Full opinion text
TABLE OF CONTENTS I. Preliminary Statement.1173 II. Standards Under Which Defendants’ Motion Must be Decided.1175 A. Rule 12(b)(1).1175 B. Review of Standards Developed in Previous Opinion .1175 1. Pleading Standards .1175 2. Substantive Sherman Act Standards . 1176 C. Analytic Framework .1180 1. Each Case Turns on Its Own Facts.1180 2. Considerations Bearing on the Tripartite Jurisdictional Test .... 1181 a. Nature of the alleged restraint.1181 b. Nature of the plaintiff .1183 III. Application of Legal Standards to Plaintiffs’ Sherman Act Allegations.1184 A. Introductory Statement.U84 B. “In Commerce” Theory .1185 C. “Affecting Commerce” Theory .1186 1. Treatment of Out-of-State Patients by Plaintiffs.1187 2. Interstate Flow of Revenues to Plaintiffs .1190 3. Use of Medical Equipment and Medical Supplies by Plaintiffs . .. 1192 4. Use of Automobiles, Gasoline, and Other Equipment by Plaintiffs . . ■ 1194 5. Prescriptions of Drugs and Medicines by Plaintiffs .-1195 6. Dissuasion of Out-of-State Physicians From Associating with Plaintiffs .1197 7. Inflating of Fees for Cardiology Services .1198 8. Diminished Interstate Investments in Plaintiffs’ Pension Portfolio . . 1200 9. Curtailment of Plaintiffs’ Practice in Connection with a New Jersey Clinic.1201 10. Lessening of Use of Out-of-State Continuing Education.1201 11. Summary .1202 D. Consistency with Prior Precedent.1202 IV. Conclusion.1205 OPINION JOSEPH S. LORD, III, Senior District Judge. I. Preliminary Statement Plaintiff Cardio-Medical Associates, Ltd., and its four physician members, brought this antitrust action against Crozer-Chester Medical Center (hereinafter referred to as “CCMC”), members of the CCMC Board of Directors, and the Chief of the Department of Medicine at CCMC (hereinafter referred to as “the CCMC defendants”), as well as several individual doctors practicing cardiology under the name of Cardiology Associates of Delaware County (hereinafter referred to as “Cardiology Associates”). Plaintiffs allege that the denial to them of certain specialized staff privileges in cardiology at CCMC violates both sections 1 and 2 of the Sherman Act, 15 U.S.C. §§ 1, 2 (1976), and section 4 of the Clayton Act, 15 U.S.C. § 15 (1976). Plaintiffs originally filed this action on July 30, 1981. In their original complaint, plaintiffs alleged that the denial to them of such privileges resulted from an unlawful conspiracy by defendants that restrained trade in violation of sections 1 and 2 of the Sherman Act. Plaintiffs also alleged that defendants’ conduct violated plaintiffs’ fourteenth amendment rights and, therefore, constituted a deprivation of a constitutionally protected property or liberty interest within the meaning of 42 U.S.C. § 1983 (1976). Pursuant to rule 12(c), the CCMC defendants, later joined by Cardiology Associates, filed a motion for judgment on the pleadings on the grounds that plaintiffs had failed to state a claim for relief or establish that this court had subject matter jurisdiction with respect to either count of the original complaint. On March 15, 1982, I issued an opinion and order granting defendants’ motion for judgment on the pleadings. Cardio-Medical Associates, Ltd. v. Crozer-Chester Medical Center, 536 F.Supp. 1065 (E.D.Pa.1982). Count II of plaintiffs’ original complaint, which alleged violations of the Constitution and section 1983, was dismissed with prejudice. Count I, however, which alleged that the actions of defendants violated the antitrust laws, was dismissed without prejudice and I granted plaintiffs sixty days to file an amended complaint. On May 13, 1982, plaintiffs, with the assistance of new counsel, filed a thirty-eight page, sixty-five paragraph amended complaint. In fifty-five paragraphs of introductory allegations, plaintiffs attempt to plead jurisdiction and venue; the identity of the parties; the identification of relevant product markets; the alleged effects that defendants’ activities have on interstate trade and commerce; and the activities allegedly constituting defendants’ conspiracy, unreasonable restraint of trade, and group boycott of plaintiffs. Count I of plaintiffs’ amended complaint then states their Sherman Act section 1 claim while Count II states their Sherman Act section 2 claim. Thus, plaintiffs’ amended complaint alleges, as did Count I of their original complaint, that defendants have prohibited plaintiffs from practicing certain cardiology procedures at CCMC in violation of sections 1 and 2 of the Sherman Act. On the basis of these allegations, plaintiffs seek permanent injunctive relief compelling defendants to permit plaintiffs to perform the specified procedures from which they allegedly have been wrongfully excluded. Plaintiffs also seek damages for the injuries allegedly sustained as a result of the denial of the opportunity to perform these procedures as well as attorneys’ fees and costs. Pursuant to rule 12(b)(1) of the Federal Rules of Civil Procedure, the CCMC defendants have moved to dismiss plaintiffs’ amended complaint for lack of subject matter jurisdiction. Defendants’ decision to proceed under rule 12(b)(1) as opposed to rule 12(b)(6) was dictated by my holding in the original Cardio-Medical opinion that “[t]he Third Circuit uniformly approaches the interstate commerce issue as one of jurisdiction.” Cardio-Medical, 536 F.Supp. at 1079 n. 15. For the reasons stated below, I grant defendants’ motion to dismiss as to both counts of plaintiffs’ amended complaint, and, having already afforded plaintiffs the opportunity to amend their complaint, dismiss their cause of action with prejudice. Again, I write at some length because of the increasing significance — to doctors, to hospitals, and to the federal courts — of this genre of cases. The large financial and administrative burdens imposed on hospital defendants and the courts as a result of the growing number of denial of hospital staff privileges cases, notwithstanding the infrequency with which plaintiffs prevail, is only one reason for this topic’s current importance. Further, my analysis of the case law discloses no comprehensive discussion of the theories underlying and of the standards to be applied in deciding claims of this type. Cardio-Medical, 536 F.Supp. at 1069. II. Standards Under Which Defendants’ Motion Must be Decided A. Rule 12(b)(1) Under the applicable Third Circuit precedents, rule 12(b)(1) is the appropriate procedural vehicle for the testing of antitrust jurisdictional challenges. See, e.g., Mortensen v. First Federal Savings & Loan Ass’n, 549 F.2d 884 (3d Cir.1977); Doctors, Inc. v. Blue Cross of Greater Philadelphia, 490 F.2d 48 (3d Cir.1973); Daley v. St. Agnes Hospital, Inc., 490 F.Supp. 1309 (E.D.Pa.1980). The Third Circuit, however, has been emphatic in its identification of a “crucial distinction” between rule 12(b)(1) motions that attack a complaint on its face and rule 12(b)(1) motions that attack a complaint factually (i.e., through the introduction of materials outside the pleadings). Mortensen, 549 F.2d at 891. Whenever the court treats a rule 12(b)(1) motion to dismiss as a facial challenge to the legal sufficiency of the pleading, it must afford the plaintiff the same safeguards as would be available to the plaintiff in a rule 12(b)(6) motion: Because 12(b)(6) results in a determination on the merits in an early stage of plaintiff’s case, the plaintiff is afforded the safeguard of having all its allegations taken as true and