Full opinion text
OPINION BRAMLETTE, District Judge. Plaintiff HTI Health Services, Inc., d/b/a Columbia Vicksburg Medical Center (“Columbia”) brought this antitrust action to enjoin a pending merger involving the defendants Quorum Health Group, Inc. (“Quorum Health”), River Region Medical Corporation (formerly known as ParkView Medical Corporation, referred to herein as “River Region”) and the Vicksburg Clinic, P.A. (the “Vicksburg Clinic”). The co-defendants are referred to collectively herein as “Quorum”. The merger is structured to align the two largest physician clinics in Vicksburg, Mississippi with one of the town’s largest hospitals, ParkView Regional Medical Center (“Park-View”). Parkview’s leading hospital rival, the Vicksburg Medical Center (‘VMC”), is owned and operated by Columbia. Columbia is a wholly-owned subsidiary of Columbia/HCA Healthcare Corp., the largest for-profit hospital chain in the country. Quorum Health, the indirect majority shareholder of River Region, is also a large, for-profit health care corporation. In its complaint filed July 29, 1996, Columbia alleged antitrust violations under the Sherman and Clayton Acts and requested preliminary and permanent injunctive relief to prohibit the merger’s consummation. Following expedited discovery, the parties’ opted to proceed directly to trial. The Court heard the case without a jury from September 30 through October 16, 1996. After the parties gave their closing arguments on November 6, 1996, the Court took the case under advisement. Now having thoroughly considered the record, legal arguments and case law, it is this Court’s opinion, based on the findings of fact and conclusions of law to follow, that Columbia has failed to carry its burden of proof under the relevant antitrust laws. Columbia’s request for injunctive and all other relief must therefore be denied. BACKGROUND A long and competitive history of a divided medical community creates the setting for this contested merger. For many years, VMC and ParkView (previously named Mercy Hospital) have been considered the leading hospitals in Vicksburg and the surrounding areas of Warren County, Mississippi. Vicksburg, a city of roughly 30,000 people, is located in the southwest quadrant of the state on the Mississippi River border with Louisiana. Although in the past as many as four hospitals have operated in Vicksburg, ParkView and VMC are the only survivors, and the city has become a “two-hospital town.” The Street Clinic and the Vicksburg Clinic are the city’s oldest physician climes. Both have operated since approximately the World War I era, and both have maintained a traditional alliance with one of the two hospitals: the Street Clinic with ParkView and the Vicksburg Clinic with VMC. The Street Clinic is located on Parkview’s medical campus, and physicians associated with that clinic are shareholders in River Region. The Vicksburg Clinic operates as a professional association and is officed on VMC’s campus in space that it leases from Columbia. Without delving into the historic reasons for these hospital/clinic alliances, suffice it to say that the age-old schism running through Vicksburg’s medical community has divided the dominant doctor and hospital groups into two, well-matched rivals. According to the executed merger agreement dated May 31, 1996 among ParkView Medical Corporation (predecessor to River Region), ParkView Sub Inc. and the Vicksburg Clinic (the “Merger Agreement”), the merger is structured to accomplish a stock-for-stock swap between River Region and the Vicksburg Clinic. In short, once the merger is consummated, the Vicksburg Clinic physicians will join their longstanding rivals at the Street Clinic as shareholders of River Region. The merged climes (referred to herein as the “River Region Clinic”) will become the single largest physician clinic in the Vicksburg area. Although the Street and Vicksburg Climes are currently the largest and most diversely specialized clinics in Warren County, they are not the only ones. Mission Primary Care (the “Mission Clinic”), also located in Vicksburg, is a family medicine clinic that was established in 1995 and is managed by a Columbia-owned medical services organization, VIP, Inc. Other clinics in Vicksburg include the Better Living Clinic and two small clinics that are operated by River Region, The Family Medicine Clinic of Vicksburg and the Women’s Clinic of Vicksburg. In addition to these smaller clinics, a number of independent physicians practice in and around Vicksburg. Columbia’s VIP manages, in whole or in part, many of the independent physicians’ practices. The revolutionary reorganization of the health care industry, which has swept much of the country since the early 1990s, has been slow to arrive in Vicksburg. Innovations that are prevalent elsewhere, such as integrated health care delivery systems, intrastate and regional networking among hospitals and other providers, and managed care options in health insurance coverage, are new to the Vicksburg community. Essentially, managed care plans such as health maintenance organizations (“HMOs”) and preferred provider organizations (“PPOs”) negotiate with doctors, hospitals and other health service providers to establish a health care network that will serve the plan’s enrollees. Because managed care plans purchase services in quantity, they negotiate for discounted rates from the health care providers, which, in principle, are passed along to customers in the form of lower health care coverage costs. With or without the pending merger, the expectation is that managed care will grow over time in Vicksburg and Warren County, thereby stimulating price competition as plan providers scramble for new customers. Managed care may make additional inroads into Warren County through a Medicaid managed care phot program, which is slated to begin in eleven Mississippi counties but which was inactive at the time of trial. Also new to Vicksburg is the growth of casino gambling. Along with the development of the casino industry, Vicksburg and Warren County are experiencing significant economic growth, a decline in unemployment and the entry of new, nongaming businesses. Documents in evidence indicate that, between 1980 and 1994, Warren County’s median family income increased 404% and its per capita income rose 126%. Against this backdrop of changing times, a group of Vicksburg’s independent physicians and clinic doctors formally met in the summer of 1993 to discuss ideas about reorganizing the area’s hospital and medical services. One idea was to eliminate the duplication of services and procedures performed at the two hospitals by assigning a specific set of services to each hospital. For example, ParkView might be designated as the pediatric and ob/gyn center, while VMC would develop as the surgical care center. The hope was that, eventually, a new hospital could be constructed on a separate, neutral site and the old hospitals could be used for psychiatric units, nursing home facilities or other purposes. Another concern voiced by the physicians was Vicksburg’s need for technologically advanced medical equipment including, but not limited to, a cardiac cath-erization laboratory, open heart surgery facilities and a permanent magnetic resonance imaging (“MRI”) device. Because of intense competition between the two hospitals, neither had been successful in receiving the required approval from the state authorities for procuring such