of treatment is in fact necessary, refer claims to dental consultants, who are licensed dentists, for further review. On the basis of the materials available, supplemented where appropriate by further diagnostic aids, the dental consultant may recommend that the insurer approve a claim, deny it, or pay only for a less expensive course of treatment.

Such review of diagnostic and treatment decisions has been viewed by some dentists as a threat to their professional independence and economic wellbeing. In the early 1970's, the Indiana Dental Association, a professional organization comprising some 85% of practicing dentists in the State of Indiana, initiated an aggressive effort to hinder insurers'

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efforts to implement alternative benefits plans by enlisting member dentists to pledge not to submit x-rays in conjunction with claim forms.1 The Association's efforts met considerable success: [106 S.Ct. 2014] large numbers of dentists signed the pledge, and insurers operating in Indiana found it difficult to obtain compliance with their requests for x-rays, and accordingly had to choose either to employ more expensive means of making alternative benefits determinations (for example, visiting the office of the treating dentist or conducting an independent oral examination) or to abandon such efforts altogether.

By the mid-1970's, fears of possible antitrust liability had dampened the Association's enthusiasm for opposing the submission of x-rays to insurers. In 1979, the Association and a number of its constituent societies consented to a Federal Trade Commission order requiring them to cease and desist from further efforts to prevent member dentists from submitting

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x-rays. In re Indiana Dental Assn., 93 F.T.C. 392. Not all Indiana dentists were content to leave the matter of submitting x-rays to the individual dentist. In 1976, a group of such dentists formed the Indiana Federation of Dentists, respondent in this case, in order to continue to pursue the Association's policy of resisting insurers' requests for x-rays. The Federation, which styled itself a "union" in the belief that this label would stave off antitrust liability,2 immediately promulgated a "work rule" forbidding its members to submit x-rays to dental insurers in conjunction with claim forms. Although the Federation's membership was small, numbering less than 100, its members were highly concentrated in and around three Indiana communities: Anderson, Lafayette, and Fort Wayne. The Federation succeeded in enlisting nearly 100% of the dental specialists in the Anderson area, and approximately 67% of the dentists in and around Lafayette. In the areas of its strength, the Federation was successful in continuing to enforce the Association's prior policy of refusal to submit x-rays to dental insurers.

In 1978, the Federal Trade Commission issued a complaint against the Federation, alleging in substance that its efforts to prevent its members from complying with insurers' requests for x-rays constituted an unfair method of competition in violation of § 5 of the Federal Trade Commission Act. Following lengthy proceedings, including a full evidentiary hearing before an Administrative Law Judge, the Commission ruled that the Federation's policy constituted a violation of § 5, and issued an order requiring the Federation to cease and desist from further efforts to organize dentists to refuse to submit x-rays to insurers. In re Indiana Federation of Dentists, 101 F.T.C. 57 (1983). The Commission based its ruling on the conclusion that the Federation's policy of requiring its members to withhold x-rays amounted to a conspiracy in restraint of trade that was unreasonable, and hence

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unlawful under the standards for judging such restraints developed in this Court's precedents interpreting § 1 of the Sherman Act. E.g., Chicago Board of Trade v. United States, 246 U.S. 231 (1918); National Society of Professional Engineers v. United States, 435 U.S. 679 (1978). The Commission found that the Federation had conspired both with the Indiana Dental Association and with its own members to withhold cooperation with dental insurers' requests for x-rays; that, absent such a restraint, competition among dentists for patients would have tended to lead dentists to compete with respect to their policies in dealing with patients' insurers; and that, in those areas where the Federation's membership was strong, the Federation's policy had had the actual effect of eliminating such competition among dentists and preventing insurers from obtaining access to x-rays in the desired manner. These findings of anticompetitive effect, the Commission concluded, were sufficient to establish that the restraint was unreasonable, even absent [106 S.Ct. 2015] proof that the...

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