{"version":"sf-healthright-moud-cea-v1","reviewedAt":"2026-09-07","organization":"HealthRIGHT 360","program":"Proposed additional nurse-led medication access","denominator":"10 incremental QALYs","confidence":"very-low","scope":"One hypothetical two-year nurse-led outpatient access expansion at ICC; not all HR360 services or a verified funding offer.","costPerspective":"Donor cash for a full clinical capacity package. Incremental pharmacy costs are separately displayed as resources; central donor pharmacy share is zero only under an explicit public-payment assumption, not verified reimbursement. No cost offsets deducted.","scenarios":[{"firstYearCost":238888,"secondYearCost":229676,"costMultiplier":0.8,"clinicPatients":28587.666666666668,"medicationYearsPer10000":16.4,"accessTransfer":1,"fundingAdditionality":1,"buprenorphineShare":1,"mortalityOut":0.05,"mortalityIn":0.015,"causalRetention":0.8,"extraDeaths":0,"drugCostPerMedicationYear":1000,"donorDrugShare":0,"benefitDelayYears":1,"utility":0.8,"annualHazard":0.055,"horizonYears":20,"discountRate":0.03,"name":"Optimistic positive","nonfatalUtilityGain":0.1},{"firstYearCost":238888,"secondYearCost":229676,"costMultiplier":1.25,"clinicPatients":28587.666666666668,"medicationYearsPer10000":8.2,"accessTransfer":0.5,"fundingAdditionality":0.5,"buprenorphineShare":0.9,"mortalityOut":0.0095,"mortalityIn":0.0043,"causalRetention":0.5,"extraDeaths":0,"drugCostPerMedicationYear":1000,"donorDrugShare":0,"benefitDelayYears":1,"utility":0.7,"annualHazard":0.08,"horizonYears":15,"discountRate":0.03,"name":"Central analyst estimate","nonfatalUtilityGain":0.03},{"firstYearCost":238888,"secondYearCost":229676,"costMultiplier":1.6,"clinicPatients":28587.666666666668,"medicationYearsPer10000":5.4,"accessTransfer":0.2,"fundingAdditionality":0.25,"buprenorphineShare":0.7,"mortalityOut":0.008,"mortalityIn":0.006,"causalRetention":0.25,"extraDeaths":0,"drugCostPerMedicationYear":1000,"donorDrugShare":0,"benefitDelayYears":1,"utility":0.6,"annualHazard":0.15,"horizonYears":10,"discountRate":0.03,"name":"Pessimistic positive","nonfatalUtilityGain":0}],"assumptions":[{"key":"costMultiplier","label":"Local/current capacity-cost factor","basis":"1.25 is a judgmental uplift to 2023 national clinical resource costs, not a measured SF quote or inflation series."},{"key":"clinicPatients","label":"Two-year primary-care population","basis":"171526 / 6 intervention clinics is a trial-scale reference, not ICC's patient count. The 75 monthly treated-patient costing assumption is a different denominator."},{"key":"medicationYearsPer10000","label":"Added medication-years per 10,000 over TWO years","basis":"Central 8.2 from PROUD adjusted trial result; optimistic 16.4 is a speculative doubling, pessimistic 5.4 is its one-sided lower bound. Cases are not confidence intervals."},{"key":"accessTransfer","label":"Transfer of trial access effect","basis":"Further expansion at an existing integrated clinic may do less than introducing a nurse model. This includes alternative treatment displaced; do not discount access twice."},{"key":"fundingAdditionality","label":"Funding additionality","basis":"Probability-equivalent share of the added capacity not supplied by existing public/private funding. Separate from patient-level access transfer."},{"key":"buprenorphineShare","label":"Buprenorphine share of extra medication time","basis":"Judgment: no current ICC drug mix observed. Remaining naltrexone time receives no mortality credit, not a claim of no benefit."