Abstinence Syndrome in U.S. Neonatal ICUs.” The New England Journal of Medicine, vol. 372, no. 22 (2015) and Walter K. Kraft et al., “Neonatal abstinence syndrome: Pharmacologic strategies for the mother and infant,” Seminars in Perinatology, 40 (2016). Literature also suggests that NICUs have a high daily cost of care and that the NICU setting makes it difficult to provide many of the non-pharmacologic treatment practices, such as rooming-in. See also Alison V. Holmes et al., “Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost,” Pediatrics, vol. 137, no.6, e1-e9 (2016). Most Infants with NAS Complete Treatment in Various Hospital Settings, and in Selected States Medicaid Pays for Services Using Bundled Payments Hospital Settings for Treating Infants with NAS Page 12 GAO-18-32 Newborn Health NICU (level III or IV).27 For example, according to these officials, most infants with NAS in Vermont are treated in well newborn nurseries, while most infants with NAS in Kentucky and Wisconsin are treated in NICUs. West Virginia perinatal collaborative officials told us that about a third of infants with NAS are treated in well newborn nurseries, while two-thirds receive treatment in either a special care nursery or NICU. According to perinatal collaborative officials and hospital providers in the four selected states, the severity of the infant’s NAS symptoms or the hospital’s capability to treat NAS can determine whether the infant receives care in a nursery or NICU. Health care providers in the four selected states described the general clinical approach for treating infants with NAS. According to these providers, they generally start with non-pharmacologic treatment—for example, swaddling or placing the infant in a quiet, dark room. Health care providers may continue to monitor and assess the severity of the infant’s NAS symptoms using one of the available scoring tools for NAS. If the infant’s symptoms meet or exceed a certain threshold, these providers may initiate pharmacologic treatment by administering morphine or methadone, for example. Some perinatal collaborative officials that we interviewed in the four selected states told us that not all hospitals may have the capability to provide pharmacologic treatment. For example, these officials told us that level I hospitals—hospitals with only well newborn nurseries—in Kentucky and Wisconsin may not provide pharmacologic treatment to infants with NAS because these hospitals may not have the staff expertise to administer the needed medication and monitor the infants who receive it. Instead, these hospitals may transfer infants with NAS who require pharmacologic treatment to hospitals with higher levels of care, such as those with a NICU. Table 1 provides information on the eight selected hospitals in our review that provide NAS services. 27The American Academy of Pediatrics defines four levels of neonatal care within a hospital—well newborn nursery (level I), special care nursery (level II), NICU (level III), and regional NICU (level IV). Well newborn nurseries can care for low-risk healthy infants. Special care nurseries can care for stable or moderately ill infants with problems that are expected to resolve rapidly. NICUs can care for more complex and critically ill infants. Page 13 GAO-18-32 Newborn Health Table 1: Selected Hospitals That Treat Infants with Neonatal Abstinence Syndrome (NAS) in Four States, 2016 Hospital (state) Hospital setting commonly used to treat infants with NASa Does hospital provide pharmacologic treatment to infants with NAS, if needed? Hospital 1 (KY) Level III neonatal intensive care unit (NICU) Yes Hospital 2 (KY) Level III NICU Yes Hospital 3 (VT) Level I well newborn nursery Yes Hospital 4 (VT) Level III NICU Yes Hospital 5 (WV) Level I well newborn nursery Yes Hospital 6 (WV) Level II special care nursery Yes Hospital 7 (WI) Level I well newborn nursery Nob Hospital 8 (WI) Level II special care nursery Yes Source: GAO review of information from and interviews with officials from selected hospitals. | GAO-18-32 Notes: According to health care providers, they generally start with non-pharmacologic treatment—for example, swaddling or placing the infant in a quiet, dark room. These providers may continue to monitor and assess the severity of the infant’s NAS symptoms using one of the available scoring tools for NAS. If the infant’s symptoms meet or exceed a certain threshold, these providers may initiate pharmacologic treatment by administering morphine or methadone, for example. a The American Academy of Pediatrics defines four levels of neonatal care within a hospital—well newborn nursery (level I), special care nursery (level II), NICU (level III), and regional NICU (level IV). Well newborn nurseries can care for low-risk healthy infants. Special care nurseries can care for stable or moderately ill infants with problems that are expected to resolve rapidly. NICUs can care for more complex and critically ill infants. Within each hospital, there may be multiple settings used to provide NAS treatment services. b Infants with NAS are provided non-pharmacologic treatment—such as swaddling and keeping the infant in a quiet, dark room—and infants who require pharmacologic treatment are transferred to another hospital to receive care in a NICU, according to hospital providers. According to a 2015 study we reviewed, nationwide,