Emergency Triage, Treatment and Transport reimbursement model is a watershed moment in modern EMS

EMS leaders react to ET3, HHS reimbursement model that recognizes the value of community paramedicine and emphasizes quality and outcomes


HHS has announced a new payment model that will make Medicare reimbursement available for certain non-transport ambulance services and ambulance transports to alternate destinations.

The new model – dubbed the Emergency Triage, Treat and Transport (ET3) Model – will make it possible for participating EMS agencies to partner with qualified healthcare providers to deliver treatment in place (on-scene or via telehealth) and with alternative destination sites (such as primary care doctors’ offices or urgent-care clinics).

HHS Secretary Alex Azar noted, “Today’s announcement shows that we can radically rethink the incentives around care delivery even in one of the trickiest parts of our system. A value-based healthcare system will help deliver each patient the right care, at the right price, in the right setting, from the right provider.”

ET3 reimbursement model will allow providers to treat in place or transport to alternative destinations (Photo/courtesy www.usfa.fema.gov)
ET3 reimbursement model will allow providers to treat in place or transport to alternative destinations (Photo/courtesy www.usfa.fema.gov)

Find the details from the ET3 model here.

We asked EMS1 Editorial Advisory Board members and industry leaders to respond to the HHS announcement and what it means for EMS. Read their responses and add your own thoughts in the comments section below.

Optimizing patient outcomes

The National Association of EMS Physicians is in strong support of the ET3 program that was announced today by CMS.  We are particularly pleased with the emphasis on patient quality and optimizing outcome while we also improve the model of care delivery.

David K. Tan, M.D., FAAEM, FAEMS, president, National Association of EMS Physicians

New EMS motto - “You call, we might haul”

The announcement of ET3 – Emergency Triage, Treatment and Transport – is a watershed moment in the half-century history of modern EMS.

EMTs and paramedics are regularly confronted with 911 callers who don’t need an ambulance transport and certainly don’t need an emergency department, but those providers are constrained by a Medicare reimbursement system that only pays for transport. ET3 gives EMS so many more options to do what’s best for the patient and get paid!

Imagine a future where EMS is incentivized to:

  • Transport a chronic inebriate to a sobering center.
  • Stay on scene with a fall patient to review medications and identify trip hazards.
  • Drop off a patient with a respiratory infection at an urgent care center.
  • Educate an asthma patient about triggers and how to prevent an attack.

EMS leaders need to follow ET3 information closely as it’s released by CMS. There are many steps to complete between now and applying to participate in ET3, including:

  • Begin discussing alternative treatment destinations with local healthcare partners.
  • Update or create non-transport and alternative transport policies.
  • Make sure your ePCR and billing vendors are prepared for documentation and billing changes which will result from on-scene/no transport care and patient transport to alternative destinations.
  • Create and improve training programs to prepare EMTs and paramedics to triage, treat and transport patients to alternative destinations.

Finally, I want to extend my gratitude to the CMS and HHS officials, as well as the many EMS leaders who have advocated for this innovation to the field delivery of EMS. Thanks!

Greg Friese, MS, NRP, EMS1 editor-in-chief

The value of EMS: response, assessment, treatment and referral

I was honored to represent NAEMT at this groundbreaking announcement. As our members know, NAEMT has been strongly advocating for this payment change for over five years. We have been in discussions with leaders of CMS and CMMI and with congressional leaders to help them understand the value of EMS to achieving our nation’s healthcare goals. In June 2018, CMS representatives reached out to NAEMT, and other industry associations including the International Association of Fire Chiefs (IAFC), the National Association of EMS Physicians (NAEMSP), and the American Ambulance Association (AAA), seeking input on the design, implementation and quality assurance mechanisms that would be necessary to allow ambulance agencies to voluntarily participate in a new payment model. At CMS’ request, NAEMT facilitated direct communication for CMS officials with organizations that were paying EMS under alternative payment models, allowing CMS officials to hear first-hand from the payers about the benefits and patient outcomes.