},{"key":"mortalityOut","label":"Out-of-treatment mortality per person-year","basis":"Central 0.0095 is an older pooled cohort calibration; not measured contemporary SF risk. Higher-risk optimistic case is a judgment."},{"key":"mortalityIn","label":"In-treatment mortality per person-year","basis":"Central 0.0043 from the same cohort synthesis; selection/confounding prevent causal interpretation."},{"key":"causalRetention","label":"Causal/transport retention of mortality difference","basis":"Central 50% is an explicit judgment, not an estimated confidence adjustment. No additional overdose-specific benefit is added to all-cause survival."},{"key":"utility","label":"Survivor health utility","basis":"Judgmental shared mortality-model value, not a treatment-induced utility gain."},{"key":"annualHazard","label":"Post-prevented-death annual hazard","basis":"Judgmental conditional survival trajectory after the avoided acute death, not lifetime treatment efficacy."},{"key":"horizonYears","label":"Post-event survival horizon","basis":"15 years central; future survival discounted at 3% annually. No indefinite medication protection assumed."},{"key":"nonfatalUtilityGain","label":"Additional nonfatal utility while covered","basis":"Analyst best guess 0.03, not a measured local gain or a published utility level. Optimistic 0.10 and pessimistic zero; apply only during added buprenorphine time, not indefinitely."}],"nullBoundary":"Zero additional coverage or full funding substitution gives zero benefit absent extra harm. With coverage, zero mortality benefit and zero nonfatal utility gain together produce zero health benefit. Greater in-treatment mortality or extra cessation-related deaths can produce harm. The pooled out-of-treatment rate already includes cessation periods; extra deaths are a stress test beyond that calibration, not an estimated additive penalty.","overlap":"Do not add these benefits to HYA access or SFAF/DOPE rescue benefits for the same person-time and avoided deaths. This rare-event approximation is for one two-year tranche; repeated tranches need a person-level survival model, not fresh independent lifetime credit every year.","sources":[{"publisher":"HealthRIGHT 360","title":"Integrated Care Center","url":"https://www.healthright360.org/program/integrated-care-center-2/","published":"Undated; current service page","retrieved":"2026-09-07","sourceType":"Local provider disclosure"},{"publisher":"JAMA Internal Medicine","title":"PROUD cluster randomized clinical trial","url":"https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2811096","published":"2023","retrieved":"2026-09-07","sourceType":"Primary cluster randomized trial"},{"publisher":"Drug and Alcohol Dependence","title":"PROUD treatment-duration secondary analysis","url":"https://pubmed.ncbi.nlm.nih.gov/39550823/","published":"2024","retrieved":"2026-09-07","sourceType":"Primary trial secondary analysis"},{"publisher":"American Journal of Managed Care","title":"Cost of implementing and sustaining the Massachusetts model","url":"https://www.ajmc.com/view/the-cost-of-implementing-and-sustaining-the-massachusetts-model","published":"2026-04-22","retrieved":"2026-09-07","sourceType":"Primary microcosting study; 2023 USD"},{"publisher":"BMJ","title":"Mortality during and after opioid substitution treatment","url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC5421454/","published":"2017-04-26","retrieved":"2026-09-07","sourceType":"Original meta-analysis of observational