equipment. As a general rule, Mississippi requires that hospitals receive state regulatory approval in the form of a “certificate of need” or “CON” before capital expenditures for certain equipment or new technology may be incurred. In an attempt to end the regulatory gridlock, the Vicksburg doctors discussed approaching the CEOs of the two hospitals to encourage them to join forces and procure the cardiac cather-ization laboratory and MRI in a profit-sharing arrangement. The doctors hoped that, by forming a joint venture, the state regulators would no longer be forced to choose between the two hospitals and could award certificates of need to the unified project. Following the 1993 meeting, letters were sent to the executives of the owners of both hospitals, but the physicians’ efforts failed. Vicksburg’s need for technologically advanced equipment remained unresolved at the time of trial. Dissatisfaction with the medical delivery system continued to grow among the community’s physicians in general, and the Vicksburg Clinic physicians in particular. In December 1994, the nineteen physician shareholders at the Vicksburg Clinic wrote to the CEO of HealthTrust, owner and operator of VMC at that time, to complain about the hospital’s failure to execute a several-year-old plan to expand the clinic’s physical facilities and improve services. The physician group expressly requested a definite commitment from HealthTrust for expansion, recruitment and strategic planning and also requested a meeting with senior management to formulate such plans. In the spring of 1995, Columbia acquired HealthTrust and assumed the management and operation of VMC. Thereafter, the Vicksburg Clime’s executive committee met with Columbia management to discuss the clime’s continuing need for expanded office space, strategic planning concerns and the doctors’ perception that Columbia’s management service organization, VIP, Inc., was competing directly with the Vicksburg Clinic’s physician recruitment efforts. Despite verbal assurances from Columbia, tension increased between the Vicksburg Clinic physicians and Columbia management. By November 1995, the Vicksburg Clinic members had initiated discussions with both River Region and Columbia regarding proposals for reorganizing the clinic through an asset purchase or otherwise. Several months later, after considering proposals from both sides, the Vicksburg Clinic’s board of directors and shareholders held a special meeting and voted to pursue River Region’s stock acquisition proposal. By February 1996, the physicians and River Region had signed a letter of intent. Negotiations continued, and the parties entered into the Merger Agreement in May 1996. Also in the spring of 1996, the merger participants received notice that the Department of Justice (“DOJ”) had opened an antitrust investigation of the proposed acquisition. To date, DOJ has not filed suit or taken any action against the Vicksburg Clinic merger. In the absence of agency intervention, Columbia filed this private civil action for injunctive and other relief. FINDINGS AND CONCLUSIONS I.Antitrust Claims Columbia’s offensive against the merger is two-fold. First, under Section 7 of the Clayton Act, Columbia claims that the proposed merger is likely to substantially lessen competition in Vicksburg’s physician, hospital and managed care markets. (Count I, Complaint.) The result, according to Columbia, will be higher prices for health care services and medical insurance coverage, which will harm the citizens of Vicksburg as well as employers such as Columbia. Second, Columbia alleges that Quorum violated Section 2 of the Sherman Act by combining or conspiring to monopolize Vicksburg’s physician and hospital services with the specific intent of making Vicksburg a “one hospital town.” (Complaint, Count II.) A. Injunctive Relief Standard Columbia has asked for both preliminary and permanent injunctive relief pursuant to Section 16 of the Clayton Act. Section 16 entitles private persons to sue for injunctive relief “when and under the same conditions and principles as injunctive relief against threatened conduct that will cause loss or damage is granted by courts of equity_” 15 U.S.C.A. § 26 (West Supp.1996) [hereinafter “Section 16”]. Under Section 16, permanent injunctive relief may issue upon a demonstration of “threatened” injury, even though the plaintiff has not yet suffered actual injury. Zenith Radio Corp. v. Hazeltine Research. Inc., 395 U.S. 100, 130, 89 S.Ct. 1562, 1580, 23 L.Ed.2d 129 (1969). In other words, a plaintiff may qualify for permanent injunctive relief under the statute by demonstrating a significant threat of injury from an impending violation of the antitrust laws or from a contemporary violation that is likely to continue or recur. Id. The remedy is flexible and may be adapted to achieve a reconciliation of the public interests that Congress sought to protect with competing private needs. Id. at 131, 89 S.Ct. at 1580-81. When adjudicating preliminary injunction requests under the antitrust laws, the courts in this circuit require that the movant meet its burden under a well-established four-pronged test by proving that: 1. there is a substantial likelihood of success on the merits; 2. there is a substantial threat that the movant will suffer irreparable injury if the injunction is not issued; 3. the threatened injury to the movant outweighs any damage the injunction might cause to the opponent; and 4. the injunction will not disserve the public interest. H & W Indus., Inc. v. Formosa Plastics Corp., U.S.A., 860 F.2d 172, 179 (5th Cir.1988); Pearl Brewing Co. v. Miller Brewing Co., 1993 WL 424236 (W.D.Tex., Mar. 31, 1993), aff'd, 52 F.3d 1066 (5th Cir.1995). The precedent in our circuit clearly warns that a preliminary injunction is an extraordinary remedy that can be granted only if the movant has clearly shown all four prerequisites. Mississippi Power & Light v. United Gas Pipe Line, 760 F.2d 618, 621 (5th Cir.1985). Indeed, the Fifth Circuit Court of Appeals instructs that the grant or denial of injunctive relief must be the product of a reasoned application of the foregoing four factors and cannot be based solely on an inquiry into the underlying merits of the substantive antitrust claims. H &W Indus., 860 F.2d at 179 (reversing the district court’s denial of a preliminary injunction where the court’s ruling was based solely on the underlying merits of the plaintiffs antitrust and breach of contract claims). With these principles in mind, the Court turns first to evaluate the likelihood of Columbia’s success on the merits. B. Antitrust Injury An initial merits issue that this Court must decide is whether Columbia has shown the threat of an “antitrust injury.” Cargill Inc. v. Monfort, 479 U.S. 104, 108, 107 S.Ct. 484, 488, 93 L.Ed.2d 427 (1986); Phototron Corp. v. Eastman Kodak Co., 842 F.2d 95, 98 (5th Cir.1988) (antitrust injury is a merits issue that must be decided at trial before a preliminary injunction can issue), cert. denied, 486 U.S. 1023, 108 S.Ct. 1996, 100 L.Ed.2d 228 (1988). Establishing a substantial likelihood of suffering antitrust injury is an overarching prerequisite to obtaining injunctive relief under Section 16; it is equally applicable to cases brought under Section 2 of the Sherman Act and those under Section 7 of the Clayton Act. T.O. Bell v. Dow Chemical, Co., 847 F.2d 1179, 1182 & n. 4 (5th Cir.1988). Unless Columbia can establish its antitrust injury in this case, it will lack standing to sue. Phototron, 872 F.2d at 98 (construing Cargill, 479 U.S. at 113, 107 S.Ct. at 491); see also T.O. Bell, 847 F.2d at 1182. The United States Supreme Court has defined antitrust injury as “ ‘injury of the type the antitrust laws were intended to prevent and that flows from that which makes defendants’ acts unlawful.’ ” Cargill, 479 U.S. at 109, 107 S.Ct. at 489 (quoting Brunswick Corp. v. Pueblo Bowl-O-Mat, Inc. 429 U.S. 477, 97 S.Ct. 690, 50 L.Ed.2d 701 (1977)); see also Associated Gen. Contractors, 459 U.S. at 538-39, 103 S.Ct. at 908-09. In the wake of this Supreme Court precedent, the Fifth Circuit has further explained that antitrust injury is proof of an anticompetitive effect upon the plaintiff. T.O. Bell, 847 F.2d at 1182 n. 4. It is clear from this circuit’s precedent that antitrust injury must be interpreted narrowly, e.g., Anago Inc. v. Tecnol Med. Products, Inc., 976 F.2d 248, 249 (5th Cir.1992), and that the plaintiffs burden is a heavy one. Phototron, 842 F.2d at 98. Examples of anticompetitive effects that are accepted as proof of antitrust injury include increased prices and decreased output. Antitrust injury, however, does not encompass the threat of decreased competition. Anago, 976 F.2d at 249; see also Pearl Brewing Co. v. Miller Brewing Co., 1993 WL 424236 (W.D.Tex.1993), aff'd, 52 F.3d 1066 (5th Cir.1995) (the fear of the loss of profits due to price competition is not antitrust injury) Similarly, the notion that a plaintiff is facing the specter of a monopoly or speculation that the plaintiff will be sold or go out of business is not enough to establish antitrust injury. Phototron, 842 F.2d at 100. In sum, it is clear from the case law that speculative statements about anticompetitive effects will not satisfy the narrow standard for establishing antitrust injury. E.g., Anago, 976 F.2d at 249; Doctor’s Hospital of Jefferson, Inc. v. Southeast Medical Alliance, Inc., 897 F.Supp. 290, 293 (E.D.La.1995) (expert’s speculative statements about increased health care costs and an environment conducive to increased prices for inpatient and outpatient hospital care fell short of the strict Fifth Circuit standard for antitrust injury), appeal pending, No. 96-30220 (5th Cir. argued Oct. 3, 1996). In essence, Columbia asserts that it will suffer two separate types of antitrust injury from the merger: one being an anti-competitive horizontal injury in certain physician services and managed care purchasing markets and the other being a vertical injury in the acute inpatient hospital services market. Columbia’s theory of horizontal injury focuses on its assertion that the merger will empower Quorum to raise prices for a number of physician services in Vicksburg. In its capacity as an employer of over 400 employees in the Vicksburg community and as a purchaser of physician services for these employees, Columbia contends that it is a proper plaintiff under the antitrust laws to challenge the alleged harm. See Blue Shield of Va. v. McCready, 457 U.S. 465, 481-84, 102 S.Ct. 2540, 2549-51, 73 L.Ed.2d 149 (1982) (consumer of mental health services had standing to challenge anticompetitive conduct in psychotherapy market). In addition, Columbia claims that it will suffer horizontal injury in the managed care purchasing markets because, as a self-insured employer, it is rn the process of “seeking to contract” for managed care physician services for its employees. Columbia argues that, after the merger, “it will no longer be able to play the two multispecialty physician groups in Vicksburg against each other” in price negotiations. Letter from Columbia to the Honorable David C. Bramlette (11/13/96) at 5 [hereinafter “Columbia Posttrial Letter”]. Columbia also asserts that it will suffer a separate injury from the likely vertical effects of the merger. Columbia argues that by virtue of the postmerger economic integration of the Vicksburg Clinic and Park-View, Quorum will have the power and economic incentive to foreclose Columbia from the acute care hospital services market. This anticompetitive vertical effect will result, according to Columbia, from the Vicksburg Clinic physicians’ financial incentive and ability to shift their patient admissions to ParkView (instead of VMC) and from Quorum’s postmerger power to exclude Columbia from competition for managed care contracts. In response, Quorum urges that Columbia’s entire standing argument rests entirely on speculation of what might happen post-merger and is therefore insufficient to demonstrate antitrust injury under the Fifth Circuit’s narrow standard. Quorum further argues that Columbia has no standing to complain of injury in at least one of the alleged product markets — physician services purchased by managed care — because, as a factual matter, Columbia is neither a managed care company nor an employer that purchases managed care products. Recognizing the fundamental importance of the antitrust injury prerequisite to the viability of Columbia’s lawsuit, the Court requested and received supplemental briefing from the parties on the issue of standing. Having thoroughly reviewed and considered the supplemental briefing, counsel’s oral arguments at trial on this issue and the many other written briefs, documents and case law submitted to the Court by the parties, it is this Court’s conclusion that Columbia has established the requisite threat of antitrust injury and, accordingly, has standing to sue for injunctive relief under Section 16. Because of the arguably speculative nature of Columbia’s complained injury, the Court acknowledges, particularly in the light of this circuit’s narrow standard, that some might regard this as a close call. However, the precise antitrust laws at issue in this case expressly require courts to deal in uncertainties and make reasoned assessments of the probable future effects of a proposed business transaction. See United States v. Rockford Memorial Corp., 898 F.2d 1278, 1286 (7th Cir.1990) (“It is regrettable that antitrust cases are decided on the basis of theoretical guesses as to what particular market-structure characteristics portend for competi-tion_ ”). Based on Columbia’s thorough pleading and briefing, which cannot be criticized as “bare bones,” it is this Court’s view that Columbia’s allegations of antitrust injury must not be lightly dismissed as speculative and are sufficient to persuade this Court that a serious analysis of the full merits of this ease is warranted. The Court’s conclusion at this early stage of its consideration is supported by the following evidence. Mr. William Patterson, chief executive officer of VMC, testified credibly that Columbia is a purchaser of hospital and physician services for its employees in the Vicksburg market. (Trial Tr. at 1653.) The fact that Columbia purchases health care services in the Vicksburg market was not contested by Quorum’s expert witness, Mr. Lloyd E. Oliver. (Id. at 2632.) The parties do not dispute that, following the merger, the surviving clinic will be the largest physician clinic in the Vicksburg area and the only multispeeialty physician climes in Vicksburg. It will possess, as a statistical matter, high percentages of market share in the alleged physician services markets. According to Dr. David Ei-senstadt, Columbia’s expert witness, these market share percentages demonstrate a substantial likelihood of monopoly power in the alleged physician services