GiveBetter x California

Operation Access

Coordinating donated outpatient surgery and specialty care

Research time: ~8 min on GPT-6 Astra Light + ~14 min on GPT-6 Astra Medium + ~14 min on GPT-6.1 Sol
  • Research — reviewed programs, finances and impact evidence.
  • Source audit — checked claims, assumptions and calculations.

Updated: 2026-10-02

Donate

Summary

What do they do? Operation Access connects uninsured Californians with donated surgery and specialty care. Staff coordinate referrals, appointments, language support and practical help while volunteer clinicians and facilities provide treatment. The network provides outpatient treatment across ten specialties, from cataracts and hernias to gynecological and orthopedic conditions.

Why we’re interested in this organization:

  • Its clinical network turns coordination spending into tangible completed care for patients facing access barriers.

  • Current eligibility requires Northern California or Central Valley residence, giving a clear California benefit boundary.

  • Public budgets, annual reporting and audited accounts support a concrete cost and activity assessment.

Our main reservations:

  • Reported encounters and people are documented, but within-specialty diagnoses, transferable health gains and net household cash effects remain judgments.

  • A former public funder declined renewal after questioning expansion impact and cost; replacement donations and substantial year-end reserves complicate the funding-gap story.

  • No current additional-slot offer is verified. Fast alternative care, limited capacity and procedural harms can erase the conditional positive estimate.

What do you get for your dollar? $332K per DALY in California. DALY is our one-year comparison unit. QALY-based health gains and income-welfare equivalents retain their original assumptions; they are not measured clinical DALYs. Conditional additional California specialty-care services, including net household resource changes. Cash-like organization costs include support and fundraising; donated clinical opportunity costs are not measured societal costs..

1529 specialty encounters /1130 reported unduplicated people in2025 across ten specialties. Services are not unique surgeries; observed mix informs a partial health/resource portfolio.

1. What do they do?

Operation Access coordinates volunteer outpatient specialty care for low-income uninsured people in Northern California and the Central Valley. The actual 501(c)(3) recipient is Ambulatory Surgery Access Coalition dba Operation Access, EIN 94-3180356; its donation page names that tax identity. The estimate concerns additional care supported by ordinary donations, rather than a quoted price for an earmarked operation. Staff handle referral matching, language/travel support and follow-up. The audit also discloses fiscal sponsorship of Western Farm Workers Association in Yuba City, without a separate amount in the material reviewed. We retain the whole financial denominator and add no unverified sponsorship benefit.

2. Monitoring and information sharing

The 2025 Form 990, page 2, reports 1,529 services to 1,130 unduplicated residents. The annual report splits those services across ten specialties, records 627 people who volunteered that year, and reports a 72-day median wait to a specialty appointment—not necessarily definitive treatment or days of delay prevented. Its approximately 1,000-person network is a roster, not the same volunteer count. Services rose 15.8% from 2024; reported referrals rose 28%, but neither gives available slots for a new donor. Patient-reported improvement lacks an untreated comparator and cannot become QALYs directly.

Our model uses the old repeat-service priors with 1,529/1,130 across a disjoint diagnosis ledger. Applying that aggregate ratio uniformly to marginal cases is a judgment. Diagnosis-specific people, baseline severity, treatment completion, validated utility, adverse events and alternative-care waits are still needed. An annual-report story requiring two operations illustrates why a procedure is not automatically a new beneficiary. The 1,130 count is verified as an original filed organizational report, not as independently audited patient-level data. Using one aggregate ratio and mutually exclusive diagnosis allocations enforces arithmetic nonoverlap, but does not demonstrate that the marginal clinical mix has the same repeat-care pattern.

3. Qualitative assessment

Operation Access makes a clinically plausible connection between scarce donated specialty capacity and patients who face financial or coverage barriers. The importance of a service depends on the diagnosis, severity, alternative treatment and wait it replaces—not simply whether surgery occurs. We assess symptom relief and preventive care separately, use finite horizons, and retain procedure harms. Reported satisfaction or a larger number of encounters does not by itself demonstrate an incremental health effect.

The cataract randomized economic evaluation found an integrated first-year incremental gain of 0.06 QALYs for expedited treatment versus ordinary waiting in women over 70. We use a 0.75 transport judgment and stop after that first-year endpoint: it is not a permanent annual utility gain. Existing procedural harm remains a separate conservative assumption, not an additional risk measured in that trial. OA's mixed-age uninsured cohort and its eye-case selection may differ substantially. Routine later treatment is the comparator, not lifetime absence of care.

The Medicine or Surgery trial supports earlier relief for selected women with refractory abnormal uterine bleeding. Its SF-36 improvement does not directly establish QALYs. We now use a 0.07 utility judgment rather than 0.10 and retain zero and 0.10 sensitivity cases; later comparator surgery limits the duration of advantage. For uncomplicated symptomatic gallstones, C-GALL found no clear overall quality-of-life superiority over conservative treatment during 18 months. That selected subgroup receives zero central gross benefit while surgical harms remain; urgent or complicated cases are not covered by that conclusion.

Minimally symptomatic hernia evidence and sham-controlled degenerative-knee evidence challenge indiscriminate treatment value. Positive-FIT follow-up survival evidence is observational and vulnerable to selection into colonoscopy. The other diagnosis-specific utility, completion, catch-up and mortality parameters remain externally informed judgments, not newly validated local effects. We would place more weight on OA diagnosis-level follow-up with a credible alternative-care comparison than on added numerical precision.

