Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?

Document Type : Original Article


1 The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel

2 Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

3 Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany

4 Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany

5 European Observatory on Health Systems and Policies, Brussels, Belgium


Hospital professionals are “dual agents” who may face dilemmas between their commitment to patients’ clinical needs and hospitals’ financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems.

We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning.

Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include ‘reshaping management,’ such as better planning of the entire course of treatment and improvement of the coding; and ‘reframing decision- making,’ which involves working with averages and developing tool-kits for decision- making.

Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision- making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.


Commentaries Published on this Paper 

  •  Systems Science and Evidence-Informed Deliberation to Mitigate Dilemmas in Situations of Dual Agency at the Hospital Level; Comment on “Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations”

         Abstract | PDF


  •  Hospital Professionals as Dual Agents: A Superordinate Identity to Solve Interprofessional Conflicts in Hospitals?; Comment on “Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?”

         Abstract | PDF


  •  If It Is Complex, Let It Be Complex – Dealing With Institutional Complexity in Hospitals; Comment on “Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?”

         Abstract | PDF


  •  Moral Lacunae in the Management of Dual Agency Dilemmas; Comment on “Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?”

         Abstract | PDF


  •  In Need of Renewal Rather Than Reconciliation: Why We Cannot Be Satisfied With Hospital Management’s Status Quo; Comment on “Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?”

         Abstract | PDF


  •  Dual Goals, Dual Agency: The Perils of Measurement and Control; Comment on “Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?”

         Abstract | PDF


  •  Navigating Dichotomies and Dilemmas; Comment on “Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?”

         Abstract | PDF


  • The Dilemmas of Leading Health Organizations in Complex Settings; Comment on “Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?”

         Abstract | PDF


Authors' Response to the Commentaries


  •  Dual Agency: A Fresh Perspective to Identify Dilemma Mitigation Strategies – A Response to the Recent Commentaries

         Abstract | PDF



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Volume 11, Issue 9
September 2022
Pages 1823-1834
  • Receive Date: 22 September 2020
  • Revise Date: 01 June 2021
  • Accept Date: 14 July 2021
  • First Publish Date: 15 August 2021