Catia Nicodemo: The impact of removing financial incentives and information provision on primary care quality: a randomized clinical trial (RCT) in Catalonia.

Event details

Author:  Catia Nicodemo (Oxford and Brunel)

Abstract: We evaluate the causal impact of withdrawing financial incentives and performance feedback on provider behavior in primary care. We implement an unblinded cluster-randomised trial across 68 practices in Catalonia (≈1,350 professionals) during 2025, assigning practices to: (i) status quo (pay-for-performance plus feedback), (ii) removal of financial incentives for seven quality indicators, or (iii) removal of both incentives and associated feedback. Outcomes are monthly indicator performance measures derived from electronic health records. Effects are estimated using generalized estimating equations accounting for clustering and baseline performance. 

Removing financial incentives leads to modest but significant declines in performance for most indicators (relative risks 0.94–0.97). The additional removal of feedback generates larger reductions (RR 0.85–0.96), consistent with a dose–response pattern. Effects are heterogeneous: declines are concentrated in recording-based and process indicators, while treatment-related indicators show little or no response. No effects are observed for unaffected control indicators. Behavioral responses mirror these patterns, with reduced use of clinical decision-support tools following the withdrawal of incentives and especially feedback.

The results indicate that both financial incentives and information provision shape provider effort, but that feedback plays a central role in sustaining performance once incentives are removed. From a policy perspective, information appears to act as a low-cost complement—and partial substitute—to monetary incentives, particularly for routine and documentation-intensive activities.

Host: Cheti Nicoletti (York)

Cluster: Health