markets. It appears to this Court that Columbia’s allegations of postmerger market concentration raise, at the very least, a classic antitrust issue: whether the effect of the merger may be to substantially lessen competition in the alleged product markets and hurt consumers by empowering the postmerger survivors to raise prices. E.g., Rockford, 898 F.2d at 1282-83. This is precisely the type of injury that the antitrust laws are designed to prevent. Cargill, 479 U.S. at 109, 107 S.Ct. at 488; see also Community Publishers. Inc. v. Donrey Corp., 892 F.Supp. 1146, 1167 (W.D.Ark.1995) (protecting consumers from monopoly prices is the central concern of antitrust law). The Court’s analysis of Columbia’s showing of antitrust injury does not rest on the evidence of market share data alone. See Community Publishers, 892 F.Supp. at 1167 (interpreting Atlantic Richfield Co. v. USA Petroleum Co., 495 U.S. 328, 110 S.Ct. 1884, 109 L.Ed.2d 333 (1990), as rejecting the proposition that antitrust injury may be presumed on the basis of market share data). Among other things, the Court has considered the abundant testimony regarding the historic competition and rivalry between the Street Clinic and the Vicksburg Clinic. The testimony indicated that the two clinics have been direct and significant competitors not just in terms of price, but also on the basis of quality and services offered. Even without the assistance of market share data, the fact that the merger will eliminate this tradition of multifaceted competition between the city’s two leading, rival clinics is enough to raise concerns about the threat of postmer-ger anticompetitive effects. Considering the high postmerger market concentrations in the physician markets that Columbia has alleged and demonstrated, coupled with evidence regarding the consequences of the merger, the Court is satisfied that Columbia has shown the requisite threat of antitrust injury and has presented something more than “the notion that (it is) facing the specter of a monopoly.” Phototron, 842 F.2d at 100. Arguably more speculative is Columbia’s theory of vertical injury in the acute care inpatient hospital services market. The linchpin of this theory is Columbia’s contention that, because the Vicksburg Clinic physicians will become postmerger equity shareholders in River Region Medical Corporation, these physicians will have a financial incentive, directly caused by the merger, to send their patients to ParkView for hospital services. Conceding that these physicians will have no postmerger contractual obligation to refer their patients to ParkView, Columbia maintains that the merger nonetheless creates the threat that Columbia will lose its primary source (or upstream supply) of hospital patient referrals and thereby become foreclosed from competing in the downstream market of acute care inpatient hospital services. In this regard, the Court noted the testimony of Dewey Greene, President of Columbia’s Delta Division, who stated that the Vicksburg Clinic physicians account for 80% or more of VMC’s total patient activity. (Trial Tr. at 533.) It is well-established that the primary vice of a vertical merger is foreclosing a competitor from a key source of supply that, absent the merger, would otherwise be open to it. Brown Shoe, 370 U.S. at 324, 82 S.Ct. at 1523. Setting aside the ultimate merits of this contention (which are addressed in Part I.C. below), the Court cannot ignore the allegation that the merger creates a questionable financial incentive for the Vicksburg Clinic physicians to steer their hospital patients to ParkView rather than VMC. But for the merger, this unique financial incentive would not exist. Finding that the alleged incentive is not beyond the realm of possibility, the Court concludes that Columbia has demonstrated the requisite threat of antitrust injury. See Community Publishers, 892 F.Supp. at 1167 (holding that a plaintiff/newspaper-owner had established the requisite threat of antitrust injury and therefore had standing to challenge a local newspaper acquisition because the transaction would create an incentive for the target newspaper to terminate its advertising sharing agreement with the plaintiff). Satisfied with Columbia’s demonstration of threatened antitrust injury from both the horizontal and vertical effects of the proposed merger, the Court will proceed to evaluate Columbia’s likelihood of success on the merits of these antitrust claims. C. Merits of Section 7 Clayton Act Claim In assessing the merits of Columbia’s Section 7 claim, this Court must appraise not merely the immediate impact of the merger upon competition, but it also must predict the merger’s impact upon competitive conditions in the future. United States v. Philadelphia Nat’l Bank, 374 U.S. 321, 362, 83 S.Ct. 1715, 1741, 10 L.Ed.2d 915 (1963). The burden is on Columbia to show that a probable anti-competitive impact will flow from the merger. Domed Stadium Hotel, Inc., v. Holiday Inns. Inc., 732 F.2d 480, 492 (5th Cir.1984). To do so, Columbia must show that the merger of the two clinics will substantially lessen competition within an established “area of effective competition,” or relevant market. Brown Shoe, 370 U.S. at 324, 82 S.Ct. at 1523. A relevant market is determined by proof of a(l) product market (the line of commerce); and (2) geographic market (the section of the country). Id.; see also Domed Stadium, 732 F.2d at 491 (first step in analyzing a Section 7 claim is defining the relevant product and geographic markets). Instead of mandating a formal or legalistic structure for defining relevant markets, Congress has adopted a pragmatic, factual approach. Brown Shoe, 370 U.S. at 336, 82 S.Ct. at 1530. 1. The Alleged Product Markets The burden is on the plaintiff to prove the relevant product market or markets. Coastal Fuels of Puerto Rico. Inc. v. Caribbean Petroleum Corp., 79 F.3d 182 (1st Cir.), cert. denied, — U.S. -, 117 S.Ct. 294, 136 L.Ed.2d 214 (1996); C.E. Services., Inc. v. Control Data Corp., 759 F.2d 1241 (5th Cir.), cert. denied, 474 U.S. 1037, 106 S.Ct. 604, 88 L.Ed.2d 583 (1985). Determining a relevant product market is generally a question of fact for the jury or factfinder, although in certain instances a legal conclusion is required. Seidenstein v. Nat’l Medical Enter., Inc., 769 F.2d 1100, 1106 (5th Cir.1985); Domed Stadium, 732 F.2d at 487. The classic test for defining the outer boundaries of a specific product market is to identify a set of goods or services that are reasonably interchangeable by consumers for the same purpose or use. Brown Shoe, 370 U.S. at 325, 82 S.Ct. at 1524; United States v. E.I. du Pont de Nemours & Co., 351 U.S. 377, 395, 76 S.Ct. 994, 1007, 100 L.Ed. 1264 (1956); Dougherty v. Continental Oil Co., 579 F.2d 954, 963, n. 4 (5th Cir.1978)(a product market is “composed of products that have reasonable interchangeability for the purposes for which they were produeed-price, use and qualities considered”). Interchangeability of products is often explained in terms of the “cross-elasticity of demand” between the product itself and substitutes for it. Brown Shoe, 370 U.S. at 325, 82 S.Ct. at 1524. This concept considers the alternative products to which consumers might turn in the event of a price increase. HERBERT HOVENKAMP, ECONOMICS AND FEDERAL ANTITRUST LAW § 3.3 (1985). A high cross-elasticity of demand between two products indicates, for antitrust purposes, that the products are in the same