4. What do you get for your dollar?

GiveBetter estimates approximately $332K per DALY for this conditional California portfolio, including health and net household resources. The mechanism is concrete: staff coordinate donated appointments and operations, interpretation and practical support; selected care relieves symptoms or prevents later disease. Our estimate is not a verified offer of additional treatment slots.

Original 2023, 2024 and 2025 returns show total expenses of $2,658,742, $2,678,152 and $2,261,505, averaging $2,532,799.67. Matching 2025 expense to its 1,529 specialty encounters gives approximately $1,479 per service including organizational support and fundraising. This is an average cash-like coordination cost, not a measured marginal operation price. We do not treat an appointment as a distinct surgery or remove overhead from donor cost.

Under the declared 0.3 funding-additionality judgment, each $1,000 supports about 0.203 additional service-equivalents or 0.150 patient/household-equivalents. That corresponds to roughly $4,930 per additional encounter and $6,671 per patient-equivalent. We use the observed specialty mix and 1,529/1,130 encounters per unique person, while assuming that ratio applies within each diagnosis. Neither the marginal mix nor one affected household per patient is measured. A 100-service capacity cap is a diagnostic assumption, not a provider commitment.

For the model's normalized donor budget, gross clinical benefit is 0.36 health years and procedural harm is 0.05430, leaving 0.30 health years. First-year household resource effects subtract 0.00092 equivalent years; the combined denominator is 0.30148. Health and consumption are distinct contributions: we do not add a survivor's ordinary lifetime earnings or call income-equivalent years measured clinical QALYs. The income comparison method values a proportional net consumption change using a logarithmic conversion.

The household branch combines savings, paid work and extra cash costs before applying that conversion, using a $30,000 annual household-consumption reference. Selected symptomatic conditions receive a declared $60 net first-year medicine-saving amount, adjusted for treatment success; it is assumed already net of alternative-care catch-up and payer offsets, not twelve months of measured purchase avoidance. A native recovery story informs the direction of the cyst pathway, but five net recovered paid days, $100 after-tax daily pay and 50% wage-loss incidence are judgments. Other pathways receive no assigned earnings gain because its magnitude is unresolved, not proven absent.

The carpal-tunnel economic trial separates improved clinical success from uncertain utility and recovery-related absence. We model a one-off 0.3-day paid-work loss for that pathway as a transport judgment, not its shadow productivity cost. All households incur a $25-per-service net travel/appointment cash assumption after assistance and avoided alternative visits. Each household's combined first-year amount is discounted at delivery delay plus half a year; clinical survival and catch-up tails are not reused for recurring wages. Costs can outweigh these modest savings, as in the center.

The previous estimate was $188K, retained as a historical comparison. The revision uses matched-year expenses, observed specialty allocation, a finite cataract endpoint, lower bleeding-utility mapping, zero uncomplicated-gallstone gross benefit, and a revised donation-response judgment. Keeping the old 0.5 funding response produces about $199K: the new price is not solely a clinical evidence downgrade. Funding response 0.1/0.8 gives about $995K/$124K; five added slots gives $1.3M; rapid alternative care gives $4.2M. These are judgment tests, not confidence limits.

The audit records $22,876,888 expenses including $20,530,000 waived clinical charges and $89,922 other donated services. Removing those leaves $2,256,966; $4,539 donated materials explains the remaining tax-expense difference. Waived charges are neither household cash savings nor measured opportunity costs. A complete societal estimate needs the actual additional clinician, facility and public resources. Null health, unknown income, complete replacement and signed harm are evaluated separately rather than converted into favorable prices.

Model, assumptions and sensitivity

2025 total same-entity tax expense/service forecasts next-year coordination costs, including support and fundraising; donated clinical opportunity costs excluded. Donation paid at time zero.

Direct California residents; share1 is assumed retained through the finite modeled effects.

donor cost / (credited California clinical health years + net first-year household-consumption-equivalent years). Funding scales added encounters once; overlap excludes only positive individual clinical credits, not signed harms.