all inferences favorable to plaintiff will be drawn. The decision disposing of the case is then purely on the legal sufficiency of plaintiff’s case: even were plaintiff to prove all its allegations he or she would be unable to prevail. In the interest of judicial economy it is not improper to dispose of the claim at that stage. Id. If the rule 12(b)(1) attack is a factual one, however, the trial court proceeds in an entirely different manner. As the Third Circuit explained in Mortensen, “no presumptive truthfulness attaches to plaintiff’s allegations, and the existence of disputed material facts will not preclude the trial court from evaluating for itself the merits of jurisdictional claims. Moreover, the plaintiff will have the burden of proof that jurisdiction does in fact exist.” Id. It should be made clear at the outset that it is my apprehension that defendants’ rule 12(b)(1) challenge in this case is a facial challenge to the legal sufficiency of plaintiffs’ amended complaint. Neither party has attempted to introduce materials outside the pleadings; thus, in reaching my decision, I have not moved beyond the pleadings. My decision is, therefore, based strictly on a reading of plaintiffs’ complaint, in the light most favorable to plaintiffs, together with any facts of which I am entitled to take judicial notice. See 2A J. Moore, Moore’s Federal Practice ¶ 12.15, at 2343-44 (1981). B. Review of Standards Developed in Previous Opinion 1. Pleading Standards The initial Cardio-Medical opinion contained an extensive discussion of the general disfavor with which all motions for summary disposition of cases are treated in federal courts. See Cardio-Medical Associates, Ltd. v. Crozer-Chester Medical Center, 536 F.Supp. 1065, 1070-72, 1078-79 (E.D.Pa.1982). To summarize, I reasoned that the line between permissible and impermissible summary disposition of cases had to be drawn as the result of an analysis of two competing policies: the “notice pleading” policy and the “efficiency” policy: Generally, summary disposition of claims on the merits is disfavored. If a complaint contains even the most basic of allegations that, when read with great liberality, could justify plaintiff’s claim for relief, motions for judgment on the pleadings should be denied. Nevertheless, a district court judge still must scrutinize complaints to ensure that they contain even these most basic and minimum allegations. This scrutiny is particularly appropriate in a case in which a party questions the jurisdiction of the court because of the federal judge’s special responsibility to determine that there is jurisdiction in each case. Notwithstanding the liberal amendment provisions of the federal rules, summary dismissal of a facially deficient complaint, without leave to amend or conduct discovery, is appropriate in the following situations: (1) if “the merits of the controversy can be fairly and fully decided” without amendment or discovery, as, for example, if plaintiff’s complaint is legally deficient and, after inquiry by the court, plaintiff can suggest no way in which it can be made legally sufficient, see [C. Wright & A. Miller, Federal Practice and Procedure § 1369, at 698 (1969); Cardio-Medical, 536 F.Supp. at 1071 n. 4]; ... or (3) if the pleadings are wholly inadequate and discovery would serve no demonstrably useful purpose, [Cardio-Medical, 536 F.Supp. at 1072 n. 5]. Id. at 1072. The initial Cardio-Medical opinion emphasized that these same standard federal pleading requirements “apply with full force to complaints in complex antitrust matters.” Id. at 1079. In antitrust matters, I continue to subscribe fully to the remarks of the trial judge in Searer v. West Michigan Telecasters, Inc., 381 F.Supp. 634 (W.D.Mich.1974), aff’d mem. 524 F.2d 1406 (6th Cir.1975), who held: It is true that summary procedure should be used sparingly in complex antitrust litigation.... However, this policy of restraint is no warrant for every plaintiff who can draft an antitrust complaint, no matter how groundless or improbable its allegations, to force his claim to trial despite its deficient factual underpinning. Id. at 643. 2. Substantive Sherman Act Standards Section 1 of the Sherman Act declares that contracts, conspiracies, and combinations in restraint of trade or commerce among the states are illegal. In addition, section 2 prohibits attempts to monopolize the sale of products or services in trade or commerce among the states. “Coverage of the Sherman Act, legislation passed pursuant to the authority granted Congress by the Commerce Clause, extends both to activities that are actually in interstate commerce and to activities that, though purely intrastate in character, nevertheless, substantially affect interstate commerce.” Cardio-Medical, 536 F.Supp. at 1073 (emphasis in original). Accord McLain v. Real Estate Board of New Orleans, 444 U.S. 232, 241, 100 S.Ct. 502, 508, 62 L.Ed.2d 441 (1980); Hospital Building Co. v. Trus tees of the Rex Hospital, 425 U.S. 738, 743, 96 S.Ct. 1848, 1851, 48 L.Ed.2d 338 (1976); United States v. Employing Plasterers Ass’n, 347 U.S. 186, 189, 74 S.Ct. 452, 454, 98 L.Ed. 618 (1954); Atlantic Cleaners & Dyers, Inc. v. United States, 286 U.S. 427, 435, 52 S.Ct. 607, 609, 76 L.Ed. 1204 (1932). Although the distinction between activities “in” commerce and activities that only “affect” commerce is still important for limited purposes under the antitrust laws, “the jurisdictional requirement of the Sherman Act may be satisfied under either the ‘in commerce’ or the ‘effect on commerce’ theory.” McLain, 444 U.S. at 242, 100 S.Ct. at 509. See Cardio-Medical, 536 F.Supp. at 1073 (citing cases). In order to satisfy the “in commerce” theory of Sherman Act jurisdiction, a plaintiff must demonstrate that its business is “actually in interstate commerce” or that its business, though essentially local in nature, is an “integral part of or ‘essential and inseparable from’ an interstate transaction.” Heille v. City of St. Paul, 512 F.Supp. 810 at 812-813 (D.Minn.1981), aff’d, 671 F.2d 1134 (8th Cir.1982). See also Goldfarb v. Virginia State Bar, 421 U.S. 773, 95 S.Ct. 2004, 44 L.Ed.2d 572 (1975). In order to satisfy the “affecting commerce” test, plaintiffs’ amended complaint must contain factual allegations that, if proved, would sustain each of three independent underlying findings: (i) the presence of interstate commerce; (ii) the existence of a substantial and adverse effect on interstate commerce; and (iii) the requisite nexus between the challenged activities of defendants and the effect on the relevant channel of interstate commerce. See Cardio-Medicai, 536 F.Supp. at 1074. “Failure to allege sufficient facts on any one of these jurisdictional prerequisites requires dismissal of plaintiffs’ [amended] complaint.” Id. Plaintiffs’ jurisdictional burden under this tripartite standard could not have been made clearer in my last opinion. Plaintiffs must first specifically identify the element or elements of interstate commerce implicated in the case. See McLain, 444 U.S. at 242, 100 S.Ct. at 509. Critically, the identified aspect of interstate commerce must relate to the activities of plaintiffs, and not defendants. See Cardio-Medical, 536 F.Supp. at 1076-78. Plaintiffs’ complaint then must contain specific factual allegations that, if proved, would demonstrate that the challenged action of defendants “substantially and adversely affects interstate commerce.” Gulf Oil Corp. v. Copp