Large randomized clinical trials on quality improvement initiatives have produced modest or temporary effects on improving depression care in primary care. Accordingly, there are increased calls for services researchers to question and challenge the approaches used to improve the quality of care for people with mental illnesses. While economic incentives have long been documented to affect physicians' behavior, scant attention has been paid to the alignment of payment incentives with quality improvement. The candidate proposes to integrate the theories and methods from economics and communications research to address how to align payment incentives with quality improvement in the daily practice of mental health treatment in primary care. The applicant requests 5 years of funding through the K01 program to carry out an intensive supervised training and research program including direct observation of mental health treatment in a wide range of clinical settings plus additional training in decision theory and communications research. The training program aims to enhance understanding of how various dynamic professional and economic factors affect physicians' decision-making. The research program will develop a heuristic dynamic economic model of physicians' decision-making and test it with two conceptually linked pilot studies. The first pilot will survey about 500 primary care physicians with vignettes designed to assess knowledge of clinical guidelines on depression treatment and to appraise potential impact of payment change on quality of care. The second study will collect a panel of patient-physician interaction data augmented with patient and physician surveys from about 100 primary care patients for 2 years. Empirical analyses will use structural equation models with categorical dependent variables and latent explanatory variables. Regular meetings will be held with mentors and other advisors to ensure an intensive supervised training and research experience. Such an experience will enable the applicant to use an interdisciplinary approach in a larger future study on how to alter incentives to promote patient-centered mental health treatment process.