relevant product market. Id. Consistent with Supreme Court precedent, the factfinder may also determine that well-defined submarkets exist within a specific product market. Brown Shoe, 370 U.S. at 325, 82 S.Ct. at 1524. Economically significant submarkets themselves can constitute relevant product markets and are often determined by examining: industry or public recognition of the submarket as a separate economic entity; the product’s peculiar characteristics and uses; unique production facilities; distinct customers; distinct prices; sensitivity to price changes; and specialized vendors. Id.; Domed Stadium, 732 F.2d at 487-88. Columbia has focused on two broad categories of product markets: physician services and hospital services. Within the physician services category, Columbia has sought to prove four distinct product markets: (1) primary care; (2) general surgery; (3) urology; and (4) otolaryngology (ear-nose-throat or “ENT”). In addition, Columbia argues that two submarkets exist in the physician services category, which are pediatrics (a submarket of primary care) and physician services purchased by managed care (also referred to during the course of this litigation as the “multispecialty clinic sub-market”). The Court concludes that, except for physician services purchased by managed care, Columbia has alleged proper product markets. The Court will address each product market and submarket. a. Primary Care According to Columbia, the primary care market in Vicksburg consists of general practitioners, family practitioners, internists and, as a distinct submarket, pediatricians. Columbia deliberately excludes obstetricians and gynecologists (“ob/gyn”) from its definition of the primary care market on the grounds that (i) ob/gyns do not typically provide routine primary care services to their female patients in the Vicksburg area; (ii) managed care plans could not use an ob/gyn to substitute for a primary care physician in forming a physician panel; and (iii) only adult women seek out ob/gyns for services. Although Quorum does not dispute the recognition of primary care as a relevant product market, it does dispute Columbia’s proposed market make-up. Quorum contends that the primary care market includes family practitioners, pediatricians, internists and ob/gyns. Quorum also denies that pedia-tries is a separate submarket. In support of its position, Quorum points to Drs. Sessums and Giffin, family practitioners at the Mission Clinic. Each of these doctors dedicates 20% or more of his practice to providing pediatric care to children. On the other hand, Quorum names no specific Vicksburg area physician who provides both ob/gyn and routine primary care services to patients. Having considered the evidence and the interchangeability of the services at issue, the Court accepts Columbia’s definition of primary care for the purposes of this antitrust lawsuit. On this issue, the Court found informative the testimony of Columbia’s expert, Dr. Eisenstadt, who stated his belief that general practitioners, family practitioners and internists in the Vicksburg area are considered “in some sense substitutable for one another and therefore they could be called primary care physicians.” (Trial Tr. at 2116.) Dr. Eisenstadt further testified that, while pediatricians provide primary care to children, they cannot substitute for internists or general practitioners in the formation of a managed care panel. {Id. at 2117.) From an antitrust market-definition perspective, Dr. Eisenstadt concluded that pediatricians would be a relevant submarket under primary care physicians. However, Dr. Eisenstadt neither included ob/gyns in the primary care market nor considered them as a submarket of primary care based on his belief that women in the Vicksburg area would not routinely use an ob/gyn for primary care purposes. Dr. Eisenstadt’s opinion was partially corroborated by Ms. Sharon Petty, vice-president and CFO of the Ameristar Casino in Vicksburg. As a health benefits provider to over 1,000 employees, Ms. Petty stated that she could not offer her employees an ob/gyn or a pediatrician as a substitute for an internist. {Id. at 1180-81.) The record does not identify any specific ob/gyn in the Vicksburg area who is generally capable of providing primary care services to the population as a whole and who would therefore be an acceptable substitute for general practitioners, family practitioners or internists. The testimony regarding the extent to which Vicksburg area ob/gyns provide primary care services to women patients was vague and unsubstantiated. See, e.g., id. at 1122 (testimony of Dr. Fagan citing unnamed surveys to support the notion that one-third of all women see only a gynecologist as a physician); id. at 2662 (Quorum’s expert incorrectly citing Dr. Fagan for the proposition that 70% of all women see only an ob/gyn). Recognizing that Columbia’s proposed definition of the primary care market may not be perfect, it is nonetheless adequately defined and inadequately refuted for the purposes of obtaining Clayton Act relief. Rockford, 898 F.2d at 1285 (forced to chose between two imperfect market definitions, court of appeals chose the less imperfect one). b. Other Physician Markets The additional physician markets proposed by Columbia (general surgery, urology and ENT) are unopposed by Quorum in its final briefing to this Court. At trial, Quorum’s expert, Mr. Oliver, accepted general surgery and urology as appropriate markets. Mr. Oliver expressed some reservation about the proposed ENT market because there was testimony at trial suggesting that Dr. Brad-field, an ENT at the Vicksburg Clinic, might have intentions of leaving the Vicksburg area. In the event that Dr. Bradfield left Vicksburg, Mr. Oliver suggested that the postmerger monopoly in ENT could disappear. With respect to the task at hand— defining relevant product markets that are supported by the record evidence — the Court finds that speculation about what Dr. Brad-field might or might not do lacks probative value. In the light of little to no opposition from Quorum, the Court accepts Columbia’s definition of the physician product markets for general surgery, urology and ENT. c. Submarket of Physician Services Purchased by Managed Care (or the “multispecialty clinic submarket”) Columbia’s proposed submarket for physician services purchased by managed care, also referred to as the “multispeeialty clinic submarket,” is not so easily demarcated as the preceding practice specialties. Indeed, Columbia itself has exhibited some difficulty throughout this litigation in naming and presenting a consistent, well-defined statement of the market that it now asks this Court to recognize. Initially, Columbia sketched a separate product market (not sub-market) of “managed care contracting for physician and hospital services.” (Complaint ¶44, emphasis added). This description has evolved into Columbia’s latest articulation on the subject, which depicts a leaner submarket without the added weight of hospital services: Plaintiff also alleged ... and proved a submarket [of the physician services product market] consisting of physician services purchased by managed care plans. This submarket can also be referred to as a multispecialty clinic submarket in Vicksburg because of the configuration of doctors in Vicksburg — two multispecialty clinics and only a few independent physicians. Given this configuration, a managed care plan must purchase