Operation Access

Full ordinary gift in donor numerator. All ten specialty allocations sum to one and include recipient program, management, fundraising and failed-referral work. Separate gross associated resource sensitivity includes all nominal services, not merely health-credited cases; no waived-charge multiplier. Prospective cash per-service costs are judgments anchored to 2025 recipient cash-like scale.

Current patient eligibility requires residence in Northern California or the Central Valley. Accordingly all modeled direct patient benefit is assigned to California: Q_CA=Q_all. This is a service-eligibility inference, not headquarters/population allocation; no Bay=0.6 or SF=0.08 factor is reused. Migration or secondary spillovers are unmodeled. Geographic nesting means these QALYs must not be summed with the same services' Bay/USA benefits.

Let F(r,H)=(1-exp(-r*H))/r with F(0,H)=H. For specialty k: nominal S_k=C*a_k/c_k; S=sum S_k; activity A=min(S*f,K)/S. For disjoint diagnosis path j within k: P_j=S_k*s_j*A*d_j/r_j, where s=case share,d=nonoverlap fraction,r=services/person. Symptom Q_j=P_j*[success_j*utility_j*(1+discount)^(-delay_j)*F(catchup_j+loss_j+mortality_j+ln(1+discount),horizon_j)-harm_j]. For CRC let z(t)=delta_hazard*exp(-catchup*latency)*F(catchup,min(max(t-latency,0),active_years)); Δsurvival(t)=exp(-baseline_mortality*t)*(exp(z(t))-1). CRC Q=P_crc*[linkage*surviving_utility*(1+discount)^(-delay)*integral_0^H Δsurvival(t)*(1+discount)^(-t)dt - harm]. Sum CRC, cataract, hernia and all named symptom paths, subtract independent harm once. Q_CA=Q_all; donor_price_10=10*C/Q_CA for positive Q_CA. Full exact parameter vectors and scenario overrides are below. Numeric reproduction uses existing lib/oa-portfolio-model.mjs and lib/oa-portfolio-foundation.mjs; its regions.us.q equals CA here solely because eligibility was independently verified.

California direct benefit share

1 fraction (judgment). Independent current eligibility check requires Northern California or Central Valley residence; residence retention over modeled life course is assumed. [eligibility]

2025 observed specialty service counts

"{\"gi\":575,\"general\":201,\"gyne\":168,\"ortho\":158,\"head_neck\":127,\"urology\":101,\"derm\":80,\"vascular\":58,\"eye\":45,\"other\":16}" reported services by specialty, not persons (observed). 2025 annual report chart text refreshed; diagnosis mapping retained from September9 visual audit. Counts sum to1529; these are specialty labels, not diagnosis frequencies. [report]

2025 cash-like expenses

2256966 USD annual expenses net of listed in-kind items (observed). Audit22876888 minus20530000 clinical waived charges minus89922 other in-kind. Not cashflow or Form990 total. [audit]

gift_usd

100000 USD (judgment). Reference ordinary unrestricted gift; every dollar retained, not an SF colonoscopy restriction.

funding_additionality

0.5 dimensionless fraction (judgment). 50% judgment for extra maintained/expanded services after replacement funding and provider bottlenecks. Existing OA care is baseline. Not estimated from the deficit or reserves.

max_additional_services

100 additional service-equivalents (judgment). 100 extra mixed-service cap is an assumption, not identified open appointments. Shared capacity reduces all specialty activity proportionately.

discount

0.03 annual discount fraction (judgment). 3% annual health discount; economic resource amounts are gross associated present-dollar allowances, not a discounted net-social ledger.

independent_harm_q

0 QALYs per entire gift (gift-date present value) (judgment). Gift-date PV health loss independent of clinical activity; central0, zero-activity adverse case1.

outside_support_per_service

60 USD per completed service-equivalent (judgment). $60 distinct nonclinical donated support per nominal mixed service, rounded from89,922/1,529; not already cash-paid interpretation/travel.

