Sadhish Siva v. American Board of Radiology

In the
United States Court of Appeals
For the Seventh Circuit
____________________
No. 21-2334
SADHISH K. SIVA,
Plaintiff-Appellant,
v.
AMERICAN BOARD OF RADIOLOGY,
Defendant-Appellee.
____________________
Appeal from the United States District Court for the
Northern District of Illinois, Eastern Division.
No. 1:19-cv-01407 — Jorge L. Alonso, Judge.
____________________
ARGUED FEBRUARY 16, 2022 — DECIDED JUNE 28, 2022
____________________
Before RIPPLE, SCUDDER, and KIRSCH, Circuit Judges.
SCUDDER, Circuit Judge. In antitrust law, “easy labels do not
always supply ready answers.” Broadcast Music, Inc. v. Colum-
bia Broad. Sys., Inc., 441 U.S. 1, 8 (1979). This appeal is a prime
example of the need to look through labels to substance. Do-
ing so reveals a pleading failure. At the outset of litigation, the
burden falls to the plaintiff to articulate—in a short and plain
statement—a plausible theory of his case. On this score
Sadhish Siva has fallen short, so we affirm the district court’s
2 No. 21-2334
dismissal of his antitrust complaint challenging an alleged ty-
ing arrangement by the American Board of Radiology.
I
A
The Board is a private, nonprofit provider of medical cer-
tifications to radiologists—one of 24 such entities nationwide,
each dedicated to a different medical specialty. Upon com-
pleting medical school and a residency program, newly
minted radiologists can seek certification through the Board.
Radiologists who pass the Board’s exam and pay the required
fee become “Board certified.” The Board is the dominant firm
in the market for radiology certifications.
Strictly speaking, Board certification is optional. As we re-
cently explained, “all states permit physicians who choose not
to become (or remain) Board certified to practice medicine,”
provided they possess a valid state medical license. Assoc. of
Am. Physicians & Surgeons, Inc. v. Am. Bd. of Med. Specialties, 15
F.4th 831, 832 (7th Cir. 2021). In medicine as in law, state li-
censing boards typically require doctors to complete a certain
number of continuing medical education (or CME) credits
each year to remain licensed to practice. But none require
physicians to obtain Board certification.
Even so, plaintiff Sadhish Siva, a Board-certified radiolo-
gist, says certification is “an economic necessity without
which a successful medical career is impossible.” Most insur-
ers will not grant in-network status to physicians who are not
Board certified. And, partially as a result, uncertified physi-
cians are often shut out from meaningful employment oppor-
tunities at hospitals, health systems, practice groups, and
other medical employers. Accordingly, Siva alleges, “almost
No. 21-2334 3
all [practicing] radiologists today have found it necessary to
purchase [Board] certifications.”
When the Board began selling certifications in 1934, radi-
ologists who passed the Board examination would remain
certified for life. But in the early 2000s the Board shifted away
from lifelong certifications to a model with two components:
“initial certification” and “maintenance of certification” or
MOC. Passing the Board exam now confers only initial certi-
fication. Radiologists who wish to remain Board certified
must now participate in and pay for the MOC program each
year. Those who do not will lose their certifications and suffer
any attending professional consequences. What that means,
Siva asserts, is that just as initial certification is voluntary in
name only, radiologists have no choice but to participate in
the MOC program.
The MOC program has three main components. First, the
program requires radiologists to obtain a certain number of
CME credits each year from third-party CME providers. The
complaint indicates that this requirement is largely “redun-
dant of other CME obligations radiologists already have for
State medical licensure and other professional purposes.” Sec-
ond, the MOC program requires radiologists to complete cer-
tain “practice improvement” activities designed to teach new
skills and practice techniques, though the complaint tells us
little about what these activities are or how often they must
be completed. Third, radiologists must pass certain Board-ad-
ministered examinations or tests.
