{"edition":"usa","organization":"Remote Area Medical","organizationId":"org:remote-area-medical","boundaryVersion":"USA-50-states-DC-v1","updated":"2026-09-14","model":{"version":"usa-alpha-remote-area-medical-2026-09-13-judgment-20260914","costScope":"Ordinary unrestricted recipient support. All recipient functions, fundraising, rental expenses and depreciation are retained in C; only recorded volunteer labor is removed for a support-dollar throughput anchor. C=10522622 is not marginal cash cost. The full-resource sensitivity restores volunteer labor. Local host costs, volunteer travel, unrecorded supplies and patient waiting/travel are additional societal costs not fully measured. G=10000 is arithmetic normalization only.","geographicAttribution":"USA means residents of 50 states and DC, not clinic citizenship or headquarters. Original return includes 7402 Philippine patients in 32770 total, while blog describes 27 states. 25368/32770=.7741 is a raw patient ratio, not a health-weighted share and not used as observed g. Unknown geographic/service-scope reconciliation; conditional g=.75 with .5 and 1 stress cases. Some reported international output may be affiliate activity outside recipient costs. That must be reconciled before using any total as a production denominator.","formula":"D=sum[t=1..T]((1−m)/1.03)^t. q_v=f×s×u×p×D−h. A=N_v×q_v+H_other. Q_all=(G/C)×b×A; Q_USA=Q_all×g; price=10G/Q_USA if positive. N_v is eye exams, not pairs. f is fraction yielding meaningful correction, p effective sustained use, s benefit not obtained otherwise. h is incremental adverse burden versus the actual alternative. It remains at s=0 only when an extra exam or prescription imposes new burden; identical replacement care cancels shared harms. H_other is annual-scale net dental/medical QALYs after deduplication and harms. Central b and g are judgments; H_other=0 leaves other health unpriced, not a proven lower bound.","counterfactual":"b discounts donor replacement, reserves, fixed volunteer slots and local-host constraints, separately from s for patient alternatives. Patients may obtain later care through Medicaid, community clinics, other charities, family payments or low-cost optical services. No-insurance status does not prove no substitute. Public funding saved is not counted as a health gain; any downstream use is unmodeled. Donated clinician opportunity cost may include other care forgone. The negative alternative-care test means an extra duplicative exam or prescription with no extra correction benefit. It is not identical replacement care, for which shared burdens cancel.","attribution":"Full recipient expense supports only the vision pathway in the conditional test; dental and medical benefits are not silently attributed to glasses. Two pairs do not create two independent QALY streams. Extractions/fillings can overlap within the same pain episode. Screening and telehealth encounters are not credited without treatment completion. Geography and affiliate-cost scope need reconciliation. A positive conditional number does not overcome unknown marginal throughput.","uncertainty":"We adopt 50% financing-sensitive throughput: cash supports a demonstrated clinic network, but volunteers, hosts and replacement funding constrain expansion. The 75% USA health share is a cautious allocation judgment, not a raw patient share. Full cash-support expenses are charged against vision health; dental and other medical benefits remain unpriced. Zero and adverse outcomes remain possible; the quantified pathway is not a complete portfolio valuation.","nativeOutcomes":"2025 N_v=7999 eye exams,15013 pairs; no unique meaningful-correction denominator. C/32770=$321.11 per reported patient and C/7999=$1315.49 per eye exam when all non-volunteer recipient cost is assigned to that pathway. The latter intentionally includes costs supporting dental and other services. Conditional b=.5 implies 3.80 additional exam-pathways per arithmetic unit, not a verified extra-patient promise.","inputs":[{"name":"G","value":10000,"unit":"USD normalization","basis":"judgment","rationale":"Arithmetic scale only.","sourceIds":[]},{"name":"FY2025 gross expense","value":19852655,"unit":"USD","basis":"observed","rationale":"Audited total with all functions and donated services; independently