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Treat in place: How EMS models are shaped by reimbursement

The ET3 model and the COVID-19 are influencing a move away from 911 transport to the ED, and toward autonomy for EMS providers


Treat-in-place programs give paramedics more autonomy in treatment and transport decisions, decrease healthcare costs and ultimately provide the patient with the best care.

Photo/American Ambulance Association

This article was originally posted Aug. 24, 2020. It has been updated with new information.

Depending on where you work, there are usually two options when a patient calls 911. The patient is either transported to the hospital or is deemed safe to stay at home. This means that many patients who don’t necessarily need hospital-level care are transported to the ED when minimal treatment interventions on site would have been sufficient or a lower acuity facility (e.g., primary care provider, urgent care, etc.) would’ve been adequate for patient care.

The majority of insurance doesn’t reimburse EMS unless the patient is transported to the hospital, leading to more transports to the ED. Policies and legislation may also dictate that patients seen by EMS can only be transported to the ED, even when it’s not a true emergency. There are several programs that have been developed to stay and treat – treat in place – patients and improve reimbursement for EMS services.

Expanding EMS scope of practice with community paramedicine

Community paramedicine is a valuable approach to EMS, often used in rural communities where there are fewer healthcare resources. In some cases, paramedics with additional training act as the patient’s primary care provider, checking up on them and managing their medical conditions. This is especially valuable in the elderly population who frequently need medical help but may not need an emergency room visit.

A BMJ study found that community paramedics can adequately manage and treat various medical conditions that would normally result in the patient being transported to the ED [1]. They commonly provided fluids, oxygen, albuterol and furosemide. They are supported by nurses and physicians who triage patients and are given the freedom to decide how to treat and whether their patient needs higher care. Ultimately, this leads to fewer ED visits and higher patient satisfaction.

Implementing the ET3 model

The ET3 model, which stands for Emergency Triage, Treatment and Transport, was developed by the Center for Medicare and Medicaid Services as a way to reimburse EMS agencies for their services that don’t lead to hospital transport. CMS found there is potential savings of $560 million per year by transporting patients to their doctor’s offices rather than an emergency department.

The ET3 model, set to launch over a 5-year period starting May 1, 2020, with 205 selected agencies was delayed until Fall 2020 due to the COVID-19 pandemic and officially launched Jan. 1, 2021. CMS released a final list of participants and Notice of Funding Opportunity on Mar. 12, 2021.

Within the ET3 model, a provider converses with the patient on the phone when they call 911 to determine what sort of response is needed. Once the ambulance arrives, EMS treats in place (e.g., giving dextrose to a hypoglycemic patient) and are supported by a “qualified healthcare practitioner,” either in person or via telehealth. A “qualified healthcare practitioner,” as described by the model, meets state and regulatory requirements to provide particular healthcare services. EMTs and paramedics don’t qualify, but NPs, PAs and physicians can be used in this role.

This team can determine whether their patient needs the emergency department or if another location (e.g., an urgent care clinic or the patient’s physician’s office) would fulfill the patient’s needs. EMS will reimbursed for delivering their patient to an alternate location at the same rate as they would receive if they took them to the ED and would also receive payment for providing on site treatment.

Treat-in-place programs save the patient and healthcare system a large bill

Various other cities and institutions have begun implementing solutions to conserve resources and improve patient care. For example, in Philadelphia, the University of Pennsylvania partnered with the Philadelphia Fire Department to establish an EMS team that would respond to and triage students [3]. This team would evaluate and treat low acuity calls, such as intoxication, therefore allowing the fire department itself to respond to more emergent calls elsewhere. Students would receive appropriate medical care and follow up while also decreasing the number of ambulance transports from the campus.

The LA Fire Department similarly implemented a Nurse Practitioner Response Unit that responds to lower acuity emergency calls [4]. Staffed by an NP and paramedic, they are able to treat patients on scene and not transport.

In Idaho, EMS either transports to the emergency department, provides treatment on scene without subsequent transport or arranges transport to an alternate location (such as the patient’s doctor’s office) [5]. As EMS is run by the government, they are able to be reimbursed for their services. Other pilot programs have instituted a treat-in-place model but may not be receiving payment for their services despite saving the patient and healthcare system a large hospital bill.

CMS policies impacted by COVID-19

Treat-in-place programs give paramedics more autonomy in treatment and transport decisions, decrease healthcare costs and ultimately provide the patient with the best care. Previously, many of these programs weren’t receiving reimbursement for their services but this may change as a result of the pandemic.

During the COVID-19 pandemic, CMS changed its policies so that EMS could be reimbursed for providing treatment on site and for taking patients to a non-emergency department location. Hopefully this policy will be continued once the pandemic is over, allowing more agencies to set up treat-in-place programs and transport patients to alternate locations.

Additional treat-in-place resources

Learn more about the expanded EMT and paramedic scope of practice with these resources:


  1. Abrashkin KA, Poku A, Ramjit A, et al. Community paramedics treat high acuity conditions in the home: a prospective observational study. BMJ supportive & palliative care. 2019.
  2. Emergency Triage, Treat and Transport (ET3) Model. Centers for Medicare & Medicaid Services; 2020. Updated May 29, 2020.
  3. Mechem C, Yates C, Rush M, et al. Deployment of alternative response units in a high-volume, urban EMS system. Prehospital Emergency Care. 2020; 24(3): 378-384.
  4. Kashani S, Ito T, Guggenheim A, et al. 88 implementation of a nurse practitioner response unit in an urban EMS system. Annals of Emergency Medicine. 2016; 68(4):S37.
  5. Gonzalez Morganti K, Alpert A, Margolis G, et al. The state of innovative emergency medical service programs in the United States. Prehospital Emergency Care. 2014; 18(1):76-85.

Marianne Meyers, BS, is a third-year medical student at the University of Washington School of Medicine interested in pursuing emergency medicine. Previously, she was a member of the Santa Clara University collegiate EMS squad where she received her B.S. in Public Health Science. Additionally, she has worked with the King County Public Health Department in Seattle, Washington studying EMT naloxone administration.