patient_time_per_service

100 USD per completed service-equivalent (judgment). $100 additional patient/caregiver time allowance per nominal service, not earnings benefits or OA-paid travel.

crc_treatment_cost_per_selected

1500 USD per selected nominal service (judgment). $1,500 expected downstream therapy/surveillance resource allowance per nominal selectedFIT service, beyond endoscopy resources; weak prior, not provider quote or complete treatment estimate. [crc] [fit]

gi_allocation

0.37 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

gi_cash_per_service

1400 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

gi_clinical_resource_per_service

2500 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

general_allocation

0.13 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

general_cash_per_service

1700 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

general_clinical_resource_per_service

5500 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

gyne_allocation

0.11 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

gyne_cash_per_service

1500 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

gyne_clinical_resource_per_service

4500 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

ortho_allocation

0.1 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

ortho_cash_per_service

1600 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

ortho_clinical_resource_per_service

5000 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

head_neck_allocation

0.08 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

head_neck_cash_per_service

1500 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

head_neck_clinical_resource_per_service

3500 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

urology_allocation

0.07 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

urology_cash_per_service

1500 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

urology_clinical_resource_per_service

4000 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

derm_allocation

0.05 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

derm_cash_per_service

1300 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

derm_clinical_resource_per_service

1800 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

vascular_allocation

0.04 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

vascular_cash_per_service

1800 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

vascular_clinical_resource_per_service

4500 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

eye_allocation

0.03 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

eye_cash_per_service

1800 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

eye_clinical_resource_per_service

2500 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator. [cataract] [eligibility]

other_allocation

0.02 dimensionless fraction (judgment). Prospective all-function cash allocation prior, loosely anchored to mixed2025 specialty service shares; specialty cash spending not observed. Ten categories sum to1; management/fundraising are allocated once across all categories. [report]

other_cash_per_service

1500 USD per completed service-equivalent (judgment). All-function cash allocation per completed specialty service-equivalent, including failed-referral work. Judgment around audited$1,476 mixed-service average, not a specialist-specific quote. No added13pp navigation multiplier. [audit] [report]

other_clinical_resource_per_service

3000 USD per completed service-equivalent (judgment). Distinct donated clinician/facility/anesthesia/pathology resource prior per nominal service; not waived charges, no patient fee or public payment subtracted. Includes repeat services through the nominal-service denominator.

eye_selected_fraction

0.65 dimensionless fraction (judgment). 65% of nominal ophthalmology services assumed selected first-eye function-limiting cataract pathway;45observedeye services also include other procedures. [cataract] [eligibility]

eye_services_per_person

1.2 services per unique person (judgment). 1.2 service-equivalents per unique selected patient-episode planning prior; avoids service=person. All associated service costs retained. [cataract] [eligibility]

eye_disjoint_fraction

0.95 dimensionless fraction (judgment). Exclusive patient ledger order CRC→cataract→hernia, fractions1/.95/.90. Prior allowance for people already credited; no second eye, repeat operation or second pathway full-person health award. [cataract] [eligibility]

eye_treatment_success

0.9 dimensionless fraction (judgment). Clinical success/transfer judgment, not observed OA success or the96%self-reported broadquality-of-life figure. [cataract] [eligibility]

eye_utility_gain

0.05 quality weight, dimensionless (judgment). .05 utility-point gain per successful person-year is a separate judgment. The RCT's.056 integrated first-yearQALY is a magnitude anchor only, not a rate multiplied by three years. [cataract] [eligibility]

eye_catchup_hazard

0.7 per year (judgment). .7/year rate prior for later public/safety-net/self-funded care catching up; discounts finite earlier-care health even when no new gift finances the initial procedure. [cataract] [eligibility]

eye_loss_hazard

0.03 per year (judgment). Recurrence or loss-of-benefit hazard prior, separate from eventual comparator care and mortality. [cataract] [eligibility]