visual-checked.","sourceIds":["ram-audit25"]},{"name":"Recorded volunteer labor","value":9330033,"unit":"USD accounting value","basis":"observed","rationale":"Recognized expense and contribution, not donor cash or health benefit.","sourceIds":["ram-audit25","ram-tax25"]},{"name":"C","value":10522622,"unit":"USD per annual historical service scale","basis":"judgment","rationale":"19852655−9330033; entire recipient remaining expense. Includes 172918 rental expense netted from tax return, depreciation and some noncash supplies. Not a marginal cash-cost estimate.","sourceIds":["ram-audit25","ram-tax25"]},{"name":"N_v","value":7999,"unit":"eye exams in2025","basis":"observed","rationale":"Output scope/location and unique persons unresolved; do not use 15013 pairs as patients.","sourceIds":["ram-output25","ram-tax25"]},{"name":"b","value":0.5,"unit":"funding/capacity-sensitive throughput fraction","basis":"judgment","rationale":"We adopt 50% financing-sensitive throughput: cash supports a demonstrated clinic network, but volunteers, hosts and replacement funding constrain expansion. The 75% USA health share is a cautious allocation judgment, not a raw patient share. Full cash-support expenses are charged against vision health; dental and other medical benefits remain unpriced.","sourceIds":["ram-faq","ram-host","ram-audit25"]},{"name":"f","value":0.6,"unit":"meaningful correction per eye exam","basis":"judgment","rationale":"Conditional 60%; .2–.9 stress. Exams can detect nonrefractive disease or produce small prescription changes. Recipient severity and dispensing completion absent.","sourceIds":["ram-faq","vision-rct"]},{"name":"s","value":0.5,"unit":"fraction of benefit not otherwise obtained","basis":"judgment","rationale":"Allows later public, charitable or purchased correction. Test 0–.8. Access barriers support need but do not measure substitution.","sourceIds":["ram-faq"]},{"name":"u","value":0.04,"unit":"QALY per effectively corrected year","basis":"judgment","rationale":"Small transfer judgment relative to cross-sectional uncorrected utility deficits; not a NEI-VFQ mapping or measured RAM treatment effect. Test 0–.08.","sourceIds":["vision-rct","vision-utility"]},{"name":"p","value":0.8,"unit":"effective sustained use","basis":"judgment","rationale":"Allows nonuse, breakage, loss and poor adaptation. Test.5–.9; recipient follow-up missing.","sourceIds":["vision-rct","vision-harm"]},{"name":"T","value":3,"unit":"years","basis":"judgment","rationale":"Conditional durability,1–4 years; not established by short trial.","sourceIds":["vision-rct"]},{"name":"m","value":0.01,"unit":"annual competing mortality","basis":"judgment","rationale":"Mixed-age allowance; no survival benefit. Stress.005–.03.","sourceIds":[]},{"name":"h","value":0.0002,"unit":"QALY per additional exam pathway","basis":"judgment","rationale":"Adverse/adaptation burden allowance, not observed event rate. Includes weak-correction pathways. Test.0001–.0005; no broad falls benefit. Incremental relative to actual alternative care; shared burdens cancel under identical replacement.","sourceIds":["vision-harm"]},{"name":"g","value":0.75,"unit":"USA health share","basis":"judgment","rationale":"We adopt 50% financing-sensitive throughput: cash supports a demonstrated clinic network, but volunteers, hosts and replacement funding constrain expansion. The 75% USA health share is a cautious allocation judgment, not a raw patient share. Full cash-support expenses are charged against vision health; dental and other medical benefits remain unpriced.","sourceIds":["ram-tax25","ram-output25"]},{"name":"H_other","value":0,"unit":"net QALYs per annual historical scale","basis":"judgment","rationale":"We adopt 50% financing-sensitive throughput: cash supports a demonstrated clinic network, but volunteers, hosts and replacement funding constrain expansion. The 75% USA health share is a cautious allocation judgment, not a raw patient share. Full cash-support expenses are charged against vision health; dental and other medical benefits remain unpriced.","sourceIds":["ram-output25"]}],"scenarios":[{"id":"central","label":"Best estimate — explicit judgment","costUSD":10000,"allPopulationQalys":0.10042042779274961,"editionQalys":0.0753153208445622,"assumptions":"C=10522622; N=7999; b=0.5; f=0.6; s=0.5; u=0.04; p=0.8; T=3; m=0.01; D=2.772964336014393; h=0.0002; g=0.75. Dental and medical net outcomes unquantified, set zero only for this vision-path test. We adopt 50% financing-sensitive throughput: cash supports a demonstrated clinic network, but volunteers, hosts and replacement funding constrain expansion. The 75% USA health share is a cautious allocation judgment, not a raw patient share. Full cash-support expenses are charged against vision health; dental and other medical benefits remain unpriced."