This is a transformative day for the EMS profession. This announcement demonstrates recognition of the additional value that EMS practitioners and agencies can bring to America’s healthcare system through the effective response, assessment, treatment and referral of patients to the most appropriate level of care for their medical needs. It is also confirmation that by working together with other EMS associations, we can truly affect major federal policy changes that enhance the services we provide to the patients and communities who rely on local EMS agencies.

There is still much work to be done as CMS develops the guidelines, eligibility, and patient safety and outcome measures for this new payment model. NAEMT has already been requested to assist with that process. We will also be hosting a series of educational sessions on how EMS agencies can implement ET3, and we will have a special session at our EMS 3.0 Workshop in Arlington, Virginia, on April 9, just prior to EMS On The Hill Day.

We thank CMS for their continued work with NAEMT, and other EMS associations, on this EMS economic transformation which we are confident will be of value to our patients, our practitioners, and our healthcare stakeholders. 

Matt Zavadsky, MS-HSA, NREMT, President, NAEMT

Exciting development a long time in coming: the devil’s in the details

The community paramedicine “demonstration projects” have been validated by CMS and have the potential to transform the industry from a “you call, we haul, that’s all” approach to a model that delivers the right care, at the right time, at the right place in the realm of urgent and emergency medical care.

For years now, we have seen a wide variety of community paramedicine/mobile integrated health projects demonstrate their efficacy at reducing overall healthcare costs while improving overall health. The challenge has been to demonstrate that effectiveness to reimbursement centers such as CMS and private insurers. No doubt it is through the efforts of dedicated EMS professionals that we have achieved a recognition that will allow these programs to flourish and even lead the ongoing changes in our healthcare system.

The devil is in the details. How will this work on a large scale? What will it take to create, on a broad scale, the connections among different healthcare organizations needed to implement these changes. As important, are we willing as a profession to embrace these changes? Increasing sophistication in decision making and a greater understanding of the overall role of EMS in healthcare demands greater knowledge and training among providers.

Art Hsieh, MA, NRP, program director, Santa Rosa Junior College

Community paramedicine results finally recognized with reimbursement

This is such a great day for EMS. We have been in the community paramedic space for over a decade now, and showing extraordinary results. Now CMS is recognizing the value EMS brings to the healthcare table and will pay us for services we have known to be beneficial for years.

Every EMS system will now need to ratchet up our game and prepare for the next generation of EMS reimbursement.

Chris Cebollero, senior partner for Cebollero & Associates

A monumental day for EMS; now what?

Today is a significant day in EMS history. Not everyone who calls 911 needs to be (or even should be) transported by EMS. But in terms of sustainability, the fee-for-transport model often stands in direct opposition to the “do what’s right for the patient” mantra.

The ET3 model simply opens the door for future possibilities. Treat and don’t transport? Sure. Transport to an alternative destination (mental health, urgent care, etc.)? Sure. Proactively treat the underserved in areas of medication compliance, routine blood testing, etc.? Sure. Telemedicine? Sure.

The big question centers around how. How do we move to this model? In an industry where tradition has a major stronghold, change will take time. Most importantly, this is an opportunity where progressive EMS systems who are addressing the entire healthcare spectrum will prevail. It’s about the system. It’s about the entire region. It’s no longer about moving a patient from Point A to Point B.

Let the innovation begin.

Kris Kaull, chief marketing officer for Pulsara, EMS1 co-founder, flight paramedic

System-wide relief, but we must protect EMS providers from enhanced liability

I absolutely love it. One of my former paramedic partners, who is now a PA in Pasadena, California, predicted this 25 years ago.

The idea that patients have more choices of both destination and provider is an absolute win for patient care. Responding 911 agencies will get some well-needed reprieve and the pressure relief that overworked emergency departments are going to feel will undoubtedly have a positive effect on the care they give and the patient satisfaction scores they receive (and depend on for Medicare reimbursement). The natural consequence has to be improved patient care and system-wide relief.

I do see some dangers, though. Many, if not most, EMS jurisdictions do not allow ambulances to transport from an uncontrolled (field) environment to anywhere except an approved emergency department. Before such a program could be fully, effectively and safely (for providers) be implemented, state and local EMS authorities would have to codify the provider’s ability to transport to alternative destinations and associated protocols and procedures would have to be developed in order to protect frontline providers from enhanced liabilities.