eye_mortality_hazard

0.02 per year (judgment). All-cause competing mortality hazard prior during symptom gain. No mortality benefit claimed for this pathway. [cataract] [eligibility]

eye_horizon_years

3 years (judgment). At most three years of possible postprocedure symptom difference centrally; no permanence claim. Later care and recurrence shorten expected benefit. [cataract] [eligibility]

eye_delay_years

0.25 years (judgment). Quarter-year procedure delay; cohort already conditioned alive at service start, so delay discounts only. [cataract] [eligibility]

eye_harm_q_per_person

0.002 QALYs per unique person (gift-date present value) (judgment). Extra procedure/recovery/complication burden per unique episode in gift-date PVQALYs; includes all repeat procedures in that episode. Independent of treatment success. No delayed no-gift procedure harm is subtracted, conservatively. [cataract] [eligibility]

hernia_selected_fraction

0.45 dimensionless fraction (judgment). 45% of nominal general-surgery services assumed selected symptomatic hernia episodes;201general services are not201hernias. [hernia] [eligibility]

hernia_services_per_person

1.2 services per unique person (judgment). 1.2 service-equivalents per unique selected patient-episode planning prior; avoids service=person. All associated service costs retained. [hernia] [eligibility]

hernia_disjoint_fraction

0.9 dimensionless fraction (judgment). Exclusive patient ledger order CRC→cataract→hernia, fractions1/.95/.90. Prior allowance for people already credited; no second eye, repeat operation or second pathway full-person health award. [hernia] [eligibility]

hernia_treatment_success

0.85 dimensionless fraction (judgment). Clinical success/transfer judgment, not observed OA success or the96%self-reported broadquality-of-life figure. [hernia] [eligibility]

hernia_utility_gain

0.04 quality weight, dimensionless (judgment). .04 utility-point gain per successful symptomatic-person-year is a judgment; minimallysymptomatic randomized evidence is essentially null. Selected pain-limiting hernia fraction and transport are unknown. [hernia] [eligibility]

hernia_catchup_hazard

0.7 per year (judgment). .7/year rate prior for later public/safety-net/self-funded care catching up; discounts finite earlier-care health even when no new gift finances the initial procedure. [hernia] [eligibility]

hernia_loss_hazard

0.08 per year (judgment). Recurrence or loss-of-benefit hazard prior, separate from eventual comparator care and mortality. [hernia] [eligibility]

hernia_mortality_hazard

0.02 per year (judgment). All-cause competing mortality hazard prior during symptom gain. No mortality benefit claimed for this pathway. [hernia] [eligibility]

hernia_horizon_years

3 years (judgment). At most three years of possible postprocedure symptom difference centrally; no permanence claim. Later care and recurrence shorten expected benefit. [hernia] [eligibility]

hernia_delay_years

0.25 years (judgment). Quarter-year procedure delay; cohort already conditioned alive at service start, so delay discounts only. [hernia] [eligibility]

hernia_harm_q_per_person

0.004 QALYs per unique person (gift-date present value) (judgment). Extra procedure/recovery/complication burden per unique episode in gift-date PVQALYs; includes all repeat procedures in that episode. Independent of treatment success. No delayed no-gift procedure harm is subtracted, conservatively. [hernia] [eligibility]

crc_selected_fraction

0.5 dimensionless fraction (judgment). 50% of nominal GI services assumed abnormal-FIT follow-up;575GI services are not575positiveFIT patients. [crc] [fit]

crc_services_per_person

1.2 services per unique person (judgment). 1.2 service-equivalents per unique selected patient-episode planning prior; avoids service=person. All associated service costs retained. [crc] [fit]

crc_disjoint_fraction

1 dimensionless fraction (judgment). Exclusive patient ledger order CRC→cataract→hernia, fractions1/.95/.90. Prior allowance for people already credited; no second eye, repeat operation or second pathway full-person health award. [crc] [fit]

