Association of Surgical Assistants v. National Board of Surgical Technology

127 F.4th 178
Court of Appeals for the Tenth Circuit·Decided January 21, 2025·No. 23-1344·Published·Cited by 3 cases

Opinion

FILED

United States Court of Appeals PUBLISH Tenth Circuit

UNITED STATES COURT OF APPEALS January 21, 2025 Christopher M. Wolpert

FOR THE TENTH CIRCUIT Clerk of Court

ASSOCIATION OF SURGICAL ASSISTANTS,

Plaintiff - Appellant, v. No. 23-1344

NATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING; ASSOCIATION OF SURGICAL TECHNOLOGISTS,

Defendants - Appellees.

Appeal from the United States District Court for the District of Colorado (D.C. No. 1:22-CV-02363-MEH)

Robert D. Lantz, Lantz Law Group, Evergreen, Colorado, for Plaintiff-Appellant.

John W. Mackay, Ray Quinney & Nebeker P.C., Salt Lake City, Utah (Brian R. Markley, Spencer Fane LLP, Overland Park, Kansas, and Jose A. Castro, Spencer Fane LLP, Denver, Colorado, with him on the brief) for Defendants-Appellees.

Before TYMKOVICH, MATHESON, and McHUGH, Circuit Judges.

TYMKOVICH, Circuit Judge.

This case involves the certification process for two types of professionals who assist surgeons in the operating room: Surgical Technologists and Surgical Assistants.

Technologists ensure a sterile and organized environment, while Assistants directly aid the surgeon. Professional organizations serve each profession. The Association of Surgical Technologists (AST) represents Technologists, and the Association of Surgical Assistants (ASA) represents Assistants. The National Board of Surgical Technology and Surgical Assisting (NBSTSA) is one of several certifying bodies for both Technologists and Assistants.

Many states require Technologists and Assistants to maintain certifications to practice their respective professions. Like other professional certifications, maintaining these certifications requires either periodically logging enough continuing education credits or retaking a certification exam. This lawsuit is about who can provide continuing education services for recertifying NBSTSA certifications. To date, NBSTSA has only authorized AST to administer continuing education services. ASA wants to join it as an education provider.

After NBSTSA refused to authorize ASA to provide continuing education services on its behalf, ASA sued NBSTSA and AST for antitrust violations and tortious business interference. NBSTSA and AST moved to dismiss ASA’s Complaint. The district court granted that motion.

We affirm. As the district court correctly explained, ASA fails to establish the threshold requirement of an antitrust claim: the relevant market. Independently, it also failed to plead a plausible conspiracy or valid antitrust injuries.

I. Background

A. Surgical Assistant and Surgical Technologist – Certifications Unless otherwise noted, we take the following material factual allegations as true for purposes of reviewing a motion to dismiss pursuant to Fed. R. Civ. P. 12(b)(6). Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). Where noted, and as the district court before us did, we take judicial notice of public information that is not reasonably subject to dispute. O’Toole v. Northrop Grumman Corp., 499 F.3d 1218, 1225 (10th Cir. 2007) (taking judicial notice of information on Northrop Grumman’s website and noting “[i]t is not uncommon for courts to take judicial notice of factual information found on the world wide web”).

Surgical Assistants are “advanced allied health practitioners” who aid a surgeon with “wound closure, bleeding control, and other interoperative technical functions that help the surgeons carry out a safe operation.” 1 Technologists, in contrast, “ensure a sterile and organized environment.” 2 NBSTSA certifies both Assistants and Technologists. Its certifications are called Certified Surgical First Assistant (CSFA) and Certified Surgical Technologist (CST), respectively. To obtain either certification, applicants must take an initial four-hour examination, and to renew a certification

1 Surgical First Assistant, MAYO CLINIC COLLEGE OF MEDICINE & SCIENCE, https://college.mayo.edu/academics/explore-health-care-careers/careers-a-z/surgicalfirst -assistant/ (last visited Dec. 9, 2024).

2 Surgical Technologist, MAYO CLINIC COLLEGE OF MEDICINE & SCIENCE, https://college.mayo.edu/academics/explore-health-care-careers/careers-a-z/surgicaltechnologist / (last visited Dec. 9, 2024).

applicants must complete a certain number of continuing education credits or retake the examination. 3 Currently, ten states require an NBSTSA certification to practice as a Technologist or Assistant. But NBSTSA—through AST (the professional association for Technologists and co-defendant in this lawsuit)—lobbies for that number to increase. FAC ¶ 15. Thus, while NBSTSA’s certifications remain voluntary in most states, “they are nevertheless valuable” to Technologists and Assistants because “many employers require” NBSTSA certification, “and such certifications are a pathway to higher pay and upward mobility.” Ord. at 2; FAC ¶ 10. NBSTSA currently certifies 60,000 Technologists and Assistants across the nation and administers its certification exam to roughly 11,000 candidates per year. FAC ¶ 11.

NBSTSA is not the only certifier of Assistants and Technologists. For Assistants, the National Surgical Assistant Association (NSAA) and American Board of Surgical Assistants (ABSA) offer competing certificates: the Certified Surgical Assistant (CSA) and Surgical Assistant-Certified (SA-C). For Technologists, the National Center for Competency Testing (NCCT) offer the Tech in Surgery (TS-C). The following table summarizes these certifications:

3 Renewals & Recertification, NBSTSA, https://www.nbstsa.org/renewalsrecertification (last visited Dec. 9, 2024); On Test Day, NBSTSA, https://www.nbstsa.org/test-day (last visited Dec. 31, 2024). Although ASA alleged “continuing education is mandatory for all CSTs and CSFAs,” FAC ¶ 13, that allegation is contradicted by NBSTSA’s website. On appeal, moreover, ASA does not dispute that CST and CSFA holders may recertify by retaking an exam. See, e.g., Aplt. Br. at 4, 16; Reply Br. at 7.

Certifying Body Technologist certification Assistant Certification NBSTSA CST CSFA NSAA CSA ABSA SA-C NCCT TS-C

B. Certification Renewal / Recertification Services NBSTSA requires its certificate holders to periodically renew their certifications.

Holders can renew two ways: (1) through completing continuing education credits or (2) by retaking a certification exam. “Most renew” via continuing education credits. 4 According to ASA, NBSTSA has vested AST with sole authority to “approve, process, and record [continuing education] credits”—which ASA calls “Recertification Services.” FAC ¶¶ 14, 15. The crux of this lawsuit is who can provide these Recertification Services.

Until December 2020, ASA and AST were affiliated, and ASA offered its members Recertification Services through an agreement with AST. At the end of 2020, ASA decided to separate from AST; aiming to create a distinct professional organization to better serve Assistants. As alleged, providing Recertification Services is critical to a professional organization’s ability to serve its members. FAC ¶ 20.

4 Id. (“Certificate holders are welcome to renew their CST or CSFA credential by testing. Most renew with AST approved continuing education credits submitted to” AST.).

ASA alleges it contacted NBSTSA sometime in September 2021 requesting authorization to provide Recertification Services. FAC ¶ 34. NBSTSA communicated this request to AST. FAC ¶ 35. Allegedly, NBSTSA—together with AST—formulated a response, which NBSTSA then unilaterally delivered. FAC ¶¶ 35–36. This response gave ASA two options:

(1) it could negotiate with AST for AST to continue performing Recertification Services for its members, which would require an “additional cost” to those members (relative to the cost charged for AST members); or

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Association of Surgical Assistants v. National Board of Surgical Technology, 127 F.4th 178 (10th Cir. 2025).

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