NURS 8100 Week 7 policy options appraisal example

Four Options, Five Criteria, No Winner Yet: Appraising Alternatives to Medicaid Prior Authorization for Buprenorphine

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College of Nursing, Walden University

NURS 8100: Healthcare Policy and Analysis

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Month Day, Year

Four Options, Five Criteria, No Winner Yet: Appraising Alternatives to Medicaid Prior Authorization for Buprenorphine

Where This Stage Sits

Bardach and Patashnik (2020) describe policy analysis as an eightfold path: define the problem, assemble some evidence, construct the alternatives, select the criteria, project the outcomes, confront the trade-offs, decide and tell the story. Earlier stages of this analysis defined the problem, the delay prior authorization may cause in starting buprenorphine for Medicaid enrollees, and mapped the stakeholders. This paper covers the middle of the path: alternatives, criteria, projected outcomes and trade-offs. It deliberately stops before deciding, because a choice made before the trade-offs are confronted tends to shape how they are described.

The Alternatives

Four alternatives are described at equal length, so that none is favored by the space it receives.

Option A: Keep the current rule. Prior authorization remains for all buprenorphine products, administered by managed care plans under the state's criteria. This is the baseline against which the others are judged.

Option B: Remove prior authorization for preferred products by agency directive. The Medicaid agency removes the requirement for buprenorphine products on its preferred drug list, amends managed care contracts to match and keeps limits on doses above a set threshold. The change could take effect within months.

Option C: Keep prior authorization with a one-day decision limit and a bridge supply. Plans must decide requests within one business day, and pharmacies dispense a short supply automatically while a request is pending. The rule stays, but its delay is capped.

Option D: Remove prior authorization by statute for all medications for opioid use disorder. The legislature bars prior authorization for all such medications in Medicaid and state-regulated plans. The change would be durable but slow, depending on the legislative calendar.

The Criteria

Each criterion is defined so that another analyst could apply it the same way.

1. Timely treatment starts. The expected change in the share of patients who receive buprenorphine on the day it is prescribed.

2. Administrative burden. The expected change in clinician and plan staff time spent on approvals.

3. Program integrity. The expected change in the risk of inappropriate doses or diversion, as judged by the drug utilization review board's own concerns.

4. Fiscal impact. The expected change in Medicaid pharmacy spending in the first two years, counting higher buprenorphine use and any offsetting reductions in acute care.

5. Feasibility and durability. How easily the option can be adopted and how likely it is to survive a change in agency leadership.

Projected Outcomes

Outcomes are projected directionally, better, worse or about the same compared with Option A, because the evidence does not support precise numbers for this state. In Medicare Part D, plans that dropped the requirement saw fills of buprenorphine-naloxone rise and related hospital and emergency use fall (Mark et al., 2020), while a study of two state Medicaid programs found a significant increase in one state and not the other (Keshwani et al., 2022). The direction is reasonably clear; the size is not.

Table 1

Projected Outcomes Compared With Keeping the Current Rule

Confronting the Trade-Offs

No option wins on every criterion. Option B offers the largest gain in timely starts and burden quickly, but a future agency head could reverse it, and removing review raises program integrity concerns the drug utilization review board takes seriously. Option C keeps oversight and reduces delay, but it leaves the approval step in place and adds a bridge supply that plans and pharmacies must administer; its effect depends on plans actually meeting a one-day limit. Option D is the most durable, but it removes all review, would take at least one legislative session and would apply to plans the agency does not control, drawing wider opposition.

Two trade-offs stand out. The first is speed against durability: the options that act fastest are easiest to undo. The second is access against oversight: the options that most improve access remove the review that the board and plans believe protects patients. The mixed evidence on how much access improves makes the second trade-off harder, since the benefit side is less certain than advocates often claim.

The fiscal criterion also deserves caution. Higher buprenorphine spending is likely under Options B and D, while any offset in hospital and emergency costs depends on whether more patients stay in treatment, which the evidence suggests but does not guarantee.

Criteria Weighting

Bardach and Patashnik (2020) caution that criteria are rarely equal, and that the weights analysts assign reflect values as much as evidence. This appraisal does not weight the criteria yet, but it names the weighting question the decision stage must answer. A clinician-advocate would weight timely treatment starts most heavily. The drug utilization review board would weight program integrity. The budget office would weight fiscal impact, and the agency director would weight feasibility and durability, since she must defend the decision after it is made.

Making those weights explicit is itself useful. If the decision stage chooses Option B, it should be able to say that it weighted timely starts and burden above durability for now, and explain why. If it chooses Option C, it should say that it weighted oversight more heavily, given the mixed evidence on how much access improves. Either choice is defensible; an undeclared weighting is not.

What Comes Next

The appraisal does not recommend an option. The next stage will decide, and it will need to weigh these trade-offs explicitly, probably by asking whether one option can be combined with the strengths of another, for example removing prior authorization by directive while retaining a dose threshold and later seeking legislation to make the change durable. Keeping the decision separate from the appraisal allows the recommendation to be judged against criteria that were set before anyone knew which option they would favor.

References

Bardach, E., & Patashnik, E. M. (2020). A practical guide for policy analysis: The eightfold path to more effective problem solving (6th ed.). CQ Press.

Keshwani, S., Maguire, M., Goodin, A., Lo-Ciganic, W.-H., Wilson, D. L., & Hincapie-Castillo, J. M. (2022). Buprenorphine use trends following removal of prior authorization policies for the treatment of opioid use disorder in 2 state Medicaid programs. JAMA Health Forum, 3(6), Article e221757. https://doi.org/10.1001/jamahealthforum.2022.1757

Mark, T. L., Parish, W. J., & Zarkin, G. A. (2020). Association of formulary prior authorization policies with buprenorphine-naloxone prescriptions and hospital and emergency department use among Medicare beneficiaries. JAMA Network Open, 3(4), Article e203132. https://doi.org/10.1001/jamanetworkopen.2020.3132