West Penn Allegheny Health System, Inc. v. UPMC

PRECEDENTIAL

UNITED STATES COURT OF APPEALS
FOR THE THIRD CIRCUIT

No. 09-4468

WEST PENN ALLEGHENY HEALTH SYSTEM, INC.,

Appellant

v.

UPMC; HIGHMARK, INC.

On Appeal from the United States District Court
for the Western District of Pennsylvania
District Court No. 2-09-cv-00480
District Judge: The Honorable Arthur J. Schwab

Argued September 15, 2010

Before: SLOVITER, BARRY, and SMITH, Circuit Judges

(Filed: November 29, 2010)

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Barak A. Bassman
James T. Giles
Barbara W. Mather (argued)
Barbara T. Sicalides
Pepper Hamilton
18th & Arch Streets
3000 Two Logan Square
Philadelphia, PA 19103

Andrew K. Fletcher
Pepper Hamilton
500 Grant Street
50th Floor
Pittsburgh, PA 15219
Counsel for Appellant

Jonathan M. Jacobson (argued)
Wilson, Sonsini, Goodrich & Rosati
1301 Avenue of the Americas
40th Floor
New York, NY 10019

Nilam A. Sanghvi
Nancy Winkelman
Schnader Harrison Segal & Lewis
1600 Market Street
Suite 3600
Philadelphia, PA 19103

Paul H. Titus
Schnader Harrison Segal & Lewis

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120 Fifth Avenue
2700 Fifth Avenue Place
Pittsburgh, PA 15222
Counsel for Appellee UPMC

Daniel I. Booker (argued)
Jeffrey J. Bresch
Donna M. Doblick
Paul G. Eastgate
Reed Smith
Suite 1200
225 Fifth Avenue
Pittsburgh, PA 15222
Counsel for Appellee Highmark, Inc.
________________

OPINION
________________

SMITH, Circuit Judge.

The plaintiff in this antitrust case is Pittsburgh’s second-
largest hospital system. It sued Pittsburgh’s dominant hospital
system and health insurer under the Sherman Act and state law.
The plaintiff asserts that the defendants violated sections 1 and
2 of the Sherman Act by forming a conspiracy to protect one
another from competition. The plaintiff says that pursuant to the
conspiracy, the dominant hospital system used its power in the
provider market to insulate the health insurer from competition,
and in exchange the insurer used its power in the insurance

3
market to strengthen the hospital system and to weaken the
plaintiff. The plaintiff also asserts that the dominant hospital
system violated section 2 of the Sherman Act by attempting to
monopolize the Pittsburgh-area market for specialized hospital
services. Finally, the plaintiff asserts state-law claims for unfair
competition and tortious interference against the dominant
hospital system. The District Court dismissed the Sherman Act
claims and, having done so, declined to exercise supplemental
jurisdiction over the state-law claims. Because we conclude that
the District Court erred in dismissing the Sherman Act claims,
we will reverse in part, vacate in part, and remand for further
proceedings.

I. Facts

The following facts are alleged in the plaintiff’s
complaint. The District Court decided this case on a motion to
dismiss. We accept as true the factual allegations in the
complaint and draw all reasonable inferences in the plaintiff’s
favor. Revell v. Port Auth., 598 F.3d 128, 134 (3d Cir. 2010).

A. Cast of Characters

This lawsuit involves three parties. The plaintiff West
Penn Allegheny Health System, Inc. (“West Penn”) is
Pittsburgh’s second-largest hospital system; it has a share of less
than 23% of the market for hospital services in Allegheny
County, which includes the City of Pittsburgh. The defendant

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University of Pittsburgh Medical Center (“UPMC”) is
Pittsburgh’s dominant hospital system. It enjoys a 55% share of
the Allegheny County market for hospital services, and its share
of the market for tertiary and quaternary care services exceeds
50%.1 West Penn and UPMC are the two major competitors in
the Allegheny County market for hospital services, and are the
only competitors in the market for tertiary and quaternary care
services. The defendant Highmark, Inc. is the dominant insurer
in the Allegheny County market for health insurance.2
Highmark’s market share has remained between 60% and 80%
since 2000.

B. Pre-Conspiracy Conduct

In 2000, The Western Pennsylvania Healthcare System
merged with several financially distressed medical providers,

1
“Tertiary care” refers to highly sophisticated, specialized
care. See Highmark Br. at 3 n.1. “Quaternary care” refers to
“advanced levels of medicine which are highly specialized and not
widely used.” Id. at 4 n.2.
2
Specifically, the relevant market with respect to Highmark
is alleged to be the Allegheny County market for “health care
financing and administration for private employers and individuals,
including indemnity insurance, managed care products such as HMO,
PPO, or POS plans, and third-party administration of employer self-
funded health plans.” JA 129. But in their briefs the parties have
referred to this market as the Allegheny County market for health
insurance, and we do the same.

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including Allegheny General Hospital, to form West Penn.
Highmark funded the merger with a $125 million loan.
Highmark’s largesse did not spring from a sense of altruism but
was intended to preserve competition in the market for hospital
services. Had the financially distressed providers comprising
West Penn failed, UPMC would have attained nearly unchecked
dominance in the market. This would not have been good for
Highmark: the more dominant UPMC becomes, the more
leverage it gains to demand greater reimbursements from
Highmark. (Reimbursements are the payments insurers give to
providers to cover services rendered to the insurers’
subscribers.)

After the merger, Highmark and West Penn continued to
enjoy a good relationship, as Highmark recognized that
preserving West Penn was in its interests. Thus, Highmark
encouraged investors to purchase bonds from West Penn,
touting its financial outlook and the quality of its medical
services. And in early 2002, Highmark gave West Penn a $42
million grant to invest in its facilities.

In contrast to Highmark, UPMC has been hostile to West
Penn since its inception. UPMC opposed the merger creating
West Penn: it intervened in the merger proceedings, filed an
unsuccessful lawsuit to prevent Highmark from funding the
merger, and attempted (with some success) to dissuade investors
from purchasing West Penn bonds. UPMC’s hostility towards
West Penn continued after the merger. Since West Penn’s

6
formation, UPMC executives have repeatedly said that they
want to destroy West Penn, and they have taken action to further
that goal on more than a few occasions. But more on that later.
See Section I.E, infra.

Historically, UPMC has also had a bitter relationship
with Highmark. For example, when UPMC demanded
purportedly excessive reimbursement rates from Highmark,
Highmark responded by forming Community Blue, a low-cost
insurance plan. To participate in Community Blue, a hospital
had to agree to accept reduced reimbursements, but would
receive a higher volume of patients. West Penn participated in
Community Blue, but UPMC did not, claiming that its
reimbursement rates were too low. UPMC responded to
Community Blue by forming its own health insurer, UPMC
Health Plan. UPMC Health Plan has been Highmark’s main
competitor in the Allegheny County market for health insurance
since its formation.

Moreover, Highmark and UPMC have faced off in
litigation in the past. In a 2001 federal lawsuit, Highmark sued
UPMC under the Lanham Act, asserting that UPMC had made
false statements about Community Blue in an advertisement.
The District Court agreed with Highmark and preliminarily
enjoined dissemination of the advertisement; we affirmed on
appeal. Highmark, Inc. v. UPMC Health Plan, Inc., 276 F.3d
160, 171–73 (3d Cir. 2001). In another 2001 lawsuit, Highmark
sought to enjoin UPMC’s proposed acquisition of a children’s

7
hospital; Highmark claimed that the acquisition would violate
the antitrust laws. The case ultimately settled, however, and
UPMC acquired the hospital.

C. The Conspiracy Begins; the Dynamics Change

In 1998, UPMC offered a “truce” to Highmark. Under
the terms of the truce, each entity would use its market power to
protect the other from competition. Highmark initially rejected
UPMC’s offer, criticizing it as an illegal “attempt to form a
‘super’ monopoly for the provision of health care in Western
Pennsylvania in which [UPMC], the leading provider of hospital
services, and Highmark, the leading health insurer, would
combine forces.” JA 95.

