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Emergency Triage, Treat and Transport Model

October 14, 2019


The first round of applications was recently closed for the Emergency Triage, Treat and Transport Model (ET3), a voluntary, five-year payment model designed to go live in January 2020.   


The ET3 Model is an important initiative which may lead to further breakthroughs, and was designed to provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare Fee-for-Service (FFS) beneficiaries following a 911 call.


The Problem


As we know, Medicare currently pays for emergency ground ambulance services only when beneficiaries are transported to a limited number of covered destinations, which creates a harmful incentive to bring beneficiaries to high-acuity, high-cost settings, e.g., hospital EDs, even when a lower-acuity, lower-cost setting may better meet an individual's needs.


The Basics of ET3


ET3 participants will be Medicare-enrolled ambulance suppliers or hospital-based ambulance providers, selected on criteria set forth in the Request for Application (RFA). Of note, the ET3 model will test two new Medicare payments to participants:


  • Payment for ambulance transport of Medicare FFS beneficiaries to alternative destinations not currently covered by Medicare
  • Payment for treatment in place when appropriate, rendered by a qualified health care practitioner (QHP) at the scene of a 911 emergency response or via telehealth.


The model aims to provide person-centered care, such that beneficiaries receive the appropriate level of care delivered safely at the right time and place while having greater control of their health care through the availability of more options.


At the same time, the plan is to encourage appropriate utilization of services to meet health care needs effectively, while increasing efficiency in the EMS system to allow for more rapid response to time-sensitive conditions.


In time, payments may be tied to performance on key quality measures designed to hold participants accountable for the quality of model interventions. This would happen no earlier than Year 3 of the model performance period.


For interested suppliers and providers, it is necessary to understand the requirements, and to develop partnerships with alternative destination sites and/or Medicare-enrolled QHPs, depending on which model interventions are to be delivered.


Three Options


A participant in the ET3 model may offer up to three options when responding to a 911 call placed by or on behalf of a Medicare FFS beneficiary whose condition qualifies:


  • Option 1: Transport the beneficiary to a covered destination, e.g. hospital emergency department. Of course, this is nothing new.
  • Option 2: Transport the beneficiary to an appropriate, lower-acuity alternative destination
  • Option 3: Initiate and facilitate treatment in place by a QHP either in-person on the scene or via telehealth


Of note: At a minimum, all participants must agree to implement the alternative destination transport intervention, whereas the treatment in place intervention is optional.


Alternative Destinations


As indicated earlier, participants must partner with alternative destination sites, which must be able to accept and furnish services to Medicare FFS beneficiaries who are transported to these sites.  Alternative destination sites include: 


  • a Medicare-enrolled institutional provider
  • a group practice that includes Medicare-enrolled QHPs
  • a solo practitioner
  • a non-Medicare-enrolled entity that employs or contracts with Medicare-enrolled QHPs who can furnish covered services to Medicare FFS beneficiaries


Examples include but are not necessarily limited to urgent care centers, primary care offices, community centers, behavioral health centers, and drug and alcohol rehab centers.


Likewise, a participant that transports a beneficiary to an approved alternative destination will receive payment at a rate equivalent to the current Medicare Part B ambulance fee schedule for:


  • BLS Emergency Transportation
  • ALS Emergency Transportation
  • Mileage


Treatment in Place


Participants who intend to implement the treatment in place intervention must partner with Medicare-enrolled QHPs to furnish services, which can be provided either in-person on the scene or via telehealth.


For the telehealth approach, a participant would need to use multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient and distant-site physician or practitioner.  Telephones, faxes and email would not meet the definition.


Regarding payment, a participant that facilitates in-person treatment in place will be paid an amount equivalent to the BLS-E or ALS1-E base rate, depending on the level of service provided.  A participant that facilitates treatment in place via telehealth will be paid a modified telehealth originating site facility fee equivalent to the BLS-E or ALS1-E base rate.


Similar to the payments for transport to alternative destinations, aligning participant payments for treatment in place with the appropriate BLS-E or ALS1-E base rate payment will align incentives to promote interventions that most appropriately address beneficiary needs.


What does the immediate future hold?


The way CMS designed the rules for the ET3 model, it's clearly favoring areas of higher population density.


There are good reasons for this, including a better chance of success if the program is tested by larger EMS agencies with access to greater resources, not to mention there are more opportunities in areas that experience higher volume. However, rural and super rural agencies could also benefit greatly as they are often faced with long trips that can make it hard to return to service in a timely manner.


For many, the next step will simply be to wait and see which applicants are chosen.  For others who are interested in participating, there is no time to waste.  A compelling plan will take time to build.


Additional Information


Click here to visit the CMS site and learn more about the ET3 program.

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