crc_treatment_linkage

0.7 dimensionless fraction (judgment). 70% judgment chance that necessary appropriate downstream management can deliver the modeled contrast. Diagnostic completion alone earns no full treatment gain. [crc] [fit]

crc_annual_fatal_hazard_reduction

0.0006 per year (judgment). .0006/year is a judgment if no later-care catchup, lasting five hazard-years after latency. It is not.0092/10 or an estimated causal attenuation of the cohort. Fiveyears×.0006=.003 cumulative hazard only as a scale check. [crc] [fit]

crc_baseline_total_mortality_hazard

0.025 per year (judgment). .025/year all-cause hazard prior already includes CRC mortality. Only the modeled CRC component changes; no second mortality hazard added. [crc] [fit]

crc_catchup_hazard

0.5 per year (judgment). .5/year aggregate hazard-effect decay prior (two-year characteristic time) for eventual ordinary diagnostic/treatment care; mean-hazard approximation, not exact random individual care-time mixture. [crc] [fit]

crc_latency_years

2 years (judgment). Two-year assumed lag from procedure to differential fatal risk. Not observed OA survival timing; existing alternative care can catch up during this lag. [crc] [fit]

crc_active_years

5 years (judgment). Five years of possibly different fatal hazard after latency, not five avoided deaths or a life expectancy. [crc] [fit]

crc_horizon_years

10 years (judgment). Ten-year finite survival observation from procedure; both arms return to common mortality after the hazard-effect window. No lifetime tail. [crc] [fit]

crc_delay_years

0.25 years (judgment). Quarter-year procedure delay; cohort already conditioned alive at service start, so delay discounts only. [crc] [fit]

crc_surviving_utility

0.75 quality weight, dimensionless (judgment). .75 utility for extra surviving person-time; no extra cancer morbidity or household benefit. [crc] [fit]

crc_harm_q_per_person

0.001 QALYs per unique person (gift-date present value) (judgment). Extra procedure/recovery/complication burden per unique episode in gift-date PVQALYs; includes all repeat procedures in that episode. Independent of treatment success. No delayed no-gift procedure harm is subtracted, conservatively. [crc] [fit]

Pathway gi_symptom_diagnosis (gi)

"{\"share\":0.5,\"utility_gain\":0.03,\"treatment_success\":0.4,\"harm_q_per_person\":0.001,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":200}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Non-FIT GI investigation → benign treatable dyspepsia/dysphagia management. Diagnostic procedure alone earns no cure; treatment linkage is a prior, alternative primary-care therapy remains baseline. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [eligibility]

Pathway general_cyst (general)

"{\"share\":0.225,\"utility_gain\":0.025,\"treatment_success\":0.85,\"harm_q_per_person\":0.002,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Painful cyst/lipoma excision. Current OA procedure explicitly listed; utility and symptom-limiting fraction are priors, not cosmetic benefit. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [eligibility]

Pathway anorectal (general)

"{\"share\":0.12,\"utility_gain\":0.05,\"treatment_success\":0.8,\"harm_q_per_person\":0.004,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Symptomatic haemorrhoid/fissure treatment. Historical minor anorectal mix only; assume persistent symptoms despite medical management. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [historical]

Pathway gallstone (general)

"{\"share\":0.065,\"utility_gain\":0.01,\"treatment_success\":0.7,\"harm_q_per_person\":0.005,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Uncomplicated symptomatic gallstone surgery. C-GALL control includes later surgery; nonsignificant small integrated QALY difference; conservative care may suffice. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [gallstone]

Pathway breast_diagnostic (general)

"{\"share\":0.14,\"utility_gain\":0.01,\"treatment_success\":0.25,\"harm_q_per_person\":0.001,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":200}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Breast lesion diagnostic assessment and linked benign symptom treatment. No unverified cancer survival gain. Prior only for changed symptom management, not all negative tests. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [historical]

