Mark S. Kamlet

The economic burden of depression

This article provides estimates of direct treatment costs and indirect costs from lost productivity associated with the morbidity and mortality of depression. Data are based on epidemiologic estimates of the prevalence of major depressive illness and on the number of suicides assumed to be secondary to depression. The number of hospitalizations, hospital days, physician and mental health provider visits, home/nursing home costs, and pharmaceutical costs are estimated. The direct and indirect costs are estimated to be approximately

QALYs: Some Challenges

16.3 billion per year. These economic figures provide a lower-bound estimate of the full economic burden of major depression and further emphasize the need for timely recognition and treatment to potentially minimize the negative impact of the illness on society.

Influences on Executive and Congressional Budgetary Priorities, 1955–1981

In the preceding article, Weinstein et al. [1] explain the QALYconcept, its methods, and their underlying assumptions. Anumber of interesting themes for discussion arise from thisfactual presentation. We restrict ourselves to addressing fourissues that we deem particularly challenging.As a general background for our selection of issues, we reit-erate a basic point about valuation perspectives: StandardQALYs are meant to express the personal utility of health out-comes as judged ex ante and “on average” by the general publicfrom behind a veil of ignorance about future health (so-called“decision utility”). Standard QALYs thus express value in termsof ex ante self-interest. There are, however, possible alternatives.First, health state utilities may in principle be elicited ex postrather than ex ante, i.e., from people who have or have had directexperience with the health states that are the object of the valu-ation (so-called “experienced utility”). Second, QALYs may beconstructed to express society’s valuation of health outcomeswhen not only self-interest but also concerns for fairness aretaken into account. The choice of approach depends on thequestion one wishes to answer, and the choice of health statevaluation techniques depends on the choice of perspective.The issues we address in the following reflect the aboveplurality in possible valuation perspectives and are in part inde-pendent of each other. One issue is intermethod variation in theestimation of ex ante health state utilities. A second is the exist-ence of unwillingness to trade lifetime in elicitations of experi-enced utility. A third is the discrepancy between aggregateindividual utility of health programs on the one hand and, on theother hand, societal valuations that include concerns for fairness.A fourth is a hitherto much overlooked distinction betweenhealthy individuals’ valuations of states of illness (which

Cost utility analysis of maintenance treatment for recurrent depression

A reduced form equation system is used to analyze the influence of economic, political, and institutional influences on the budgetary priorities of the executive branch and Congress during fiscal 1955–81. Three related issues are considered: the extent to which political and macroeconomic factors affect priorities; the degree of interdependence among the components of the federal budget and between spending and revenues; and differences between the executive branch and Congress with respect to these issues. Both types of interdependence are present within both executive branch and congressional budgeting, although this interdependence is stronger within the executive branch. The influence of economic conditions on budgetary outcomes is strong but varies considerably across spending categories. There is no evidence of apolitical business cycle. Political variables exert a modest influence on the budgetary outcomes examined; differences between Democratic and Republican budgetary policies, as well as differences in the budgetary priorities of different presidential administrations, are small by comparison with the differences between executive and congressional policies.

An empirical examination of bias in revenue forecasts by state governments

This paper presents a cost-utility analysis of three maintenance treatments for recurrent depression: interpersonal therapy (IPT-M), imipramine drug therapy (Drug), and a combination of the two. We base our analysis on the results of the University of Pittsburghs Controlled Clinical Trial of Maintenance Therapies for Recurrent Depression. We construct a Markovian state-transition model to incorporate clinical effectiveness into cost and quality-of-life impacts; we assign empirical values to the parameters of this model; and we then use Monte Carlo analysis to compare the relative cost effectiveness of the different maintenance treatments. For the patients who met the eligibility standards for the study, Drug maintenance treatment is cost-effective in the strongest sense of the term compared to either a placebo group or IPT-M: it both improves expected lifetime health (measured in quality-adjusted life years, or QALYs) and reduces direct medical costs. This is true even when relatively severe side effects of the drug are considered. Compared to the placebo group, IPT-M and the combination of IPT-M and Drug each improve expected lifetime health, although in neither case are expected direct medical costs reduced. Still, the cost of the resulting health improvements, under

The Political Economy of Deficit Spending in Nine Industrialized Parliamentary Democracies The Role of Fiscal Institutions

5000/QALY, are very reasonable. A similar conclusion holds comparing Drug and IPT-M to IPT-M alone. All of the above conclusions are quite robust to sensitivity analyses.

Whom do you trust? An analysis of executive and congressional economic forecasts

Abstract This analysis examines the influence of economic forecast errors and political and institutional factors on the general fund revenue forecast errors of 23 states for the period 1978 to 1987. During this period states in the sample underestimated their revenue by only 0.5%. This modest tendency toward conservative forecasting is further reduced after controlling for economic uncertainty. Moreover, the analysis reveals no systematic relationship between revenue forecast errors and state political and institutional factors. Thus, the results cast substantial doubt on the prevailing belief as found in the literature, that state revenue forecasts have a pronounced conservative bias.

Presidential Management of Budgetary and Fiscal Policymaking

This article analyzes the influence of four sets of factors on deficit spending in 9 industrialized parliamentary democracies during 1958-1990. This article analyzes the influence of these factors and introduces and tests the importance of an additional potential influence on the size of a countrys fiscal deficit: the “strength of fiscal bureaucracy.” It is argued that the stronger a countrys fiscal bureaucracy, the lower its deficit, ceteris paribus. Empirically, the authors find that the state of a nations economy heavily affects its deficit. Little systematic relationship is found between the ideology of the ruling political party and a nations deficit or between the political strength of the ruling party and deficits, in contrast to the findings of Roubini and Sachs. Finally, it is found that the strength of a countrys fiscal bureaucracy is an important influence on the deficit in these 9 industrialized parliamentary democracies.

Value measurement in cost-utility analysis: explaining the discrepancy between rating scale and person trade-off elicitations

Economic forecasts play an increasing role in U.S. budgetary and fiscal policies. This paper analyzes the accuracy and bias of economic forecasts prepared by the Executive Branch and Congress. Short-run forecasts by the Executive Branch for the forthcoming year do not appear biased. They are as accurate as private forecasts and the forecasts of the Congressional Budget Office (CBO); they are not sensitive to political factors such as the size of the deficit. At the same time, the accuracy of Executive branchs short-run economic forecasts has not improved over the period from 1962 to 1984, and the forecasts themselves can be well approximated by simple, single-equation models that use a small number of variables. In contrast to short-run forecasts, long-run economic forecasts of both the Executive branch and CBO are consistently optimistic. The degree of optimism increases with the length of the forecasting horizon and the degree of fiscal pressure the year in which they are issued. The Reagan Administrations long-run forecasts, while typically optimistic, have not been rosier than those issued under previous administrations.

Upsetting National Priorities: The Reagan Administration's Budgetary Strategy

Since the appearance of Neustadts work on the presidency in 1960, the works of Allison, Halperin, Kanter, and others have developed an important intellectual approach to the study of the presidency that views the occupant of the White House as a person embedded in an organizational, rather than an exclusively political, context. I Presidents preside at the apex of a complex structure with important intraorganizational politics; they may persuade, or they may delegate, but they function within a sometimes constraining organizational context. This article analyzes an aspect of the managerial role of the president-management of the several policy processes that culminate in the annual presidents budget transmitted to Congress. The approach to this management task adopted by Presidents Eisenhower, Kennedy, and Johnson mirrored the political goals, staff organization, and even the personalities of each man. Despite substantial variation in the demands placed upon the policy processes