MOC has taken various forms over the years, with most
changes involving its testing component. In 2002 the Board
began selling only 10-year certifications that could be re-
newed by passing “onerous, full-day, high stakes, closed
4 No. 21-2334
book [recertification] examinations every ten years.” Starting
in 2006, the Board charged radiologists an annual MOC par-
ticipation fee in addition to fees associated with the 10-year
exams. Then, in 2013, the Board unveiled “MOC 2.0,” which
added annual evaluations on top of the 10-year recertification
exams. Finally, 2019 saw the introduction of “MOC 3.0,” the
program’s current iteration, which dropped the 10-year exam
altogether in favor of what the Board calls an Online Longitu-
dinal Assessment program or OLA. OLA tests consist of two
multiple choice questions emailed to radiologists each week,
or 104 per year, of which a radiologist must answer 52 cor-
rectly to pass. According to the complaint, OLA questions are
very easy, so few radiologists are likely to fail.
When the Board adopted the MOC program in the early
2000s, it imposed the requirement only prospectively. Radiol-
ogists who became Board certified prior to MOC’s arrival,
therefore, are “grandfathered” into lifetime certifications re-
gardless of whether they participate in (or pass) the MOC pro-
gram. The Board nevertheless offers these radiologists the op-
portunity to partake in the MOC program voluntarily. Ac-
cording to one study cited in the complaint, however, only
14% do so.
B
The Board says this is all legitimate and lawful. It is in the
certifications business, after all, and a certifying entity gets to
decide what applicants must do to earn its stamp of approval.
On this view, the Board believes it was well within its rights
to redesign its certification process to require participation in
its MOC program—to move from a model of one-time, life-
long certification to a new design it says ensures radiologists
No. 21-2334 5
remain well-qualified to practice radiology throughout their
careers.
But Siva sees things differently. He contends that MOC
should be thought of not as part of the Board’s certification
product but as a unique product in its own right. And so,
Siva claims, the Board’s decision to revoke the certification of
radiologists who refuse to participate in the MOC program
reflects not a benign product redesign but rather an illegal ty-
ing arrangement that violates § 1 of the Sherman Act, 15
U.S.C. § 1.
A tying arrangement is “an agreement by a party to sell
one product but only on the condition that the buyer also pur-
chases a different (or tied) product.” N. Pac. R. Co. v. United
States, 356 U.S. 1, 5 (1958). Not all ties are prohibited, though.
Indeed, many “are fully consistent with a free, competitive
market.” Illinois Tool Works Inc. v. Indep. Ink, Inc., 547 U.S. 28,
45 (2006).
A tie is illegal only when the seller “exploit[s] … its control
over the tying product to force the buyer into the purchase of
a tied product” and in so doing “coerces the abdication of
buyers’ independent judgment as to the ‘tied’ product’s mer-
its and insulates it from the competitive stresses of the open
market.” Jefferson Parish Hosp. Dist. No. 2 v. Hyde, 466 U.S. 2,
12–13 (1984) (quoting Times-Picayune Pub. Co. v. United States,
345 U.S. 594, 605 (1953)); see also Sheridan v. Marathon Petro-
leum Co. LLC, 530 F.3d 590, 592 (7th Cir. 2008) (explaining that
the “traditional antitrust concern” with ties “is that if the
seller of the tying product is a monopolist, the tie-in will force
anyone who wants the monopolized product to buy the tied
product from him as well, and the result will be a second mo-
nopoly”). “When such ‘forcing’ is present,” the Supreme
6 No. 21-2334
Court has underscored, “competition on the merits in the
market for the tied item is restrained and the Sherman Act is
violated.” Jefferson Parish, 466 U.S. at 12.
