NURS 8100 Week 8 DNP policy analysis example

Removing the Approval Step, With the Implementation Attached: A DNP Policy Analysis of Medicaid Prior Authorization for Buprenorphine

Student Name

College of Nursing, Walden University

NURS 8100: Healthcare Policy and Analysis

Instructor Name

Month Day, Year

Removing the Approval Step, With the Implementation Attached: A DNP Policy Analysis of Medicaid Prior Authorization for Buprenorphine

Executive Summary

This analysis recommends that the composite state's Medicaid agency issue a directive ending prior authorization for the buprenorphine products its preferred drug list names, retain review only for doses above a set daily threshold and amend managed care contracts to match, with a twelve-month monitoring plan and a later request to the legislature to make the change durable. The recommendation follows from a staged analysis of the problem, the stakeholders and four alternatives judged against five criteria. It favors speed and reduced burden over durability in the near term, while retaining the review that most concerns the program's clinical advisers. The implementation plan names every clearance point the change must pass and the costs and risks at each.

Problem and Background

Adults enrolled in the state's Medicaid program who are ready to begin buprenorphine for opioid use disorder must wait for a prior authorization decision before the pharmacy will dispense it. The rule began as a utilization control when the drug was new and costly. Since then, the federal waiver requirement for prescribing buprenorphine has been repealed (Consolidated Appropriations Act, 2023, Pub. L. No. 117-328), and generic formulations have lowered its cost.

Stone (1989) described how problems are framed through causal stories. The agency's story is stewardship: review protects patients and the program. The alternative story, tested throughout this analysis, is that a routine procedure holds up treatment just when a patient has decided to begin. The evidence now supports that story in part. Removing prior authorization in Medicare Part D plans was associated with more buprenorphine-naloxone prescriptions and fewer related hospital and emergency visits (Mark et al., 2020). Across two state Medicaid programs, Keshwani et al. (2022) saw fills climb clearly after removal in Illinois but not in California. Both findings point the way the delay story predicts; how far they go depends on local conditions.

Stakeholders in Brief

The full stakeholder map appears in Appendix A. In summary, clinicians, the medical society, pharmacists and recovery advocates support removal, with pharmacists asking for dose safeguards. Managed care plans and pharmacy benefit managers oppose it, and their power is chiefly contractual and technical. The drug utilization review board is divided. The agency and the health committee chair are cautious or undeclared and hold the formal authority. Stakeholder analyses are most useful when they shape the recommendation rather than decorate it (Brugha & Varvasovszky, 2000), and this one shapes two features of the recommendation: the retained dose threshold, which answers the board's and pharmacists' concern, and the contract and systems plan, which answers the plans' technical power.

Alternatives and the Decision

Four alternatives were appraised against five criteria defined in advance: timely treatment starts, administrative burden, program integrity, fiscal impact and feasibility with durability (Bardach & Patashnik, 2020). The projected-outcomes matrix from the appraisal is carried forward unchanged in Appendix B. Option B, removal by directive for preferred products, promised the biggest improvement on same-day starts and paperwork and could be adopted quickly, but it is reversible and slightly weaker on program integrity. Option C, a one-day decision limit with a bridge supply, preserved oversight but left the approval step in place and depended on plans meeting a deadline. Option D, removal by statute, was the most durable but slow and removed all review.

The recommendation combines Option B with two features drawn from the others: a retained review for doses above a threshold, which answers the program integrity concern, and a plan to seek legislation after a year of monitoring, which answers the durability concern. This weighting places timely starts and reduced burden first in the near term, a choice justified by the consistent direction of the evidence and by the fact that every day of delay affects patients who may not return.

Implementation

Pressman and Wildavsky (1984) showed that a policy's chances of being carried out as intended fall with each clearance point it must pass, the separate approvals and actions by different actors that implementation requires. The recommendation must pass six.

1. Agency director's decision. The director issues a directive amending the preferred drug list criteria. Timing: month 1.

2. Drug utilization review board. The board reviews the dose threshold and the monitoring plan. Timing: next scheduled meeting, month 1 or 2.

3. Managed care contract amendments. The agency amends plan contracts to remove the requirement and adopt the threshold. Plans may request a rate review. Timing: months 2 to 4.

4. Pharmacy benefit manager system changes. Claims systems are updated to stop requiring authorization below the threshold. Timing: months 3 to 4, with testing before go-live.

5. Notices to pharmacies and prescribers. The agency issues a provider bulletin and plans notify their networks. Timing: two weeks before go-live.

6. Monitoring. The agency reports quarterly on buprenorphine fills, same-day starts, doses above the threshold, related emergency and hospital use and spending. Timing: quarterly for twelve months.

Cost categories include agency staff time for the directive and contract amendments, plan and benefit manager system costs, possible rate adjustments and higher pharmacy spending. The analysis does not estimate these in dollars because the state's rates and volumes are not public, but it names them so the agency's budget office can price them. Two risks deserve plans of their own. If plans slow the system changes, the agency can set a contractual deadline. If monitoring shows a rise in high-dose prescribing, the threshold can be lowered without restoring the whole rule.

Limitations

The evidence comes from other programs and may not predict this state's results. The analysis relied on public documents rather than interviews for stakeholder positions. And the fiscal projection is directional, since the state's cost data are not available. These limits argue for the monitoring plan: the recommendation should be judged by what happens in this state, not only by what happened elsewhere.

Conclusion

The approval step for buprenorphine was designed for a different regulatory and pricing environment. Removing it for preferred products, while keeping review where the risk is greatest and monitoring the results, offers the most benefit soonest with the fewest new risks. Seeking legislation after a year would protect the change from reversal once its effects are known.

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.

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).

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

Pressman, J. L., & Wildavsky, A. (1984). Implementation (3rd ed.). University of California Press.

Stone, D. A. (1989). Causal stories and the formation of policy agendas. Political Science Quarterly, 104(2), 281-300. https://doi.org/10.2307/2151585