Pathway aub (gyne)

"{\"share\":0.65,\"utility_gain\":0.1,\"treatment_success\":0.8,\"harm_q_per_person\":0.015,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Refractory abnormal uterine bleeding → definitive outpatient treatment. Ms trial supports surgery vs expanded medical care; no hysterectomy-vs-ablation transfer, fertility/recovery losses retained. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [aub] [aub-activity]

Pathway pelvic (gyne)

"{\"share\":0.25,\"utility_gain\":0.07,\"treatment_success\":0.7,\"harm_q_per_person\":0.01,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Symptomatic pelvic prolapse/incontinence treatment. Case-mix and utility priors, not confirmed OA frequency; pessary/conservative alternatives retained. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [pelvic]

Pathway gyne_diagnostic (gyne)

"{\"share\":0.1,\"utility_gain\":0.02,\"treatment_success\":0.3,\"harm_q_per_person\":0.002,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":200}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Gynaecologic diagnostic workup → nonmalignant symptom management. Diagnosis without management has zero benefit through linkage; no automatic cancer cure. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [historical]

Pathway cts (ortho)

"{\"share\":0.35,\"utility_gain\":0.03,\"treatment_success\":0.8,\"harm_q_per_person\":0.004,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Carpal tunnel decompression for symptomatic confirmed CTS. Primary economic trial .04 at12months is nonsignificant point utility, not integrated QALY. .03 here is an independent transfer prior. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [cts-econ]

Pathway foot_tendon (ortho)

"{\"share\":0.45,\"utility_gain\":0.06,\"treatment_success\":0.75,\"harm_q_per_person\":0.005,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Painful foot deformity / tendon or trigger-finger intervention. 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. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [foot] [foot-catchup]

Pathway degenerative_knee (ortho)

"{\"share\":0.2,\"utility_gain\":0,\"treatment_success\":0.8,\"harm_q_per_person\":0.006,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Degenerative knee arthroscopy without acute mechanical indication. Null benefit central, not assume all orthopaedic surgery is useful; harm retained. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [knee]

Pathway nasal (head_neck)

"{\"share\":0.7,\"utility_gain\":0.04,\"treatment_success\":0.8,\"harm_q_per_person\":0.004,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Septal nasal obstruction surgery versus nasal medical therapy. NAIROS validates symptom mechanism, not SNOT22-to-QALY conversion or universal ENT benefit. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [nasal]

Pathway ear (head_neck)

"{\"share\":0.3,\"utility_gain\":0.03,\"treatment_success\":0.7,\"harm_q_per_person\":0.003,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":200}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Conductive ear disease treatment. Clinical indication and utility priors; no all-ENT survival credit. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [historical]

Pathway bph (urology)

"{\"share\":0.45,\"utility_gain\":0.06,\"treatment_success\":0.8,\"harm_q_per_person\":0.006,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Bothersome BPH/outlet obstruction treatment. TURP vs watchful waiting trial supports symptom relief, not current OA frequency; modern medication baseline matters. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [bph]

Pathway stone (urology)

"{\"share\":0.35,\"utility_gain\":0.05,\"treatment_success\":0.75,\"harm_q_per_person\":0.005,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":200}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Symptomatic urinary stone treatment. No prophylactic life-saving claim for asymptomatic stones; spontaneous passage and medical treatment in comparator. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [historical]

Pathway scrotal (urology)

"{\"share\":0.2,\"utility_gain\":0.025,\"treatment_success\":0.75,\"harm_q_per_person\":0.004,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Symptomatic benign scrotal/hydrocele treatment. Indication and finite utility priors; no infertility or cancer mortality award. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [historical]

Pathway derm_cyst (derm)

"{\"share\":0.8,\"utility_gain\":0.02,\"treatment_success\":0.8,\"harm_q_per_person\":0.002,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Symptomatic benign skin cyst/lesion treatment. Current OA cyst/lipoma service; disjoint allocation from general surgery required. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [eligibility]

