NURS 8100 Week 5 stakeholder power map example

Who Gets What When the Approval Step Changes: A Stakeholder Power Map for Medicaid Prior Authorization of Buprenorphine

Student Name

College of Nursing, Walden University

NURS 8100: Healthcare Policy and Analysis

Instructor Name

Month Day, Year

Who Gets What When the Approval Step Changes: A Stakeholder Power Map for Medicaid Prior Authorization of Buprenorphine

Background

The composite state's Medicaid program has required prior authorization for buprenorphine since the drug first entered its preferred drug list. The rule began as a utilization control, a way for the agency to confirm diagnosis and dose before paying for a medication that was then new, expensive and subject to concern about diversion. When the state moved most enrollees into managed care, it wrote the rule into its contracts, so each plan now administers its own approval process under the state's criteria.

Two changes since then have unsettled the rule's rationale. Federal law ended the separate waiver clinicians once needed to prescribe buprenorphine, so any clinician with the appropriate controlled substance registration can now prescribe it (Consolidated Appropriations Act, 2023, Pub. L. No. 117-328). And generic formulations have lowered the drug's cost. The rule remains, and the question for this map is who would gain or lose if it changed, and what each could do about it.

Lasswell (1936) defined politics as the study of who gets what, when and how. Applied to a single rule, that definition turns a list of interested parties into an analysis of stakes and power: what each actor stands to gain or lose, and what resources each can bring to bear.

Method

Positions were established without interviews, from public documents: minutes of the state's drug utilization review board, public comments on the most recent managed care contract, testimony at a legislative hearing on opioid treatment, association position statements and news coverage. Where an actor's position was not stated publicly, it was inferred from its stake and marked as inferred. Stakeholder analysis in health policy is only as good as its sources, and reviews of the method recommend stating how each position was established and how confident the analyst is in it (Brugha & Varvasovszky, 2000; Varvasovszky & Brugha, 2000). Power was typed rather than rated high or low, because different kinds of power matter at different decision points: authority matters when the agency decides, votes matter when the legislature acts and public legitimacy matters in both.

Stakeholder Table

Table 1 summarizes ten actors.

Table 1

Stakeholders, Positions and Power

Power Figure

A power figure, described here in words, places actors on two axes: support or opposition to removing the rule, and the kind of power they hold. The upper left, opposed with strong resource and technical power, holds the managed care plans and pharmacy benefit managers. The upper right, supportive with legitimacy and expertise, holds clinicians, the medical society and recovery advocates. The agency and the committee chair sit near the center, undeclared or cautious, with formal authority. That arrangement means the decision will turn on the two actors in the middle, and the analysis in later weeks must address what would move them.

Positions Most Likely to Shift

Not every position in the table is fixed. The drug utilization review board is divided, and its members are clinicians who read evidence; a summary of the published studies on removing prior authorization, including the mixed results across states, could move its recommendation. The committee chair is undeclared, and constituent stories of overdose deaths after delayed treatment, told by recovery advocates rather than by clinicians, are the kind of evidence legislators respond to. The pharmacists' association supports removal with safeguards, and a proposal that includes clear dispensing guidance could turn its conditional support into active support.

The managed care plans are least likely to move on the principle, but they may accept removal if the state adjusts their payment rates to account for higher buprenorphine use or if the change is paired with quality measures that reward treatment starts. Their opposition is partly about money and partly about control, and a proposal that addresses both may convert opposition into acceptance, even if not support.

Analysis

Three findings emerge. First, the supporters are numerous and hold legitimacy, but they lack formal authority; they can shape the agency's and legislature's view but cannot change the rule themselves. Second, the opponents' main power is technical and contractual rather than political: plans and benefit managers administer the rule and can slow its removal through system changes or contract negotiations, even after a decision is made. Third, the agency's caution is rooted in stakes that deserve respect, program integrity and budget, and a proposal that ignores them will fail.

The map also shows who is missing from public discussion: patients who never started treatment because an approval was delayed. Their stake is the largest and their voice the quietest, which is typical of policy contests where losses fall on people who never became visible to the system.

For the analysis that follows, the map suggests that options should be judged partly on how they address the plans' technical power and the agency's concerns, not only on how they serve patients. An option that removes the rule without a plan for claims systems and monitoring would win supporters and lose at implementation.

References

Brugha, R., & Varvasovszky, Z. (2000). Stakeholder analysis: A review. Health Policy and Planning, 15(3), 239-246. https://doi.org/10.1093/heapol/15.3.239

Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, 136 Stat. 4459 (2022).

Lasswell, H. D. (1936). Politics: Who gets what, when, how. Whittlesey House.

Varvasovszky, Z., & Brugha, R. (2000). A stakeholder analysis. Health Policy and Planning, 15(3), 338-345. https://doi.org/10.1093/heapol/15.3.338