Matched2025 expenses
2261505 USD (observed). Original same-entity total expense, not waived hospital charges [990-2025]
Observed specialty counts
"{\"gi\":575,\"general\":201,\"gyne\":168,\"ortho\":158,\"head_neck\":127,\"urology\":101,\"derm\":80,\"vascular\":58,\"eye\":45,\"other\":16}" service encounters (observed). Native2025 chart; counts sum1529, not diagnoses [report]
Observed unduplicated patients
1130 people (observed). Organizational reported count; marginal within-path ratio remains judgment [990-2025]
Funding additionality
0.3 fraction (judgment). Dated reserves and replacement fundraising inform a subjective prior, not a measured marginal effect [audit] [budget] [report]
Household resource parameters
"{\"gift\":100000,\"funding\":0.3,\"cap\":100,\"costPerService\":1479.0745585349903,\"baselineConsumption\":30000,\"medicationAnnual\":60,\"cystNetRecoveredPaidDays\":5,\"netPayPerRecoveredDay\":100,\"paidWorkShare\":0.5,\"ctsExtraLostPaidDays\":0.3,\"patientNetCashPerService\":25,\"overlap\":0,\"resourcesScale\":1,\"healthIndependentHarm\":0,\"incomeIndependentHarm\":0,\"healthNull\":false,\"incomeNull\":false,\"healthZero\":false,\"incomeZero\":false}" conditional first-year inputs (judgment). Net amounts after alternativecare/payer offsets, not observed household incomes; independent harm inputs are gift-date equivalent-year diagnostics [report] [cts-econ] [budget] [income-method]
Foundation clinical vector
"{\"gift_usd\":100000,\"funding_additionality\":0.3,\"max_additional_services\":100,\"discount\":0.03,\"bay_share\":0.6,\"sf_share\":0.08,\"independent_harm_q\":0,\"outside_support_per_service\":60,\"patient_time_per_service\":100,\"crc_treatment_cost_per_selected\":1500,\"gi_allocation\":0.3760627861347286,\"gi_cash_per_service\":1479.0745585349903,\"gi_clinical_resource_per_service\":2500,\"general_allocation\":0.131458469587966,\"general_cash_per_service\":1479.0745585349903,\"general_clinical_resource_per_service\":5500,\"gyne_allocation\":0.10987573577501634,\"gyne_cash_per_service\":1479.0745585349903,\"gyne_clinical_resource_per_service\":4500,\"ortho_allocation\":0.10333551340745585,\"ortho_cash_per_service\":1479.0745585349903,\"ortho_clinical_resource_per_service\":5000,\"head_neck_allocation\":0.08306082406801832,\"head_neck_cash_per_service\":1479.0745585349903,\"head_neck_clinical_resource_per_service\":3500,\"urology_allocation\":0.06605624591236102,\"urology_cash_per_service\":1479.0745585349903,\"urology_clinical_resource_per_service\":4000,\"derm_allocation\":0.052321778940483975,\"derm_cash_per_service\":1479.0745585349903,\"derm_clinical_resource_per_service\":1800,\"vascular_allocation\":0.03793328973185088,\"vascular_cash_per_service\":1479.0745585349903,\"vascular_clinical_resource_per_service\":4500,\"eye_allocation\":0.029431000654022238,\"eye_cash_per_service\":1479.0745585349903,\"eye_clinical_resource_per_service\":2500,\"other_allocation\":0.010464355788096796,\"other_cash_per_service\":1479.0745585349903,\"other_clinical_resource_per_service\":3000,\"eye_selected_fraction\":0.65,\"eye_services_per_person\":1.3530973451327433,\"eye_disjoint_fraction\":1,\"eye_treatment_success\":1,\"eye_utility_gain\":0.04369288612091463,\"eye_catchup_hazard\":0,\"eye_loss_hazard\":0.03,\"eye_mortality_hazard\":0.02,\"eye_horizon_years\":1,\"eye_delay_years\":0.25,\"eye_harm_q_per_person\":0.002,\"hernia_selected_fraction\":0.45,\"hernia_services_per_person\":1.3530973451327433,\"hernia_disjoint_fraction\":1,\"hernia_treatment_success\":0.85,\"hernia_utility_gain\":0.04,\"hernia_catchup_hazard\":0.7,\"hernia_loss_hazard\":0.08,\"hernia_mortality_hazard\":0.02,\"hernia_horizon_years\":3,\"hernia_delay_years\":0.25,\"hernia_harm_q_per_person\":0.004,\"crc_selected_fraction\":0.5,\"crc_services_per_person\":1.3530973451327433,\"crc_disjoint_fraction\":1,\"crc_treatment_linkage\":0.7,\"crc_annual_fatal_hazard_reduction\":0.0006,\"crc_baseline_total_mortality_hazard\":0.025,\"crc_catchup_hazard\":0.5,\"crc_latency_years\":2,\"crc_active_years\":5,\"crc_horizon_years\":10,\"crc_delay_years\":0.25,\"crc_surviving_utility\":0.75,\"crc_harm_q_per_person\":0.001}" finite clinical inputs (judgment). Cataract integrated first-year gain with0.75transport; observed specialty allocations and matched cost replace prior spending mix [cataract] [report] [990-2025]
Pathway gi_symptom_diagnosis (gi)
"{\"id\":\"gi_symptom_diagnosis\",\"category\":\"gi\",\"share\":0.5,\"name\":\"Non-FIT GI investigation → benign treatable dyspepsia/dysphagia management\",\"utility_gain\":0.03,\"treatment_success\":0.4,\"harm_q_per_person\":0.001,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Diagnostic procedure alone earns no cure; treatment linkage is a prior, alternative primary-care therapy remains baseline.\",\"downstream_resource_per_nominal_service\":200}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway general_cyst (general)
"{\"id\":\"general_cyst\",\"category\":\"general\",\"share\":0.225,\"name\":\"Painful cyst/lipoma excision\",\"utility_gain\":0.025,\"treatment_success\":0.85,\"harm_q_per_person\":0.002,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Current OA procedure explicitly listed; utility and symptom-limiting fraction are priors, not cosmetic benefit.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway anorectal (general)
"{\"id\":\"anorectal\",\"category\":\"general\",\"share\":0.12,\"name\":\"Symptomatic haemorrhoid/fissure treatment\",\"utility_gain\":0.05,\"treatment_success\":0.8,\"harm_q_per_person\":0.004,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Historical minor anorectal mix only; assume persistent symptoms despite medical management.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway gallstone (general)
"{\"id\":\"gallstone\",\"category\":\"general\",\"share\":0.065,\"name\":\"Uncomplicated symptomatic gallstone surgery\",\"utility_gain\":0,\"treatment_success\":0.7,\"harm_q_per_person\":0.005,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"C-GALL control includes later surgery; nonsignificant small integrated QALY difference; conservative care may suffice.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [c-gall-full]
Pathway breast_diagnostic (general)
"{\"id\":\"breast_diagnostic\",\"category\":\"general\",\"share\":0.14,\"name\":\"Breast lesion diagnostic assessment and linked benign symptom treatment\",\"utility_gain\":0.01,\"treatment_success\":0.25,\"harm_q_per_person\":0.001,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"No unverified cancer survival gain. Prior only for changed symptom management, not all negative tests.\",\"downstream_resource_per_nominal_service\":200}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway aub (gyne)