Courts applying Jefferson Parish have found such anticom-
petitive forcing when four elements are present. As a thresh-
old matter, the challenged tying arrangement must involve
two separate products or services. See Reifert v. S. Cent. Wis-
consin MLS Corp., 450 F.3d 312, 317 (7th Cir. 2006). From there
the plaintiff must allege that the defendant has “sufficient eco-
nomic power in the tying product market to restrain free com-
petition in the tied product market,” that “the tie affects a not-
insubstantial amount of interstate commerce in the tied prod-
uct,” and that the defendant “has some economic interest in
the sales of the tied product.” Id.Siva asserts that the Board’s conduct checks each box. His
chain of reasoning entails a few links. Prior to introducing the
MOC program, the Board sold only lifetime certifications to
radiologists who had recently completed a residency pro-
gram. In Siva’s view, then, certification represents a one-time,
“knowledge-based assessment of postgraduate medical edu-
cation and training.” But the MOC program, as the Board’s
own bylaws acknowledge, serves a different purpose: “[t]o
promote lifelong and continuous learning, professional
growth, quality, and competence.”
That latter purpose, Siva alleges, has long been served by
a separate category of products—what Siva calls continuing
professional development or CPD products. The term CPD
encompasses a variety of “educational and developmental ac-
tivities”—seminars, conferences, videos, and the like—aimed
at “promot[ing] the development of both medical and non-
medical competencies, including professionalism, and
No. 21-2334 7
interpersonal, managerial and communication skills.” Ac-
cording to Siva’s complaint, a robust market for CPD prod-
ucts (populated by medical schools, hospitals, professional
societies, and other organizations) has existed for decades
separate from and alongside the market for certifications.
Siva’s basic contention is that the Board’s MOC program—
requiring, as it does, radiologists to complete a variety of con-
tinuing education activities to retain their certifications—is
nothing but a cleverly named CPD product, just like any other
available in that separate market. By Siva’s account, then, the
Board has used its monopoly in certification—a one-time,
early-career assessment of competency—to force radiologists
to purchase a lifetime subscription to its CPD offering, a prod-
uct some radiologists would like to buy from other providers
in the CPD market. And that scheme, Siva says, has all the
makings of an illegal tying arrangement under § 1 of the Sher-
man Act.
C
The district court dismissed Siva’s complaint, concluding
that it had not plausibly alleged the first element of a tying
claim—that certification and MOC are two separate products.
The district court did not quibble with Siva’s assertions that
“MOC is a kind of CPD product” and that CPD products have
long been sold separately from certifications, a factor the Su-
preme Court has indicated points toward a finding of sepa-
rate products. Instead, the district court reasoned that even if
MOC was a CPD product by another name, that fact “d[id]
not separate it from [the Board’s] core certification product
because it does not account for the fact that MOC has been es-
sentially integrated into the certification product in a way that
no other CPD product has.” And so, because “radiologists
8 No. 21-2334
buy [MOC] to maintain [Board] certification,” the court con-
cluded that MOC “is not ‘fungible’ with CPD products that
do not serve that purpose,” and thus could not be thought of
as a separate product from certification.
Siva declined the district court’s invitation to amend his
complaint and instead appealed, asserting that the court’s
analysis reflected legal error.
II
At the pleading stage, Siva bears the burden of alleging
facts giving rise to a plausible inference that, after discovery,
he will be able to prove each element of his tying claim. See
Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 570 (2007) (explain-
ing that a plaintiff must allege “enough facts to state a claim
for relief that is plausible on its face”). Ensuring compliance
with this standard is particularly important in the antitrust
context so as to avoid “the potentially enormous expense of
[antitrust] discovery in cases with no reasonably founded
hope” of success. Id. at 559 (cleaned up); see also Assoc. of Am.
Physicians & Surgeons, 15 F.4th at 835 (recognizing that
“Twombly bars [a] discover-first, plead-later approach” in part
because “modern antitrust litigation is expensive”).
We agree with the district court that Siva failed to carry his
pleading burden, though we reach that conclusion for differ-
ent reasons.