},{"id":"conditional","label":"Vision-only conditional throughput case","costUSD":10000,"allPopulationQalys":0.10042042779274961,"editionQalys":0.0753153208445622,"assumptions":"C=10522622; N=7999; b=0.5; f=0.6; s=0.5; u=0.04; p=0.8; T=3; m=0.01; D=2.772964336014393; h=0.0002; g=0.75. Dental and medical net outcomes unquantified, set zero only for this vision-path test."},{"id":"favorable","label":"Durable high-yield vision case","costUSD":10000,"allPopulationQalys":1.446097156939923,"editionQalys":1.446097156939923,"assumptions":"C=10522622; N=7999; b=1; f=0.9; s=0.8; u=0.08; p=0.9; T=4; m=0.005; D=3.671546124436823; h=0.0001; g=1. Dental and medical net outcomes unquantified, set zero only for this vision-path test."},{"id":"pessimistic","label":"Short weak correction with alternatives","costUSD":10000,"allPopulationQalys":-0.0001780637309292649,"editionQalys":-0.00008903186546463245,"assumptions":"C=14000000; N=7999; b=0.1; f=0.2; s=0.2; u=0.01; p=0.5; T=1; m=0.03; D=0.9417475728155339; h=0.0005; g=0.5. Dental and medical net outcomes unquantified, set zero only for this vision-path test."},{"id":"no-capacity","label":"No additional clinic throughput","costUSD":10000,"allPopulationQalys":0,"editionQalys":0,"assumptions":"C=10522622; N=7999; b=0; f=0.6; s=0.5; u=0.04; p=0.8; T=3; m=0.01; D=2.772964336014393; h=0.0002; g=0.75. Dental and medical net outcomes unquantified, set zero only for this vision-path test."},{"id":"alternative-care","label":"Extra duplicative exam without additional correction benefit","costUSD":10000,"allPopulationQalys":-0.0007601717518694486,"editionQalys":-0.0005701288139020864,"assumptions":"C=10522622; N=7999; b=0.5; f=0.6; s=0; u=0.04; p=0.8; T=3; m=0.01; D=2.772964336014393; h=0.0002; g=0.75. Dental and medical net outcomes unquantified, set zero only for this vision-path test. This is extra, duplicative care with new burden; it is not a mere change of provider for identical care."},{"id":"full-resource","label":"Recorded volunteer resource costs included","costUSD":10000,"allPopulationQalys":0.053226442646658524,"editionQalys":0.039919831984993895,"assumptions":"C=19852655; N=7999; b=0.5; f=0.6; s=0.5; u=0.04; p=0.8; T=3; m=0.01; D=2.772964336014393; h=0.0002; g=0.75. Dental and medical net outcomes unquantified, set zero only for this vision-path test."}],"sensitivity":["Conditional vision-only price≈$1.33 million/10; favorable≈$69000; unfavorable and fixed-capacity cases have no positive price. These are not confidence limits or a bounded range.","At conditional clinical inputs and g=.75, b must be≥.6639 for $1 million/10 or≥6.639 for $100000/10. The tighter threshold cannot be achieved on that vision pathway merely by funding more of the same mix.","At b=.5 and g=.75, annual-scale total net QALYs must be≥280.603 for $1 million/10 or≥2806.033 for $100000/10. Conditional vision supplies 211.337; H_other must add≥69.266 or≥2594.695 respectively. These are required net health gains, not outputs or measured effects.","Restoring recorded volunteer resource cost raises the conditional price to≈$2.51 million/10, still excluding unrecorded volunteer travel, host expenditure and patient waiting. This is a resource-cost sensitivity, not the cash donation price.","If all meaningful corrections occur in USA residents, g=1 reduces the conditional vision price to≈$996000/10; if g=.5 it rises to≈$1.99 million. Neither patient counts nor affiliate headquarters establish this health share.","If treatment merely replaces equivalent later correction, s=0 preserves adverse burden and produces negative net modeled vision health. If cash cannot unlock clinicians/hosts, b=0 gives zero.","A $100 eye-exam-and-glasses fundraising illustration is not substituted for the full-recipient $1315 historical cost per