The complaint alleges, however, that in the summer of
2002, over the course of several meetings, Highmark
reconsidered and decided to accept UPMC’s offer of a truce.
The complaint alleges that UPMC agreed to use its power in the
provider market to prevent Highmark competitors from gaining
a foothold in the Allegheny County market for health insurance,
and in exchange Highmark agreed to take steps to strengthen
UPMC and to weaken West Penn. The complaint offers the
following factual allegations in support of the conspiracy claim.

UPMC engaged in conduct that effectively insulated
Highmark from competition. First, it refused to enter into
competitive provider agreements with Highmark’s rivals. This

8
prevented the rivals from entering the Allegheny County health
insurance market because, given UPMC’s dominance, an insurer
cannot succeed in the market without being able to offer a
competitively-priced plan that includes UPMC as an in-network
provider.3

Second, UPMC shrunk UPMC Health Plan (Highmark’s
main competitor in the insurance market). It cut the Health
Plan’s advertising budget and increased its premiums, which led
to a sharp drop in enrollment. It also refused to sell the Health
Plan to insurers interested in buying it, which might have
revived it as a Highmark competitor. UPMC acknowledged that
it decided to shrink the Health Plan as a result of negotiations
with Highmark, in which Highmark had agreed to take
Community Blue off the market.

Meanwhile, Highmark took action that enhanced
UPMC’s dominance. Most significantly, it paid UPMC
supracompetitive reimbursement rates. To afford UPMC’s
reimbursements, Highmark had to increase its insurance
premiums (which, according to West Penn, it was able to do
without losing business because UPMC had insulated it from
competition). Highmark, moreover, provided UPMC with $230

3
In fact, United Healthcare tried to enter the Allegheny
County insurance market in 2005 and 2006, but it was effectively
prevented from doing so because UPMC would not offer it a
competitive contract.

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million to build a new facility for its children’s hospital, $70
million of which was a grant and the remainder of which was a
low-interest loan. In addition, Highmark vowed not to offer a
health plan that did not include UPMC as an in-network
provider. Thus, in 2004, Highmark eliminated its low-cost
insurance plan, Community Blue, in which UPMC had declined
to participate. With the elimination of a leading low-cost
insurance plan, health insurance premiums in Allegheny County
rose. Furthermore, in 2006, Highmark publicly supported
UPMC’s acquisition of Mercy Hospital, which, other than West
Penn, was UPMC’s only other competitor in the market for
tertiary and quaternary care services. Finally, in 2006,
Highmark leaked confidential financial information regarding
West Penn to UPMC, “which in turn leaked a distorted version
of the information to credit-rating agencies and to the business
media in an attempt to destroy investor confidence in West
Penn.” JA 113.

In addition, Highmark essentially cut West Penn off from
its financial support, thus hampering its ability to compete with
UPMC. Highmark, for instance, repeatedly rejected West
Penn’s requests to refinance the $125 million loan that was used
to fund the 2000 merger.4 Although Highmark believed
refinancing the loan made business sense, it declined to do so

4
Even so, the loan agreement allowed West Penn to obtain
financing elsewhere and to repay the loan early, which West Penn did
in 2007. See JA 710–11.

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out of fear that UPMC would retaliate against it for violating
their agreement—an agreement that Highmark candidly
admitted was “probably illegal.” Highmark said that it was
under a “constant barrage” from UPMC and that UPMC was
“obsessed” with driving West Penn out of business. Highmark
explained that if it helped West Penn financially, UPMC would
allow one of Highmark’s competitors to enter the Allegheny
County insurance market or would sell UPMC Health Plan to a
Highmark competitor. Indeed, UPMC had sent Highmark a
letter containing such a warning. JA 107–09.

Moreover, Highmark maintained West Penn’s
reimbursement rates at artificially depressed levels and
repeatedly refused to increase them. In 2005 and 2006, for
example, West Penn asked Highmark for a general increase in
its rates, which were originally set in 2002. Highmark initially
acknowledged that West Penn’s rates were too low and
suggested that it would raise them, but it ultimately refused to
follow through, explaining that it could not help West Penn
because, if it did, UPMC would retaliate.

Finally, Highmark “discriminated against West Penn []
in the award of grants to improve the quality of medical care in”
Allegheny County. In November 2005, for example,

Highmark launched a program to provide grant
dollars to improve the implementation of
information technology in health care. The

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 program provided for grants of $7,000 per
physician, with an aggregate limit of $500,000 per
health system. Only two health systems in
Western Pennsylvania employed enough
physicians to be limited by the $500,000 cap:
UPMC and West Penn []. Highmark waived the
cap in UPMC’s case, awarding a grant of $8
million. [But] Highmark consistently refused to
raise the cap for West Penn. . . .

JA 113.

D. The Effects of the Conspiracy

The conspiracy ended in 2007, when the Antitrust
Division of the Department of Justice began investigating
Highmark’s and UPMC’s relationship. During the years
covered by the conspiracy, UPMC and Highmark reaped record
profits. UPMC’s net income rose from $23 million in 2002 to
over $618 million in 2007, and Highmark’s net income rose
from $50 million in 2001 to $398 million in 2006. UPMC’s
increased revenue came largely from the “sweetheart”
reimbursements it received from Highmark, and Highmark
increased its earnings by raising premiums.5 On the other hand,

5
For example, from 2002–2006, “health insurance premiums
for single individuals in the Pittsburgh area rose approximately 55%
and health insurance premiums for Pittsburgh families rose
approximately 51%.” JA 105. The increases in nearby regions were

12
West Penn struggled during the years covered by the conspiracy.
It was forced to scale back its services, and to abandon projects
to expand and improve its services and facilities. In essence,
West Penn was unable to compete with UPMC as vigorously as
it otherwise would have.

E. UPMC’s Unilateral Conduct

Besides the conspiracy with Highmark, UPMC has taken
a number of actions on its own to weaken West Penn. Most
significantly, UPMC has systematically “raided” key physicians
from West Penn. Even before West Penn’s formation, UPMC
hired physicians, including neurosurgeons, oncologists, hand
surgeons, cardiologists, gastroenterologists, pulmonologists, and
primary care physicians from two of West Penn’s predecessor
hospitals, including Allegheny General. UPMC lured these
physicians away by paying them salaries that were well above
market rates. Although UPMC incurred financial losses because
of the hirings (that is, it paid the physicians more money than
they generated), it admitted that it was willing to do so in order
to injure the hospitals.

UPMC’s physician “raiding” has “continued unabated”
since West Penn’s formation. JA 117. In 2002, UPMC
attempted to hire the entire anesthesiology staff of a West Penn
hospital. UPMC did so even though its internal analysis showed

much lower.

13
that the raid would be unprofitable. As before, though, UPMC
admitted that it was not trying to earn profits. It was trying to
drive the hospital out of business. In the end, the
anesthesiologists were lured away by UPMC’s bloated salary
offers. But they quit not long after joining UPMC, because
UPMC lacked sufficient operating space to absorb them.

The complaint identifies many additional examples of so-
called physician raiding. In 2003, UPMC hired two primary
care practitioners from a West Penn hospital; UPMC admitted
that it took the practitioners on in order to injure the hospital. In
2005, UPMC hired a surgical group from a West Penn hospital.
In 2006, UPMC hired a radiologist, an orthopedic surgeon, a
cardiovascular surgeon, and an entire vascular lab department
from West Penn. UPMC was unable to absorb the
cardiovascular surgeon and vascular lab staff. In 2008, UPMC
took cardiovascular surgeons, cardiologists, and nine primary
care physicians from West Penn. UPMC agreed to pay one of
the primary care physicians roughly $500,000—a figure well
above the revenue generated by the physician’s practice and
more than four times the salary he received at West Penn. In
2009, UPMC offered Allegheny General’s key bariatric surgeon
a bloated salary in an attempt to hire him away. In an internal
email to UPMC’s CEO, a UPMC executive said that if the
surgeon joined UPMC, “[Allegheny General] will not have a
sustainable bariatrics program unless they just merge it with
[West Penn].” The executive also said that even if Allegheny
General raised the surgeon’s salary and persuaded him to stay,

14
at least UPMC “will have forced [Allegheny General] to incur
higher costs.” JA 120–21. The surgeon ended up leaving
Allegheny General to join UPMC.