A
The separate-products question in tying law is notoriously
murky. A savvy lawyer can describe any product as a tie of its
components, and any tie as a single product. To cut through
the metaphysics, the Supreme Court has set out a separate-
products test rooted in the purpose of the rule against tying—
No. 21-2334 9
to prevent monopolists from leveraging power in one market
to restrict competition in a second. See Phillip E. Areeda &
Herbert Hovenkamp, Antitrust Law: An Analysis of Antitrust
Principles and Their Application ¶ 1700d1 (4th ed. 2015) (Areeda
& Hovenkamp). That forbidden result can occur, the Court
has explained, only where “there is a sufficient demand for
the purchase of [the tied product] separate from [the tying
product] to identify a distinct product market in which it is
efficient to offer [the tied product] separately from [the tying
product].” Jefferson Parish, 466 U.S. at 21–22. The question
“whether one or two products are involved” thus turns on
“the character of the demand for the two items.” Id. at 19.
Courts performing this inquiry must assess market de-
mand “at the pre-contract rather than post-contract stage”—
before the alleged tying arrangement went into effect. Viame-
dia, Inc. v. Comcast Corp., 951 F.3d 429, 469 (7th Cir. 2020) (cit-
ing Areeda & Hovenkamp ¶ 1802d6). Doing otherwise by
looking at market demand in the post-tie world runs the risk
of “immuniz[ing] the worst-case scenario of a successful tie
by which a monopolist successfully leverages a monopoly in
the tying product into a monopoly in the tied product.”
Areeda & Hovenkamp ¶ 1745d1.
From this pre-contract vantage point, a number of objec-
tive indicators of market demand help answer the separate-
products question. Some useful considerations are “how the
market participants have sold and purchased the [items],” Vi-
amedia, 951 F.3d at 469, whether the two items are “separately
priced and purchased,” Jefferson Parish, 466 U.S. at 20, and
whether they are “distinguishable in the eyes of buyers.” Id.
at 19. But one factor courts may not consider, the Supreme
Court has made clear, is “the functional relation between” the
10 No. 21-2334
two items. Id. And so, “the mere fact that two items are com-
plements, [or] that ‘one … is useless without the other,’ …
does not make them a single ‘product’ for purposes of tying
law.” United States v. Microsoft Corp., 253 F.3d 34, 86 (D.C. Cir.
2001) (quoting Jefferson Parish, 466 U.S. at 19). The focus is not
on how the products function together, but on how consumer
demand for them interacts.
Assessing consumer demand may be especially difficult
when a defendant creates a product bundle that has not been
marketed in the past. See id. at 89 (explaining that “[t]he per
se rule’s direct consumer demand and indirect industry cus-
tom inquiries are, as a general matter, backward-looking and
therefore systemically poor proxies for overall efficiency in
the presence of new and innovative integration”). In such
cases, a finding of separate products may, by deeming bene-
ficial innovation illegal, undermine antitrust’s goal of promot-
ing consumer welfare. It is therefore essential to distinguish
between those cases in which a defendant has “discovered a
desirable new way of combining inputs into a better product,”
and those that represent only “an anticompetitive tie that no
one has tried before.” Areeda & Hovenkamp ¶ 1746. To do so,
it is helpful to ask whether, in the past, “buyers were put-
ting the items together to operate in the same manner as the
defendant’s bundle.” Id. ¶ 1746a. If they were, the new bun-
dle is more likely to be a tie than a truly innovative new prod-
uct. See id.B
Siva sees a straightforward tying arrangement here: the
Board, to his eye, has leveraged its monopoly in the certifica-
tion market to force radiologists to purchase MOC, a
No. 21-2334 11
CPD product some radiologists would prefer to purchase
elsewhere.
If we start with “how the market participants have sold
and purchased the [items],” it is easy to see that CPD products
and certifications are separate products. Viamedia, 951 F.3d at
469. Prior to the creation of the MOC program, Board certifi-
cations were valid for life, and radiologists separately pur-
chased CPD products from third-party vendors, both to com-
ply with state licensing requirements and, one imagines, for
their own betterment as medical professionals. Siva’s com-
plaint identifies various institutions—medical schools, pro-
fessional societies, clinics, and the like—that have sold CPD
products to radiologists “for decades” without selling accom-
panying certification products. All told, “the character of the
demand” for CPD products is distinct from that for certifica-
tions, so they are separate products under Jefferson Parish, 466
U.S. at 19.
