Autonomy in Healthcare: Who Rules?

When we examine one of the leading foundational values of our American culture, autonomy, it often is promoted as basic in understanding Americans. Most often this concept is offered when focusing on individual autonomy. As I have been watching the evolution of healthcare delivery it seems to me autonomy is indeed a central feature in healthcare. Yet, my assessment is corporate autonomy is becoming the dominate autonomous actor in healthcare.

The word autonomy is derived from the Greek autos (self) and nomos (rule, governance, or law), and originally this referred to the self-rule or self-governance of independent city-states.  Subsequently, autonomy as a concept has been extended to individuals, and as outlined by Beauchamp and Childress, may be defined as “self-rule that is free from controlling interference by others and limitations that prevent meaningful choice, such as inadequate understanding." When considering what is currently happening inside healthcare it appears to me that our larger health systems have coopted part of Beauchamp and Childress’ definition of autonomy and are growing in market influence to be free of “…controlling interference by others.”   

As validation of my impression on corporate autonomy, PricewaterhouseCoopers (PwC) through their Health Research Institute cites a primary inflator of healthcare costs is the growing rate of provider megamergers. This research arm inside the consultancy of PwC estimates that by 2019, 93 percent of most metropolitan hospital markets will be considered highly concentrated using census data. This concentration is a “stand-in” for giving health system autonomy in contracting an upper hand compared to the self-insured, employer-based market. Often, the stated intent of the mergers is to gain an advantage of scale to deliver value to consumers, yet as PwC outlines the short-term result is often higher healthcare prices.

When considering the appropriate balance of autonomy in healthcare between individuals and the healthcare mega providers, my sense is we need to move along the autonomy continuum to be closer to the individual rather than the provider. That will restore the dignity and sacred quality both patients and physicians desire.