"{\"id\":\"aub\",\"category\":\"gyne\",\"share\":0.65,\"name\":\"Refractory abnormal uterine bleeding → definitive outpatient treatment\",\"utility_gain\":0.07,\"treatment_success\":0.8,\"harm_q_per_person\":0.015,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Ms trial supports surgery vs expanded medical care; no hysterectomy-vs-ablation transfer, fertility/recovery losses retained.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [aub]
Pathway pelvic (gyne)
"{\"id\":\"pelvic\",\"category\":\"gyne\",\"share\":0.25,\"name\":\"Symptomatic pelvic prolapse/incontinence treatment\",\"utility_gain\":0.07,\"treatment_success\":0.7,\"harm_q_per_person\":0.01,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Case-mix and utility priors, not confirmed OA frequency; pessary/conservative alternatives retained.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway gyne_diagnostic (gyne)
"{\"id\":\"gyne_diagnostic\",\"category\":\"gyne\",\"share\":0.1,\"name\":\"Gynaecologic diagnostic workup → nonmalignant symptom management\",\"utility_gain\":0.02,\"treatment_success\":0.3,\"harm_q_per_person\":0.002,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Diagnosis without management has zero benefit through linkage; no automatic cancer cure.\",\"downstream_resource_per_nominal_service\":200}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway cts (ortho)
"{\"id\":\"cts\",\"category\":\"ortho\",\"share\":0.35,\"name\":\"Carpal tunnel decompression for symptomatic confirmed CTS\",\"utility_gain\":0.03,\"treatment_success\":0.8,\"harm_q_per_person\":0.004,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Primary economic trial .04 at12months is nonsignificant point utility, not integrated QALY. .03 here is an independent transfer prior.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway foot_tendon (ortho)
"{\"id\":\"foot_tendon\",\"category\":\"ortho\",\"share\":0.45,\"name\":\"Painful foot deformity / tendon or trigger-finger intervention\",\"utility_gain\":0.06,\"treatment_success\":0.75,\"harm_q_per_person\":0.005,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Named mechanical function hypothesis; OA ortho/podiatry totals not diagnosis frequencies. Utilities are priors. Torkki hallux-valgus RCT11368700 supports the painful-bunion subset only; two-year catch-up12807332 rules out lifelong timing gain.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway degenerative_knee (ortho)
"{\"id\":\"degenerative_knee\",\"category\":\"ortho\",\"share\":0.2,\"name\":\"Degenerative knee arthroscopy without acute mechanical indication\",\"utility_gain\":0,\"treatment_success\":0.8,\"harm_q_per_person\":0.006,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Null benefit central, not assume all orthopaedic surgery is useful; harm retained.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway nasal (head_neck)
"{\"id\":\"nasal\",\"category\":\"head_neck\",\"share\":0.7,\"name\":\"Septal nasal obstruction surgery versus nasal medical therapy\",\"utility_gain\":0.04,\"treatment_success\":0.8,\"harm_q_per_person\":0.004,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"NAIROS validates symptom mechanism, not SNOT22-to-QALY conversion or universal ENT benefit.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway ear (head_neck)
"{\"id\":\"ear\",\"category\":\"head_neck\",\"share\":0.3,\"name\":\"Conductive ear disease treatment\",\"utility_gain\":0.03,\"treatment_success\":0.7,\"harm_q_per_person\":0.003,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Clinical indication and utility priors; no all-ENT survival credit.\",\"downstream_resource_per_nominal_service\":200}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway bph (urology)
"{\"id\":\"bph\",\"category\":\"urology\",\"share\":0.45,\"name\":\"Bothersome BPH/outlet obstruction treatment\",\"utility_gain\":0.06,\"treatment_success\":0.8,\"harm_q_per_person\":0.006,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"TURP vs watchful waiting trial supports symptom relief, not current OA frequency; modern medication baseline matters.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway stone (urology)
"{\"id\":\"stone\",\"category\":\"urology\",\"share\":0.35,\"name\":\"Symptomatic urinary stone treatment\",\"utility_gain\":0.05,\"treatment_success\":0.75,\"harm_q_per_person\":0.005,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"No prophylactic life-saving claim for asymptomatic stones; spontaneous passage and medical treatment in comparator.\",\"downstream_resource_per_nominal_service\":200}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway scrotal (urology)
"{\"id\":\"scrotal\",\"category\":\"urology\",\"share\":0.2,\"name\":\"Symptomatic benign scrotal/hydrocele treatment\",\"utility_gain\":0.025,\"treatment_success\":0.75,\"harm_q_per_person\":0.004,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Indication and finite utility priors; no infertility or cancer mortality award.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway derm_cyst (derm)
"{\"id\":\"derm_cyst\",\"category\":\"derm\",\"share\":0.8,\"name\":\"Symptomatic benign skin cyst/lesion treatment\",\"utility_gain\":0.02,\"treatment_success\":0.8,\"harm_q_per_person\":0.002,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Current OA cyst/lipoma service; disjoint allocation from general surgery required.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway skin_lesion (derm)
"{\"id\":\"skin_lesion\",\"category\":\"derm\",\"share\":0.2,\"name\":\"Localized skin lesion diagnosis and treatment\",\"utility_gain\":0.03,\"treatment_success\":0.6,\"harm_q_per_person\":0.003,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Symptom/functional relief only; no melanoma mortality extrapolation.\",\"downstream_resource_per_nominal_service\":200}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway veins (vascular)
"{\"id\":\"veins\",\"category\":\"vascular\",\"share\":1,\"name\":\"Symptomatic uncomplicated varicose vein treatment\",\"utility_gain\":0.04,\"treatment_success\":0.8,\"harm_q_per_person\":0.003,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"REACTIV randomized conservative comparator; integrated two-year .054Q not annual gain.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway pterygium (eye)