Paving Co., 419 U.S. 186, 195, 95 S.Ct. 392, 398, 42 L.Ed.2d 378 (1974). See Cardio-Medical, 536 F.Supp. at 1074 (collecting cases). Previous cases have exhaustively defined the scope of this substantiality test. Sherman Act jurisdiction cannot be established and the substantiality requirement cannot be met through allegations of effects on commerce that are “incidental,” “inconsequential,” or “de minimis.” See Rosemound Sand & Gravel Co. v. Lambert Sand & Gravel Co., 469 F.2d 416, 418 (5th Cir.1972); Searer v. West Michigan Telecasters, Inc., 381 F.Supp. 634, 640-41 (W.D.Mich.1974), aff’d mem. 524 F.2d 1406 (6th Cir.1975); Marston v. Ann Arbor Property Managers Ass’n, 302 F.Supp. 1276, 1279-80 (E.D.Mich.1969), aff’d, 422 F.2d 836 (6th Cir.1970), cert. denied, 399 U.S. 929, 90 S.Ct. 2244, 26 L.Ed.2d 796 (1970). Further, the requisite allegations on substantiality cannot be satisfied through vague or conclusory statements in the complaint. See Wolf v. Jane Phillips Episcopal-Memorial Medical Center, 513 F.2d 684 (10th Cir.1975); Cardio-Medical, 536 F.Supp. at 1078-79; Grigg v. Blue Cross and Blue Shield of Michigan, 1980-2 Trade Cas. (CCH) ¶ 63,500 (E.D.Mich.1980). Finally, plaintiffs must allege with specificity the logical nexus between the challenged activities of defendants (in this case, denying plaintiffs the right to practice specialized cardiology procedures) and the effect on the relevant channel of interstate commerce identified previously. See Cardio-Medical, 536 F.Supp. at 1074; Daley v. St. Agnes Hospital, Inc., 490 F.Supp. 1309 (E.D.Pa.1980). Implicit in this tripartite jurisdictional test, particularly in the substantiality and nexus requirements, is my view that a mere shifting in the flow of interstate commerce or the simple substitution of one party for another in that flow does not establish a “substantial and adverse effect” on interstate commerce for purposes of Sherman Act jurisdiction, at least in a case such as this in which plaintiffs have not been totally foreclosed from practicing their profession in the relevant market. It is my view that the case law firmly supports my holding. For example, in Cartrade, Inc. v. Ford Dealers Advertising Association of Southern California, 446 F.2d 289 (9th Cir.1971), cert. denied, 405 U.S. 997, 92 S.Ct. 1249, 31 L.Ed.2d 465 (1972), the Ninth Circuit held that there was no effect on commerce in a case in which plaintiff, an automobile trading agency, was replaced by another agency established through the joint efforts of the defendants in that case. Although the court of appeals acknowledged that the business of the plaintiff Cartrade affected interstate commerce, it ruled that the actions of the defendants in replacing the plaintiff with a new agency had no effect on interstate commerce. The district court reached a similar result in Dominion Parking Corp. v. Baltimore and Ohio Railway Co., 450 F.Supp. 441 (E.D.Va.1978). In Dominion Parking, a former lessee of parking lots brought an antitrust action against the owner of the lots and the new lessee following the termination of plaintiff’s lease. The district judge rejected plaintiff’s argument that the termination had had an effect on interstate commerce, noting that the case “concern[ed] the potential effect on interstate commerce of substituting one parking lot operator for another. Although plaintiffs are affected by the substitution, interstate commerce is not.” Id. at 446 (emphasis supplied). Most significantly, a shifting of interstate commerce has been found insufficient to sustain jurisdiction in a case involving the denial of hospital staff privileges to a physician. In Moles v. Morton F. Plant Hospital, Inc., 1980-81 Trade Cas. (CCH) ¶ 63,600 (M.D.Fla.1978), aff’d mem. 617 F.2d 293 (5th Cir.1980), cert. denied, 449 U.S. 919, 101 S.Ct. 317, 66 L.Ed.2d 147 (1980), plaintiffs argued that the refusal of defendant hospital to renew or grant them staff privileges resulted in an effect on interstate commerce because their patients’ bills were paid by funds that travelled in interstate commerce. In rejecting this argument, the trial judge explained that: Here all the allegations regard a diminution of interstate insurance payments to plaintiffs, but the flow in interstate commerce would be the same. The effect of the defendants’ actions would be on the plaintiffs but not on the flow of interstate commerce. This differs from the Rex Hospital case where it was alleged that interstate commerce would be substantially reduced by the loss of plaintiffs’ purchases of supplies. Plaintiff hospital in Rex also allegedly paid over its revenue to an out-of-state parent corporation. Thus, payments were alleged to be reduced by defendants’ actions. Id. at 77,189. Plaintiffs vigorously contested the position that a mere shifting of interstate commerce from one business to another does not affect interstate commerce. None of the cases cited by plaintiffs in support of their position even addresses the specific issue underlying my conclusion: whether interstate commerce is substantially burdened, and thus whether antitrust jurisdiction is established, when commerce shifts from one party to another, but otherwise remains unchanged, as a result of an alleged violation of the antitrust laws. First, the effect on interstate commerce was not at issue in either Klor’s, Inc. v. Broadway-Hale Stores, Inc., 359 U.S. 207, 79 S.Ct. 705, 3 L.Ed.2d 741 (1959), or United States v. Topco Associates, Inc., 405 U.S. 596, 92 S.Ct. 1126, 31 L.Ed.2d 515 (1972). The issue in Klor’s was simply whether harm to one business, as opposed to many, could constitute the requisite “public injury,” or competitive harm, required by section 1 of the Sherman Act. Although the Supreme Court held that such harm could constitute the required injury, because the jurisdiction of the federal courts was clear on the record and unchallenged, Justice Black was not required to, and did not, address the interstate commerce jurisdictional issue, much less whether shifting triggered jurisdiction. On its facts, the Topeo case is even more remote from the issue under consideration in the instant case. In Topeo, the only question addressed by the Court was whether the trial court erred in applying the rule of reason rather than a per se rule to the alleged violation. Justice Marshall’s opinion contains not a single word on the interstate commerce jurisdictional issue, again because of the obviousness of federal jurisdiction independent of any shifting argument. A second group of cases cited by plaintiffs in support of their position discusses the interstate commerce requirement, but fails to make a specific holding with respect to the shifting issue addressed in the instant case. For example, in Hospital Building Co. v. Trustees of the Rex Hospital, supra, the Court simply said that to sustain jurisdiction the restraint must place “unreasonable burdens” on interstate commerce; a substantial and adverse reduction in such commerce would be sufficient. Although shifting was not addressed, Hospital Building Co., by requiring a “burden” on interstate commerce, supports my analysis that a mere shifting would be insufficient to establish jurisdiction. Further, in Harold Friedman, Inc. v. Thorofare Markets, Inc., 587 F.2d 127 (3d Cir.1978), the Third Circuit ruled that an increase in interstate commerce flowing from an alleged restraint may be sufficient to establish federal jurisdiction. The court of appeals, however, did