{"version":"sf-sfchc-hcv-cea-v1","reviewedAt":"2026-09-07","organization":"San Francisco Community Health Center","program":"Proposed expansion of integrated hepatitis C treatment","denominator":"10 incremental QALYs","confidence":"very-low","scope":"One additional HCV-positive eligible enrollee offered integrated clinical access instead of facilitated referral; not generic navigation or all SFCHC services.","costPerspective":"Gross additional clinical package cost, with no deduction for usual-care clinical costs or assumed reimbursement. Donor pharmacy share is zero under an unverified public/assistance-payment scenario; gross package DAA resources before funding displacement are reported separately. Not a complete societal incremental cost-effectiveness analysis.","nullBoundary":"No additional confirmed cures, zero funding additionality, or immediate universal counterfactual cure produces no positive benefit. Reinfection and later cure are not known locally. Treatment or implementation harms can outweigh gains; the central model assumes no extra harm.","overlap":"SFCHC already offers integrated care and has public support. Adding navigation inside that existing service cannot inherit the entire integrated-care-versus-referral effect. Deduplicate patients and shared health gains with SFAF, DOPE, HYA and medication-access programs; do not add independent lifetime gains to the same person without a joint model.","scenarios":[{"costPerEnrollee2020":6035,"startup2020":4677,"downtime2020":3030,"plannedEnrollees":100,"discountRate":0.035,"horizonYears":20,"donorDrugShare":0,"harmQalysPerEnrollee":0,"name":"Optimistic positive","costMultiplier":1,"downtimeShare":0,"accessTransfer":1,"fundingAdditionality":0.9,"referenceQalysPerCure":6.4,"reinfectionHazard":0.02,"excessMortalityHazard":0.01,"laterCureProbability":0.2,"laterCureYears":5,"benefitShape":0,"drugCostPerStart":10000},{"costPerEnrollee2020":6035,"startup2020":4677,"downtime2020":3030,"plannedEnrollees":100,"discountRate":0.035,"horizonYears":20,"donorDrugShare":0,"harmQalysPerEnrollee":0,"name":"Central analyst estimate","costMultiplier":1.35,"downtimeShare":0.5,"accessTransfer":0.5,"fundingAdditionality":0.5,"referenceQalysPerCure":4,"reinfectionHazard":0.069,"excessMortalityHazard":0.03,"laterCureProbability":0.7,"laterCureYears":3,"benefitShape":1,"drugCostPerStart":15000},{"costPerEnrollee2020":6035,"startup2020":4677,"downtime2020":3030,"plannedEnrollees":100,"discountRate":0.035,"horizonYears":20,"donorDrugShare":0,"harmQalysPerEnrollee":0,"name":"Pessimistic positive","costMultiplier":1.7,"downtimeShare":1,"accessTransfer":0.2,"fundingAdditionality":0.25,"referenceQalysPerCure":2.3,"reinfectionHazard":0.12,"excessMortalityHazard":0.06,"laterCureProbability":0.9,"laterCureYears":1,"benefitShape":2,"drugCostPerStart":25000}],"assumptions":[{"key":"costPerEnrollee2020","label":"Clinical cost per trial enrollee, 2020 USD","basis":"Kapadia microcosting: $6,035 excludes startup, physician downtime and DAA medication. Multiply by 84/82 to retain excluded participants' resources against the eligible efficacy denominator."},{"key":"startup2020","label":"Program startup, 2020 USD","basis":"Published $4,677; spread over an assumed 100 additional eligible people, not a verified expansion size."},{"key":"plannedEnrollees","label":"People sharing startup costs","basis":"100-person hypothetical tranche; never equated with local contract targets."},{"key":"downtime2020","label":"Full physician downtime per trial enrollee","basis":"Published $3,030; multiplied by scenario share and 84/82. Flexibility may require idle capacity; it is not automatically free."},{"key":"downtimeShare","label":"Downtime charged to this package","basis":"0/50/100% judgment: integrated clinics may use some availability for other services. No local allocation verified."},{"key":"costMultiplier","label":"Local/current cost multiplier","basis":"1/1.35/1.7 judgment, not an inflation series or SFCHC quote."},{"key":"accessTransfer","label":"Fraction of trial incremental access retained","basis":"Trial 55/82 minus 19/83 SVR12 difference. 100/50/20% judgment for otherwise referral-only people; could be zero inside existing integrated care."},{"key":"fundingAdditionality","label":"Share of expansion caused by gift","basis":"90/50/25% judgment; current public service and replacement funding can make this zero."},{"key":"referenceQalysPerCure","label":"External lifetime QALY-per-cure anchor","basis":"MONARCH age-40 discounted bounds 2.3 (F0) to 6.4 (F4), algebra from 0.23–0.64 QALY per ten-percentage-point SVR improvement. Central 4 is a severity-mix judgment, not measured SF health."},{"key":"horizonYears","label":"Effective health-benefit allocation window","basis":"20-year heuristic, not a rerun of the lifetime Markov model. External total is allocated across this window only to stress-test timing and durability."},{"key":"benefitShape","label":"Timing weight exponent","basis":"Annual weight year^shape: uniform / linearly later / quadratically later. Source does not provide this timing distribution; it is a major model judgment."