In other instances, UPMC tried unsuccessfully to lure
physicians away from West Penn. Between 2002 and 2009,
UPMC attempted to hire a cardiology group, a urology group, an
anesthesiology staff, a radiology staff, a “premier podiatrist,”
and an endocrinology group from West Penn. UPMC did not
need the additional physicians, and although the doctors
remained with West Penn, they did so only after West Penn
agreed to increase their salaries.

In addition to hiring physicians away from West Penn,
UPMC has pressured community hospitals into entering joint
ventures with it for the provision of oncology services. UPMC
told the hospitals that unless they entered the joint ventures, it
would build UPMC satellite facilities next to them, draining
their business. Nearly every community hospital in the
Pittsburgh metropolitan area (except those owned by West Penn)
acquiesced and entered a joint venture with UPMC. These joint
ventures function as exclusive-dealing arrangements, i.e., the
community hospitals refer all of their oncology patients to
UPMC facilities. Moreover, under pressure from UPMC, many
of the community hospitals have begun sending all of their
tertiary and quaternary care referrals to UPMC facilities.

Finally, UPMC has repeatedly made false statements
about West Penn’s financial health in order to discourage
investors from purchasing West Penn bonds. On one occasion,
for example, UPMC disseminated “a book of false and
defamatory information about West Penn[’s] finances that was

15
printed in a format designed to appear as if it were authored by
West Penn.” JA 122. The book, which was distributed to
investment bankers and credit-rating agencies, gave investors a
distorted impression of West Penn’s financial stability. On the
whole, UPMC’s efforts to forestall investment in West Penn
were somewhat successful. Although West Penn has been able
to issue debt when necessary, UPMC’s disparagement has
caused it to pay artificially inflated financing costs on the debt.

II. Procedural History

On April 21, 2009, West Penn initiated this lawsuit in the
United States District Court for the Western District of
Pennsylvania. UPMC and Highmark filed motions to dismiss,
but West Penn sought and was granted leave to submit an
amended complaint, which it filed on August 28, 2009. The
amended complaint (hereafter, “the complaint”) includes five
counts. Counts 1 and 2 assert that UPMC and Highmark
violated sections 1 and 2 of the Sherman Act, respectively, by
conspiring to protect one another from competition. Count 3
alleges that UPMC violated section 2 of the Sherman Act by
attempting to monopolize the Allegheny County market for
“acute care inpatient services,” or, in the alternative, the
Allegheny County market for “high-end tertiary and quaternary
acute care inpatient services.” JA 126. (For simplicity’s sake,
we will refer to the two collectively as the market for
“specialized hospital services.”) Counts 4 and 5 assert state-law
claims against UPMC for unfair competition and tortious
interference with business relations. The complaint requests
damages, including treble and punitive damages, and injunctive
relief, including an order requiring Highmark to “end any
discrimination in reimbursement (both direct and indirect)

16
between UPMC and West Penn.” JA 142.

On September 18, 2009, UPMC and Highmark filed
renewed motions to dismiss. The defendants moved to dismiss
the conspiracy claims on three bases. They argued (1) that the
complaint fails adequately to allege an unlawful conspiracy, (2)
that even if it does allege a conspiracy, it fails to allege that
West Penn sustained an “antitrust injury” as a result of the
conspiracy, and (3) that the conspiracy claims are time-barred.

UPMC urged the Court to dismiss the attempted
monopolization claim on the ground that the complaint fails to
allege “anticompetitive conduct,” an element of such a claim.
Finally, UPMC argued that if the Court dismissed the Sherman
Act claims, it should decline to exercise supplemental
jurisdiction over the state-law claims.

On October 29, 2009, the District Court issued a lengthy
opinion dismissing the complaint in its entirety. First, the Court
discussed the pleading standard that applies in complex cases,
including in antitrust cases. Noting that discovery in complex
cases is expensive and time-consuming, the Court stated that
judges presiding over such cases have a duty to act as
“gatekeepers.” Although the Court did not elaborate on what it
meant by this, it suggested that, in order to prevent complex
cases lacking merit from proceeding to discovery, courts must
subject pleadings in such cases to heightened scrutiny. After
discussing the pleading standard—and taking on the role of
gatekeeper—the Court proceeded to address the merits.

The Court dismissed the conspiracy claims on the ground
that the complaint fails to allege a conspiracy. According to the

17
Court, the complaint “is long on innuendo and frequently repeats
the buzz word that the defendants ‘conspired,’” but ultimately
fails to allege “any facts which evidence a concerted action.”
JA 55. The Court also concluded that the conspiracy claims are
deficient because the complaint fails to allege that West Penn
sustained an antitrust injury as a consequence of the conspiracy.
With respect to the attempted monopolization claim, the Court
agreed with UPMC that the complaint fails to allege
anticompetitive conduct. Finally, after dismissing the federal
claims, the Court declined to exercise supplemental jurisdiction
over the state-law claims.6

West Penn filed this timely appeal.

III. Jurisdiction and Standard of Review

The District Court had jurisdiction over the Sherman Act
claims under 28 U.S.C. §§ 1331 and 1337(a), and supplemental
jurisdiction over the state-law claims under 28 U.S.C. § 1367(a).
This Court has jurisdiction under 28 U.S.C. § 1291. Our review
of a district court’s ruling on a motion to dismiss is plenary.

6
In reaching its decision, the District Court relied heavily on
evidence extrinsic to the complaint. The general rule, of course, is
that “a district court ruling on a motion to dismiss may not consider
matters extraneous to the pleadings.” In re Burlington Coat Factory
Sec. Litig., 114 F.3d 1410, 1426 (3d Cir. 1997). A limited exception
exists for documents that are “integral to or explicitly relied upon in
the complaint.” Id. (emphasis in original and internal quotation
marks omitted). No purpose would be served by examining each
document that the District Court relied on and determining whether
it was properly considered. But based on an initial review, we believe
that the Court may have considered several documents which should
not have been within its purview.

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Jones v. ABN Amro Mortg. Grp., Inc., 606 F.3d 119, 123 (3d
Cir. 2010).

IV. The Pleading Standard

Under Federal Rule of Civil Procedure 8, a complaint
must contain a “short and plain statement of the claim showing
that the pleader is entitled to relief.” In Bell Atlantic Corp. v.
Twombly, 550 U.S. 544 (2007), the Supreme Court held that to
satisfy Rule 8, a complaint must contain factual allegations that,
taken as a whole, render the plaintiff’s entitlement to relief
plausible. Id. at 556, 569 n.14; Howard Hess Dental Labs., Inc.
v. Dentsply Int’l, Inc., 602 F.3d 237, 246 (3d Cir. 2010); Phillips
v. County of Allegheny, 515 F.3d 224, 234 (3d Cir. 2008). This
“‘does not impose a probability requirement at the pleading
stage,’ but instead ‘simply calls for enough facts to raise a
reasonable expectation that discovery will reveal evidence of’
the necessary element.” Phillips, 515 F.3d at 234 (quoting
Twombly, 550 U.S. at 556). In determining whether a complaint
is sufficient, courts should disregard the complaint’s legal
conclusions and determine whether the remaining factual
allegations suggest that the plaintiff has a plausible—as opposed
to merely conceivable—claim for relief. Ashcroft v. Iqbal, 129
S. Ct. 1937, 1949–50 (2009); Fowler v. UPMC Shadyside, 578
F.3d 203, 210–11 (3d Cir. 2009).

The District Court opined that judges presiding over
antitrust and other complex cases must act as “gatekeepers,” and
must subject pleadings in such cases to heightened scrutiny.
The District Court’s gloss on Rule 8, however, is squarely at
odds with Supreme Court precedent. Although Twombly
acknowledged that discovery in antitrust cases “can be

19
expensive,” 550 U.S. at 558, it expressly rejected the notion that
a “‘heightened’ pleading standard” applies in antitrust cases, id.
at 569 n.14, and Iqbal made clear that Rule 8’s pleading
standard applies with the same level of rigor in “‘all civil
actions,’” 129 S. Ct. at 1953. See also Swierkiewicz v. Sorema
N.A., 534 U.S. 506, 512–13 (2002); Leatherman v. Tarrant
County Narcotics Intelligence & Coordination Unit, 507 U.S.
163, 167–68 (1993) (rejecting Fifth Circuit’s adoption of a
heightened pleading standard for civil rights cases alleging
municipal liability); 5 Charles Alan Wright & Arthur R. Miller,
Federal Practice & Procedure § 1221 (3d ed. 2004) (noting that
Rule 8’s pleading standard applies with the same degree of rigor
“in every case, regardless of its size, complexity, or the numbers
of parties that may be involved”).

