{"version":"sf-hya-medication-access-cea-v1","reviewedAt":"2026-09-07","organization":"Homeless Youth Alliance","program":"Supported buprenorphine initiation and retention","confidence":"very-low","denominator":"10 incremental quality-adjusted life years","amountSemantics":"modeled marginal donor expenditure, not a verified funding offer","formula":"10 * costPerSupportedInitiation / (additionality * coveredYears * untreatedAnnualMortality * (1 - mortalityHazardRatio) * transferRetention * qalysPerDeath)","scope":"HYA-supported access to an on-site collaborative clinic; no attribution of all prescriber, pharmacy or public services to HYA","anchors":{"sharedAnnualProposedUsd":5111593,"sharedAnnualServiceHours":18300,"publishedSharedHourlyUsd":279.32,"agreementId":"1000037481","agreementStatus":"May 2026 proposal; subject to budget finalization, not proof of execution","sfMedicationRetention":{"months":[1,3,6,9,12],"fractions":[0.37,0.27,0.27,0.26,0.18]},"externalUntreatedMortalityPer100PersonYears":5,"externalAdjustedMortalityHazardRatio":0.63},"scenarios":[{"name":"Optimistic positive","costPerSupportedInitiation":1000,"additionality":0.75,"coveredYears":0.5,"untreatedAnnualMortality":0.08,"mortalityHazardRatio":0.46,"transferRetention":1,"qalysPerDeath":8},{"name":"Central analyst estimate","costPerSupportedInitiation":2793.2,"additionality":0.5,"coveredYears":0.25,"untreatedAnnualMortality":0.05,"mortalityHazardRatio":0.63,"transferRetention":0.5,"qalysPerDeath":5.1541},{"name":"Pessimistic positive","costPerSupportedInitiation":6000,"additionality":0.25,"coveredYears":0.08333333333333333,"untreatedAnnualMortality":0.02,"mortalityHazardRatio":0.87,"transferRetention":0.25,"qalysPerDeath":3}],"judgments":[{"key":"costPerSupportedInitiation","label":"Donor cost per supported initiation","basis":"Ten assumed service hours * $279.32 shared-service budget benchmark = $2,793.20. The broad SFAF bundle is not an HYA-specific marginal rate. Includes failed engagement effort allocated over initiations; not ten hours of prescriber time."},{"key":"additionality","label":"Additional uptake and funding","basis":"50% jointly allows alternative treatment access and replacement of existing finance. Conditional on prescriber and pharmacy capacity."},{"key":"coveredYears","label":"Medication-covered years per initiation","basis":"Three months is a judgment informed loosely by intermittent SF retention, not an area calculated from sparse observations. Active prescriptions do not prove adherence. No extra completion multiplier is applied."},{"key":"untreatedAnnualMortality","label":"Untreated annual mortality rate","basis":"5% is transferred from an older Massachusetts adult overdose-survivor cohort; youth baseline risk may differ substantially."},{"key":"mortalityHazardRatio","label":"External mortality association","basis":"0.63 is adjusted observational association, not randomized causal effect. The source's primary exposure includes the month after discontinuation; using it for covered time is an approximation."},{"key":"transferRetention","label":"Causal and population transfer","basis":"50% jointly discounts residual confounding and transfer to HYA-supported recipients. It is not a measured correction."},{"key":"qalysPerDeath","label":"Healthy survival per averted death","basis":"5.1541 reuses the SFAF illustration: utility 0.70, annual hazard 0.08, 15-year horizon and 3% discount. Consistency does not validate transfer to youth; this is not a joint longitudinal medication/survival model."