Secretary for Health—and eight operating divisions: the Administration for Children and Families, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Food and Drug Administration, the Health Resources and Services Administration, the Indian Health Service, the National Institutes of Health, and SAMHSA. See GAO, Prenatal Drug Use and Newborn Health: Federal Efforts Need Better Planning and Coordination, GAO-15-203 (Washington, D.C., February 10, 2015). 8 Pub. L. No. 114-198, § 504, 130 Stat. 695, 731 (2016). Page 3 GAO-18-32 Newborn Health we briefed your staff on our preliminary findings in July 2017. This report includes information shared during that briefing and 1. describes the hospital settings for treating infants with NAS and how Medicaid pays for services in these hospital settings; 2. describes the non-hospital settings for treating infants with NAS and how Medicaid pays for services in these non-hospital settings; 3. describes the recommended practices and challenges for addressing NAS; and 4. examines HHS’s strategy for addressing NAS. To address our first three audit objectives describing care settings for treating infants with NAS, Medicaid payment for NAS treatment, and the recommended practices and challenges for addressing NAS, we did the following: • We selected 32 stakeholders based on their relevant experience to cover a range of perspectives on NAS. This included stakeholders from site visits we conducted in four states—Kentucky, Vermont, West Virginia, and Wisconsin. We selected these states because they met the following criteria: (1) high incidence rate of NAS as of 2013; (2) variation in United States geographic regions with high rates of NAS as of 2012; (3) more than 40 percent of births in the state were financed by Medicaid in 2016; and (4) the state has a perinatal quality collaborative—a state or multi-state network of teams working to improve health outcomes for mothers and infants—with work related to NAS.9 The stakeholders we selected within these states consisted of four state agencies, including Medicaid officials; officials from the perinatal collaborative that work on NAS in each state; officials from one residential treatment facility in each state that provides prenatal and postpartum care to mothers; and hospital providers, including physicians or nurses, from eight hospitals (two hospitals in each state).10 We also selected 12 additional stakeholders outside of these four states, including health care providers or administrators in four 9 See Jean Y. Ko et al., “Incidence of Neonatal Abstinence Syndrome – 28 states, 1999- 2013,” CDC MMWR, vol. 65 (2016); Stephen W. Patrick et al., “Increasing Incidence and Geographic Distribution of Neonatal Abstinence Syndrome,” 650-651; and Kaiser Family Foundation State Health Facts: Births Financed by Medicaid, downloaded on October 31, 2016. 10We selected hospitals and residential treatment facilities based on recommendations from state perinatal collaboratives. Page 4 GAO-18-32 Newborn Health non-hospital settings across the United States; officials from five medical specialty societies, such as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists; and three experts, such as the authors of studies we identified. We interviewed each of these 32 stakeholders and requested information from stakeholders about treating infants with NAS, including the utilization of available hospital and non-hospital care settings and associated costs of treatment services. For example, we requested protocols for screening and treating infants with NAS from hospital and non-hospital care settings. We reviewed available protocols provided by hospitals and a non-hospital care setting. We also reviewed available information reported by state officials, hospital and non-hospital providers, and state perinatal collaboratives on the utilization of hospital and non-hospital care settings, the facility’s cost of treating NAS in hospital and non-hospital settings, length of stay for treating infants with NAS, or the amount of Medicaid payments for treating infants with NAS. We discussed the information provided by stakeholders and examined the information for obvious errors. The information obtained from these stakeholders is not generalizable to other states or other hospital and non-hospital settings. In addition, in some cases, stakeholders collected information differently, including information on Medicaid payments; as a result, the information reported by stakeholders is not directly comparable. • We conducted a literature review to identify relevant peer-reviewed articles published between January 2013 and December 2016.11 As a result, we identified and reviewed 40 relevant studies. We examined the methodologies for each of these studies and determined that the studies were sufficiently reliable for our audit objectives. • We interviewed officials from HHS, including those from the Centers for Medicare & Medicaid Services (CMS) and HHS’s Behavioral Health Coordinating Council—which includes officials from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Indian Health Service, the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration, among others—concerning NAS treatment services, settings of