eye-exam pathway. Restricting spending to a favored program would answer a different donation question.","Improved visual function does not automatically mean fewer falls, survival, learning gains or earnings; no such addition is credited. Dental pain relief may be important but teeth extracted cannot be assigned independent patient-level QALYs."],"missingInputs":["Funding-contingent clinic/telehealth expansion plan, confirmed clinicians and hosts, contribution replacement and current cost per additional completed service mix.","Reconciliation of 32770 headline patients,7402 Philippine patients,436 clinics and 7999 eye exams, with domestic/foreign resident health and recipient-versus-affiliate cost scope.","Unique patients with meaningful corrected acuity, severity, prior glasses, dispensing completion and sustained use; generic utility and adverse effects.","Unique symptomatic dental patients and causal pain/function improvement, duration, repeat procedures, complications and alternative treatment timing.","Medical screening referrals, diagnoses, treatment initiation and longitudinal outcomes, avoiding overlap with dental/vision cases.","Current building/capacity utilization, loan repayment funding, local host costs, volunteer travel/opportunity cost and patient waiting/travel burden."]},"sources":[{"id":"ram-audit25","title":"FY2025 audited financial statements, with 2024 comparative","publisher":"Remote Area Medical / Pugh & Company","url":"https://www.ramusa.org/wp-content/uploads/RAM-Final-2025-Audited-Financial-Statements.pdf","published":"2026-07-31","retrieved":"2026-09-13"},{"id":"ram-audit24","title":"FY2024 audited financial statements, with 2023 comparative","publisher":"Remote Area Medical / Pugh & Company","url":"https://www.ramusa.org/wp-content/uploads/Final-2024-Audited-Financial-Statements.pdf","published":null,"retrieved":"2026-09-13"},{"id":"ram-tax25","title":"FY2025 original Form 990, Part III and Schedule D reconciliation","publisher":"Remote Area Medical / IRS","url":"https://www.ramusa.org/wp-content/uploads/RAM-2025-990-Final-Public.pdf","published":"2026-08-18","retrieved":"2026-09-13"},{"id":"ram-output25","title":"RAM by the Numbers: Our Impact in 2025","publisher":"Remote Area Medical","url":"https://www.ramusa.org/02/ram-by-the-numbers-our-impact-in-2025/","published":"2026-02-04","retrieved":"2026-09-13"},{"id":"ram-faq","title":"Current clinic access and volunteer capacity FAQ","publisher":"Remote Area Medical","url":"https://www.ramusa.org/frequently-asked-questions/","published":null,"retrieved":"2026-09-13"},{"id":"ram-host","title":"Community hosting: responsibilities, costs and planning time","publisher":"Remote Area Medical","url":"https://www.ramusa.org/host-a-ram-clinic/","published":null,"retrieved":"2026-09-13"},{"id":"ram-home","title":"Current mobile clinics and Tennessee telehealth","publisher":"Remote Area Medical","url":"https://www.ramusa.org/","published":null,"retrieved":"2026-09-13"},{"id":"ram-unit","title":"Donation illustrations for vision, telehealth and dental care","publisher":"Remote Area Medical","url":"https://telehealth.ramusa.org/grateful-for-your-support-how-you-directly-impact-our-success/","published":null,"retrieved":"2026-09-13"},{"id":"ram-vision26","title":"Free eye exams and eyeglasses: current program description","publisher":"Remote Area Medical","url":"https://www.ramusa.org/05/free-eye-exam-and-eyeglasses-help-ram-patients-see-clearly-again/","published":"2026-05-08","retrieved":"2026-09-13"},{"id":"vision-rct","title":"Randomized immediate versus delayed refractive correction in older US adults","publisher":"Coleman et al., Journal of the American Geriatrics Society","url":"https://pubmed.ncbi.nlm.nih.gov/16776781/","published":null,"retrieved":"2026-09-13"},{"id":"vision-utility","title":"Utility and uncorrected refractive error","publisher":"Tahhan et al., Ophthalmology / Johns Hopkins University","url":"https://pure.johnshopkins.edu/en/publications/utility-and-uncorrected-refractive-error-4/","published":null,"retrieved":"2026-09-13"},{"id":"vision-harm","title":"VISIBLE randomized trial: glasses, falls and adverse effects","publisher":"Haran et al., BMJ","url":"https://www.bmj.com/content/340/bmj.c2265","published":"2010-05-25","retrieved":"2026-09-13"}]}