Multi-Principal Agency and the Compliance with Professional Guidelines in Health Systems: Economic and Regulatory Perspectives

Amid the trend of rising health expenditure in developed economies, changing the healthcare delivery models is an important point of action for service regulators to contain this trend. Such a change is mostly induced by either financial incentives or regulatory tools issued by the regulators and targeting service providers and patients. This creates a tripartite interaction between service regulators, professionals, and patients that manifests a multi-principal agent relationship, in which professionals are agents to two principals: regulators and patients. This thesis is concerned with such a multi-principal agent relationship in healthcare and attempts to investigate the determinants of the (non-)compliance to regulatory tools in light of this tripartite relationship. In addition, the thesis provides insights into the different institutional, economic, and regulatory settings, which govern the multi-principal agent relationship in healthcare in different countries. Furthermore, the thesis provides and empirically tests a conceptual framework of the possible determinants of (non-)compliance by physicians to regulatory tools issued by the regulator. The main findings of the thesis are first, in a multi-principal agent setting, the utilization of financial incentives to align the objectives of professionals and the regulator 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, soft law tools as 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 the determinants of (non-)compliance to them. 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 soft law 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.

A reforma administrativa da Nova Zel??ndia nos anos 80-90: controle estrat??gico, efici??ncia gerencial e accountability

O artigo discute o processo de reforma administrativa implementada na Nova Zel??ndia a partir de 1984, com a chegada do Partido Trabalhista ao poder, abordando seus principais desdobramentos nos anos 90. Parte de uma apresenta????o do modelo administrativo em vigor na Nova Zel??ndia antes das reformas empreendidas em 1984, delimitando dessa forma o quadro referencial para comparar a situa????o anterior com a atual, de maneira que proporcione uma avalia????o sobre os impactos das medidas empreendidas. Em seguida, apresenta uma descri????o dos objetivos e princ??pios norteadores da reforma tais como, separa????o das fun????es comerciais das n??o-comerciais; separa????o entre as fun????es administrativas e de assessoria; princ??pio do ???quem usa paga???, user pays; transpar??ncia na concess??o de subs??dios; neutralidade competitiva, descentraliza????o e aumento do poder discricion??rio do administrador; melhoramento da accountability, entre outros. A seguir, s??o apresentadas as principais medidas empreendidas pelo governo trabalhista entre 1984 e 1990, dando ??nfase ?? metodologia adotada para a implementa????o e accountability dos contratos de gest??o firmados entre os executivos- chefe e os ministros. Posteriormente, o autor apresenta as modifica????es introduzidas nas regras de contrata????o de pessoal no servi??o p??blico neozeland??s e, de um modo mais geral, na pol??tica de recursos humanos. Finalmente, ?? tra??ado um perfil da situa????o atual da Nova Zel??ndia, bem como ?? feita a apresenta????o sucinta daqueles que o autor considera como sendo os ???suportes conceituais da reforma???: o movimento gerencialista, a teoria do Public Choice e a teoria Principal-Agente.

Organiza????o dos usu??rios, participa????o na gest??o e controle das organiza????es sociais

O artigo discute a participa????o dos usu??rios na gest??o das Organiza????es Sociais, prevista num projeto da reforma do aparelho de Estado atualmente em curso. A participa????o dos usu??rios na gest??o das institui????es p??blicas ?? um instrumento que pode resolver problemas da rela????o principal-agente, garantindo a implementa????o eficiente das pol??ticas. No projeto das Organiza????es Sociais, essa participa????o ?? viabilizada, entre outros meios, pela presen??a de entidades representativas da sociedade civil no Conselho de Administra????o da institui????o, pressupondo, portanto, a organiza????o dos usu??rios. Por essa raz??o, no artigo s??o analisadas as possibilidades de organiza????o dos usu??rios com base na abordagem da ???l??gica da a????o coletiva???.