On that much everyone seems to agree. And Siva says that
is the end of the matter: if CPD products and certifications are
separate products, and (as he alleges) MOC is a CPD product,
then MOC and certifications must also be separate products.
Likewise, Siva adds, because radiologists for decades “were
putting [CPD products and certifications] together to operate
in the same manner as the [Board’s] bundle,” there is no risk
that tying liability here would stifle beneficial innovation.
Areeda & Hovenkamp ¶ 1746a.
The Board, appealing to the nature of certifications, resists
this conclusion. Because a certifying entity “has the right to
set its own certification standards,” the Board says, its deci-
sion to exercise that right to modify its certification product to
contain a CPD-style component is not subject to antitrust
12 No. 21-2334
scrutiny. After all, only the Board can offer “a program to
maintain its own certification.”
The district court saw things much like the Board. In its
view, the long history of separate demand for CPD products
and certifications did not indicate separate products here, be-
cause “MOC has been essentially integrated into the certifica-
tion product in a way that no other CPD product has.” As the
district court put it, “a maintenance-of-certification program
that lacks the imprimatur of the certifying entity has no value
to any physician seeking to demonstrate that he has obtained
and maintained certification.”
Recall, though, that we must assess market demand from
a pre-tie rather than a post-tie perspective. See Viamedia, 951
F.3d at 469. In the pre-tie world, Board certification was not
something that needed to be “maintained” through comple-
tion of any CPD program; it was valid for life. So the district
court was right to observe that “CPD products serve a differ-
ent purpose from certification and had nothing to do with it”
prior to the introduction of the MOC program. But the district
court never went the next step to see that, in Siva’s view, this
is precisely the problem: CPD products, he alleges, still have
nothing to do with certification—in other words, consumer
demand for the two products remains distinct. As such, Siva
says, the Board’s decision to name its CPD product “mainte-
nance of certification” is nothing but a clever means of dis-
guising a tying arrangement. Siva therefore urges that we see
through that strategic naming decision—that marketing
ploy—in conducting the separate-products analysis.
A fanciful example shows that Siva must be right. Suppose
that, instead of the MOC program as it currently stands, the
Board decided it would revoke the certifications of any
No. 21-2334 13
radiologist who did not purchase a monthly subscription of
Board-branded office supplies. Further suppose that the
Board calls its office-supplies subscription program “mainte-
nance of certification.” It is easy to see that, despite the name,
the arrangement concerns separate products. Consumer de-
mand for office supplies has nothing to do with consumer de-
mand for radiology certifications. The Board’s decision to call
its office supplies “maintenance of certification” does not
make the two distinct products (radiology certifications and
office supplies) one. See William Shakespeare, Romeo and Ju-
liet, act II, sc. ii (“What’s in a name? That which we call a rose
by any other name would smell as sweet.”). The Board sells
medical certifications. As to office supplies, its “imprimatur”
is irrelevant: radiologists do not demand the Board’s stamp of
approval as to their taste in pens and staplers.
Just so here, on Siva’s account. In reaching the conclusion
that certification and MOC were a single product in part be-
cause of the degree of “integrat[ion]” between the two, the
district court improperly approached the analysis from a
post-tie perspective. See Viamedia, 951 F.3d at 469. And in
crediting the Board’s characterization of its product over the
well-pleaded and contrary allegations in Siva’s complaint, the
district court also “may have drifted beyond reviewing the le-
gal sufficiency of [Siva’s] allegations into a fact-finding role.”