It is, of course, true that judging the sufficiency of a
pleading is a context-dependent exercise. See Iqbal, 129 S. Ct.
at 1950; Twombly, 550 U.S. at 567–68; Phillips, 515 F.3d at
232. Some claims require more factual explication than others
to state a plausible claim for relief. See In re Ins. Brokerage
Antitrust Litig., 618 F.3d 300, 320 n.18 (3d Cir. 2010). For
example, it generally takes fewer factual allegations to state a
claim for simple battery than to state a claim for antitrust
conspiracy. See A. Benjamin Spencer, Understanding Pleading
Doctrine, 108 Mich. L. Rev. 1, 13–18 (2009). But, contrary to
the able District Court’s suggestion, this does not mean that
Twombly’s plausibility standard functions more like a
probability requirement in complex cases.

We conclude that it is inappropriate to apply Twombly’s
plausibility standard with extra bite in antitrust and other
complex cases. We now turn to address whether West Penn’s

20
complaint satisfies the plausibility standard.

V. The Conspiracy Claims

West Penn asserts conspiracy claims under sections 1 and
2 of the Sherman Act, 15 U.S.C. §§ 1 and 2. Section 1 provides
that “[e]very contract, combination in the form of trust or
otherwise, or conspiracy, in restraint of trade or commerce
among the several States . . . is declared to be illegal.” Despite
its seemingly absolute language, section 1 has been construed to
prohibit only unreasonable restraints of trade. Standard Oil Co.
v. United States, 221 U.S. 1, 58 (1911); United States v. Brown
Univ., 5 F.3d 658, 668 (3d Cir. 1993). Some agreements are so
plainly anticompetitive that they are condemned per se; that is,
they are conclusively presumed to unreasonably restrain trade.
E.g., United States v. Trenton Potteries Co., 273 U.S. 392,
397–400 (1927) (horizontal agreements to fix prices); Palmer v.
BRG of Ga., Inc., 498 U.S. 46, 49–50 (1990) (per curiam)
(horizontal agreements to divide markets). Other agreements
are condemned only if evaluation under the fact-intensive rule
of reason indicates that they unreasonably restrain trade. E.g.,
Leegin Creative Leather Prods., Inc. v. PSKS, Inc., 551 U.S. 877
(2007) (vertical agreements to maintain resale prices).

Section 2 imposes liability on “[e]very person who shall
monopolize, or attempt to monopolize, or combine or conspire
with any other person or persons, to monopolize any part of the
trade or commerce among the several States.” 15 U.S.C. § 2;
see also Howard Hess, 602 F.3d at 253 (listing the elements of

21
a section 2 conspiracy claim).7

UPMC and Highmark defend the District Court’s
dismissal of the conspiracy claims on several bases. We address
each in turn.

A. Agreement

First, we address the defendants’ argument that the
conspiracy claims were properly dismissed because the
complaint fails to allege an agreement. To prevail on a section
1 claim or a section 2 conspiracy claim, a plaintiff must establish
the existence of an agreement, sometimes also referred to as a
“conspiracy” or “concerted action.” Twombly, 550 U.S. at 553;
Gordon v. Lewistown Hosp., 423 F.3d 184, 207 & n.16 (3d Cir.
2005). An agreement exists when there is a unity of purpose, a
common design and understanding, a meeting of the minds, or
a conscious commitment to a common scheme. Copperweld
Corp. v. Indep. Tube Corp., 467 U.S. 752, 771 (1984); Howard
Hess, 602 F.3d at 254; Gordon, 423 F.3d at 208.

A plaintiff may plead an agreement by alleging direct or

7
Commentators have noted that, to the extent it bans
conspiracies to monopolize, section 2 is largely superfluous, as
conspiracies to monopolize will usually—if not always—run afoul of
section 1’s prohibition of conspiracies that unreasonably restrain
trade. See, e.g., Mark T.L. Sargent, Economics Upside-Down: Low-
Price Guarantees as Mechanisms for Facilitating Tacit Collusion,
141 U. Pa. L. Rev. 2055, 2109 (1993). Even so, the fact that
Congress created a redundant cause of action is not a basis for
dismissal. See JTC Petroleum Co. v. Piasa Motor Fuels, Inc., 190
F.3d 775, 779–80 (7th Cir. 1999).

22
circumstantial evidence, or a combination of the two. If a
complaint includes non-conclusory allegations of direct
evidence of an agreement, a court need go no further on the
question whether an agreement has been adequately pled. Ins.
Brokerage, 618 F.3d at 323 (“Allegations of direct evidence of
an agreement, if sufficiently detailed, are . . . adequate.”); see
also Toledo Mack Sales & Serv., Inc. v. Mack Trucks, Inc., 530
F.3d 204, 219–20 & n.10 (3d Cir. 2008) (citing Rossi v.
Standard Roofing, Inc., 156 F.3d 452, 466 (3d Cir. 1998)).

West Penn’s theory on the conspiracy claims is that in the
summer of 2002, UPMC and Highmark formed an agreement to
protect one another from competition. West Penn asserts that
UPMC agreed to use its power in the provider market to exclude
Highmark’s rivals from the Allegheny County health insurance
market, and that in exchange Highmark agreed to take steps to
strengthen UPMC and to weaken its primary rival, West Penn.
We conclude that the complaint contains non-conclusory
allegations of direct evidence of such an agreement.

The complaint alleges that in 2005, West Penn asked
Highmark to refinance the loan that was used to fund the 2000
merger, that Highmark agreed that refinancing was a good idea,
but that Highmark would not sign off on the refinancing.
Highmark explained that if it helped West Penn out financially,
UPMC, which was “obsessed” with driving West Penn out of
business, would retaliate against it for violating their
agreement—an agreement that Highmark admitted was
“probably illegal.” Indeed, UPMC had sent Highmark a letter
warning that if it extended financial assistance to West Penn,
UPMC would enter a provider agreement with a Highmark
competitor, thus reducing Highmark’s dominance in the

23
insurance market. The complaint also alleges that in 2005 and
2006, West Penn asked Highmark to increase its reimbursement
rates, that Highmark acknowledged that the rates were too low
and suggested that it would raise them, but that Highmark
refused to follow through, explaining that if it increased West
Penn’s rates, UPMC would retaliate against it for violating their
agreement. Finally, the complaint alleges that at an employees’
meeting, UPMC’s CEO admitted that he decided to shrink
UPMC Health Plan as a result of “negotiations” with Highmark,
during which Highmark had agreed to take Community Blue off
the market. In all, these allegations of direct evidence are
sufficient to survive a motion to dismiss on the agreement
element. See Ins. Brokerage, 618 F.3d at 323.8

B. Unreasonable Restraint

The defendants make a half-hearted argument that even
if the complaint alleges that they formed a conspiracy to shield
one another from competition, the section 1 claim is still
deficient because the complaint does not allege that the
conspiracy unreasonably restrained trade. We disagree. At the
pleading stage, a plaintiff may satisfy the unreasonable-restraint
element by alleging that the conspiracy produced
anticompetitive effects in the relevant markets. See Howard
Hess, 602 F.3d at 253; Brown Univ., 5 F.3d at 668.
Anticompetitive effects include increased prices, reduced
output, and reduced quality. Toledo Mack, 530 F.3d at 226;
Brown Univ., 5 F.3d at 668–69.

8
Because we conclude that the allegations of direct evidence
are by themselves sufficient, we do not address the sufficiency of the
circumstantial allegations. See Ins. Brokerage, 618 F.3d at 323.