Pathway skin_lesion (derm)

"{\"share\":0.2,\"utility_gain\":0.03,\"treatment_success\":0.6,\"harm_q_per_person\":0.003,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":200}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Localized skin lesion diagnosis and treatment. Symptom/functional relief only; no melanoma mortality extrapolation. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [historical]

Pathway veins (vascular)

"{\"share\":1,\"utility_gain\":0.04,\"treatment_success\":0.8,\"harm_q_per_person\":0.003,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Symptomatic uncomplicated varicose vein treatment. REACTIV randomized conservative comparator; integrated two-year .054Q not annual gain. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [veins]

Pathway pterygium (eye)

"{\"share\":0.35,\"utility_gain\":0.025,\"treatment_success\":0.8,\"harm_q_per_person\":0.003,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Symptomatic pterygium treatment. Current OA explicitly offered; first-eye cataract cohort excluded; finite symptom/vision utility prior. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [eligibility]

Pathway other_assessment (other)

"{\"share\":1,\"utility_gain\":0,\"treatment_success\":0,\"harm_q_per_person\":0.0005,\"services_per_person\":1.2,\"disjoint_fraction\":0.85,\"catchup_hazard\":0.7,\"loss_hazard\":0.1,\"mortality_hazard\":0.02,\"horizon_years\":3,\"delay_years\":0.25,\"downstream_resource_per_nominal_service\":0}" Parameter vector: share/success/disjoint fractions; utility_gain quality weight; harm_q_per_person QALY/person; services_per_person services/person; hazards per year; horizon/delay years; downstream_resource_per_nominal_service USD/service (judgment). Specialty assessment without established diagnosis-changing intervention. Only2%wholegift allocation; centralzero benefit explicitly due absent disease/intervention evidence, not blanket residual zero for major specialties. All numerical values are scenario judgments, not observed diagnostic mix or observed OA utility estimates. [historical]

Central, conditional portfolio model: Cost: $100K; California QALYs: 0.5136735945144643; all-population QALYs: 0.5136735945144643. All numerical central inputs below; California residency required for care. Mix, utility, funding additionality, catch-up and harm parameters remain judgments.

No benefit from less-evidenced pathways; harms retained: Cost: $100K; California QALYs: -0.009344364422171401; all-population QALYs: -0.009344364422171401. Override central inputs with {"baseOverrides":{},"allPaths":{"utility_gain":0},"pathOverrides":{}}. All direct modeled beneficiaries remain California residents; scenarios are not confidence bounds.

Rapid access to alternative care: Cost: $100K; California QALYs: 0.04646966310240659; all-population QALYs: 0.04646966310240659. Override central inputs with {"baseOverrides":{"eye_catchup_hazard":4,"hernia_catchup_hazard":4,"crc_catchup_hazard":4},"allPaths":{"catchup_hazard":4},"pathOverrides":{}}. All direct modeled beneficiaries remain California residents; scenarios are not confidence bounds.

Full funding replacement or no added capacity: Cost: $100K; California QALYs: 0; all-population QALYs: 0. Override central inputs with {"baseOverrides":{"funding_additionality":0},"allPaths":{},"pathOverrides":{}}. All direct modeled beneficiaries remain California residents; scenarios are not confidence bounds.

Adverse health from additional pathways: Cost: $100K; California QALYs: -0.12818107721082567; all-population QALYs: -0.12818107721082567. Override central inputs with {"baseOverrides":{},"allPaths":{"utility_gain":-0.01},"pathOverrides":{}}. All direct modeled beneficiaries remain California residents; scenarios are not confidence bounds.

