however, successful collaborations have improved entire industries. Examples are the automotive and electronics industry.

In the electronics industry, as in any fast-changing industry, most of what is proprietary is old, not current or future. Manufacturers whose products are in competition at the retail level collaborate on a next generation of technology, and for this reason sharing proprietary information and technologies is not a competitive threat.

What would induce determined competitive health plans to collaborate, even on quality improvement? There is, at present, little reward in the market for investing in quality. In part this is because they do not perceive that it will bring increased market share, and in part it is because investment in quality by one plan is likely to result in a ''flee-rider problem" where all plans benefit. Further, the market imperative for plans to engage most of the physicians in an area of nonexclusive relationships creates networks that are too large and too broad to efficiently address improvement efforts, even if plans were willing to accept the free-rider burden.

Collaboration is a strategy that plans might use to achieve economies of scale and avoid the free-rider problem. Purchasers are likely to be an important stimulus to bringing competing plans to the table to encourage specific quality improvement initiatives that they would not likely undertake on their own and to achieve. Potential areas for collaboration include:

  • the identification of substandard practitioners, in part through carrying out the objectives of the Health Care Quality Improvement Act of 1986;
  • joint practitioner educational efforts;
  • joint public education efforts; and
  • joint development of guidelines for the use of effective therapies.

Antitrust Issues

Although one can make a plausible case for collaboration, there are barriers. One barrier is the perceived threat of antitrust scrutiny, though the perception is likely to be worse than the reality. Nevertheless, better guidance is needed about what forms of collaboration concerning quality that the antitrust laws clearly permit, what activities represent per se violations, and where there is uncertainty.

The market paradigm is embodied in the antitrust laws. These laws would welcome, not oppose, many forms of collaboration among competing health plans where the collaboration has the potentia for improving the quality of care. Although antitrust law takes a dim view of concerted action that is antithetical to competition, it is clearly not intended to discourage all competitor collaboration, much of which is clearly procompetitive. Only if the likely anticompetitive effects outweigh the procompetitive ones will a particular collaboration be deemed a restraint of trade.

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