Attitude change in arbitrarily large organizations

The alignment of collective goals and individual behavior has been extensively studied by economists under a principal-agent framework. Two main solutions have been presented: explicit incentive contracts and monitoring. These solutions correspond to changes in the objective situation faced by individuals. However, an extensive literature in social psychology provides evidence that behavior is influenced, not only by situational constraints, but also by attitudes. Therefore, an important aspect of organization is to choose the structures and procedures that best contribute to the dissemination of the desired attitudes throughout the organization. This paper studies how the initial configuration of attitudes and the size of the organization affect the optimal organizational structure and the timing of information flows when the objective is to align the members' attitudes. We identify and characterize three factors that affect the optimal organizational structures and procedures and the degree of alignment of attitudes: (1) clustering effects; (2) member cross-influence effects; and (3) leader cross-influence effects.

Positive self-image and incentives in organizations

This paper investigates the implications of individuals’ mistaken beliefs of their abilities on incentives in organizations using the principal-agent model of moral hazard. The paper shows that if effort is observable, then an agent’s mistaken beliefs about own ability are always favorable to the principal. However, if effort is unobservable, then an agent’s mistaken beliefs about own ability can be either favorable or unfavorable to the principal. The paper provides conditions under which an agent’s over estimation about own ability is favorable to the principal when effort is unobservable. Finally, the paper shows that workers’ mistaken beliefs about their coworkers’ abilities make interdependent incentive schemes more attractive to firms than individualistic incentive schemes.

Improving the effort concept: a revision of the traditional approach in the context of controlled Dynamic Stochastic Environments

The objective of this paper is to re-evaluate the attitude to effort of a risk-averse decision-maker in an evolving environment. In the classic analysis, the space of efforts is generally discretized. More realistic, this new approach emploies a continuum of effort levels. The presence of multiple possible efforts and performance levels provides a better basis for explaining real economic phenomena. The traditional approach (see, Laffont, J. J. & Tirole, J., 1993, Salanie, B., 1997, Laffont, J.J. and Martimort, D, 2002, among others) does not take into account the potential effect of the system dynamics on the agent's behavior to effort over time. In the context of a Principal-agent relationship, not only the incentives of the Principal can determine the private agent to allocate a good effort, but also the evolution of the dynamic system. The incentives can be ineffective when the environment does not incite the agent to invest a good effort. This explains why, some effici

Why is it so Hard to Value Intangibles? Evidence from Investments in High-Technology Start-Ups

The paper uses a range of primary-source empirical evidence to address the question: ‘why is it to hard to value intangible assets?’ The setting is venture capital investment in high technology companies. While the investors are risk specialists and financial experts, the entrepreneurs are more knowledgeable about product innovation. Thus the context lends itself to analysis within a principal-agent framework, in which information asymmetry may give rise to adverse selection, pre-contract, and moral hazard, post-contract. We examine how the investor might attenuate such problems and attach a value to such high-tech investments in what are often merely intangible assets, through expert due diligence, monitoring and control. Qualitative evidence is used to qualify the more clear cut picture provided by a principal-agent approach to a more mixed picture in which the ‘art and science’ of investment appraisal are utilised by both parties alike

Complexity and Bounded Rationality in Individual Decision Problemsing.

I develop a model of endogenous bounded rationality due to search costs, arising implicitly from the problems complexity. The decision maker is not required to know the entire structure of the problem when making choices but can think ahead, through costly search, to reveal more of it. However, the costs of search are not assumed exogenously; they are inferred from revealed preferences through her choices. Thus, bounded rationality and its extent emerge endogenously: as problems become simpler or as the benefits of deeper search become larger relative to its costs, the choices more closely resemble those of a rational agent. For a fixed decision problem, the costs of search will vary across agents. For a given decision maker, they will vary across problems. The model explains, therefore, why the disparity, between observed choices and those prescribed under rationality, varies across agents and problems. It also suggests, under reasonable assumptions, an identifying prediction: a relation between the benefits of deeper search and the depth of the search. As long as calibration of the search costs is possible, this can be tested on any agent-problem pair. My approach provides a common framework for depicting the underlying limitations that force departures from rationality in different and unrelated decision-making situations. Specifically, I show that it is consistent with violations of timing independence in temporal framing problems, dynamic inconsistency and diversification bias in sequential versus simultaneous choice problems, and with plausible but contrasting risk attitudes across small- and large-stakes gambles.