physician services from one of the two multispecialty clinics to have a marketable panel. Whether this market is called a “multispecialty clinic submarket” or “physician services purchased by managed care submarket,” it does not change the fact that without the merger there are only two significant sellers of physician services in Vicksburg — the Vicksburg Clinic and the Street Clinic— and after the merger there would be only one — River Region. Columbia Posttrial Letter at 3. Having studied Columbia’s most recent effort to nail down a definition of this seemingly slippery submarket, the Court refers to the testimony of Columbia’s own expert witness, Dr. Eisenstadt. Contrary to Columbia’s written and oral arguments to this Court, Dr. Eisenstadt specifically asserted on cross-examination that managed care purchases of multispeeialty clinic services are not a submarket, but rather a separate product market. (Trial Tr. at 2292.) Dr. Eisenstadt also described multispecialty clinic services as a “cluster of services” market. Columbia, however, has not pursued this theory in its final briefs or arguments to this Court. (Id. at 2125.) It is the plaintiff’s burden to define its product markets, C.E. Services, 759 F.2d at 1244, and the Court now has before it a cafeteria of differing definitions from which to chose. On the basis of these inconsistencies alone, some might find that Columbia has failed to define its product market sufficiently. The Court, however, will disregard Columbia’s earlier variations on the theme of managed care and multispecialty clinics and will focus its attention on the final interpretation, cited in pertinent part above. See Columbia Posttrial Letter at 3-4. Quorum vigorously argues against the proposed multispecialty clinic submarket on the ground that Columbia is attempting to allege an invalid cluster of services market. According to Quorum, multispecialty clinics do not gather complex, interrelated and interdependent services under one roof like commercial banks (see supra note 9); rather, they offer separate and sometimes competing services that are available independently elsewhere. Relying on Blue Cross & Blue Shield United of Wise. v. Marshfield Clinic, 65 F.3d 1406 (7th Cir.1995), Quorum further argues that purchases by managed care are nothing more than discounted pricing methods and, like an HMO (which is a form of managed care), do not constitute a separate product market. Id. at 1409,1411 (reversing jury finding that HMO was a separate product market; “HMO is basically a method of pricing services”). This Court is aware of no precedent that has recognized either physician services purchased by managed care or multispecialty physician clinics as a relevant product market (and/or submarket) under the antitrust laws. In the absence of precedent bearing directly on point, the Court will depend on conventional antitrust tools to parse an arguably unconventional market. See, e.g., Brown Shoe, 370 U.S. at 325, 82 S.Ct. at 1524; see also supra discussion at Part I.C.l. A review of the facts regarding the current state of managed care in Vicksburg is essential to determining whether the market segment identified by Columbia qualifies as an economically significant submarket under the Brown Shoe doctrine. On this issue, the Court found credible the testimony of Charles Pitts, CEO of United Healthcare of Mississippi, Inc. (“United Health”), a subsidiary of a nationwide managed health care services company. Mr. Pitts also serves as board chair of Mississippi’s HMO trade association and testified that he is familiar with the development of managed care nationwide and, most importantly, in Mississippi. (See generally Trial Tr. at 258-379.) Pitts stated that, compared with the rest of the country, managed care is in its infancy in Mississippi. He estimated that only 1% to 2% of Mississippi’s population is enrolled in an HMO product (compared with 20% to 25% for the nation as a whole). Within Mississippi, the HMO industry is better-established in the southeast comer of the state as compared to Vicksburg, which is one of the industry’s newer locations. Pitts further testified that United Health has marketed its managed care products in Vicksburg only since March 1996, although United Health recently acquired a company that has been offering “a product” in Vicksburg for several years. Pitts did not offer any specifics about the product or its performance record. Pitts’s testimony regarding the infancy of managed care in Mississippi was confirmed by the testimony of Dr. Eisenstadt (id. at 2399), by the testimony of Rissa Richardson, a provider relation manager for American Medical Plans of Mississippi (id, at 388), and by Columbia’s own documents. (Exhibit DQ-121, p. HCA9685 (VMC’s Strategic Review FY ’96 noting “relatively immature status” of managed care)). Ms. Richardson explained that her company markets both commercial and Medicaid HMO/managed care products in Mississippi. At the time of trial, American Medical had no Vicksburg enrollees for its commercial product, and the anticipated Warren County Medicaid pilot program (in which Richardson hopes to participate as an HMO provider) had not begun operations. Richardson testified that there are only fourteen HMOs in Mississippi, all in varying stages of development including those with membership, those that are poised to begin services, and those “that are just in the loose stages of forming and developing.” (Trial Tr. at 385.) With respect to managed care companies, Richardson further stated, “... almost everyone in Mississippi is a new kid on the block.” (Id. at 388.) The Court found informative Mr. Pitts’s testimony about his company’s efforts to construct its Vicksburg network of physician providers. At the time of trial, United Health had contracted with primary care physicians and specialists who practice independently in the Vicksburg area and at the Vicksburg Clinic. According to Pitts, the “rule of thumb” in developing a network of physician providers is to attempt to contract with representatives of every service available in the market (primary care physicians, cardiologists, etc.) and to secure as large a representation as possible. Pitts stressed that, particularly in a fledgling managed care market like Mississippi, a managed care product designer needs to attract new customers by offering the broadest physician choice possible in its provider network. Ideally, the network would include from 40% up to 100% of the primary care physicians available in the local market; in Vicksburg, it also would include physicians located in towns within dose proximity to Vicksburg and Jackson specialists, if none are available in Vicksburg. By way of example, Pitts testified that it would not be desirable, from a marketability standpoint, to contract solely with the Mission Clinic in establishing his network of physician providers because this would result in a very limited representation. He conceded, nonetheless, that the five or six primary care physicians associated with the Mission Clinic would be sufficient to service the adult primary care needs of his company’s entire customer population in Vicksburg and Warren County. Similarly, Ms. Richardson testified that health care consumers prefer a broad choice of physicians on HMO provider panels. In terms of marketability, Richardson stated that she would want to have at least one of the two largest clinics in Vicksburg on her panel. Although she