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Peer-reviewed, empirical data is needed to pursue alternative payment structures


How should agencies reconcile the end of ET3 and what should they do going forward?

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With the decision by the Centers for Medicare and Medicaid Innovation (CMMI) to discontinue the Emergency Triage, Treatment and Transport (ET3) alternative payment model effective at the end of the year, what does this mean for the ambulance industry regarding future payment reform?

Let’s rewind.

For over a decade now, many ambulance agencies across the nation have been demonstrating (quite successfully) the ability to offer care to patients in their communities where ambulance transport is not required. This care may be termed “community paramedicine,” “mobile healthcare” or “advanced paramedicine.” Regardless of name, this care plays an important role in the access to healthcare for many communities. Funding for these initiatives has been a patchwork over the years – from short-term grant funding, to partial funding from Medicaid programs in certain states, to some insurance payers selectively paying for certain procedures or chronic disease management initiatives. Some communities have provided tax revenues to assist ambulance agencies with funding these critical programs.

Then, in 2018, the EMS industry had its first break at a program within CMMI to demonstrate what a national payment model could look like where funding would be available for ambulance agencies who respond to a 911 call where transport does not end at a hospital emergency room. Many of us recall when the CMS administrator, CMMI director, and secretary of HHS announced this program. In August 2019, the request for applications opened. On February 27, 2020, CMMI announced the selection of 205 applicants to participate in the ET3 demonstration program.

Then, the COVID-19 public health emergency was declared and the model was delayed.

The COVID-19 public health emergency waiver allowed for designations that were not originally covered by Medicare. In addition, treatment in place was also covered in the event a local or regional protocol met the requirements of the waiver issued by the Centers for Medicare and Medicaid Services (CMS).

Trust but verify

While these are the facts, I encourage the industry to look within.

Yes, the ET3 model was not perfect and not exactly what the industry wanted. However, it could be implemented broadly in many communities.

Yes, the requirement of the Alternative Destination (AD) entity was problematic in many rural communities. However, in the communities where AD entities were available, it only required one to be compliant with the model’s prerequisite.

Yes, the requirement to bill for treatment in place requiring a telehealth partner did not make sense in some cases because ambulance agencies are protocol driven with medical oversight. However, this was a demonstration to provide not only payment, but also quality. This requirement is an indicator to EMS at large how regulators, legislators, and other healthcare specialties view the care we provide. As Ronald Reagan stated: “Trust but verify.”

Yes, the participation agreements the ET3 participants had to agree to were restrictive and required ambulance agencies to adhere to certain standards. However, this is what being a healthcare provider is about, versus a transport provider (commodity). The participation agreements are very similar to the Conditions of Participation our healthcare colleagues, who provide healthcare services, are required to agree to when becoming a healthcare provider for the Medicare program.

The economics

In the end, it came down to economics.

The estimated savings to the healthcare program based on the present Medicare fee-for-service volume was not attained. Yes, there are a myriad of reasons for this and we can definitely point to the transition over the past 6 years to Medicare Advantage programs, Accountable Care Organizations, and the COVID-19 public health emergency. Ultimately, this was our one shot at demonstrating we are more than just transport entities and the termination of this program will have a short-term impact on that narrative.

As we move past this model, my suggestion is to take the good, the bad and the ugly of the ET3 model to shape our mission forward. If we learned anything from this demonstration, it is the following three points:

  1. Data is vital
  2. Peer-reviewed, empirical science regarding quality outcomes for patient care in the communities we serve is needed to pursue alternative payment structures
  3. Funding is local

With that being said, thank you to the CMMI for allowing the ambulance community to be a part of a national demonstration program in exploring a payment model that does not just follow transport. While the model was not perfect, it did allow us to gain insight on what could be, and what may need to be tweaked in future payment reform.

To my industry colleagues, we have just begun.

Continue to innovate.

Continue to collaborate.

But, most of all, data is your friend, and peer-reviewed medical journals and academia are needed to further the mission of mobile healthcare and community paramedicine as an ambulance industry.

Asbel Montes began his career in the ambulance industry in 1999. During his EMS career, he has directed and lead revenue cycle teams for air and ground ambulance agencies, culminating in his current position as managing partner of Solutions Group.

Throughout his career, Asbel has been a member of numerous organizations, including the Healthcare Financial Managers Association (HFMA), the American Ambulance Association (AAA), the National EMS Managers Association (NEMSMA), and the National Association of EMTs (NAEMT).

He previously served on the Board of Directors for the American Ambulance Association (AAA) and numerous committees. Notably, he chaired the AAA Payment Reform Committee helping to navigate healthcare changes and the correlation to the air and ground ambulance industry. He has also testified as an expert witness before federal and state health committees regarding ambulance reimbursement and veteran health initiatives related to emergency medicine.

In 2016, Asbel was appointed to the Ambulance Transport Alternatives Task Force for the State of Louisiana by Governor John Bel Edwards. In 2020, Asbel was named to the Air Ambulance and Patient Billing Advisory Committee by the Secretary of the United States Department of Transportation. In 2022, he was named chair of the Ground Ambulance and Patient Billing Advisory Committee tasked by Congress to provide recommendations to the Secretaries of Health and Human Services, Labor and Treasury on ways to protect consumers from balance billing when using ground ambulance services.

Asbel is a respected thought leader on reimbursement initiatives within the industry and is a requested speaker at numerous healthcare conferences. Asbel is a contributing author in several EMS magazines and co-authored the book, Management of Ambulance Services, as published by Prentice Hall in 2014.