La gripe A desde la teoría de la elección racional: propuestas para la toma de decisiones de políticas preventivas

This article is a reflection on the social uncertainty caused by Influenza A and on the consequences that it can have on decision making in health promotion policies. We use concepts and metaphors of the Rational Choice Theory, among them, the “ingratitude effect” or the “distrust effect”, as we analyse how these can become obstacles for the efficiency of prevention policies. Then, we focus on the information asymmetry of the principal-agent relationship, and we propose measures to diminish the “moral risk” that they cause. We finish by advancing some proposals for designing lines and strategies of action in health promotion policies.

Sharing competences in strategic alliances: a case study of the Cosan and Shell biofuel venture

In a competitive world, the way a firm establishes its organizational arrangements may determine the enhancement of its core competences and the possibility of reaching new markets. Firms that find their skills to be applicable in just one type of market encounter constraints in expanding their markets, and through alliances may find a competitive form of value capture. Hybrid forms of organization appear primarily as an alternative to capturing value and managing joint assets when the market and hierarchy modes do not present any yields for the firm's competitiveness. As a result, this form may present other challenging issues, such as the allocation of rights and principal-agent problems. The biofuel market has presented a strong pattern of changes over the last 10 years. New intra-firm arrangements have appeared as a path to participate or survive among global competition. Given the need for capital to achieve better results, there has been a consistent movement of mergers and acquisitions in the Biofuel sector, especially since the 2008 financial crisis. In 2011 there were five major groups in Brazil with a grinding capacity of more than 15 million tons per year: Raízen (joint venture formed by Cosan and Shell), Louis Dreyfus, Tereos Petrobras, ETH, and Bunge. Major oil companies have implemented the strategy of diversification as a hedge against the rising cost of oil. Using the alliance of Cosan and Shell in the Brazilian biofuel market as a case study, this paper analyses the governance mode and challenging issues raised by strategic alliances when firms aim to reach new markets through the sharing of core competences with local firms. The article is based on documentary research and interviews with Cosan's Investor Relations staff, and examines the main questions involving hybrid forms through the lens of the Transaction Cost Economics (TCE), Agency Theory, Resource Based View (RBV), and dynamic capabilities theoretical approaches. One focal point is knowledge "appropriability" and the specific assets originated by the joint venture. Once the alliance is formed, it is expected that competences will be shared and new capabilities will expand the limits of the firm. In the case studied, Cosan and Shell shared a number of strategic assets related to their competences. Raízen was formed with economizing incentives, as well to continue marshalling internal resources to enhance the company's presence in the world energy sector. Therefore, some challenges might be related to the control and monitoring agents' behavior, considering the two-part organism formed by distinctive organizational culture, tacit knowledge, and long-term incentives. The case study analyzed illustrates the hybrid arrangement as a middle form for organizing the transaction: neither in the market nor in the hierarchy mode, but rather a more flexible commitment agreement with a strategic central authority. The corporate governance devices are also a challenge, since the alignment between the parent companies in the joint ventures is far more complex. These characteristics have led to an organism with bilateral dependence, offering favorable conditions for developing dynamic capabilities. However, these conditions might rely on the partners' long-term interest in the joint venture.