"{\"id\":\"pterygium\",\"category\":\"eye\",\"share\":0.35,\"name\":\"Symptomatic pterygium treatment\",\"utility_gain\":0.025,\"treatment_success\":0.8,\"harm_q_per_person\":0.003,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Current OA explicitly offered; first-eye cataract cohort excluded; finite symptom/vision utility prior.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Pathway other_assessment (other)
"{\"id\":\"other_assessment\",\"category\":\"other\",\"share\":1,\"name\":\"Specialty assessment without established diagnosis-changing intervention\",\"utility_gain\":0,\"treatment_success\":0,\"harm_q_per_person\":0.0005,\"services_per_person\":1.3530973451327433,\"disjoint_fraction\":1,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"basis\":\"Only2%wholegift allocation; centralzero benefit explicitly due absent disease/intervention evidence, not blanket residual zero for major specialties.\",\"downstream_resource_per_nominal_service\":0}" finite diagnosis parameters (judgment). Within-specialty allocation and utility/transport assumptions; AUB0.07; uncomplicated gallstone0 gross benefit; procedural harms retained [report] [historical]
Central net resource ledger
"[{\"id\":\"gi_symptom_diagnosis\",\"people\":2.818593912011536,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.0015551323563769027,\"incomeEquivalent\":-0.0015551323563769027},{\"id\":\"general_cyst\",\"people\":0.44337707711555396,\"annualMedicationNet\":51,\"annualWorkNet\":212.5,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.001896157261816813,\"burdenEquivalent\":-0.0002424979389053191,\"incomeEquivalent\":0.0016536593229114938},{\"id\":\"anorectal\",\"people\":0.23646777446162875,\"annualMedicationNet\":48,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.00018487867853861294,\"burdenEquivalent\":-0.0001302603091466187,\"incomeEquivalent\":0.000054618369391994245},{\"id\":\"gallstone\",\"people\":0.12808671116671558,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.00007067062342978865,\"incomeEquivalent\":-0.00007067062342978865},{\"id\":\"breast_diagnostic\",\"people\":0.2758790702052336,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.0001522136504641602,\"incomeEquivalent\":-0.0001522136504641602},{\"id\":\"aub\",\"people\":1.0705754963188168,\"annualMedicationNet\":48,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.0008370129227370038,\"burdenEquivalent\":-0.0005897357279772289,\"incomeEquivalent\":0.00024727719475977494},{\"id\":\"pelvic\",\"people\":0.41175980627646785,\"annualMedicationNet\":42,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.0002817151762514792,\"burdenEquivalent\":-0.00022686676023140056,\"incomeEquivalent\":0.00005484841602007867},{\"id\":\"gyne_diagnostic\",\"people\":0.16470392251058716,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.00009087382117263293,\"incomeEquivalent\":-0.00009087382117263293},{\"id\":\"cts\",\"people\":0.5421504115973493,\"annualMedicationNet\":48,\"annualWorkNet\":0,\"annualCtsLoss\":30,\"firstYearExtraCash\":-63.82743362831858,\"flowEquivalent\":0.0004238719288219441,\"burdenEquivalent\":-0.0005637873911573284,\"incomeEquivalent\":-0.00013991546233538434},{\"id\":\"foot_tendon\",\"people\":0.6970505291965922,\"annualMedicationNet\":45,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.000510942570601282,\"burdenEquivalent\":-0.0003840146461466915,\"incomeEquivalent\":0.00012692792445459047},{\"id\":\"degenerative_knee\",\"people\":0.3098002351984854,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.00017092933030090477,\"incomeEquivalent\":-0.00017092933030090477},{\"id\":\"nasal\",\"people\":0.8715582566185238,\"annualMedicationNet\":48,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.0006814143665871762,\"burdenEquivalent\":-0.00048010536828915426,\"incomeEquivalent\":0.00020130899829802192},{\"id\":\"ear\",\"people\":0.37352496712222444,\"annualMedicationNet\":42,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.00025555590988527046,\"burdenEquivalent\":-0.00020580056106705625,\"incomeEquivalent\":0.000049755348818214216},{\"id\":\"bph\",\"people\":0.4455829332206064,\"annualMedicationNet\":48,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.00034837213679850563,\"burdenEquivalent\":-0.0002454531944740389,\"incomeEquivalent\":0.00010291894232446675},{\"id\":\"stone\",\"people\":0.34656450361602714,\"annualMedicationNet\":45,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.0002540340347504263,\"burdenEquivalent\":-0.00019092711309824949,\"incomeEquivalent\":0.00006310692165217682},{\"id\":\"scrotal\",\"people\":0.19803685920915837,\"annualMedicationNet\":45,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.0001451623055716722,\"burdenEquivalent\":-0.000109101207484714,\"incomeEquivalent\":0.000036061098086958185},{\"id\":\"derm_cyst\",\"people\":0.6274435143260463,\"annualMedicationNet\":48,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.0004905570243147274,\"burdenEquivalent\":-0.0003456326610855553,\"incomeEquivalent\":0.0001449243632291721},{\"id\":\"skin_lesion\",\"people\":0.15686087858151157,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.0000865464963548885,\"incomeEquivalent\":-0.0000865464963548885},{\"id\":\"veins\",\"people\":0.5686206848579796,\"annualMedicationNet\":48,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.0004445673032852218,\"burdenEquivalent\":-0.00031322959910878455,\"incomeEquivalent\":0.00013133770417643725},{\"id\":\"pterygium\",\"people\":0.15440992735367545,\"annualMedicationNet\":48,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.00012072301770245245,\"burdenEquivalent\":-0.00008505803768902337,\"incomeEquivalent\":0.000035664980013429074},{\"id\":\"other_assessment\",\"people\":0.1568608785815116,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.00008654649635488851,\"incomeEquivalent\":-0.00008654649635488851},{\"id\":\"eye\",\"people\":0.2867612936568259,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.00015821781364878053,\"incomeEquivalent\":-0.00015821781364878053},{\"id\":\"hernia\",\"people\":0.8867541542311079,\"annualMedicationNet\":51,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0.0007365892049892101,\"burdenEquivalent\":-0.0004884273671117065,\"incomeEquivalent\":0.0002481618378775036},{\"id\":\"crc\",\"people\":2.818593912011536,\"annualMedicationNet\":0,\"annualWorkNet\":0,\"annualCtsLoss\":0,\"firstYearExtraCash\":-33.82743362831858,\"flowEquivalent\":0,\"burdenEquivalent\":-0.0015551323563769027,\"incomeEquivalent\":-0.0015551323563769027}]" per-path first-year household inputs and equivalents (judgment). Inspect individual households and gains/losses before lossless same-delay geometric serialization; group reference amounts are not observed cash [report] [budget] [cts-econ] [income-method]