not address the issue whether a mere shifting in the flow of interstate commerce would be sufficient. Friedman is, therefore, wholly consistent with the result that I reach in the instant case: plaintiffs must allege facts that, if proved, would support a finding that there has been some change (either an increase or a decrease) in the flow of interstate commerce. Only one case cited by plaintiffs discusses shifting, but the discussion appears in a context distinct from the interstate commerce question. Following Friedman, the Tenth Circuit held in Mishler v. St. Anthony Hospital Systems, 1981-2 Trade Cas. (CCH) ¶ 64,342 (10th Cir.1982), that an increase in interstate commerce may constitute the requisite “unreasonable burden on commerce” necessary to vest a federal trial court with jurisdiction. Id. at 74,586. The court of appeals then addressed an entirely different issue — whether a diversion of revenues can constitute the “requisite harm to the public,” id., necessary for an antitrust violation. Its answer in the affirmative, just like the Klor’s decision discussed above, is totally separate from an inquiry into whether interstate commerce has been implicated sufficiently to grant a federal court jurisdiction over the cause of action. In sum, I hold that, at least in a case in which the plaintiff has not been foreclosed from doing business in the relevant market, a mere shifting in commerce from one party to another as a result of a restraint allegedly violative of the antitrust laws is insufficient in and of itself to vest a federal trial court with jurisdiction over an antitrust case. C. Analytic Framework My decision in the instant case turns on more than application of these general standards of law to the allegations contained in plaintiffs’ amended complaint. Following a review of every decided denial of hospital staff privileges case, as well as a large selection of antitrust jurisdiction cases involving the health-care industry, there emerges an analytic framework that both explains the jurisdictional determinations made in the previous cases and assists me in reaching a decision on this case. 1. Each Case Turns on Its Own Facts The first crucial principle in my analytic framework is that each denial of hospital staff privileges case must turn on its own peculiar and unique facts. The Third Circuit has emphasized that an evaluation of the sufficiency of interstate commerce allegations requires “a practical, case-by-case economic judgment, not a conclusion derived from application of abstract or mechanistic forumlae [sic].” Rasmussen v. American Dairy Ass’n, 472 F.2d 517, 523 (9th Cir.1972); see Mandeville Island Farms v. American Crystal Sugar Co., 334 U.S. 219, 232-233 [68 S.Ct. 996, 1004-1005, 92 L.Ed. 1328] ... (1948). That is, the issue is one of degree which defies precise tests and which necessarily yields somewhat imprecise resolutions. As a result, the precedent in this area is unlikely to dictate the outcome in any given case. Instead, it is more likely to communicate a general sense as to how much of an impact local activities must have upon interstate commerce before they confer jurisdiction.... Doctors, Inc. v. Blue Cross of Greater Philadelphia, 490 F.2d 48, 51 (3d Cir.1978). Accord Crane v. Intermountain Health Care, Inc., 637 F.2d 715, 717 (10th Cir.1980) (citing Doctors with approval), rev’d on other grounds, 637 F.2d at 719 (10th Cir.1981) (en banc); Harold Friedman, Inc. v. Thorofare Markets, Inc., 587 F.2d 127, 132 (3d Cir.1978) (emphasizing that effect on interstate commerce must be viewed on a case-by-case basis). The Ninth Circuit has taken the same view on this issue, but still emphasized the obligation of a federal trial judge to draw some line when evaluating plaintiffs’ jurisdictional allegations: A determination of whether the interstate commerce requirement of the Sherman Act has been met requires an evaluation of the particular facts presented in each case. The cases do not provide easily applicable standards for determining whether the necessary relationship with interstate commerce exists. [See Rasmussen v. American Dairy Ass’n, 472 F.2d 517, 527 n. 20 (9th Cir.1972), cert. denied, 412 U.S. 950, 93 S.Ct. 3014, 37 L.Ed.2d 1003 (1973).] ... We find it unnecessary to catalog the facts of each case cited by the parties, as there emerges no “bright line” dividing the cases in which the required nexus with interstate commerce has been found and those in which it has not. In Rasmussen, supra, 472 F.2d at 526, we noted this difficulty yet emphasized that some line must be drawn “or federal regulation is boundless.” Thornhill Publishing Co., Inc. v. General Telephone & Electronics Corp., 594 F.2d 730, 739 (9th Cir.1979). 2. Considerations Bearing on the Tripartite Jurisdictional Test With full cognizance of the cautionary instructions given by both the Third and Ninth Circuits, I have identified two considerations that influence the practical economic judgments a trial court is required to make when assessing a facial challenge to its own jurisdiction: the nature of the alleged restraint in each case and the nature of the specific plaintiff in each case. My evaluation of these two considerations — the second and third parts of my framework— results in a nearly complete harmonization of what might appear to be harshly conflicting precedents. a. Nature of the alleged restraint The second part of my framework to aid in the analysis of denial of hospital staff privileges claims is the nature of the alleged restraint in each particular case. In all but one denial of hospital staff privileges or related health-care industry case in which there has been an ultimate finding that federal jurisdiction under the Sherman Act exists, the alleged restraint involved was either an industry or class-wide combination or boycott or a total exclusion from participation in the trade or business at issue. Hospital Building Co. v. Trustees of the Rex Hospital, 425 U.S. 738, 96 S.Ct. 1848, 48 L.Ed.2d 338 (1976) (total boycott of a major hospital); Hahn v. Oregon Physicians’ Service and Physicians’ Association of Clackamas County, 1982-2 Trade Cas. (CCH) ¶ 64,970 (9th Cir.1982) (exclusion of four podiatrists from insurance coverage; complaint worded in class-action-like terms); Mishler v. St. Anthony’s Hospital Systems, 1981-2 Trade Cas. (CCH) ¶ 64,342 (10th Cir.1981) (total exclusion from emergency room referral list of the major regional hospital in the area); Crane v. Intermountain Health Care, Inc., 637 F.2d 715 (10th Cir.1981) (en banc) (total exclusion including restrictions on outside laboratory owned by plaintiff); Feminist Women’s Health Center, Inc. v. Mohammad, 586 F.2d 530 (5th Cir.1978) (attempted destruction of plaintiff’s clinic), cert. denied sub nom. Palmer v. Feminist Women’s Health Center, Inc., 444 U.S. 924, 100 S.Ct. 262, 62 L.Ed.2d 180 (1979); Ballard v. Blue Shield of Southern West Virginia, Inc., 543 F.2d 1075 (4th Cir.1976) (denial of all insurance proceeds for chiropractic services in an entire state), cert. denied, 430 U.S. 922, 97 S.Ct. 1341, 51 L.Ed.2d 601 (1977); Doctors, Inc. v. Blue Cross of Greater Philadelphia, 490 F.2d 48 (3d Cir.1973) (alleged inability to survive by major hospitals in the Philadelphia metropolitan area); Everhart v. Jane C. Stormont Hospital and Training School for Nurses, 1982-1 Trade Cas. (CCH) ¶ 64,703 (D.Kan.1982) (total denial of staff privileges to one doctor by three hospital defendants); Dos