Hallituksen riippumattomuus Suomen corporate governance -suosituksessa

Tutkimuksen tavoitteena on tutkia, kuinka Suomen vuonna 2004 voimaan tullut corporate governance -suositus tukee hallituksen riippumattomuutta. Tutkimuksessa määritellään hallituksen riippumattomuuden käsite. Tämän määritelmän avulla tarkastellaan, kuinka Suomen corporate governance -suosituksessa ohjataan hallituksen riippumattomuutta. Tutkimus on kvalitatiivinen tutkimus, joka on luonteeltaan osittain teoreettinen ja osittain normatiivinen. Tutkimusstrategiassayhdistyvät deskriptiivisyys ja komparatiivisuus. Tutkimuksessa Suomen corporategovernance -suosituksen hallituksen riippumattomuutta koskevia suosituksia verrataan toisaalta päämies-agenttiteorian pohjalta muodostettuun riippumattoman hallituksen määritelmään ja toisaalta keskeisimpiin ulkomaisiin corporate governance -säännöstöihin. Riippumattomaksi hallitukseksi määriteltiin hallitus, jonka toimintaa toimiva johto tai merkittävä osakkeenomistaja ei voi suoraan tai välillisesti dominoida. Suomen suosituksessa voidaan nähdä pyrkimys kohti riippumaton-ta hallitusta. Suomen suositus ei kuitenkaan tue hallituksen riippumattomuutta parhaalla mahdollisella tavalla. Sekä toimivalle johdolle että yhtiön merkittäville osakkeenomistajille jää valtaa vaikuttaa hallituksen toimintaan enemmän kuin osakkeenomistajien etujen kannalta olisi suositeltavaa.

The Swiss reform of the allocation of tasks : The conventions-programs as a new partnership model for vertical cooperation ?

This research examines the impacts of the Swiss reform of the allocation of tasks which was accepted in 2004 and implemented in 2008 to "re-assign" the responsibilities between the federal government and the cantons. The public tasks were redistributed, according to the leading and fundamental principle of subsidiarity. Seven tasks came under exclusive federal responsibility; ten came under the control of the cantons; and twenty-two "common tasks" were allocated to both the Confederation and the cantons. For these common tasks it wasn't possible to separate the management and the implementation. In order to deal with nineteen of them, the reform introduced the conventions-programs (CPs), which are public law contracts signed by the Confederation with each canton. These CPs are generally valid for periods of four years (2008-11, 2012-15 and 2016-19, respectively). The third period is currently being prepared. By using the principal-agent theory I examine how contracts can improve political relations between a principal (Confederation) and an agent (canton). I also provide a first qualitative analysis by examining the impacts of these contracts on the vertical cooperation and on the implication of different actors by focusing my study on five CPs - protection of cultural heritage and conservation of historic monuments, encouragement of the integration of foreigners, economic development, protection against noise and protection of the nature and landscape - applied in five cantons, which represents twenty-five cases studies.

Exits - Pääomasijoittajan irtautumisvaihtoehtojen juridista tarkastelua

Pääomasijoittaminen on Suomessa verrattain uusi ilmiö. Tutkielman tarkoitus on ollut tarkastella pääomasijoittajan irtautumista kohdeyhtiöstä juridisesta näkökulmasta. Tutkielman ydin on ollut selvittää pääomasijoittamisen toimijoiden roolien ja niistä johtuvien intressien ristiriitojen vaikutusta irtautumiseen sekä sitä, miten intressiristiriitoja vähennetään erityisesti pääomasijoittajan näkökulmasta. Teoreettisena viitekehyksenä on käytetty päämies-agenttiteoriaa sekä teoriaa asymmetrisestä tiedosta ja moraalisesta uhkapelistä. Toisena tutkimusongelmana on selvitetty pääomasijoittamisen sijoittumista eri oikeudenalojen yhtymäkohtaan sekä luotu katsaus yleisesti pääomasijoittamista koskevaan lainsäädäntöön. Keskeisenä tavoitteena on ollut selvittää, aiheuttaako amerikkalaiseen sopimusmalliin perustuva sopimuskäytäntö ongelmia suomalaisessa juridisessa ympäristössä. Tutkimus on oikeustaloustieteellinen ja tutkimuskohteeseen on tutustuttu alan koti- ja ulkomaisen tutkimuksen ja kirjallisuuden lisäksi teemahaastatteluin. Tutkielman loppupäätelmä on, että pääomasijoittajan irtautumisen turvaamiseksi käytetään juridisesti tehokkaita menetelmiä, joista osakassopimuksen ehdot ovat ennemminkin ennaltaehkäiseviä kuin korjaavia. Intressiristiriitaa vähentämään käytetään myös kannustinjärjestelmä (osakeomistusta, optio-oikeuksia). Tutkimuksessa ei havaittu merkittäviä ongelmia amerikkalaisen sopimusmallin soveltamisessa suomalaiseen käytäntöön.