Central conditional health and household resources: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: 0.00. Exact overrides: {}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

retained Funding Half: Cost: $100K; California health QALYs: 0.50; all-population health QALYs: 0.50. Income-equivalent healthy years: 0.00. Exact overrides: {"funding":0.5}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

low Funding: Cost: $100K; California health QALYs: 0.10; all-population health QALYs: 0.10. Income-equivalent healthy years: 0.00. Exact overrides: {"funding":0.1}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

high Funding: Cost: $100K; California health QALYs: 0.81; all-population health QALYs: 0.81. Income-equivalent healthy years: 0.00. Exact overrides: {"funding":0.8}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

complete Replacement: Cost: $100K; California health QALYs: 0.00; all-population health QALYs: 0.00. Income-equivalent healthy years: 0.00. Exact overrides: {"funding":0}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

five Slots: Cost: $100K; California health QALYs: 0.07; all-population health QALYs: 0.07. Income-equivalent healthy years: 0.00. Exact overrides: {"cap":5}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

cost2026 Budget Same Output: Cost: $100K; California health QALYs: 0.36; all-population health QALYs: 0.36. Income-equivalent healthy years: 0.00. Exact overrides: {"costPerService":1242.6422498364943}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

cost Three Year Mean Same Output: Cost: $100K; California health QALYs: 0.27; all-population health QALYs: 0.27. Income-equivalent healthy years: 0.00. Exact overrides: {"costPerService":1656.5073032483103}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

aub Legacy Utility: Cost: $100K; California health QALYs: 0.33; all-population health QALYs: 0.33. Income-equivalent healthy years: 0.00. Exact overrides: {"aubUtility":0.1}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

aub No Utility: Cost: $100K; California health QALYs: 0.24; all-population health QALYs: 0.24. Income-equivalent healthy years: 0.00. Exact overrides: {"aubUtility":0}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

fast Other Care: Cost: $100K; California health QALYs: 0.02; all-population health QALYs: 0.02. Income-equivalent healthy years: 0.00. Exact overrides: {"fastCatchup":4}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

income Null: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Exact overrides: {"incomeNull":true}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

health Null: Cost: $100K; California health QALYs: unknown; all-population health QALYs: unknown. Income-equivalent healthy years: 0.00. Exact overrides: {"healthNull":true}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

all Null: Cost: $100K; California health QALYs: unknown; all-population health QALYs: unknown. Exact overrides: {"healthNull":true,"incomeNull":true}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

income Zero: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: 0.00. Exact overrides: {"incomeZero":true}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

health Benefit Zero Harms Retained: Cost: $100K; California health QALYs: -0.05; all-population health QALYs: -0.05. Income-equivalent healthy years: 0.00. Exact overrides: {"healthZero":true}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

resource Signed Harm: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: -0.10. Exact overrides: {"medicationAnnual":0,"cystNetRecoveredPaidDays":0,"patientNetCashPerService":300}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

independent Health Harm: Cost: $100K; California health QALYs: -0.70; all-population health QALYs: -0.70. Income-equivalent healthy years: 0.00. Exact overrides: {"healthIndependentHarm":1}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

independent Income Harm: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: -1.00. Exact overrides: {"incomeIndependentHarm":1}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

half Overlap: Cost: $100K; California health QALYs: 0.12; all-population health QALYs: 0.12. Income-equivalent healthy years: 0.00. Exact overrides: {"overlap":0.5}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

full Overlap: Cost: $100K; California health QALYs: -0.05; all-population health QALYs: -0.05. Income-equivalent healthy years: 0.00. Exact overrides: {"overlap":1}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

consumption15000: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: 0.00. Exact overrides: {"baselineConsumption":15000}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

consumption60000: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: 0.00. Exact overrides: {"baselineConsumption":60000}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

no Medication Savings: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: -0.01. Exact overrides: {"medicationAnnual":0}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

work Recovery Null: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: 0.00. Exact overrides: {"cystNetRecoveredPaidDays":0}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

net Twenty Cyst Days: Cost: $100K; California health QALYs: 0.30; all-population health QALYs: 0.30. Income-equivalent healthy years: 0.00. Exact overrides: {"cystNetRecoveredPaidDays":20}. Clinical and first-year household resource ledgers are independent; positive-path overlap leaves harms. Unknown branches are not zero; diagnostic inputs are judgments, not probability bounds.