cohorts"}],"evaluatedScenarios":[{"firstYearCost":238888,"secondYearCost":229676,"costMultiplier":0.8,"clinicPatients":28587.666666666668,"medicationYearsPer10000":16.4,"accessTransfer":1,"fundingAdditionality":1,"buprenorphineShare":1,"mortalityOut":0.05,"mortalityIn":0.015,"causalRetention":0.8,"extraDeaths":0,"drugCostPerMedicationYear":1000,"donorDrugShare":0,"benefitDelayYears":1,"utility":0.8,"annualHazard":0.055,"horizonYears":20,"discountRate":0.03,"name":"Optimistic positive","nonfatalUtilityGain":0.1,"trialMedicationYears":46.88377333333333,"localMedicationYears":46.88377333333333,"additionalBuprenorphineYears":46.88377333333333,"deathsPrevented":1.3127456533333335,"survivalQalys":7.717208191824503,"presentQalysPerDeath":7.492435137693692,"mortalityQalys":9.83566165988933,"nonfatalQalys":4.551822653721683,"netQalys":14.387484313611013,"capacityCost":374851.2,"incrementalDrugResourceCost":46883.77333333333,"donorCost":374851.2,"resourceCost":421734.9733333333,"costPerQaly":26053.978015140492,"costPerTenQalys":260539.7801514049,"resourceCostPerTenQalys":293126.2784657626,"qalysPer100k":3.838185475626332,"maximumDonorCostFor100k":143874.84313611014,"requiredAdditionalBupYearsFor100k":122.15087996934966},{"firstYearCost":238888,"secondYearCost":229676,"costMultiplier":1.25,"clinicPatients":28587.666666666668,"medicationYearsPer10000":8.2,"accessTransfer":0.5,"fundingAdditionality":0.5,"buprenorphineShare":0.9,"mortalityOut":0.0095,"mortalityIn":0.0043,"causalRetention":0.5,"extraDeaths":0,"drugCostPerMedicationYear":1000,"donorDrugShare":0,"benefitDelayYears":1,"utility":0.7,"annualHazard":0.08,"horizonYears":15,"discountRate":0.03,"name":"Central analyst estimate","nonfatalUtilityGain":0.03,"trialMedicationYears":23.441886666666665,"localMedicationYears":11.720943333333333,"additionalBuprenorphineYears":5.274424499999999,"deathsPrevented":0.013713503699999997,"survivalQalys":5.154058058915759,"presentQalysPerDeath":5.003939863025009,"mortalityQalys":0.06862154782617094,"nonfatalQalys":0.1536240145631068,"netQalys":0.22224556238927773,"capacityCost":585705,"incrementalDrugResourceCost":11720.943333333333,"donorCost":585705,"resourceCost":597425.9433333334,"costPerQaly":2635395.702408218,"costPerTenQalys":26353957.02408218,"resourceCostPerTenQalys":26881344.082223002,"qalysPer100k":0.037944965876896684,"maximumDonorCostFor100k":2222.455623892777,"requiredAdditionalBupYearsFor100k":1390.0195659976614},{"firstYearCost":238888,"secondYearCost":229676,"costMultiplier":1.6,"clinicPatients":28587.666666666668,"medicationYearsPer10000":5.4,"accessTransfer":0.2,"fundingAdditionality":0.25,"buprenorphineShare":0.7,"mortalityOut":0.008,"mortalityIn":0.006,"causalRetention":0.25,"extraDeaths":0,"drugCostPerMedicationYear":1000,"donorDrugShare":0,"benefitDelayYears":1,"utility":0.6,"annualHazard":0.15,"horizonYears":10,"discountRate":0.03,"name":"Pessimistic positive","nonfatalUtilityGain":0,"trialMedicationYears":15.437340000000003,"localMedicationYears":3.0874680000000008,"additionalBuprenorphineYears":0.5403069000000001,"deathsPrevented":0.00027015345000000007,"survivalQalys":2.7867312385446508,"presentQalysPerDeath":2.7055643092666513,"mortalityQalys":0.000730917532345253,"nonfatalQalys":0,"netQalys":0.000730917532345253,"capacityCost":749702.4,"incrementalDrugResourceCost":3087.4680000000008,"donorCost":749702.4,"resourceCost":752789.868,"costPerQaly":1025700392.7576796,"costPerTenQalys":10257003927.576796,"resourceCostPerTenQalys":10299244917.337889,"qalysPer100k":0.00009749435674012155,"maximumDonorCostFor100k":7.30917532345253,"requiredAdditionalBupYearsFor100k":55419.299953968446}]}