I can also see that fire departments and local hospitals may lose revenue as a result and I can predict some push back. However, if the best and most appropriate patient care is the goal, everyone should be on board.

David Givot, defense attorney

Open the door to proving value with EMS degrees

The recent ET3 model is the big break we were waiting for. Everyone sees the positive, but I think we must be aware of the challenges. This will challenge our public safety model as we more closely align with healthcare, make us actually prove our value (rather than rely on being the “heroes” for funding), and make education (hint: degrees) even more important.

EMS has been given the open door. How we step through it and handle this amazing opportunity is totally up to us now.

Daniel Limmer, co-founder, Limmer Creative, paramedic

Moving towards people-centered EMS

EMS’s boat was rocked when CMS announced an innovative pilot program to test a new reimbursement model for EMS. Called ET3, for Emergency Triage, Treat and Transport, the program facilitates payment for non-transport services for Medicare recipients.

This is potentially a momentous turning point for EMS and an exciting opportunity to move toward a truly people-centered EMS system.

ET3 will be piloted for five years beginning in 2020 and EMS agencies must apply to participate. According to the initial CMS announcement, organizations chosen for the program will be reimbursed for transport to an alternative destination, such as a doctor’s office or urgent care, as well as for appropriate “treat-and-release” as long as a “qualified healthcare practitioner” is involved in the decision, either on scene or through telehealth.

Over time this could be a clinical, operational and financial game changer for EMS. But the federal government is not known for handing out “free” money. The program will clearly include intense scrutiny and measurement to make sure that patients are having good outcomes, at less cost. Other impacts, such as decreased emergency department wait times and improved EMS response time, should be assessed as well.

The future of EMS reimbursement is always a featured topic at the Pinnacle EMS Leadership Forum, and this summer’s event will include special sessions to find out more about the implementation of ET3. I’ll also be discussing the implications during my annual Pinnacle Leadership Series talk, this year titled “Rock the Boat!”

This is potentially a momentous turning point for EMS and an exciting opportunity to move toward a truly people-centered EMS system.

Jay Fitch, PhD, founding partner, Fitch & Associates

A better model for care delivery

Providing a better model for care delivery has been a key initiative for us over the past several years. This announcement fully supports our commitment to provide appropriate care in the most appropriate setting and supports many of the models we currently have in place.

— Edward Van Horne, AMR President and CEO

EMS once saved firefighters; Moving towards ET3 will save them

The ability for EMS to move away from the "you call, we haul" model of EMS is the number one priority, or should be for 911 EMS and fire-based EMS services. The current model as stated is unsustainable and EMS and fire departments that want to stick to that model will suffer unnecessarily. It is driven often by greed and makes EMS a money-making scheme rather than a community asset to deliver the most appropriate care each time a call is answered. 

As a fire-medic and policy/program influencer, I remind our industry that at one time in our history as firefighters, we were dying as an industry. It was EMS that saved us and our jobs by giving the fire service a new set of missions. Today, just as EMS saved the fire service, the ability for EMS to adjust their aim away from the money scheme of “call-haul” and towards ET3 and really the larger picture of community or advanced practicing paramedic, will save EMS. We all know it’s a broken system. Let’s do something to fix it instead of kicking the can down the street. That something starts with programs like this.

Thomas Beers OMS, EMS Manager, Cleveland Clinic, IAFF fire-medic, and Deputy Admin Team Rubicon

effectively involve stakeholders

EMS systems must be able to demonstrate the value they bring to the healthcare system, not only by resuscitating the sick and injured but also by triaging and linking patients to the appropriate healthcare service they need.

Prehospital and in-hospital emergency medical care is oftentimes the only consistent contact the patient has with the healthcare system, but there is so much more that can be done if the right stakeholders can be effectively involved. There is still a lot more to be done, but this is an important first step that we’ve been advocating for several years.

— Gustavo E. Flores MD EMT-P FP-C

 

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