Santos v. Columbus-Cuneo-Cabrini Medical Center, 1982-1 Trade Cas. (CCH) ¶ 64,498 (N.D.Ill.1981) (total denial of staff privileges by one hospital in which plaintiff physician had practiced medicine for one year); Malini v. Singleton & Associates, 516 F.Supp. 440 (S.D.Tex.1981) (total denial of staff privileges by three hospital defendants); Feldman v. Jackson Memorial Hospital, 509 F.Supp. 815 (S.D.Fla.1981) (although not a class action, complaint alleges general denial to all podiatrists; also alleges total destruction of business); Hyde v. Jefferson Parish Hospital District No. 2, 513 F.Supp. 532 (E.D.La.1981) (total denial of staff privileges), rev’d on other grounds, 686 F.2d 286 (5th Cir.1982); Robinson v. Magovern, 456 F.Supp. 1000 (W.D.Pa.1978) (total denial of staff privileges); Zamiri v. William Beaumont Hospital, 430 F.Supp. 875 (E.D.Mich.1977) (total denial of staff privileges). See also J.P. Mascaro & Sons, Inc. v. William J. O’Hara, Inc., 565 F.2d 264 (3d Cir.1977) (alleged industry-wide price fix). But see Stone v. William Beaumont Hospital, No. 79-74212 (E.D.Mich. Aug. 17, 1981) (denial of heart catheterization privileges). On the other hand, the cases in which the ultimate decision was a holding that federal jurisdiction did not exist usually involve only partial restraints on the plaintiff’s ability to conduct his profession. Wolf v. Jane Phillips Episcopal-Memorial Medical Center, 513 F.2d 684, 685 (10th Cir.1975) (total exclusion of one doctor from two local hospitals); Elizabeth Hospital, Inc. v. Richardson, 269 F.2d 167 (8th Cir.) (denial of county medical society membership to chief of staff of plaintiff hospital; both hospital and chief of staff continued to practice medicine), cert. denied, 361 U.S. 884, 80 S.Ct. 155, 4 L.Ed.2d 120 (1959); Riggall v. Washington County Medical Society, 249 F.2d 266 (8th Cir.1957) (denial of county medical society membership to one doctor; doctor continued to practice medicine), cert. denied, 355 U.S. 954, 78 S.Ct. 540, 2 L.Ed.2d 530 (1958); Spears Free Clinic & Hospital for Poor Children v. Cleere, 197 F.2d 125 (10th Cir.1952) (defendants prevented licensing of plaintiff clinic; clinic still operated); Pao v. Holy Redeemer Hospital, No. 81-2918 (E.D.Pa. March 17, 1982) (ophtha-mological surgeon on staff at a number of other hospitals denied privileges at defendant hospital), after amended complaint, 547 F.Supp. 484 (E.D.Pa.1982) (dismissing antitrust count for failure to state a claim); Nara v. American Dental Ass’n, 526 F.Supp. 452 (W.D.Mich.1981) (American Dental Association suspended plaintiff’s membership; plaintiff still practiced medicine as a dentist); Barr v. National Right to Life Committee, Inc., 1981-2 Trade Cas. (CCH) ¶ 64,315 (M.D.Fla.1981) (denial of staff privileges to one doctor at two hospitals); Grigg v. Blue Cross and Blue Shield of Michigan, 1980-2 Trade Cas. (CCH) ¶ 63,500 (E.D.Mich.1980) (two ear-and-throat doctors excluded from one union health plan); Daley v. St. Agnes Hospital, Inc., 490 F.Supp. 1309 (E.D.Pa.1980) (nursing supervisor blacklisted by former employer); Moles v. Morton F. Plant Hospital, Inc., 1980-81 Trade Cas. (CCH) ¶ 63,600 (M.D.Fla.1978) (two local doctors excluded from the staff of one local hospital); Capili v. Shott, No. 78-1009-B1 (S.D.W.Va. March 15, 1978), aff’d, 620 F.2d 438 (4th Cir.1980) (one doctor totally excluded from the staff of one hospital); Sokol v. University Hospital, Inc., 402 F.Supp. 1029 (D.Mass.1975) (total exclusion of one doctor from the staff of one hospital); Harron v. United Hospital Center, Inc., 384 F.Supp. 194 (N.D.W.Va.1974) (total exclusion of one doctor from the staff of one hospital), rev’d on other grounds, 522 F.2d 1133 (4th Cir.1975), cert. denied, 424 U.S. 916, 96 S.Ct. 1116, 47 L.Ed.2d 321 (1976); Nankin Hospital v. Michigan Hospital Service, 361 F.Supp. 1199 (E.D.Mich.1973) (local hospital brings suit against a hospital service corporation that refused to renew a contract with plaintiff; at most, plaintiff could show a partial diminution in business).23456 The logic underlying this distinction between total and partial exclusions is apparent. Put quite simply, it is obvious that a total exclusion is more likely substantially and adversely to affect interstate commerce than a partial exclusion. Thus, analysis of the nature of the alleged restraint in each case will have a significant bearing on both the substantiality and nexus requirements of the tripartite jurisdictional test. b. Nature of the plaintiff The third and final element in this framework for analyzing federal court jurisdiction over denial of hospital staff privileges cases involves the nature of the specific plaintiff in each case. Judges sustaining their Sherman Act jurisdiction have been able to rely not only on the more exclusive restraints discussed above, but also have decided cases brought by large institutional plaintiffs or individual physician plaintiffs with hospital-based practices that would be particularly foreclosed by defendants’ conduct. On the other hand, judges that have been unwilling to sustain their antitrust jurisdiction have relied not only on the pleading of less restrictive exclusions, but also have decided cases brought by individual physician plaintiffs whose practice is primarily independent of the defendant hospital or association. Many of the cases in which federal courts have sustained their own antitrust jurisdiction have involved large institutional plaintiffs (such as a hospital or clinic) or have involved class-based claims asserted for the benefit of large numbers of physicians. Hospital Building Co. v. Trustees of the Rex Hospital, supra (large hospital’s expansion plans blocked); Hahn v. Oregon Physicians’ Service and Physicians’Association of Clackamus County, supra (although not pleaded formally as a class action, complaint alleges denial to all podiatrists); Feminist Women’s Health Center, Inc. v. Mohammad, supra, (clinic asserted tortious interference with contractual relations); Ballard v. Blue Shield of Southern West Virginia, Inc., supra, (class action on behalf of chiropractors); Doctors, Inc. v. Blue Cross of Greater Philadelphia, supra, (effectively, a class action on behalf of all Philadelphia hospitals); Feldman v. Jackson Memorial Hospital, supra (although not pleaded formally as a class action, complaint alleges denial to all podiatrists). All of the remaining cases in which federal courts have found Sherman Act jurisdiction involve individual doctors, or small groups of doctors, who have a primarily hospital-based medical practice. Mishler v. St. Anthony’s Hospital Systems, supra (neurosurgeon); Crane v. Intermountain Health Care, Inc., supra (pathologist); Everhart v. Jane C. Stormont Hospital and Training School for Nurses, supra (cardiovascular surgeon); Dos Santos v. Columbus-Cuneo-Cabrini Medical Center, supra (anesthesiologists); Malini v. Singleton & Associates, supra (radiologist); Hyde v. Jefferson Parish Hospital District, No. 2, supra (anesthesiologist); Robinson v. Magovern, supra (cardiothoracic surgeon). On the other side of the jurisdictional coin, every court that has declined to exercise antitrust jurisdiction has been confronted with single or small-group physician plaintiffs; indeed, many physician plaintiffs in the non-jurisdiction cases have primarily non-hospital-based practices. Wolf v. Jane Phillips Episcopal-Memorial Medical Center, supra (osteopathic physician); Elizabeth