Zimmerman v. Bornick, 25 F.4th 491, 493 (7th Cir. 2022). The
mere fact that, as the district court found, “radiologists buy
[MOC] to maintain [Board] certification,” does not mean that
MOC “is not ‘fungible’ with CPD products that do not serve
that purpose”—it may just mean that alleged the tying ar-
rangement has worked as planned.
14 No. 21-2334
As the Supreme Court has explained, while firms are enti-
tled to “substantial latitude” to design and redesign products
in the pursuit of “legitimate business interests, … none of that
means a party can relabel a restraint as a product feature and
declare it immune from § 1 scrutiny.” Nat’l Collegiate Athletic
Ass’n, 141 S. Ct. 2141, 2163 (2021) (cleaned up). We are there-
fore not required to accept the label the Board has given its
product. We must instead determine what its product is—or,
more precisely, what Siva’s complaint alleges it to be—guided
by the Supreme Court’s precedents. We know that CPD prod-
ucts and certification products exist in separate markets. And
so we must decide whether Siva has alleged sufficient facts to
make it plausible that MOC is in fact a CPD product that com-
petes on the merits in that separate CPD market.
C
Siva has fallen short. He alleges that the Board has lever-
aged its monopoly in radiology certifications to restrain trade
in the market for continuing education CPD products. But just
as the Board cannot escape tying liability by naming a CPD
product “maintenance of certification,” Siva cannot survive
dismissal by asserting in conclusory fashion that MOC is a
CPD product. See Ashcroft v. Iqbal, 556 U.S. 662, 681 (2009) (ex-
plaining that conclusory allegations are “not entitled to be as-
sumed true” at the pleading stage). Saying so is not enough:
he must instead plead facts making it plausible that MOC is a
substitute for other CPD products. See Reifert, 450 F.3d at 318(“Products and services are in the same market when they are
good substitutes for one another.”).
To do so, the well-pleaded facts in Siva’s complaint must
permit an inference of what economists call “cross-price elas-
ticity” between MOC and other CPD offerings, such that—in
No. 21-2334 15
a world without the tying arrangement—an increase in the
price of other CPD products relative to MOC would shift sales
to MOC. Id. at 319. Put in plainer English, the two products
must be “reasonabl[y] interchangeab[le]” in the minds of rel-
evant consumers, Brown Shoe Co. v. United States, 370 U.S. 294,
325 (1962), meaning that a radiologist shopping for CPD
products might see the Board’s MOC program as a viable op-
tion for filling that need.
To know whether the required cross-price elasticity could
plausibly exist, it is essential to define not only what a CPD
product is, but also what consumer demand in the CPD mar-
ket looks like. Paragraph 99 of Siva’s complaint reveals that
the CPD market is, at bottom, a market for educational con-
tent across a broad range of topics, including:
value-based delivery and cost reduction, clinical
knowledge and skills, patient experience, prac-
tice improvement, diversity and inclusion, in-
terprofessional practice, doctor wellness and
burnout, patient safety, working in teams,
health care disparities, and population health.
Paragraph 100, meanwhile, describes the variety of educa-
tional “[m]ethods and tools” employed by CPD vendors:
[L]ectures, clinical case conferences, morbidity
and mortality conferences, panel discussions,
audience response systems, team-based learn-
ing, video or digital presentations, small group
or paired interactions, online learning, coaching
and mentoring, self-reflection and self-assess-
ment, peer observation and feedback, patient-
led activities, debate formats, and simulations.
16 No. 21-2334
… Performance (i.e., the outcome or effective-
ness of the CPD product) is usually measured
by examinations and simulations.
Crucially, Siva’s complaint indicates that demand for this
content seems to be driven largely by state licensing require-
ments. As the complaint explains, the first CPD products ap-
peared in the 1940s and 1950s, and they “proliferated in the
ensuing years, especially as they became required for State
medical licensure, which typically requires 40–50 hours of
CME credit every two years.” The complaint goes on to ex-
plain that, as a result, “[t]he terms CME and CPD are some-
times used interchangeably or in tandem, for example as
‘CPD/CME.’” The “CPD market” described in Siva’s com-
plaint thus seems primarily to be one for educational content
accredited to satisfy state CME requirements. To the extent
there exists a standalone market for non-accredited CPD
products, Siva’s complaint tells us next to nothing about it.