24
 Here, the complaint alleges that the relevant markets are,
on one hand, the Allegheny County market for specialized
hospital services and, on the other hand, the Allegheny County
market for health insurance.9 The complaint plausibly suggests
that by denying West Penn capital, the conspiracy caused West
Penn to cut back on its services (including specialized hospital
services) and to abandon projects to expand and improve its
services and facilities. The complaint also plausibly suggests
that by shielding Highmark from competition, the conspiracy
resulted in increased premiums and reduced output in the market
for health insurance. These allegations are sufficient to suggest
that the conspiracy produced anticompetitive effects in the
relevant markets.10

C. Antitrust Injury

We now turn to the defendants’ argument that the
conspiracy claims were properly dismissed on the ground that
the complaint fails to allege antitrust injury. In Brunswick Corp.
v. Pueblo Bowl-O-Mat, Inc., 429 U.S. 477 (1977), the Supreme
Court held that an antitrust plaintiff must do more than show
that it would have been better off absent the violation; the
plaintiff must establish that it suffered an antitrust injury. An

9
The defendants do not challenge West Penn’s definition of
the relevant markets.
10
In so concluding, we do not reach West Penn’s argument
that—given the horizontal aspect of the conspiracy, i.e., UPMC’s
agreement to shrink UPMC Health Plan—the conspiracy is subject to
per se condemnation. Even if the more demanding rule of reason
applies, the complaint adequately alleges that the conspiracy stifled
competition in the relevant markets.

25
antitrust injury is an “injury of the type the antitrust laws were
intended to prevent and that flows from that which makes [the]
defendants’ acts unlawful.” Id. at 489. “The injury should
reflect the anticompetitive effect either of the violation or of
anticompetitive acts made possible by the violation.” Id.; see
also Atl. Richfield Co. v. USA Petroleum Co., 495 U.S. 328,
334, 344 (1990) (“[An] injury, although causally related to an
antitrust violation, nevertheless will not qualify as an ‘antitrust
injury’ unless it is attributable to . . . a competition-reducing
aspect or effect of the defendant’s behavior.”).

The antitrust-injury requirement helps ensure “that the
harm claimed by the plaintiff corresponds to the rationale for
finding a violation of the antitrust laws in the first place, and it
prevents losses that stem from competition from supporting suits
by private plaintiffs for . . . damages.” Atl. Richfield, 495 U.S.
at 342; see also Cargill, Inc. v. Monfort of Colo., Inc., 479 U.S.
104, 109–10 (1986) (declaring that “it is inimical to the antitrust
laws to award damages for losses stemming from continued
competition”) (internal punctuation omitted); Serfecz v. Jewel
Food Stores, 67 F.3d 591, 597 (7th Cir. 1995) (“When the
plaintiff’s injury is linked to the injury inflicted upon the market,
such as when consumers pay higher prices because of a market
monopoly or when a competitor is forced out of the market, the
compensation of the injured party promotes the designated
purpose of the antitrust law—the preservation of competition.”);
IIA Phillip E. Areeda, Herbert Hovenkamp et al., Antitrust Law
¶ 337a, at 82-83 (3d ed. 2007).

So, for example, in Brunswick, a group of bowling alleys
sued a manufacturer of bowling equipment, claiming that the
latter’s acquisition of several financially distressed alleys

26
violated the antitrust laws. 429 U.S. at 479-80. The plaintiffs
said that if the struggling alleys had been allowed to fail, their
profits would have increased, as displaced bowlers would have
patronized their alleys. Id. at 481. The Supreme Court held,
however, that the plaintiffs had not sustained an antitrust injury.
The acquisitions in question were unlawful, if at all, because
they tended to give the defendant monopoly power in the
bowling alley market. And the plaintiffs were complaining
about profits lost as a result of continued competition (the
defendant’s rescuing the distressed alleys), not about injuries
linked to reduced competition. The plaintiffs thus failed to
establish antitrust injury. Id. at 487-89.

As a general matter, the class of plaintiffs capable of
satisfying the antitrust-injury requirement is limited to
consumers and competitors in the restrained market, Carpet
Group Int’l v. Oriental Rug Imps. Ass’n, Inc., 227 F.3d 62,
76–77 (3d Cir. 2000); Gulfstream III Assocs., Inc. v. Gulfstream
Aerospace Corp., 995 F.2d 425, 429 (3d Cir. 1993); Gregory
Mktg. Corp. v. Wakefern Food Corp., 787 F.2d 92, 95 (3d Cir.
1986), and to those whose injuries are the means by which the
defendants seek to achieve their anticompetitive ends, Blue
Shield of Va. v. McCready, 457 U.S. 465, 479 (1982); Broadcom
Corp. v. Qualcomm Inc., 501 F.3d 297, 320–21 (3d Cir. 2007);
Areeda & Hovenkamp, supra, ¶ 339, at 123.

West Penn asserts that three aspects of the conspiracy
caused it antitrust injury. First, West Penn says it was injured as
a result of Highmark’s decision to take Community Blue off the
market. It explains that Community Blue subscribers often
received treatment at West Penn hospitals and that it lost
business when Community Blue was eliminated. West Penn’s

27
injury in this regard, however, is not antitrust injury. As West
Penn seems to acknowledge, Highmark’s elimination of
Community Blue violated the antitrust laws, if at all, because it
tended to reduce competition in the Allegheny County market
for health insurance and thus tended to cause, among other
things, an increase in premiums. West Penn participates in the
insurance market not as a consumer or a competitor but as a
supplier—it sells hospital services to insurers. A supplier does
not suffer an antitrust injury when competition is reduced in the
downstream market in which it sells goods or services.
Schuylkill Energy Res., Inc. v. Pa. Power & Light Co., 113 F.3d
405, 410, 415 (3d Cir. 1997); SAS of P.R., Inc. v. P.R . Tele. Co.,
48 F.3d 39, 44–45 (1st Cir. 1995); Serfecz, 67 F.3d at 597–98;
Int’l Raw Materials, Ltd. v. Stauffer Chem. Co., 978 F.2d 1318,
1327–28 (3d Cir. 1992); Alberta Gas Chems. Ltd. v. E.I. Du
Pont De Nemours & Co., 826 F.2d 1235, 1241–42 (3d Cir.
1987). Although a supplier may lose business when competition
is restrained in the downstream market in which it sells goods
and services, such losses are merely byproducts of the
anticompetitive effects of the restraint. See Areeda &
Hovenkamp, supra, ¶ 350c, at 237-38. We conclude, then, that
West Penn did not sustain an antitrust injury based on the
elimination of Community Blue.

Second, West Penn alleges that it sustained an antitrust
injury based on Highmark’s refusals to refinance the $125
million loan. It explains that Highmark’s refusals caused it to
incur inflated financing costs, which in turn deprived it of
capital that it would have used to improve and expand its
medical facilities. But even if Highmark would not refinance
the loan, the loan agreement allowed West Penn to obtain
financing elsewhere and to repay the loan early without

28
penalty.11 In fact, West Penn did so in 2007. Because
Highmark was just one of many possible sources of financing,
we conclude that—even if it acted with anticompetitive
motives—Highmark’s refinancing refusals could not have been
“competition-reducing aspect[s] . . . of the” conspiracy, Atl.
Richfield, 495 U.S. at 344, and thus did not give rise to an
antitrust injury. See Paycom Billing Servs., Inc. v. Mastercard
Int’l, Inc., 467 F.3d 283, 294 (2d Cir. 2006); Johnson v. Univ.
Health Servs., Inc., 161 F.3d 1334, 1338 (11th Cir. 1998)
(defendant’s refusal to provide the plaintiff financing with
which to open her own business did not give rise to antitrust
injury because plaintiff could have obtained financing from
many other sources); Christofferson Dairy, Inc. v. MMM Sales,
Inc., 849 F.2d 1168, 1173–74 (9th Cir. 1988) (defendant’s
refusal to sell plaintiff surplus milk did not give rise to antitrust
injury where “there were ‘plenty’ of other sources for surplus
milk”).

Finally, West Penn argues that it sustained an antitrust
injury in the form of artificially depressed reimbursement rates.
The complaint alleges that during the conspiracy, West Penn
asked Highmark to renegotiate and raise its rates. The
complaint suggests that Highmark acknowledged that the rates
were too low and initially agreed to raise them, but that
Highmark refused to follow through, citing its agreement with
UPMC, under which it was not to do anything to benefit West
Penn financially. West Penn asserts that the amount of the
u n d erpaym ents— i.e ., the difference betw e e n th e

11
Although this case is considered on a motion to dismiss, the
loan agreement may be reviewed because it is integral to the
complaint. Burlington Coat, 114 F.3d at 1426.