Favorable combination: Cost: $100K; California QALYs: 2.150969144084584; all-population QALYs: 2.150969144084584. Override central inputs with {"baseOverrides":{"funding_additionality":0.8,"eye_utility_gain":0.1,"hernia_utility_gain":0.1,"eye_catchup_hazard":0.2,"hernia_catchup_hazard":0.2},"allPaths":{"catchup_hazard":0.2,"horizon_years":5},"pathOverrides":{}}. All direct modeled beneficiaries remain California residents; scenarios are not confidence bounds.

Benefits last at most one year: Cost: $100K; California QALYs: 0.2879782775452944; all-population QALYs: 0.2879782775452944. Override central inputs with {"baseOverrides":{"eye_horizon_years":1,"hernia_horizon_years":1},"allPaths":{"horizon_years":1},"pathOverrides":{}}. All direct modeled beneficiaries remain California residents; scenarios are not confidence bounds.

Counterfactual: Without a new gift, existing funded OA care and other providers continue. f represents the fraction of nominal activity that is maintained/expanded because of new funds, K capacity; catch-up hazards separately represent patients obtaining equivalent care later. Modern medical management and spontaneous remission remain alternatives. Uninsured at intake does not mean no lifetime access.

Attribution: The all-diagnosis ledger partitions each specialty into shares summing to one; repeat services are converted to people and disjoint fractions discount patient overlap. These fractions are priors, not an audited unique-person ledger. Provider donations are complementary inputs; no additional arbitrary provider-credit multiplier is added after modeling funded additional activity. No extra navigation completion multiplier on already-completed services; no productivity/caregiver benefit or duplicate all-cancer survival gain.

Conditional scenario model dominated by diagnostic mix, baseline utility, funding additionality and later-care assumptions. Favorable, rapid-catch-up, null and adverse states are deliberately wide stress tests, not probability intervals or empirical bounds. The central input set is a transparent judgment, not an observed expectation. Twenty-one supplementary named paths plus CRC/cataract/hernia cover the full specialty allocation; the small other-assessment path has no central benefit and retains burden.

Sensitivity

• Central CA price is $1,946,761.54 per ten QALYs; favorable joint assumptions produce $464,906.72 and rapid later care $21,519,415.75. Null or negative health never produces a favorable displayed price.
• With central utilities but one-year symptom horizons, price rises to $3,472,484.13; no lifetime constant-utility extrapolation is used.
• Setting the supplementary pathways' utility gains to zero while retaining burdens yields -0.00934 QALYs; the conclusion depends on these less-observed paths, not merely established cataract outcomes.
• Funding replacement/capacity failure yields zero added activity and zero QALYs. This is a real scenario given unknown marginal slots, not a proof that replacement occurs.
• The broad gross-associated-resource numerator is $369,105.29 centrally, implying about $7.19M per ten California QALYs; this includes uncredited nominal activity and is not a net economic estimate. Cost shares/resources are explicit priors, not billed charges.
• Benchmark: one QALY per $100,000 yields $1M per ten QALYs and ten yields$100k. Central 0.514 QALYs is below both hurdles. The favorable 2.151 QALYs exceeds only the $1M hurdle.
• AUB is the largest individual modeled pathway at 0.12014 QALYs; its 0.10 utility and 65% of gynecological allocation are not measured OA parameters. Audit this pathway, alternative therapy and long-term follow-up first in beta.

Unresolved inputs

• Current diagnosis/indication distribution within each specialty, with unique linked patients and repeat procedures.
• Marginal funded service capacity, clinician/facility slot constraints, current unrestricted reserves and grant replacement.
• OA baseline and follow-up utility and complications by diagnosis, including conservative-care alternatives.
• Observed time to equivalent treatment without OA, future coverage access and spontaneous improvement.
• Treatment linkage after positive diagnostic findings and causal CRC survival effect after selection bias.
• Actual incremental donated clinical resource cost, patient time and downstream costs; current allowances are gross associated judgments.
• California residence retention and out-of-state spillover; direct eligibility currently supports all-CA assignment.