Hospital, Inc. v. Richardson, supra (physician chief-of-staff of plaintiff hospital denied privileges at separate hospital); Riggall v. Washington County Medical Society, supra (physician chief-of-staff of hospital denied medical society membership); Nara v. American Dental Association, supra (single dentist); Barr v. National Right to Life Committee, Inc., supra (obstetrician); Grigg v. Blue Cross and Blue Shield of Michigan, supra (two ear and throat doctors); Daley v. St. Agnes Hospital, Inc., supra (director of nursing); Moles v. Morton F. Plant Hospital, Inc., supra (two local physicians); Capili v. Shott, supra (one anesthesiologist); Sokol v. University Hospital, Inc., supra (one cardiac surgeon); Harron v. United Hospital Center, Inc., supra (one radiologist). The logical underpinnings of this final consideration are also apparent. For example, restraints applied against major business entities in the health-care industry (such as entire hospitals or classes of physicians) are obviously more likely to affect interstate commerce more substantially and adversely than restraints applied against single doctors. Further, and specific to the denial of hospital staff privileges genre of cases, a hospital’s exclusion of a physician whose entire practice is based at a hospital is far more likely to affect interstate commerce because the denial is more likely to result in a total foreclosure than that same hospital’s exclusion of a doctor whose primary practice is not hospital-based. Thus, as with the nature of the alleged restraint component of this framework, the nature of the specific plaintiff in each case should, as a matter of practical economics, influence a court’s determination on both the substantiality and nexus requirements of the tripartite jurisdictional test. III. Application of Legal Standards to Plaintiffs’ Sherman Act Allegations A. Introductory Statement It is against this legal background that I must determine whether defendants are entitled to a dismissal of plaintiffs’ amended complaint or whether plaintiffs have now pleaded sufficient factual allegations to support jurisdiction under the Sherman Act. As has been made abundantly clear by the excellent briefs prepared by both sides throughout this litigation, by the initial opinion in this case, and by the statement of legal standards just completed, plaintiffs’ allegations that defendants’ conduct violates the antitrust laws raise exceedingly complex jurisdictional issues under the Sherman Act. Before proceeding to an analysis of the sufficiency of plaintiffs’ interstate commerce allegations — -the only allegations at issue at this point in these proceedings — it is essential to reiterate the fairly simple factual underpinnings of the instant case. The four individual plaintiffs in this case are the sole shareholders and physician-employees of the corporate plaintiff, Cardio-Medical Associates, Ltd. See Amended Complaint ¶¶ 4-8. The offices of all four of these local physician-plaintiffs are “located within the buildings housing defendant CCMC.” Id. at ¶ 37. All four individual physician plaintiffs currently enjoy staff privileges at CCMC and, in fact, admit patients to that hospital. Transcript of Oral Argument on Defendants’ Motion to Dismiss, at 5 (July 29, 1982). Indeed, except for the individual plaintiff Cass, who practices only internal medicine, the remaining individual plaintiffs are actively engaged in the practice of cardiology within the Cardiology Department at CCMC. Id. Thus, plaintiffs allege merely that the denial to them of the opportunity to perform certain specialized cardiology procedures at CCMC is the result of an unlawful conspiracy on the part of defendants that has restrained trade in violation of sections 1 and 2 of the Sherman Act. E.g., Amended Complaint ¶ 49. The issue I must consider, therefore, is whether this limited denial of privileges to the individual physician-plaintiffs can, under any set of facts proved, substantially and adversely affect interstate commerce. My conclusion that no such effect is pleaded in plaintiffs’ amended complaint is reached in three separate stages: (i) Plaintiffs’ amended complaint does not satisfy the jurisdictional standards of the antitrust laws under the “in commerce” theory, (ii) Plaintiffs’ amended complaint does not satisfy the tripartite jurisdictional standard of the antitrust laws under the “affecting commerce” theory, (iii) This decision is consistent with the vast majority of decided antitrust jurisdiction cases. Each of these is addressed below. B. “In Commerce” Theory Plaintiffs apparently attempt to satisfy the interstate commerce requirement of the Sherman Act by alleging in their amended complaint that their activities are actually “in” interstate commerce. The imagery of a “continuous and integrated stream of interstate commerce” is repeated throughout the paragraphs of plaintiffs’ amended complaint in an effort to create the impression that plaintiffs’ activities occur within the flow of interstate commerce. Plaintiffs’ amended complaint alleges that both plaintiffs and defendants are engaged in the “provision of cardiology services ... to patients with cardiac or potential cardiac conditions.” Amended Complaint ¶ 30. But the provision of such services is an activity that occurs entirely within the Commonwealth of Pennsylvania and is, therefore, wholly local in nature. As a matter both of precedent and inescapable logic, the provision of cardiology services cannot be considered an activity that occurs in interstate commerce. As a result, the “in commerce” theory of antitrust jurisdiction is inapplicable in the instant case. It is well established that the provision of medical services is an intrastate transaction. The Seventh Circuit has held squarely that: “It is true that medical practice per se, and without more is a local activity. To bring it within the reach of the antitrust laws a substantial and adverse effect upon interstate commerce is required.” Williams v. St. Joseph Hospital, 629 F.2d 448, 454 (7th Cir.1980). The excellently reasoned opinion by Chief Judge Young in Moles v. Morton F. Plant Hospital, Inc., 1980-81 Trade Cas. (CCH) ¶ 63,600 (M.D.Fla.1978), aff’d mem. 617 F.2d 293 (5th Cir.1980), cert. denied, 449 U.S. 919, 101 S.Ct. 317, 66 L.Ed.2d 147 (1980), also emphasizes the intrastate nature of the practice of medicine in stating “[plaintiffs’] work involves practicing medicine and furnishing medical services which is wholly intrastate.” Id. at 77,189 (citing Wolf v. Jane Phillips Episcopal-Memorial Medical Center, 513 F.2d 684 (10th Cir.1975)). Accord Riggall v. Washington County Medical Society, 249 F.2d 266 (8th Cir.1957), cert. denied, 355 U.S. 954, 78 S.Ct. 540, 2 L.Ed.2d 530 (1958). It is important to keep analytically distinct the “in commerce” and the “affecting commerce” theories of jurisdiction. Thus, plaintiffs cannot negate the essentially intrastate character of their business by identifying incidental ties with interstate commerce; such an approach is appropriate only under the “affecting commerce” theory of jurisdiction. For example, simply because plaintiffs might use equipment or drugs emanating from out-of-state in connection with the provision of cardiology services does not convert plaintiffs’ activities to those that are “in commerce.” See St. Anthony-Minneapolis, Inc. v. Red Owl Stores, Inc., 316 F.Supp. 1045 (D.Minn.1970) (incidental flow of supplies in interstate commerce