PhD defence A.M.M.A. (Ayman) Fouda

Dissertation in short:

Amid the trend of rising health expenditure in developed economies, optimizing clinical decisions is an important issue for service regulators and funders to contain this trend. Such a change is mostly induced by financial or regulatory tools issued by the regulators and targeting professionals and patients. This creates a tripartite interaction between service regulators or funders, professionals, and patients that manifests a multi-principal agent relationship, in which professionals are agents to two principals: service regulators and patients. This thesis is concerned with the multi-principal agent relationship in healthcare and primarily attempts to theoretically and empirically investigate the determinants of the (non-)compliance to regulatory tools in light of this tripartite relationship. The main findings of the thesis are, first, in a multi-principal agent setting, using financial incentives to align the objectives of professionals and the regulator/funder is important but not the only solution. This finding is based on the heterogeneity in the financial incentives provided to professionals in different health markets, which does not provide a one-size-fits-all model of financial incentives to influence clinical decisions. Second, clinical practice guidelines (CPGs) are important tools to mitigate the problems of the multi-principal agent setting in health markets as they reduce information asymmetries while preserving the autonomy of professionals. Third, CPGs are complex and heterogeneous, and so are their determinants of (non-)compliance. Fourth, CPGs work but under conditions. Factors such as intra-professional competition between service providers or practitioners might lead to non-compliance to CPGs – if CPGs are likely to reduce the professional’s utility. Finally, different degrees of mandate have different effects on providers’ compliance. Generally, the stronger the mandate, the stronger the compliance. However, even with a strong mandate, drivers such as intra-professional competition and co-management of patients by different professionals affected the (non-)compliance.