},{"key":"discountRate","label":"Reference health discount rate","basis":"3.5% matches MONARCH. Normalize the annual weights to the already-discounted anchor, avoiding a second discount of its total."},{"key":"reinfectionHazard","label":"Annual reinfection hazard approximation","basis":"Central .069 from 4 events/57.9 post-cure person-years in the external trial; 0.02/0.12 scenarios. Treating this short follow-up rate as a sustained hazard is speculative; no retreatment benefit included."},{"key":"excessMortalityHazard","label":"Excess competing mortality hazard","basis":"1/3/6% annually by judgment, additional to general mortality embedded in the reference model, not total mortality."},{"key":"laterCureProbability","label":"Counterfactual eventual cure probability","basis":"20/70/90% among people counted as additional one-year cures; judgment, not the trial control cure rate already subtracted."},{"key":"laterCureYears","label":"Years until counterfactual cure","basis":"5/3/1-year judgment. No incremental health credit thereafter for that fraction. Does not model irreversible disease prevented before later cure."},{"key":"drugCostPerStart","label":"Resource cost per additional DAA start","basis":"$10K/$15K/$25K analyst assumptions, not current net Medi-Cal prices. Start difference 64/82 minus 22/83, scaled by access transfer; do not multiply by cure success again. This is a conservative gross-package resource sensitivity before funding displacement, not gift-attributable net resource use."},{"key":"donorDrugShare","label":"Donor fraction of medication costs","basis":"Zero central conditional on public/assistance payment, unverified locally. Setting one charges full drug resources without changing health."},{"key":"harmQalysPerEnrollee","label":"Additional implementation harm","basis":"Zero central; explicit stress parameter for adverse effects and model omissions, not a measured harm estimate."}],"sources":[{"key":"provider","title":"SFCHC Wellness Clinic","url":"https://www.sfcommunityhealth.org/wellness-clinic","date":"Undated; retrieved 7 September 2026","note":"Local HCV testing, counseling and treatment; FQHC/public support. No priced expansion.","publisher":"San Francisco Community Health Center","published":"Undated","retrieved":"2026-09-07","sourceType":"Provider disclosure"},{"key":"entity","title":"SFCHC donation identity","url":"https://www.sfcommunityhealth.org/donate","date":"Undated; retrieved 7 September 2026","note":"Asian and Pacific Islander Wellness Center, Inc.; EIN 94-3096109. General giving route, not a restricted HCV offer.","publisher":"San Francisco Community Health Center","published":"Undated","retrieved":"2026-09-07","sourceType":"Provider disclosure"},{"key":"trial","title":"Eckhardt et al.: accessible HCV care randomized trial","url":"https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2790054","date":"14 March 2022; retrieved 7 September 2026","note":"Integrated care compared with referral already containing navigation; SVR12 is 12 weeks after treatment, measured within one year of enrollment.","publisher":"JAMA Internal Medicine","published":"14 March 2022","retrieved":"2026-09-07","sourceType":"Primary research"},{"key":"cost","title":"Kapadia et al.: co-located HCV microcosting","url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC9836210/","date":"7 October 2022; retrieved 7 September 2026","note":"2020 USD; 84 cost enrollees versus 82 eligible efficacy participants; excludes drugs and usual-care cost comparison.","publisher":"Drug and Alcohol Dependence Reports","published":"7 October 2022","retrieved":"2026-09-07","sourceType":"Primary research"},{"key":"health","title":"McEwan et al.: incremental SVR and lifetime QALYs","url":"https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0117334","date":"2015; retrieved 7 September 2026","note":"UK modeled lifetime benefit with 3.5% discounting, not current SF observed health or a reinfection/catch-up-treatment model.","publisher":"PLOS ONE","published":"2015","retrieved":"2026-09-07","sourceType":"Primary research"},{"key":"local-contract","title":"SFDPH FY2025–26 CHEP program objectives","url":"https://media.api.sf.gov/documents/Final_FY25-26_CHEP_Prog._Objectives_01.06.20251.pdf","date":"FY2025–26 filename; retrieved 7 September 2026","note":"Page 10 HCV Treatment & Navigation contract 1000036520: targets, not outcomes. Stale internal headers; SVR4 not SVR12. No verified corresponding dollar line.","publisher":"San Francisco Department of Public Health","published":"FY2025–26 filename","retrieved":"2026-09-07","sourceType":"Public contract objectives"},{"key":"navigation","title":"CTN-0064 randomized HCV care facilitation trial","url":"https://academic.oup.com/ofid/article/8/8/ofab334/6310155","publisher":"Open Forum Infectious Diseases","published":"2021","retrieved":"2026-09-07","sourceType":"Primary research","note":"Small secondary cure outcome: 6/41 versus 5/53 among RNA-positive people; not the integrated-care trial."}],"evaluatedScenarios":[{"costPerEnrollee2020":6035,"startup2020":4677,"downtime2020":3030,"plannedEnrollees":100,"discountRate":0.035,"horizonYears":20,"donorDrugShare":0,"harmQalysPerEnrollee":0,"name":"Optimistic 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