Historical clinical-only estimate: Cost: $100K; California health QALYs: 0.53; all-population health QALYs: 0.53. Income-equivalent healthy years: 0.00. Frozen prior accepted estimate; original central clinical vector and scenarios retained in data/california/oa-ca-pre-recalibration-model.json. Not a newly recalibrated income-zero claim.

Counterfactual: Already funded activity and alternative public/charity care; each clinical diagnosis has finite catch-up, treatment failure, mortality and procedure risk.

Attribution: Funding response0.3 and cap100 are declared judgments; annual count and dated reserves do not identify new donor-sensitive slots. One unique patient/household assumed; specialty diagnosis shares remain priors.

Conditional central, not empirical expected value; no scenario weights. Net household incidence, clinical transport, case selection and marginal capacity unresolved. Unknown components are not zero.

Sensitivity

  • central: $332K per DALY. {}
  • retainedFundingHalf: $199K per DALY. {"funding":0.5}
  • lowFunding: $995K per DALY. {"funding":0.1}
  • highFunding: $124K per DALY. {"funding":0.8}
  • completeReplacement: no finite positive estimate. {"funding":0}
  • fiveSlots: $1.3M per DALY. {"cap":5}
  • cost2026BudgetSameOutput: $279K per DALY. {"costPerService":1242.6422498364943}
  • costThreeYearMeanSameOutput: $371K per DALY. {"costPerService":1656.5073032483103}
  • aubLegacyUtility: $304K per DALY. {"aubUtility":0.1}
  • aubNoUtility: $422K per DALY. {"aubUtility":0}
  • fastOtherCare: $4.2M per DALY. {"fastCatchup":4}
  • incomeNull: no finite positive estimate. {"incomeNull":true}
  • healthNull: no finite positive estimate. {"healthNull":true}
  • allNull: no finite positive estimate. {"healthNull":true,"incomeNull":true}
  • incomeZero: $331K per DALY. {"incomeZero":true}
  • healthBenefitZeroHarmsRetained: no finite positive estimate. {"healthZero":true}
  • resourceSignedHarm: $494K per DALY. {"medicationAnnual":0,"cystNetRecoveredPaidDays":0,"patientNetCashPerService":300}
  • independentHealthHarm: no finite positive estimate. {"healthIndependentHarm":1}
  • independentIncomeHarm: no finite positive estimate. {"incomeIndependentHarm":1}
  • halfOverlap: $812K per DALY. {"overlap":0.5}
  • fullOverlap: no finite positive estimate. {"overlap":1}
  • consumption15000: $333K per DALY. {"baselineConsumption":15000}
  • consumption60000: $331K per DALY. {"baselineConsumption":60000}
  • noMedicationSavings: $339K per DALY. {"medicationAnnual":0}
  • workRecoveryNull: $333K per DALY. {"cystNetRecoveredPaidDays":0}
  • netTwentyCystDays: $327K per DALY. {"cystNetRecoveredPaidDays":20}

Unresolved inputs

  • Current approved but unfunded unique cases and volunteer/facility capacity
  • Diagnosis-specific repeats, validated utility, alternative-care waits and outcome follow-up
  • Net household medicine, wages, benefits, travel and paid-leave incidence
  • Marginal unrestricted budget and additional provider/public opportunity costs

Health and income breakdown

For the modeled $100K: 0.30 health QALYs + 0.00 income-equivalent healthy years in California: $332K per DALY. Income equivalents are welfare comparisons, not observed QALYs or DALYs.

Method and caveats.

5. Funding and previous grants

The CMSP May 2025 minutes, pages 2 and 14, record refusal of renewed funding after the five-year $5.7M grant. The board questioned expansion reach, rising per-person costs and changing public coverage. OA reported stronger referrals and restructured staffing. This is a genuine adverse funder assessment—not proof of no clinical benefit, and not proof a new gift restores lost care.

The audited year-end accounts show cash down $246,920 but total net assets up $177,249: receivables and restricted support changed. There were $913,650 restricted net assets and $2,531,766 financial assets available within twelve months; OA reported 16 months of operating cash against an eight-month target. These are December 2025 balances, not current bank balances. The 2025 budget-versus-actual statement reports a $222,752 operating deficit before future-pledge timing adjustments; it is not the GAAP surplus or cashflow. The 2026 budget plans $1.9M revenue and expense after restructuring, including $1.6M personnel. Replacement donations and reserves mean grant loss cannot be equated with present funding room.