}],"nullBoundary":"No additional medication-covered time or no transferred mortality benefit means no finite price. Positive scenarios are not confidence intervals. Discontinuation risk, adverse effects and repeated recipients require a fuller signed longitudinal model.","fundingRoom":{"verifiedUsd":null,"status":"unverified","nextEvidence":"A priced additional HYA plan, actual fills and coverage days, alternative uptake, clinician capacity and public-versus-private cost allocation; no contact has been made."},"overlapBoundary":"HYA, GLIDE and HRTC are named subcontractors in the May 2026 proposed SFAF agreement. Prime-only ledgers miss subcontract exposure. This is distinct from the historical $250K/26,016-dose anchor, with no verified supersession crosswalk. Do not add this mortality estimate to full SFAF naloxone benefits for overlapping people.","excluded":["Naloxone rescues","Nonfatal morbidity and quality-of-life gains during treatment","Housing, employment and family benefits","Publicly financed medication and prescriber costs","Healthcare savings"],"sources":[{"publisher":"SF collaborative syringe-access services","title":"March 2025 service schedule","url":"https://media.api.sf.gov/documents/2025_SAC_SCHEDULE_1.pdf","published":"2025-03","retrieved":"2026-09-07","sourceType":"HYA-site Street Medicine and buprenorphine service identity, not initiation outcomes"},{"publisher":"SF Health Commission","title":"Proposed SFAF agreement 1000037481","url":"https://media.api.sf.gov/documents/SFAF_-_1000037481_-_HC_Memo_May_2026.cleaned.pdf","published":"2026-05-04","retrieved":"2026-09-07","sourceType":"Shared proposed service-cost benchmark and named subcontractors; not paid grants"},{"publisher":"Carter, Zevin and Lum","title":"Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco","url":"https://link.springer.com/article/10.1186/s13722-019-0149-1","published":"2019-05-06","retrieved":"2026-09-07","sourceType":"Uncontrolled 95-person SF cohort; medication retention differs from adherence"},{"publisher":"Larochelle et al., Annals of Internal Medicine","title":"Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality","url":"https://www.mcstap.com/docs/Larochelle%20Annals%202018OF.pdf","published":"2018-06-19","retrieved":"2026-09-07","sourceType":"Observational mortality association; excludes deaths in first 30 days after index overdose"},{"publisher":"Market for Impact","title":"Versioned survival illustration and original cohort/utility sources","url":"https://ai.rhyslindmark.com/donate/api/sf-naloxone-model","published":"2026-09-07","retrieved":"2026-09-07","sourceType":"Internal analyst assumption provenance, not independent evidence"}],"evaluatedScenarios":[{"name":"Optimistic positive","costPerSupportedInitiation":1000,"additionality":0.75,"coveredYears":0.5,"untreatedAnnualMortality":0.08,"mortalityHazardRatio":0.46,"transferRetention":1,"qalysPerDeath":8,"deathsPreventedPerSupportedInitiation":0.0162,"qalysPerSupportedInitiation":0.1296,"supportedInitiations":100,"additionalQalys":12.959999999999999,"costPerTenQalys":77160.49382716049},{"name":"Central analyst estimate","costPerSupportedInitiation":2793.2,"additionality":0.5,"coveredYears":0.25,"untreatedAnnualMortality":0.05,"mortalityHazardRatio":0.63,"transferRetention":0.5,"qalysPerDeath":5.1541,"deathsPreventedPerSupportedInitiation":0.00115625,"qalysPerSupportedInitiation":0.005959428124999999,"supportedInitiations":35.80123156236575,"additionalQalys":0.2133548662824001,"costPerTenQalys":4687026.91166361},{"name":"Pessimistic positive","costPerSupportedInitiation":6000,"additionality":0.25,"coveredYears":0.08333333333333333,"untreatedAnnualMortality":0.02,"mortalityHazardRatio":0.87,"transferRetention":0.25,"qalysPerDeath":3,"deathsPreventedPerSupportedInitiation":0.000013541666666666666,"qalysPerSupportedInitiation":0.000040625,"supportedInitiations":16.666666666666668,"additionalQalys":0.0006770833333333334,"costPerTenQalys":1476923076.923077}]}