29
reimbursements it would have received in a competitive market
and those it actually received—constitutes an antitrust injury.
For their part, the defendants do not take issue with West Penn’s
suggestion that its reimbursement rates would have been greater
absent the conspiracy. They argue, instead, that paying West
Penn depressed reimbursement rates was not an element of the
conspiracy that posed antitrust problems. They reason that low
reimbursement rates translate into low premiums for subscribers,
and that it would therefore be contrary to a key purpose of the
antitrust laws—promoting consumer welfare—to allow West
Penn to recover the amount of the underpayments. West Penn
has it right.

Admittedly, had Highmark been acting alone, West Penn
would have little basis for challenging the reimbursement rates.
A firm that has substantial power on the buy side of the market
(i.e., monopsony power) is generally free to bargain aggressively
when negotiating the prices it will pay for goods and services.
Kartell v. Blue Shield of Mass., Inc., 749 F.2d 922, 926–30 (1st
Cir. 1984) (Breyer, J.); Travelers Ins. Co. v. Blue Cross of W.
Pa., 481 F.2d 80, 84 (3d Cir. 1973). This reflects the general
hesitance of courts to condemn unilateral behavior, lest vigorous
competition be chilled. Am. Needle, Inc. v. NFL, 130 S. Ct.
2201, 2209 (2010); Goldwasser v. Ameritech Corp., 222 F.3d
390, 397 (7th Cir. 2000).

But when a firm exercises monopsony power pursuant to
a conspiracy, its conduct is subject to more rigorous scrutiny,
see Am. Needle, 130 S. Ct. at 2209, and will be condemned if it
imposes an unreasonable restraint of trade, see Standard Oil,
221 U.S. at 58. “This is so because unlike independent action,
‘concerted activity inherently is fraught with anticompetitive

30
risk’ insofar as it ‘deprives the marketplace of independent
centers of decisionmaking that competition assumes and
demands.’” Am. Needle, 130 S. Ct. at 2209 (quoting
Copperweld, 467 U.S. at 768–69) (internal punctuation omitted).

Here, the complaint suggests that Highmark has
substantial monopsony power. It alleges that Highmark has a
60%–80% share of the Allegheny County market for health
insurance, that there are significant entry barriers for insurers
wishing to break into the market (including UPMC’s
unwillingness to deal competitively with non-Highmark
insurers), and that medical providers have very few alternative
purchasers for their services.12 The complaint also alleges that
Highmark paid West Penn depressed reimbursement rates, not
as a result of independent decisionmaking, but pursuant to a
conspiracy with UPMC, under which UPMC insulated
Highmark from competition in return for Highmark’s taking
steps to hobble West Penn. In these circumstances, it is
certainly plausible that paying West Penn depressed
reimbursement rates unreasonably restrained trade. Such short-
changing poses competitive threats similar to those posed by
conspiracies among buyers to fix prices, see Mandeville Island
Farms v. Am. Crystal Sugar Co., 334 U.S. 219 (1948), and other
restraints that result in artificially depressed payments to
suppliers—namely, suboptimal output, reduced quality,
allocative inefficiencies, and (given the reductions in output)
higher prices for consumers in the long run. See Brown v. Pro
Football, Inc., 50 F.3d 1041, 1061 (D.C. Cir. 1995) (Wald, J.,

12
Indeed, the complaint alleges that the only other insurer
with a significant market share is UPMC Health Plan, and that UPMC
Health Plan has basically been unwilling to deal with West Penn.

31
dissenting) (discussing the anticompetitive effects of
monopsony) (citing Roger D. Blair & Jeffrey L. Harrison,
Monopsony 36–43, 72 (1993)); Areeda & Hovenkamp, supra,
¶ 350b, at 234–235 & n.8; John J. Miles, Health Care &
Antitrust Law § 15B:4 (2010) (collecting sources and discussing
the problems linked to insurer monopsony); Roger D. Blair &
John E. Lopatka, Predatory Buying and the Antitrust Laws,
2008 Utah L. Rev. 415, 415 (observing that the “exercise of
monopsony power . . . misallocates resources and thereby
reduces social welfare”); see also St. Bernard Gen. Hosp., Inc.
v. Hosp. Serv. Ass’n, 712 F.2d 978, 985–87 (5th Cir. 1983)
(prima facie antitrust violation shown where insurer that was
controlled by participating hospitals limited reimbursements
paid to non-participating hospitals).

The defendants argue, though, that Highmark’s paying
West Penn depressed reimbursements did not pose antitrust
problems because it enabled Highmark to set low insurance
premiums and thus benefitted consumers. We disagree. First,
even if it were true that paying West Penn depressed rates
enabled Highmark to offer lower premiums, it is far from clear
that this would have benefitted consumers, because the premium
reductions would have been achieved only by taking action that
tends to diminish the quality and availability of hospital
services. See Brown, 50 F.3d at 1061 (Wald, J., dissenting);
Warren S. Grimes, The Sherman Act’s Unintended Bias Against
Lilliputians, 69 Antitrust L.J. 195, 210 (2001) (“The very nature
of monopsony or oligopsony power is that it tends to suppress
output and reduce quality or choice.”). Second, the complaint
alleges that Highmark did not pass the savings on to consumers.
It alleges, instead, that Highmark pocketed the savings, while
repeatedly ratcheting up insurance premiums. See also Roger D.

32
Blair & Jeffrey L. Harrison, Antitrust Policy and Monopsony, 76
Cornell L. Rev. 297, 339 (1991) (explaining that “lower input
prices resulting from the exercise of monopsony power do not
ultimately translate into lower prices to the monopsonist’s
customers”).

But most importantly, the defendants’ argument reflects
a basic misunderstanding of the antitrust laws. The Ninth
Circuit’s discussion in Knevelbaard Dairies v. Kraft Foods, Inc.,
232 F.3d 979 (9th Cir. 2000), illustrates the point well. There,
the plaintiff milk producers established that the defendant
cheese makers had conspired to depress the price they paid for
milk. The cheese makers argued that the plaintiffs’ injuries
were not antitrust injuries—i.e., were not the kind of injuries
“the antitrust laws were intended to prevent,” Brunswick, 429
U.S. at 489—because the conspiracy enabled them to purchase
milk at lower costs and thus to sell cheese to consumers at lower
prices. Knevelbaard Dairies, 232 F.3d at 988. The Ninth
Circuit properly rejected this argument:

The fallacy of th[e defendants’] argument
becomes clear when we recall that the central
purpose of the antitrust laws . . . is to preserve
competition. It is competition—not the collusive
fixing of prices at levels either low or high—that
these statutes recognize as vital to the public
interest. The Supreme Court’s references to the
goals of achieving “the lowest prices, the highest
quality and the greatest material progress,” [N.
Pac. Ry. Co. v. United States, 356 U.S. 1, 4
(1958)], and of “assur[ing] customers the benefits
of price competition,” [Associated Gen.
Contractors of Cal., Inc. v. Cal. State Council of
Carpenters, 459 U.S. 519, 538 (1983)], do not

33
 mean that conspiracies among buyers to depress
acquisition prices are tolerated. Every precedent
in the field makes clear that the interaction of
competitive forces, not price-rigging, is what will
benefit consumers.

Id.; see also Mandeville, 334 U.S. at 235. Similar reasoning
applies here. Highmark’s improperly motivated exercise of
monopsony power, like the collusive exercise of oligopsony
power by the cheese makers in Knevelbaard, was
anticompetitive and cannot be defended on the sole ground that
it enabled Highmark to set lower premiums on its insurance
plans.

Having concluded that paying West Penn artificially
depressed reimbursement rates was an anticompetitive aspect of
the alleged conspiracy, it follows that the underpayments
constitute an antitrust injury. See Atl. Richfield, 495 U.S. at 334
(holding that an antitrust injury is an injury that is “attributable
to an anti-competitive aspect of the practice under scrutiny”);
Brunswick, 429 U.S. at 489; Areeda & Hovenkamp, supra, ¶
350, at 235 (noting that “sellers receiving illegally low prices .
. . suffer antitrust injury”).