does not transform an essentially intrastate activity into an interstate enterprise). Further, plaintiffs’ treatment of some patients who travel in interstate commerce in order to receive medical care does not transform plaintiffs’ practice into an interstate enterprise. See Elizabeth Hospital, Inc. v. Richardson, 269 F.2d 167, 170 (8th Cir.) (“fact that some of plaintiff’s patients might travel in interstate commerce does not alter the local character of plaintiff’s hospital”), cert. denied, 361 U.S. 884, 80 S.Ct. 155, 4 L.Ed.2d 120 (1959); Plum Tree, Inc. v. N.K. Winston Corp., 351 F.Supp. 80 (S.D.N.Y.1972) (in a case in which transaction is intrastate in character, the mere incidental flow of customers and supplies in interstate commerce does not change that character). Finally, “in commerce” jurisdiction is not created by the allegation that plaintiffs’ cardiology practice involves receipt of out-of-state payments. See Dominion Parking Corporation v. Baltimore & Ohio Railway Co., 450 F.Supp. 441, 444-45 (E.D.Va.1978) (“passage of checks, reports, and documents from one state to another cannot transform .. . a purely local business into an activity of interstate commerce.”). The provision of cardiology services also cannot be considered “an integral, essential and inseparable part of an interstate transaction.” Heille v. City of St. Paul, Minnesota, 512 F.Supp. 810 at 813 (D.Minn.1981), aff’d, 671 F.2d 1134 (8th Cir.1982). In Heille, both plaintiff and defendant were in the business of collecting rubbish. The trial court rejected plaintiff’s argument that rubbish collection was “in commerce” stating that the transaction in question “starts and ends with the pick-up and deposit of the rubbish.” Id. at 813. As in Heille, the performance of cardiology services by plaintiffs is a transaction that both begins and ends within a single state; it is, therefore, not “in commerce.” C. “Affecting Commerce” Theory As plaintiffs have failed to satisfy the “in commerce” theory of Sherman Act jurisdiction, their amended complaint must be dismissed unless it meets the tripartite “affecting commerce” jurisdictional test. See part II.B.2. supra. My holding that plaintiffs’ amended complaint is fatally deficient in this regard as well is based on an analysis of each of the ten channels of interstate commerce identified in plaintiffs’ complaint as being substantially and adversely affected by defendants’ alleged illegal activities. The following analysis demonstrates conclusively that, for each channel, plaintiff has failed to allege sufficient facts on at least one of the required jurisdictional elements. 1. Treatment of Out-of-State Patients by Plaintiffs Paragraphs 37 and 38 of plaintiffs’ amended complaint contain allegations to the effect that plaintiffs treat patients who travel in interstate commerce. Plaintiffs argue that these allegations identify a relevant channel of interstate commerce and that defendants’ conduct has had a substantial and adverse effect on that channel because the total volume of patients serviced by plaintiffs, including those from out-of-state, would increase were it not for defendants’ alleged antitrust violations. As I held in the initial Cardio-Medical opinion, “allegations relating to the treatment of patients who [travel] in interstate commerce do not satisfy the interstate commerce requirement of the antitrust laws.” See Cardio-Medical, 536 F.Supp. at 1081. Regardless of whether this holding is analyzed under the presence of interstate commerce or nexus prong of the tripartite jurisdictional test, my position remains precisely the same: “the treatment of patients who must ‘travel in interstate commerce’ does not constitute the practice of medicine in ‘interstate commerce as the transportation of such patients is incidental.’ ” Capili v. Shott, No. 78-1009-B1, slip op. at 3 (S.D. W.Va. March 15, 1978), aff’d, 620 F.2d 438 (4th Cir.1980) (quoting Riggall v. Washington County Medical Society, 249 F.2d 266, 268 (10th Cir.1957), cert. denied, 355 U.S. 954, 78 S.Ct. 540, 2 L.Ed.2d 530 (1958)). This holding has substantial support in a number of the decided health-care industry cases. Wolf v. Jane Phillips Episcopal-Memorial Medical Center, 513 F.2d 684 (10th Cir.1975); Elizabeth Hospital, Inc. v. Richardson, 269 F.2d 167 (8th Cir.), cert. denied, 361 U.S. 884, 80 S.Ct. 155, 4 L.Ed.2d 120 (1959); Riggall v. Washington County Medical Society, supra; Spears Free Clinic and Hospital for Poor Children v. Cleere, 197 F.2d 125 (10th Cir.1952); Nara v. American Dental Ass’n, 526 F.Supp. 452 (W.D.Mich.1981); Barr v. National Right to Life Committee, 1981-2 Trade Cas. (CCH) ¶ 64,315 (M.D.Fla.1981); Daley v. St. Agnes Hospital, Inc., 490 F.Supp. 1309 (E.D.Pa.1980); Capili v. Shott, supra; ¶ 63,443 (E.D.Pa.1980); Capili v. Shott, supra; Nankin Hospital v. Michigan Hospital Service, 361 F.Supp. 1199 (E.D.Mich.1973). See Hospital Building Co. v. Trustees of the Rex Hospital, 425 U.S. 738, 96 S.Ct. 1848, 48 L.Ed.2d 338 (1976) (interstate travel of patients pleaded in complaint but not mentioned by Supreme Court); Doctors, Inc. v. Blue Cross of Greater Philadelphia, 490 F.2d 48 (3d Cir.1973) (district court judge held that interstate travel of patients did not satisfy the jurisdictional requirement of the Sherman Act; court of appeals did not reach the issue). Concededly, an equally impressive array of courts have reached the opposite conclusion. Hahn v. Oregon Physicians’ Service & Physicians’ Association of Clackamus County, 1982-2 Trade Cas. (CCH) ¶ 64,970 (9th Cir.1982), rev’g, 1981-1 Trade Cas. (CCH) ¶ 63,923 (D.Or.1981); Mishler v. St. Anthony’s Hospital Systems, 1981-2 Trade Cas. (CCH) ¶ 64,342 (10th Cir.1981); Crane v. Intermountain Health Care, Inc., 637 F.2d 715 (10th Cir.1980) (en banc); Feminist Women’s Health Center, Inc. v. Mohammad, 586 F.2d 530 (5th Cir.1978), cert. denied sub nom. Palmer v. Feminist Women’s Health Center, Inc., 444 U.S. 924, 100 S.Ct. 262, 62 L.Ed.2d 180 (1979); Everhart v. Jane C. Stormont Hospital, 1982-1 Trade Cas. (CCH) ¶ 64,703 (D.Kan.1982); Dos Santos v. Columbus-Cuneo-Cabrini Medical Center, 1982-1 Trade Cas. (CCH) ¶ 64,498 (N.D.Ill.1981); Robinson v. Magovern, 521 F.Supp. 842 (W.D.Pa.1981), aff’d, 688 F.2d 824 (3d Cir.1982); Malini v. Singleton & Associates, 516 F.Supp. 440 (S.D.Tex.1981); Feldman v. Jackson Memorial Hospital, 509 F.Supp. 815 (S.D.Fla.1981); Hyde v. Jefferson Parish Hospital District, No. 2, 513 F.Supp. 532 (E.D.La.1981), rev’d on other grounds, 686 F.2d 286 (5th Cir.1982); Stone v. William Beaumont Hospital, No. 79-74212 (E.D.Mich. Aug. 17, 1981). Unfortunately, very few of the above-cited cases contain any analysis in support of their holdings; rather, the conclusions of the courts tend to be expressed in concluso-ry terms. Indeed, the Barr case is the only opinion in which any reference is made to the particular facts involved in the decided cases. See Barr, 1981-2 Trade Cas. (CCH) at 74,409 (“plaintiff does not assert that his patients are crossing state lines with the purpose of availing themselves of his services, but rather that a number of them happen to be in Florida for vacation or business purposes”). I decline to follow the lead of the remainder of the above-cited cases by merely expressing my holding in conclusory terms. First, on the facts of this case, plaintiffs have not pleaded sufficient factual allegations to demonstrate a nexus between the denial to them of the right to use specialized