Under fee-for-service, Medicaid pays health care providers a  fee for each service provided to a Medicaid beneficiary. 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

According to the literature we reviewed, most infants with NAS in the  United States are treated in a hospital setting, often in the neonatal  intensive care unit (NICU), which has a relatively high daily cost of care. Efforts are also underway to open a neonatal withdrawal center  in Arizona and Ohio, according to stakeholders we interviewed. State officials and health care providers in the non-hospital  settings we examined described various ways in which Medicaid covered  services they provided to treat infants with NAS. Recommended Practices for Addressing NAS Include Prioritizing Non-Pharmacologic Treatment, While Challenges Include Maternal Use of Multiple Substances

		Recommended Practices for Addressing NAS Include Prioritizing Non- Pharmacologic Treatment, Educating Mothers, and Addressing Stigma

The 32 stakeholders we interviewed and the literature we reviewed  identified several recommended practices for addressing NAS—that is,  treating women with opioid use disorders during pregnancy or treating  infants diagnosed with NAS after birth. The most frequently  recommended practices were (1) prioritizing non-pharmacologic  treatment, such as allowing the mother to reside with the infant during  treatment, to facilitate the mother-infant bond; (2) educating mothers on  prenatal care, treatment for NAS, and available resources for after an  infant’s discharge; (3) educating health care providers on the stigma  faced by women who use opioids during pregnancy and on how to screen  for and treat NAS; and (4) using a protocol in a hospital or non-hospital  setting for screening and treating infants with NAS. The most frequently cited challenges included (1) the use of multiple  substances by pregnant women, which can exacerbate NAS; (2) the  stigma faced by women who use opioids during pregnancy, which may  affect whether they seek prenatal care to address NAS, among other  things; (3) hospital staff burden and limited physical capacity to care for  infants with NAS; (4) limited coordination of care for mothers and infants  with NAS; and (5) gaps in research and data on NAS. For  example, the Strategy recommends the following: promoting non-pharmacologic treatment, such as rooming-in; providing continuing medical education to health care providers for  managing and treating infants with NAS, such as on NAS treatment  protocols;  conducting research on the long-term effects of prenatal drug  exposure so that appropriate services can be developed for infants  with NAS; and establishing clear definitions of NAS and standardizing the use of  diagnosis codes to collect more meaningful and actionable data on  NAS. However, HHS does not include any  information in the Strategy on how the department and other stakeholders  will implement the recommendations. Specifically, HHS does not include  in its Strategy the following:  the explicit priorities among the numerous recommendations and  associated efforts the department has initiated related to NAS;  timeframes for partial or full implementation of these  recommendations;  clear roles and responsibilities for the recommendations, such as the  extent to which HHS will need to rely on the medical community and  federal and public stakeholders for implementation; and  the methods that will be used to assess the department’s progress in  implementing any of these recommendations. HHS officials told us that they expect to develop a separate plan to guide  implementation of the recommendations and that efforts to develop this  plan were likely to begin in July 2017. HHS recently published a strategy with key recommendations that have  the potential to address some of the challenges related to treating NAS. In its written  comments, HHS concurred with our recommendation to expeditiously  take steps to address NAS and re-stated that its Strategy will be used to  inform planning and policy across HHS. Specifically, HHS said that as  part of its broader initiative to address the opioid crisis, the department  will develop and implement a plan—that will include priorities, timeframes,  roles and responsibilities, and methods for assessing progress—to  address as appropriate and possible, the NAS-related recommendations  in its Strategy. Specifically, these stakeholders included those from site visits we  conducted to four states—Kentucky, Vermont, West Virginia, and  Wisconsin. “Increasing  Incidence and Geographic Distribution of Neonatal Abstinence Syndrome:  United States 2009 to 2012.” Journal of Perinatology, vol. HHS Publications No.
Why GAO Did This Study

As the opioid crisis has increased in recent years, so has the number of pregnant women who use opioids, which can result in NAS. A recent peer-reviewed study found that cases of NAS have grown nearly five-fold between 2000 and 2012 and that most infants with NAS are covered under Medicaid.
The Comprehensive Addiction and Recovery Act of 2016 includes a provision for GAO to examine NAS in the United States and related treatment services covered under Medicaid. This report 1) describes the hospital and non-hospital settings for treating infants with NAS and how Medicaid pays for services, 2) describes recommended practices and challenges for addressing NAS, and 3) examines HHS's strategy for addressing NAS.
GAO reviewed HHS documentation and interviewed HHS officials. GAO also conducted site visits to four states—Kentucky, Vermont, West Virginia, and Wisconsin—selected based on several factors, including incidence rates of NAS and geographic variation. GAO interviewed stakeholders from 32 organizations, including health care providers and state officials in the selected states.

What GAO Found

The prenatal use of opioids or other drugs can produce a withdrawal condition in newborns known as neonatal abstinence syndrome (NAS). Health care providers, state officials, and other stakeholders told GAO that most infants with NAS are treated in the hospital—such as in a neonatal intensive care unit—though some may be referred to a non-hospital setting—such as a neonatal withdrawal center with nursery rooms—to complete their treatment. The table below provides more information on settings for treating infants with NAS and on how Medicaid pays for services in these settings.
According to stakeholders GAO interviewed and literature reviewed, there are several recommended practices and challenges associated with addressing NAS. The most frequently recommended practices included prioritizing non-pharmacologic treatment to infants—treatment that does not involve medications—such as allowing the mother to reside with the infant during treatment; educating mothers and health care providers on treatment of NAS, among other things; and using a protocol in the hospital or non-hospital setting for screening and treating infants with NAS. The most frequently cited challenges included the maternal use of multiple drugs—or polysubstance use—as it can exacerbate NAS symptoms; stigma faced by pregnant women who use opioids; hospital staff burden and limited physical capacity to care for infants with NAS; limited coordination of care for mothers and infants with NAS; and gaps in research and data on NAS, such as research on the long-term effects of the condition.
In May 2017, the Department of Health and Human Services (HHS) published a strategy document that makes key recommendations to address NAS. The Strategy recommends, for example, that health care providers receive continuing education on managing and treating infants with NAS and promote non-pharmacologic treatment. According to HHS officials, these recommendations will inform planning and policy across the department. However, HHS has yet to determine how and when the recommendations will be implemented, including establishing priorities; the roles and responsibilities of other federal, state, and public stakeholders; implementation timeframes; and methods for assessing progress. HHS officials told GAO that they expect to develop an implementation plan sometime in 2017 but had no timeline for doing so. Without a plan that clearly specifies how HHS will implement the Strategy and assess its progress, the department increases the risk that its recommendations for addressing NAS will not be implemented.

What GAO Recommends

HHS should expeditiously develop a plan for implementing the recommendations included in its strategy related to addressing NAS. HHS concurred that it should expeditiously address NAS, but noted implementation of the strategy is contingent on funding.