D. Statute of Limitations 13

13
Although Federal Rule of Civil Procedure 8(c) suggests that
“a statute of limitations defense cannot be used in the context of a
Rule 12(b)(6) motion to dismiss,” Oshiver v. Levin, Fishbein, Sedran
& Berman, 38 F.3d 1380, 1384 n.1 (3d Cir. 1994), our cases
recognize that a defendant may raise a limitations defense in a motion
to dismiss, Robinson v. Johnson, 313 F.3d 128, 135 & n.3 (3d Cir.
2002) (citing cases). For the defendant to prevail, though, the
plaintiff’s tardiness in bringing the action must be apparent from the

34
 Highmark argues that the conspiracy claims are time-
barred. Under 15 U.S.C. § 15b, a suit to recover damages for a
violation of the Sherman Act must be “commenced within four
years after the cause of action accrued.” In Zenith Radio Corp.
v. Hazeltine Research, Inc., 401 U.S. 321 (1971), the Supreme
Court declared that an antitrust cause of action generally
“accrues and the statute [of limitations] begins to run when a
defendant commits an act that injures a plaintiff’s business.” Id.
at 338. However, “[i]n the context of a continuing conspiracy
to violate the antitrust laws, . . . each time a plaintiff is injured
by an act of the defendants a cause of action accrues to [it] to
recover the damages caused by that act and . . . as to those
damages, the statute of limitations runs from the commission of
the act.” Id.; Hanover Shoe, Inc. v. United Shoe Mach. Corp.,
392 U.S. 481, 502 n.15 (1968); In re Lower Lake Erie Iron Ore
Antitrust Litig., 998 F.2d 1144, 1172 (3d Cir. 1993) (“[A]n
injurious act within the limitations period may serve as a basis
for an antitrust suit.”); see also Klehr v. A.O. Smith Corp., 521
U.S. 179, 189–90 (1997).

West Penn initiated this lawsuit on April 21, 2009, and so
the limitations period extends back to April 21, 2005. See 15
U.S.C. § 15b. The complaint adequately alleges that the
defendants performed injurious acts in furtherance of the
conspiracy within the limitations period. The complaint alleges,
for example, that as part of the conspiracy, Highmark refused to
increase West Penn’s reimbursement rates in 2006. On a
straightforward reading of Zenith, it therefore appears that West
Penn may, consistent with the statute of limitations, recover

face of the complaint. Id.

35
damages for the acts that occurred within the limitations period.
See 401 U.S. at 338.

Highmark acknowledges all of this, but urges us to adopt
a limitation on Zenith. Citing persuasive authority, Highmark
asks us to hold that no cause of action accrues based on
injurious acts that occur within the limitations period, if those
acts are merely “reaffirmations” of acts done or decisions made
outside the limitations period. See Highmark Br. at 38–46
(citing, e.g., Grand Rapids Plastics, Inc. v. Lakian, 188 F.3d
401, 406 (6th Cir. 1999)). Highmark says that under this
standard West Penn’s conspiracy claims are time-barred,
because the acts that allegedly occurred within the limitations
period were merely manifestations of decisions made or acts
done outside the limitations period. We reject Highmark’s
proposed standard, as it is inconsistent with controlling
precedent.

We start with Hanover Shoe. There, a shoe manufacturer
sued a shoemaking machinery company for monopolization
under section 2 of the Sherman Act. The manufacturer asserted
that in 1912, the machinery company had established a lease-
only policy for its most important equipment, under which it
would lease—but would not sell—the equipment to
manufacturers. 392 U.S. at 483. The manufacturer claimed that
the lease-only policy had enabled the machinery company to
maintain a monopoly in the market for shoemaking equipment,
and that as a result, it had incurred artificially inflated costs in
carrying out its business. Id. at 484. Although the manufacturer
asserted that the lease-only policy had been established in 1912,
it did not file suit against the machinery company until 1955.
Citing the time gap, the machinery company asserted that the

36
suit was time-barred. The Supreme Court disagreed:

[The machinery company] has . . . advanced the
argument that because the earliest impact on [the
manufacturer] of [the machinery company’s] lease
only policy occurred in 1912, [the manufacturer’s]
cause of action arose during that year and is now
barred by the applicable . . . statute of limitations.
. . . [But w]e are not dealing with a violation
which, if it occurs at all, must occur within some
specific and limited time span. . . . Rather, we are
dealing with conduct which constituted a
continuing violation of the Sherman Act and
which inflicted continuing and accumulating harm
on [the manufacturer]. Although [the
manufacturer] could have sued in 1912 for the
injury then being inflicted, it was equally entitled
to sue in 1955.

Id. at 502 n.15. The Court so held even though the injurious
acts that took place within the limitations period—i.e., instances
in which the machinery company persisted in its refusal to offer
its equipment for sale—were simply manifestations of the lease-
only policy, which had been established in 1912, well before the
start of the limitations period. See id.; see also Klehr, 521 U.S.
at 189–90 (noting that in the context of a price-fixing
conspiracy, any given sale gives rise to a cause of action to
recover the damages caused by that sale); Harold Friedman, Inc.
v. Thorofare Mkts., 587 F.2d 127, 138–39 (3d Cir. 1978)
(section 1 suit challenging shopping center’s refusal to lease
space to grocery store deemed timely, even though refusal was
“grounded upon an exclusivity clause in a lease that was entered
into [between the shopping center and a rival grocery store]
more than four years before the commencement of the suit”).

37
 Our decision in Lower Lake Erie is along the same lines.
There the plaintiffs, which included docking and transportation
companies, sued a railroad under section 1 of the Sherman Act.
The companies proved that the defendant had participated in a
conspiracy among railroads to exclude the companies from the
market for the handling and transportation of iron ore. 998 F.2d
at 1153–54. The railroads had excluded the companies by,
among other things, refusing to lease them dock property
suitable for the shipment of iron ore, and by overcharging the
companies to use the railroads to ship ore. Id. The defendant
argued that because the conspiracy had gotten under way outside
the limitations period, the companies’ claims were time-barred.
We disagreed, reasoning that the companies’ claims were timely
because the railroads’ exclusionary conduct, including refusing
to lease dock property and overcharging for use of the railroads,
had continued into the limitations period. See id. at 1172;
accord Bell v. Dow Chem. Co., 847 F.2d 1179, 1186–87 (5th
Cir. 1988); Imperial Point Colonnades Condo., Inc. v.
Mangurian, 549 F.2d 1029, 1035, 1041–43 (5th Cir. 1977),
followed in Harold Friedman, 587 F.2d at 139 & nn. 43–45;
Poster Exch., Inc. v. Nat’l Screen Serv. Corp., 517 F.2d 117,
127–28 (5th Cir. 1975). But see, e.g., David Orgell, Inc. v.
Geary’s Stores, Inc., 640 F.2d 936, 937–38 (9th Cir. 1981).
Taken together, Hanover Shoe and Lower Lake Erie leave no
room for Highmark’s proposed rule. In each case, the plaintiff’s
suit was timely even though the acts that occurred within the
limitations period were reaffirmations of decisions originally
made outside the limitations period.

Finally, we note that the policies underlying limitations
statutes—namely, providing potential defendants with repose
and avoiding prejudice caused by lost evidence, faded

38
memories, and unavailable witnesses, see Wilson v. Garcia, 471
U.S. 261, 271–72 (1985)—do not counsel in favor of
recognizing Highmark’s proposed rule. As for repose, the Fifth
Circuit said it well in Poster Exchange, where it rejected a rule
strikingly similar to the one Highmark proposes here:

[Adopting the defendant’s rule] would . . .
improperly transform the limitations statute from
one of repose to one of continued immunity. For
according to [the defendant’s] argument, a
plaintiff who suffers [damage from a continuing
antitrust violation] is barred not only from
proving violations and damages more than four
years old, but is barred forever from complaining
of [the continuation] of the unlawful conduct. The
function of the limitations statute is simply to pull
the blanket of peace over acts and events which
have themselves already slept for the statutory
period, thus barring the proof of wrongs
embedded in time-passed events. Employing the
limitations statute additionally to immunize recent
repetition or continuation of violations and
damages occasioned thereby not only extends the
statute beyond its purpose, but also conflicts with
the policies of vigorous enforcement of private
rights through private actions.