cardiology procedures and any substantial effect on the interstate travel of patients. These plaintiffs already have staff privileges at CCMC and, indeed, already maintain offices on the premises of CCMC. It is logically inconceivable that granting the individual plaintiffs the right to perform certain additional specialized procedures will have any discernible impact on the travel of their patients in interstate commerce. This is not merely a shifting argument; it is a statement of logic based on my conviction that patients do not choose cardiologists because they either can, or cannot, perform services that the patient cannot even pronounce. Thus, even assuming (which I do not) that travel of patients is a relevant channel of interstate commerce, on the facts of this case, as pleaded in plaintiffs’ amended complaint, there is no logical nexus between the alleged restraint and the identified channel of commerce. Second, it is my view that the travel of patients in interstate commerce is so remote from and incidental to the provision of medical care that it will almost never be a relevant channel of interstate commerce in denial of hospital staff privileges cases. A simple analogy might help to illuminate this position. Let us assume that the plaintiff in another antitrust case is a house painter who performs all of his services in Ocean City, New Jersey. The defendant, a large painting contracting firm that is allegedly seeking to monopolize the house-painting market in Ocean County, moves to dismiss plaintiffs Sherman Act complaint for lack of federal court jurisdiction. Plaintiff replies that a substantial percentage of the houses he paints are owned by people who live in New York, Pennsylvania, and Delaware, and who, therefore, must travel in interstate commerce in order to get to their summer homes. Obviously, our hypothetical plaintiff’s argument must be rejected. The travel of his customers in interstate commerce is simply too remote from his business or trade to vest a federal court with jurisdiction; his customers’ travel in interstate commerce is wholly incidental to his painting of their houses. Plaintiffs in this ease, like the plaintiff in Barr, do not assert that their patients travel in interstate commerce for the purpose of securing medical care from plaintiffs. Because the typical patient at most travels in interstate commerce to get to a particular hospital, as opposed to a particular doctor, in a standard denial of hospital staff privileges claim, the travel of patients in interstate commerce is so remote from and incidental to the provision of medical services that it is insufficient to vest a federal court with jurisdiction. This analysis is inconsistent with the analysis of the Tenth Circuit in Crane v. Intermountain Health Care, Inc., 637 F.2d 715 (10th Cir.1981) (en banc). In a footnote, the court of appeals appeared to conclude that McLain v. Real Estate Board of New Orleans, Inc., 444 U.S. 232, 100 S.Ct. 502, 62 L.Ed.2d 441 (1980), eliminated any doubt that “an interstate flow of people seeking a purely local service can have a substantial effect on interstate commerce.” Crane, 637 F.2d at 726 n. 4. In McLain, the Supreme Court observed in passing, but did not hold, that on remand the plaintiffs might be able to “establish that, apart from the commerce in title insurance and real estate financing, an appreciable amount of interstate commerce is involved with the local residential real estate market arising out of the interstate movement of people.” McLain, 444 U.S. at 245, 100 S.Ct. at 510. See also Mortensen v. First Federal Savings and Loan Ass’n, 549 F.2d 884, 887-88 (3d Cir.1977) (Third Circuit identifies out-of-state real estate purchasers as one of “several interstate contacts”). Although I have no quibble with the Supreme Court’s position in McLain or with the Third Circuit’s holding in Mortensen, I must disagree with the unreasoned and unwarranted extensions of those two holdings undertaken by the Tenth Circuit in Crane. It is most certainly not the law that any antitrust plaintiff who can identify some interstate movement of people, no matter how remote the connection with the alleged antitrust violation, satisfies federal jurisdictional requirements. Unlike the healthcare industry,, and unlike our hypothetical local house painter, there is a logical nexus between the interstate travel of people and purchases of residential real estate — as a direct result of people moving in interstate commerce residential real estate will be bought and sold. The logical connection between patient travel in interstate commerce and the receipt of medical services is so remote and incidental that any extension of the McLain and Mortensen residential real estate holdings to the health-care industry is wholly unwarranted. 2. Interstate Flow of Revenues to Plaintiffs Paragraphs 41, 44, and 45 of plaintiffs’ amended complaint allege that several hundred thousand dollars in annual revenues flow in interstate channels to plaintiffs from out-of-state private insurers and the federal government. In addition, plaintiffs allege in these same paragraphs that defendants’ activities have foreclosed substantial additional revenues in this channel of interstate commerce. Although the interstate flow of revenues argument appears to be plaintiffs’ strongest point on the facts of this case, I hold, as I did in the initial opinion on this case, “that such allegations are insufficient to sustain the jurisdiction of a federal trial court.” Cardio-Medical, 536 F.Supp. at 1081-82 n. 19. This position is consistent with the result reached in a number of other denial of hospital staff privileges cases. Barr v. National Right to Life Committee, Inc., supra; Moles v. Morton F. Plant Hospital, Inc., supra; Capili v. Shott, supra. See Feminist Women’s Health Center v. Mohammad, supra (district court held that interstate flow of revenues did not vest federal court with jurisdiction; court of appeals did not reach issue); Doctors, Inc. v. Blue Cross of Greater Philadelphia, supra (district court held that interstate flow of revenues did not vest federal court with jurisdiction; court of appeals did not reach issue). Concededly, however, the majority of cases considering this issue have reached the opposite conclusion. Hospital Building Co. v. Trustees of the Rex Hospital, supra; Hahn v. Oregon Physicians’ Service & Physicians’ Association of Clackamas County, supra; Mishler v. St. Anthony’s Hospital Systems, supra; Crane v. Intermountain Health Care, Inc., supra; Ballard v. Blue Shield of Southern West Virginia, Inc., 543 F.2d 1075 (4th Cir.1976), cert. denied, 430 U.S. 922, 97 S.Ct. 1341, 51 L.Ed.2d 601 (1977); Everhart v. Jane C. Stormont Hospital & Training School for Nurses, supra; Dos Santos v. Columbus-Cuneo-Cabrini Medical Center, supra; Malini v. Singleton & Associates, supra; Feldman v. Jackson Memorial Hospital, supra; Hyde v. Jefferson Parish Hospital District No. 2, supra; Stone v. William Beaumont Hospital, supra; Robinson v. Magovern, 456 F.Supp. 1000 (W.D.Pa.1978); Zamiri v. William Beaumont Hospital, 430 F.Supp. 875 (E.D.Mich.1977). Again, it is unfortunate that, in most of the above-cited cases, no analysis is supplied to support the individual court’s conclusions. I remain both unsatisfied and frustrated with mere conclusory holdings on complex jurisdictional issues and therefore offer the following analysis in support of my position. First, the relatio