already has a contract with the primary care physicians at the Vicksburg Clinic, she nonetheless has contracted with other physicians, including those at the Mission Clime and the Better Living Clinic. Richardson testified that her company is continuing to meet and negotiate with physicians in order to broaden its Vicksburg provider panel. Based on the evidence, including the aforementioned trial testimony, the Court finds as a fact that the managed care industry is still in its early stages of development in the Vicksburg area. Indeed, managed care providers are just beginning to enter the Vicksburg health care market. They are in the process of simultaneously building the broadest possible provider panels and establishing first-time client relationships with area employers. At this juncture, managed care purchases of physician services in Vicksburg can hardly be described as a well-defined, economic entity within the meaning of Brown Shoe. In sum, it is this Court’s view that Columbia is, at best, precipitous in seeking submarket status for a very limited and economically immature segment of the Vicksburg physician services market. See F.T.C. v. Butterworth Health Corp., 946 F.Supp. 1285, 1300 & n. 5 (criticizing the FTC for its artificial and misleading focus on recipients of hospital services purchased by managed care at discounted rates — a very limited segment of hospital care consumers). The premise of Columbia’s proposed mul-tispecialty clinic submarket is that, postmer-ger, a managed care plan must purchase physician services from the River Region multispecialty clinic in order to have a marketable provider panel. At the heart of this premise is Dr. Eisenstadt’s opinion that, in communities where multispecialty clinic services are available, managed care plans prefer to “one-stop shop” at the multispecialty clinic, rather than build a provider panel of smaller clinics and independent physicians. (Trial Tr. at 2044.) In essence, Columbia claims that the River Region Clinic will be the only place to one-stop shop in Vicksburg after the merger and that no substitute for this multispecialty clinic will be available to managed care plans. The Court concludes that Columbia’s fundamental premise in this regard is unfounded. It is well-established that, in defining a market, one must determine whether products or services exist that are good substitutes for the product or service in question. BrownShoe, 370 U.S. at 325, 82 S.Ct. at 1524; see generally ANTITRUST ADVISER § 1.23 (Irving Scher ed.1995). Based on the testimony of Charles Pitts, the Court finds as a fact that physicians not associated with the Vicksburg and Street Clinics are currently being used by, and are available for use by, managed care plans. Nothing in the record suggests that independent physicians in the Vicksburg area or physicians associated with the smaller Vicksburg clinics (e.g., the Mission Clinic) are incapable of providing acceptable physician services to managed care plans. To the contrary, the testimonial and documentary evidence indicates that a number of physicians such as Drs. Sessums (Mission Clinic), Daniel Dare (Southern Orthopedics), Yoshinobu Namihira (Better Living Clinic), Roy Kellum, Joel Payne, Earl Stub-blefield and James Tucker serve on managed care panels. (Trial Tr. at 146, 148-49, 283; Exhibits DVC-373; DQ-532, -533, -534, - 535, -536, -541, -545, -546, -547 and -551; PX-454.) Pitts voiced no dissatisfaction with the independent physicians currently serving on his company’s panel and expressed a clear desire to sign up as many of these doctors as possible. It therefore appears to this Court that there is an inconsistency between Dr. Eisenstadt’s opinion and the testimony of Mr. Pitts. Although Dr. Eisenstadt’s opinion regarding one-stop shopping may hold true in other parts of the country, the Court finds that it is not the rule in Vicksburg’s yet-to-be-developed managed care market. As Mr. Pitts credibly testified, the best standard in Vicksburg is an offering of the broadest physician choice possible at this stage of managed care development. The Court further notes that, even if one-stop shopping were the preference of managed care companies in Vicksburg, there is nothing in the antitrust laws or in our precedent that protects a consumer’s shopping preference where viable substitutes are available in the market. Simply put, the antitrust laws protect consumer access to free and competitive markets; they do not protect the personal likes and dislikes of every consumer in that market. Thus, in the total absence of evidence to prove the incompetence of any Vicksburg area physician who is not associated with the Vicksburg or Street Clinics, this Court finds as a fact that, from an antitrust perspective, valid substitutes for the physician services offered by the two dominant climes not only exist in Vicksburg but they are being solicited by managed care providers. Before leaving this issue the Court notes that, to the extent Columbia is claiming sub-market status based on the distinct discount pricing that is associated with managed care purchases (see Columbia Posttrial Letter at 4), the Court rejects this argument as myopic. Although distinct pricing is one of the indicia to be considered under the Brown Shoe submarket test, the seven factors listed in Brown Shoe are neither comprehensive nor definitive and must be applied in accord with the peculiar attributes of any given market and the specific facts of a given case. Considering the totality of the record evidence in this case, Columbia’s proposed sub-market of managed care purchases of physician services does not pass muster under Brown Shoe. Brown Shoe, 370 U.S. at 325, 82 S.Ct. at 1524; see also Marshfield Clinic, 65 F.3d at 1409, 1411 (HMO, a method of discount pricing, was not a separate product market in the light of record evidence). d. The Hospital Market Columbia defines the relevant hospital services market as “acute inpatient hospital services provided in common by Parkview and VMC.” (Plaintiffs Proposed Findings of Fact and Conclusions of Law at ¶ 116; emphasis in original.) Quorum offers no opposition to this market. In fact, Quorum’s expert, Mr. Oliver, affirmatively testified that acute inpatient hospital services constitute a relevant product market in this case. (Trial Tr. at 2805.) The Court therefore finds that Columbia has identified an appropriate hospital services product market. 