With that market structure in mind, we turn to the dispos-
itive question: whether the complaint’s well-pleaded allega-
tions permit an inference that radiologists would see the
Board’s MOC product as a true competitor in the CPD market
as Siva describes it. He says the answer is yes. His complaint
asserts that the MOC program “encompasse[s]” all of the
same educational topics using “[a]ll or many” of the same ed-
ucational formats, making it just like any other CPD product
available on the market. But a closer look at the complaint’s
description of MOC undermines that assertion.
Recall that the MOC program has three main components:
(1) a requirement that radiologists obtain a certain number of
CME credits each year “from third party CME providers”;
(2) an examination component currently consisting of the
No. 21-2334 17
weekly OLA tests; and (3) a series of so-called “practice im-
provement projects.”
Siva’s theory of the case starts to come undone at the first
requirement. By his own characterization, demand for CPD
products is really just demand for educational content that
satisfies state CME requirements. But there is no indication in
the complaint that the Board itself actually produces, offers,
or otherwise has a financial stake in any accredited CME
products. Instead, MOC’s primary feature is a requirement
that radiologists purchase CME (or CPD) products from other
providers—the same medical schools, hospitals, professional
societies, and other organizations that have long offered
CPD/CME products. Indeed, it seems radiologists could not
purchase these products from the Board even if they wanted
to—the Board does not offer them.
Two conclusions flow from that observation. The first is
that MOC is an “unlikely substitute[ ]” for a run-of-the-mill
CPD/CME offering. Reifert, 450 F.3d at 319. No radiologist
looking to fulfill his state CME obligations, in other words,
would do so by purchasing MOC, because MOC simply im-
poses a redundant obligation that he purchase those credits
elsewhere. The CPD/CME market is a market for educational
content, Siva’s complaint tells us, but the MOC program con-
tains no such content. MOC thus does not plausibly compete
in the market for CPD/CME products. Our second point is
that, for this reason, the alleged MOC tie poses no risk of fore-
closing competition in the market for CPD/CME products—
the hallmark of an illegal tying arrangement and the lynchpin
of Siva’s theory of the case. See id. at 320.
Do not let the acronyms distract. What all of this means in
concrete terms is that Siva has failed to allege that the Board’s
18 No. 21-2334
challenged conduct could plausibly give rise to the result for-
bidden by the rule against tying—the use of monopoly power
in one market (radiology certifications) to restrict competition
in a second market (continuing education products). Put an-
other way, despite Siva’s conclusory assertions that the
Board’s maintenance of certification program is a continuing
education product, the well-pleaded facts point in the oppo-
site direction—that the Board does not offer any product that
could plausibly compete in the continuing education market.
Our conclusion holds even when we consider the MOC
program’s remaining two components—the Board-adminis-
tered OLA tests and practice improvement projects. To be
sure, unlike the CME-credit requirement, these features of the
MOC program actually involve Board-created educational
content. But Siva’s complaint gives us no reason to think ra-
diologists would view these tests and activities as viable CPD
products in their own right. Radiologists cannot earn CME
credits by completing the weekly OLA tests or the practice-
improvement projects. Nor does it seem radiologists would
buy them for any other reason.
Indeed, to hear Siva tell it, these aspects of the program are
good for nothing at all: the exams are “onerous and ineffec-
tive” and “wholly superfluous,” he says, and the practice im-
provement activities are “burdensome and meritless” “make-
work with no value.” All told, Siva says radiologists “receive
nothing of benefit in return” for the MOC fees they are forced
to pay. The program, he concludes, is “worthless”—a money-
making scheme that provides no independent professional
value to radiologists.