517 F.2d at 127–28 (internal citations omitted). With regard to
the policy of avoiding prejudice, the defendants “hardly are in
a position to argue for the protection of the statute of limitations
on the traditional ground that evidence has been lost, memories
have faded, and witnesses have disappeared . . . when it is the
defendants’ own recent conduct that results in a finding of a
newly accruing cause of action.” Imperial Point, 549 F.2d at

39
1041 (internal citations and punctuation omitted).

We thus end up where we started: Zenith should be
applied on its terms. Under Zenith, West Penn’s conspiracy
claims are not time-barred because the complaint adequately
alleges that the defendants performed injurious acts in
furtherance of the conspiracy within the limitations period.

VI. The Attempted Monopolization Claim

In addition to the conspiracy claims, West Penn alleges
that UPMC violated section 2 of the Sherman Act by attempting
to monopolize the Allegheny County market for specialized
hospital services. The elements of attempted monopolization
are (1) that the defendant has a specific intent to monopolize,
and (2) that the defendant has engaged in anticompetitive
conduct that, taken as a whole, creates (3) a dangerous
probability of achieving monopoly power. Spectrum Sports, Inc.
v. McQuillan, 506 U.S. 447, 456 (1993); Swift & Co. v. United
States, 196 U.S. 375, 396 (1905); Lepage’s Inc. v. 3M, 324 F.3d
141, 162 (3d Cir. 2003) (en banc) (holding that a court should
consider a defendant’s anticompetitive conduct “as a whole
rather than considering each aspect in isolation”) (citing Cont’l
Ore Co. v. Union Carbide & Carbon Corp., 370 U.S. 690, 699
(1962)). The District Court dismissed the attempted
monopolization claim on the ground that the complaint fails to
allege anticompetitive conduct, and the parties have addressed
only that issue here. We limit our review accordingly.

Broadly speaking, a firm engages in anticompetitive
conduct when it attempts “to exclude rivals on some basis other
than efficiency,” Aspen Skiing Co. v. Aspen Highlands Skiing

40
Corp., 472 U.S. 585, 605 (1985) (internal quotation marks
omitted), or when it competes “on some basis other than the
merits,” Lepage’s, 324 F.3d at 147. “Conduct that impairs the
opportunities of rivals and either does not further competition on
the merits or does so in an unnecessarily restrictive way may be
deemed anticompetitive.” Broadcom, 501 F.3d at 308. The line
between anticompetitive conduct and vigorous competition is
sometimes blurry, but distinguishing between the two is critical,
because the Sherman Act “directs itself not against conduct
which is competitive, even severely so, but against conduct
which unfairly tends to destroy competition itself.” McQuillan,
506 U.S. at 458; United States v. Aluminum Co. of Am., 148
F.2d 416, 429–30 (2d Cir. 1945).

“‘Anticompetitive conduct’ can come in too many
different forms, and is too dependent upon context, for any court
or commentator ever to have enumerated all the varieties.”
Lepage’s, 324 F.3d at 152 (quoting Caribbean Broad Sys., Ltd.
v. Cable & Wireless PLC, 148 F.3d 1080, 1087 (D.C. Cir.
1998)). For present purposes, it is sufficient to note that
anticompetitive conduct can include a conspiracy to exclude a
rival, Areeda & Hovenkamp, supra, ¶ 806f3, at 428; see
Lepage’s, 324 F.3d at 157, hiring a rival’s employees not to use
them but to deny them to the rival, Universal Analytics, Inc. v.
MacNeal-Schwendler Corp., 914 F.2d 1256, 1258 (9th Cir.
1990) (per curiam); Areeda & Hovenkamp, supra, ¶ 702, at 205,
a hospital’s coercing providers not to refer patients to a rival,
Potters Med. Ctr. v. City Hosp. Ass’n, 800 F.2d 568, 576–77,
580 (6th Cir. 1986); see M&M Med. Supplies & Serv., Inc. v.
Pleasant Valley Hosp., 981 F.2d 160, 166–67 (4th Cir. 1992) (en
banc), and making false statements about a rival to potential
investors and customers, see Lepage’s, 324 F.3d at 153 (citing

41
Int’l Travel Arrangers, Inc. v. Western Airlines, Inc., 623 F.2d
1255 (8th Cir. 1980)); Caribbean, 148 F.3d at 1087; see
generally Maurice E. Stucke, Symposium, When a Monopolist
Deceives, 76 Antitrust L.J. 823 (2010).14

The complaint alleges the following anticompetitive
conduct. First, the defendants engaged in a conspiracy, a
purpose of which was to drive West Penn out of business.
Second, UPMC hired employees away from West Penn by
paying them bloated salaries. UPMC admitted to hiring some of
the employees not because it needed them but in order to injure
West Penn; UPMC could not absorb some of the employees and
had to let them go; and UPMC incurred financial losses as a
result of the hiring. These allegations are sufficient to suggest
that at least some of the hirings were anticompetitive. See
Universal Analytics, 914 F.2d at 1258 (Anticompetitive or
predatory hiring “can be proved by showing the hiring was made
with [anticompetitive] intent, i.e. to harm the competition
without helping the [defendant], or by showing a clear nonuse

14
We previously recognized—though perhaps in overly broad
terms—that making false statements about a rival, without more,
rarely interferes with competition enough to violate the antitrust laws.
See Santana Prods., Inc. v. Bobrick Washroom Equip., Inc., 401 F.3d
123, 132 (3d Cir. 2005) (stating, in the context of a section 1 case,
that “‘deception, reprehensible as it is, can be of no consequence so
far as the Sherman Act is concerned’”). But in some cases, such
defamation, which plainly is not competition on the merits, can give
rise to antitrust liability, especially when it is combined with other
anticompetitive acts. See Lepage’s, 324 F.3d at 153, 162; Int’l
Travel, 623 F.2d at 1268, 1270; Caribbean, 148 F.3d at 1087.

42
in fact.”).15 Relatedly, UPMC tried unsuccessfully to lure a
number of employees away from West Penn; UPMC could not
have absorbed the additional employees, and although the
employees remained with West Penn, they did so only after
West Penn raised their salaries to supracompetitive levels.
Third, UPMC approached community hospitals and threatened
to build UPMC satellite facilities next to them unless they
stopped referring oncology patients to West Penn and began
referring all such patients to UPMC. Nearly all of the
community hospitals caved in, which deprived West Penn of a
key source of patients. Moreover, under pressure from UPMC,
several of the community hospitals have stopped sending any of
their tertiary and quaternary care referrals to West Penn and
have begun sending them all to UPMC. Finally, on several
occasions, UPMC made false statements about West Penn’s
financial health to potential investors, which caused West Penn
to pay artificially inflated financing costs on its debt.

Viewed as a whole, these allegations plausibly suggest
that UPMC has engaged in anticompetitive conduct, i.e., that
UPMC has competed with West Penn “on some basis other than
the merits.” Lepage’s, 324 F.3d at 147. The District Court
erred in concluding otherwise.16

15
UPMC argues that we may not consider hirings made
outside the limitations period in determining whether the new hirings
were anticompetitive. Not so. Toledo Mack, 530 F.3d at 217
(holding that it is proper to consider pre-limitations period conduct in
determining whether conduct within the limitations period violated
the antitrust laws).
16
West Penn also claims that UPMC’s acquisition of Mercy
Hospital was anticompetitive. It says that, besides West Penn, Mercy
was UPMC’s only other competitor in the market for specialized

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 VII. The State-Law Claims

After dismissing the federal claims, the District Court
declined to exercise supplemental jurisdiction over the state-law
claims. Having determined that the federal claims were
improperly dismissed, we will vacate the dismissal of the state-
law claims for reconsideration by the District Court.

VIII. Conclusion

For the reasons set forth above, the judgment of the
District Court will be reversed in part and vacated in part, and
the case will be remanded for further proceedings.

hospital services, and that the acquisition brought UPMC one step
closer to monopoly. As UPMC points out, however, West Penn has
failed to allege that it sustained an antitrust injury as a result of the
acquisition, and thus may not challenge it. See Alberta Gas, 826 F.2d
at 1241–42 (gas producer sustained no antitrust injury as a result of
an acquisition of a potential competitor by another competitor);
Areeda & Hovenkamp, supra, ¶ 348b, at 204.

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