DHCS current rules freeze new full-scope enrollment for some adults from January 2026, while existing eligible enrollees can retain coverage by renewal and exceptions remain. Later scheduled changes are not already realized OA demand. Current English intake wording and OA's earlier bridge-care description differ; publicly eligible but unenrolled patients may obtain care later. We use a 0.3 funding-additionality judgment and separately test 0, 0.1, 0.5 and 0.8. Dated reserves, an approved smaller budget, layoffs and replacement fundraising challenge automatic 0.5 additionality, but do not identify 0.3 or establish present funding room. The next decisive evidence is funded versus unfunded approved cases, current slots, enrollment alternatives and 2026 unrestricted commitments. The CMSP minutes quantify the expansion concern: 91% of grant-period people served came from the original four counties and 9% from the eighteen expansion counties. This describes the grant evaluation, not California-wide clinical ineffectiveness. Current English intake explicitly says uninsured and ineligible for full-scope Medi-Cal, Medicare or CMSP; the Spanish version says uninsured without the same eligibility qualification. That inconsistency and historical bridge-care language require clarification before assuming all current participants are excluded from public alternatives.

Annual expenses

Organization-level spending, including programs, administration and fundraising. The research list averages three comparable, consecutive full fiscal years when available.

  • FY 2023: $2.7M; Ambulatory Surgery Access Coalition dba Operation Access, EIN 94-3180356, 12-month period, Calendar-year Form 990 Part I line 18 recipient expenses; excludes donated clinical service valuation. Source
  • FY 2024: $2.7M; Ambulatory Surgery Access Coalition dba Operation Access, EIN 94-3180356, 12-month period, Calendar-year Form 990 Part I line 18 recipient expenses; excludes donated clinical service valuation. Source
  • FY 2025: $2.3M; Ambulatory Surgery Access Coalition dba Operation Access, EIN 94-3180356, 12-month period, Calendar-year Form 990 Part I line 18 recipient expenses; excludes donated clinical service valuation. Source

6. Sources

  1. 2025 audited financial statements. Operation Access. Published: not stated; retrieved: 2026-09-14.
  2. 2025 annual report. Operation Access. Published: not stated; retrieved: 2026-09-14.
  3. 2026 budget. Operation Access. Published: not stated; retrieved: 2026-09-14.
  4. Patient eligibility and procedures. Operation Access. Published: not stated; retrieved: 2026-09-14.
  5. Donate. Operation Access. Published: not stated; retrieved: 2026-09-14.
  6. OA facilitated donated colonoscopy. California Colorectal Cancer Coalition. Published: not stated; retrieved: 2026-09-13.
  7. First-eye cataract randomized economic evaluation. Sach et al.. Published: not stated; retrieved: 2026-09-13.
  8. Watchful waiting versus repair. Fitzgibbons et al.. Published: not stated; retrieved: 2026-09-13.
  9. Mortality after positive FIT without program colonoscopy. Zorzi et al.. Published: not stated; retrieved: 2026-09-13.
  10. Immortal-time concern in positive-FIT mortality comparison. Methodological correspondence. Published: not stated; retrieved: 2026-09-09.
  11. Navigation after abnormal stool test trial. PRECISE investigators. Published: not stated; retrieved: 2026-09-09.
  12. Medi-Cal eligibility changes. California DHCS. Published: not stated; retrieved: 2026-09-14.
  13. Surgery versus splinting economic evaluation. Korthals-de Bos et al.. Published: not stated; retrieved: 2026-09-09.
  14. Medicine or Surgery randomized trial. Kuppermann et al.. Published: not stated; retrieved: 2026-09-14.
  15. TURP versus watchful waiting. Wasson et al.. Published: not stated; retrieved: 2026-09-09.
  16. Septoplasty versus medical management. NAIROS investigators. Published: not stated; retrieved: 2026-09-13.
  17. Varicose veins randomized clinical/economic trial. REACTIV investigators. Published: not stated; retrieved: 2026-09-09.
  18. Conservative treatment versus cholecystectomy. C-GALL investigators. Published: not stated; retrieved: 2026-09-09.
  19. Painful hallux valgus surgery versus orthosis/wait. Torkki et al.. Published: not stated; retrieved: 2026-09-09.
  20. Hallux valgus two-year randomized follow-up. Torkki et al.. Published: not stated; retrieved: 2026-09-09.
  21. Pessary versus surgery for prolapse. van der Vaart et al.. Published: not stated; retrieved: 2026-09-09.
  22. Degenerative meniscus surgery versus sham. Sihvonen et al.. Published: not stated; retrieved: 2026-09-13.
  23. Historical OA services1994–2008. Matula et al.. Published: not stated; retrieved: 2026-09-09.
  24. Actual refractory uterine bleeding and donated hysterectomy pathway. Operation Access / treating partner Sutter Health. Published: 2023-12-06; retrieved: 2026-09-13.
  25. 2023 Form 990, page 1 total expenses. Operation Access / IRS. Published: not stated; retrieved: 2026-09-14.
  26. 2024 Form 990, page 1 total expenses. Operation Access / IRS. Published: not stated; retrieved: 2026-09-14.
  27. 2025 Form 990, page 1 total expenses (signed May 7, 2026). Operation Access / IRS. Published: not stated; retrieved: 2026-09-14.
  28. Our Impact. Operation Access. Published: not stated; retrieved: 2026-09-14.
  29. 2025 operating budget versus actual, prepared February 25, 2026. Operation Access. Published: 2026-02-25; retrieved: 2026-09-14.
  30. May 28, 2025 governing board minutes: OA renewal decision. CMSP Governing Board. Published: 2025-05-28; retrieved: 2026-09-14.
  31. Operation Access final grant report and response. CMSP / Operation Access. Published: 2025-03-20; retrieved: 2026-09-14.
  32. C-GALL randomized trial. BMJ. Published: not stated; retrieved: 2026-10-02.
  33. Comparing income and healthy life years. Coefficient Giving. Published: not stated; retrieved: 2026-09-30.