We do not doubt the sincerity of Siva’s frustrations with
the MOC program, but these allegations do not help him
No. 21-2334 19
plead an unlawful tying arrangement. To the contrary, they
confirm our earlier conclusion that no radiologist shopping
for CPD products would voluntarily purchase MOC if given
the option. The products are not substitutes. As the Supreme
Court in Jefferson Parish explained, “when a purchaser is
‘forced’ to buy a product he would not have otherwise bought
even from another seller in the tied product market, there can
be no adverse impact on competition because no portion of
the market which would otherwise have been available to
other sellers has been foreclosed.” 466 U.S. at 16. If MOC is
truly useless as a CPD product, in other words, then forcing
radiologists to buy it poses no threat to competition in the
CPD market. The arrangement is therefore innocuous from an
antitrust perspective—at least on the allegations in Siva’s pre-
sent complaint.
That result makes sound sense. Siva alleges that the Board
is a monopolist in radiology certifications, but he does not as-
sert that it obtained that monopoly unlawfully. See 15 U.S.C.
§ 2 (prohibiting only “monopoliz[ing]” and “attempt[ing] to
monopolize”). If that is true, then the Board is well within its
rights to charge a monopoly price for its certifications. See Ver-
izon Commc’ns Inc. v. Law Offices of Curtis V. Trinko, LLP, 540
U.S. 398, 407 (2004) (explaining that “[t]he mere possession of
monopoly power, and the concomitant charging of monopoly
prices, is not only not unlawful; it is an important element of
the free-market system”). What is more, it may choose
whether to collect that monopoly price all at once or over
time. It would seem perfectly lawful, therefore, for the Board
to charge radiologists an annual fee to maintain their certifi-
cations in good standing. And there is no reason for the result
to change if, in addition to the annual fee, the Board makes
them jump through some hoops as well. As long as those
20 No. 21-2334
hoops do not harm competition in a second market, the Sher-
man Act is not violated.
The only factual allegation in the complaint that might in-
dicate that MOC is not worthless is Siva’s claim that some ra-
diologists who are grandfathered into lifetime certifications
nevertheless purchase MOC unbundled from certification.
For these radiologists, participating in the MOC program has
no bearing one way or the other on their continued certifica-
tion. And so they must have decided to pay for access to the
MOC program for some other reason. But what is missing
from this portion of the complaint is some factual allegation
that these radiologists have purchased MOC instead of some
other CPD offering available on the market—that they are
buying MOC as their CPD product of choice.
Without such an allegation, we are left to conclude that
Siva has failed to plead a plausible claim for tying. He has not
plausibly alleged that MOC is a viable competitor in the mar-
ket for CPD products. He therefore cannot identify a “distinct
product market in which it is efficient to offer [MOC] sepa-
rately from [certification].” Jefferson Parish, 466 U.S. at 21–22.
And more fundamentally, there is no chance that, as currently
pled, the Board’s decision to force radiologists to purchase
MOC could possibly restrain “competition on the merits in
the [CPD] market.” Id. at 12.
* * *
Much of Siva’s pleading deficit here stems from not at-
tending to the commands of Federal Rule of Civil Proce-
dure 8. To survive dismissal, a complaint must articulate “a
short and plain statement of the claim showing that the
pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2). But Siva’s
No. 21-2334 21
complaint is neither short nor plain—its 379 paragraphs span
nearly 80 pages. We understand, of course, that complex anti-
trust claims may lend themselves to lengthier complaints. But
in Siva’s case, that added length clouded rather than clarified
his theory of the case. Having undertaken our own fresh,
thorough review of Siva’s complaint, “accepting all well-
pleaded factual allegations as true and drawing permissible
inferences in [Siva’s] favor,” Aluminum Trailer Co. v. Westches-
ter Fire Ins. Co., 24 F.4th 1134, 1136 (7th Cir. 2022), we conclude
that the district court was right to dismiss it for failure to state
a tying claim under § 1 of the Sherman Act.
The district court’s judgment is AFFIRMED.