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Autonomy: The Missing Ingredient in the Cure of the Medical Care Crisis

Autonomy is an interesting word.

Most commonly, autonomy is defined as the condition of self-governance or self-regulation. Autonomy especially rings true for Americans. It is like liberty -- the state of being free from societal restrictions on our way of life. Liberty can be thought of as a patriotic autonomy, the basis for our freedom and self-control. Together, freedom and self-control constitute free will. Loss of free will -- to be controlled by someone or something -- almost always erodes our sense of purpose and meaning. Coming full circle then, autonomy gives us a sense of purpose and meaning to life. As such, purpose driven people are usually highly motivated performers who are almost always autonomous.

Last week, we mentioned the University of South Carolina School of Medicine Greenville. Starting the school was a purpose-driven initiative led by an extraordinary group of individuals with autonomy. Their drive enabled them to overcome the stress and fatigue of their task. They were resilient in their effort. It is said that clinical burnout works just the opposite. Individuals with burnout succumb to stress and exhaustion. They lose resiliency.

Autonomy, therefore, is about self-governed, purpose-driven people with resiliency.

But there is also a second definition for autonomy. Derived from the writings of German eighteenth century philosopher Immanual Kant, it states that autonomy comes with expectation. When an agent acts with autonomy, it always does so in accordance with moral duty rather than self-interest. Moral duty generally refers to a higher, more virtuous calling -- an overarching purpose or righteous vision. Notice that the commonality between the two definitions is purpose. Autonomous people who succeed always seem to exhibit a sense of purpose. And purpose breeds resiliency in times of stress. In other words, autonomy plays a role in preventing clinical burnout.

In our research of the unbalanced medical care environment, the missing ingredient is always autonomy --self-governance and behavior in accordance with moral duty rather than self-interest. In fact, none of the medical care environment’s components -- doctors, hospitals, payors and universities/innovators -- act autonomously when unbalanced. They are either controlled by (or at the effect of) another component or act in accordance with self-interest, not moral duty.

How did we get to this point? Why have we displaced our moral duty? What does moral duty even mean? What is the difference between self-governance and self-interest? Aren’t they the same? To that point, how can an environment become balanced (i.e., integrated) when all its components act autonomously? Control is the name of the game, right?

Let’s start with doctor autonomy.

Over the past thirty years, shrinking reimbursement and mounting administrative burden have forced doctors into survival mode (self-interest over moral duty) and toward employment by hospitals and payors. In South Carolina it is said that more than 70% of doctors are employed by a system or larger provider. In most cases, employed doctors are treated as valued employees at the bottom of the corporate reporting structure (e.g., a board of directors/ trustees, CEO, vice presidents, managers and employees). Like all employees, doctors are expected to adopt the mission, vision and policies of their employer. In other words, they must follow the rules. Doctors are no longer in control. They have surrendered their autonomy. This is not meant as a criticism. It is always part of the equation doctors weigh when considering employment—autonomy with lower income versus better income and loss of autonomy. It’s their only choice, right?

Turns out, there is a middle ground. In 1994 the Greenville Health System (GHS) created GHS Partners In Health, Inc., a company to house the growing number of doctors that it was employing. GHS Partners In Health (later known as the University Medical Group or UMG), was a separate company within the GHS corporate structure alongside the hospital. It was led by a physician leader reporting to a CEO over both the medical group and hospital who answered to the GHS Board of Trustees. UMG had a board of physician leaders, who oversaw the affairs of the medical group. Those included an independent financial bottom line, to which the medical group was held accountable and were at financial risk, separate billing and collecting, control of clinical practice operations and human resources, and oversight of all medical care. None of the doctors had restrictive covenants and were free to leave on relatively short notice. The UMG board had a transactional relationship with the hospital where subsidy dollars for physician directorships, call coverage and teaching were negotiated every year. The medical group managed its affairs (including its finances) according to the terms of those negotiations. Over time, the transactional partnership between the medical group and the hospital became transformational -- even starting a new medical school together. In this model, GHS had created a middle ground. Doctors were both employed and autonomous.

The success of the GHS model, which is scalable for any medical care environment in crisis, can be summed up with one word: autonomy.

In fact, autonomy, as we will see, is the lynchpin and missing ingredient capable of curing the entire Medical Care Crisis.


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