2. The Geographic Markets The next hurdle that Columbia must overcome in presenting its prima facie case is to define the proper geographic market for each identified product market. See United States v. Connecticut Nat’l Bank, 418 U.S. 656, 669, 94 S.Ct. 2788, 2796, 41 L.Ed.2d 1016 (1974) (burden of producing evidence of geographic markets rests with the plaintiff). A properly defined geographic market reflects the commercial realities of the industry at issue and is one that is economically significant. Brown Shoe, 370 U.S. at 336-87, 82 S.Ct. at 1529-30. The Fifth Circuit has explained that the geographic component of a relevant market definition encompasses the area of effective competition in which the product or its reasonably interchangeable substitutes are traded. Hornsby Oil Co. Inc. v. Champion Spark Plug Co.. Inc., 714 F.2d 1384, 1393 (5th Cir.1983). Stated otherwise, the key question in determining a geographic market is “where does a potential buyer look for potential suppliers of the service — what is the geographical area in which the buyer has, or, in the absence of monopoly, would have, a real choice as to price and alternative services?” United States v. Grinnell Corp., 384 U.S. 563, 588-89, 86 S.Ct. 1698, 1713, 16 L.Ed.2d 778 (1966). Our precedent unmistakably demonstrates that delineating geographic markets is no easy endeavor and that some “fuzziness” may be inherent in any attempt to do so. Philadelphia Nat’l Bank, 374 U.S. at 360 n. 37, 83 S.Ct. at 1739 n. 37. This case is no exception. a. Primary Care At its broadest, Columbia delineates the geographic market for primary care physician services as Warren County and five surrounding zip codes: 71282 (Tallulah, Louisiana); 39150 (Port Gibson, Mississippi); 39086 (Hermanville, Mississippi); 39144 (Pattison, Mississippi); and 39156 (Redwood, Mississippi) (Exhibit PX-419.) Columbia’s expert, Dr. Eisenstadt, testified that 87% of the visits to the primary care physicians at the Vicksburg, Street and Mission Clinics (the “representative clinics”) were made by patients living in this geographic area. (Trial Tr. at 2132.) Dr. Eisenstadt based this opinion on physician visit data produced by the representative clinics to which he applied a modified Elzinga-Hogarty analysis. Because of a lack of certain patient destination data, Dr. Eisenstadt was unable to.perform a complete E-H analysis of patient inflows and outflows in the primary care and other physician markets. Specifically, Dr. Eisenstadt had data showing the area from which the representative climes draw their patients, which permitted him to perform a LOFI measurement (defined swpra, at note 13). He could not, however, perform a LIFO measurement (defined id.) because none of the clinics, the State of Mississippi or any other public source keeps records that show where the residents of a specific area go for physician services. Notwithstanding the lack of patient destination data, Dr. Eisenstadt was able to express an unqualified opinion regarding the geographic market for primary care due, in part, to his experience in drawing inferences from hospital markets (for which there was complete patient flow data). (Trial Tr. at 2132-38.) In its challenge to the proposed geographic market, Quorum’s expert, Mr. Oliver, stated to the Court that the defendants were not trying to define their own version of the geographic markets for physician services; instead, they were trying to show where it was likely that patients “come from and where they travel_” (Id. at 2706.) In this spirit, Mr. Oliver suggested that Columbia’s proposed geographic market for primary care physician services was illogical because it extended thirty-six miles west but only seventeen miles east. Mr. Oliver postulated that, if people were willing to drive thirty-six miles in one direction, they would be willing to drive the same distance in all directions. To illustrate his point, Mr. Oliver presented the Court with a collection of diagrams, which are no doubt similar to what another Judge has described as “a dizzying series of concentric circles.” Cf. Marshfield Clinic, 65 F.3d at 1411 (Posner, J.) (equating the plaintiff’s proposed market derived from concentric circles drawn around clinic offices with a hunt for the snark of delusive exactness); Exhibits DQ-612-13. In Mr. Oliver’s diagram of the primary care geographic market, each circle represents an area thirty-six miles in radius that surrounds a community outside of Dr. Eisenstadt’s proposed geographic market where, nonetheless, a family practitioner or internist practices. Because it is not supported by record evidence, the Court rejects Mr. Oliver’s theory that patients are just as likely to drive a certain distance in one direction as in any other direction and therefore finds that Quorum’s concentric circle illustrations lack probative value in determining the geographic market for primary care services. More probative was Mr. Oliver’s calculation and illustration of the area from which 90% of the internal medicine and family practice visits to the Vicksburg and Street Clinics originate. (Exhibit DQ-612.) The Court notes that Mr. Oliver did not analyze data from the Mission Clinic. This analysis nonetheless resulted in a slightly larger geographic area than the one proposed by Dr. Eisen-stadt and included certain communities that Dr. Eisenstadt had excluded such as Utica and Edwards, Mississippi. (Trial Tr. 2697.) Inexplicably, Quorum did not counter Dr. Ei-senstadt’s provisional service area with evidence of 90% of all primary care visits to the representative clinics but instead focused on just two components of primary care and two of the representative clinics. Conceivably, the geographic market based on 90% of all primary care visits (not just internal medicine and family practice) would be even larger than the market presented by Quorum. However, no party has introduced evidence that supports such a configuration, and the Court is left to choose between a proposed geographic market that corresponds to the relevant product market (i.e., primary care physician services) and one that, for no reason apparent on this record, does not. Having thoroughly reviewed the record before reaching a decision on this issue, the Court has weighed, among other things, Dr. Eisenstadt’s detailed testimony regarding the rationale behind his methodology with the troublesome gaps that pepper the expert testimony offered by Quorum. On this record, the Court must choose Columbia’s proposed geographic market of Warren County and the five surrounding zip codes as set forth on Exhibit PXM19. b. Pediatrics Submarket Columbia proposes a pediatrics geographic market consisting of the area where patients reside and who account for 88% of the pediatric visits to the Vicksburg and Street Clinics. (Exhibit PX-430.) Roughly, this geographic area encompasses Vicksburg and the immediately surrounding zip codes. (Trial Tr. at 2141 — d2.) Dr. Eisenstadt testified that Columbia’s proposed geographic area for the pediatrics market was very close in size and zip code identity to that of the hospital market, which he consistently used as a reference point in drawing the provisional geographic markets. Quorum offered no alternative geographic market for pediatrics and no specific challenge to Columbia’s proposal. In the absence of opposition (setting aside Quorum’s general opposition to the recognition of pediatrics as a submarket), the Court accepts Columbia’s proposed geographic market for pediatrics. c. General Surgery Columbia proposes a general surgery geographic market consisting of the area where patients reside and who account for 82% of the general surgery visits to the Vicksburg and Street Clinics, the only clinics that offer general surgery services. (Exhibit PX-429.) Like the geographic market for pediatrics, Columbia’s proposed area for general surgery encompasses Warren County and the immediately surrounding zip codes. Quorum offers an alternative geographic market that consists of an area representing patients who comprise 90% of the general surgery visits to the Vicksburg and Street Climes. (Exhibit DQ-614.) This area includes Warren County and approximately ten surrounding zip codes. (Id.) Mr. Oliver suggested that the geographic market could be even larger than this 90% area if one took into consideration the overlap among concentric circles of thirty-six and fifty-one mile radii drawn around nearby cities with general surgeons. (Id.; Trial