ET3: What You Need to Know

Ambulance service providers across the U.S. will soon have the chance to partner with the Centers for Medicare and Medicaid Services (CMS) in an experimental 5-year payment model aimed at providing greater flexibility, reducing costs, and increasing efficiencies for Medicare beneficiaries following a 911 call.

The proposed model, called Emergency Triage, Treat, and Transport (ET3), is designed to help Medicare beneficiaries access the “most appropriate emergency services at the right time and place” by allowing ambulance companies to choose new treatment options, based on the patient’s presenting symptoms. Medicare currently pays for emergency ground ambulance services only when beneficiaries are transported to a limited number of covered destinations.

According to the CMS, this creates a perverse incentive to bring beneficiaries to high-acuity, high-cost settings (e.g., hospital emergency departments), even when a lower-acuity, lower-cost setting may more appropriately meet an individual’s needs. For example, according to the U.S. Departments of Health and Human Services and Transportation, Medicare could save $560 million per year by transporting individuals to doctors’ offices rather than a hospital ED.

New Treatment Options

ET3 organizers hypothesize that a revised payment model not only has the potential to reduce costs, but also improve the quality of care, reducing avoidable transports to the hospital ED, and reduce avoidable inpatient admissions. During this 5-year program, ET3 will pay ambulance agencies to add two additional treatment options to their services, when appropriate:

• Transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic)
• On-scene “treatment in place” with a qualified health care practitioner, either in-person of via qualified telehealth technology

A preview of the Request for Application (RFA) for potential applicants, as well as a program FAQ page, were recently released online, in efforts to begin educating agencies on the requirements, expectations, and payment model. The official application process will open in Summer 2019.

ET3 Participant Requirements

Participating agencies will be expected to align with their local resources to meet the requirements of the ET3 program, including partnerships with lower-acuity facilities and health care providers. Alternative destination sites must be enrolled in Medicare or employ or contract with Medicare-enrolled practitioners, and must be able to accept and furnish services to Medicare FFS beneficiaries. Similarly, treatment-in-place health care practitioners must be Medicare-enrolled qualified and able to furnish services, either in-person on the scene or via telehealth technology. Each ET3 participant must ensure that at least one of the non-ED options is available at all times.

It’s important to note that agencies do not have to offer the treatment-in-place option; the minimum requirement is to establish alternative transport locations. If an ambulance agency does choose to offer the on-scene treatment options, it must employ the appropriate teleheatlh technology (for example, a minimum of audio and video connectivity, as opposed to telephone-only communications). During a call, a patient who is eligible for the new intervention options may still choose to be transported to a Medicare-covered destination (like the ED) and these transports will still be covered as usual by state regulations.

Monitoring and Feedback

In its program explanation, CMS acknowledges that the ET3 model will require “robust monitoring,” both on the part of participants and the CMS. Agencies will be expected to regularly report on requested metrics, and the CMS will regularly be monitoring additional statistics to ensure no negative outcomes are inadvertently created by the new model.

Participants who demonstrate high quality of care based on performance may be eligible for a performance-based payment increases after three years of participation. Additionally, participants will be expected to participate in “learning communities” and activities, such as webinars, interviews, and in-person meetings, to ensure feedback is being received and best practices shared.

Important ET3 Dates

According to the RFA preview, the official RFA will be available in the summer of 2019. The ET3 model will have a five-year performance period with an anticipated start date of January 2020. The performance period for all participants, regardless of start date, will end at the same time; therefore only applicants selected through the first RFA will participate for the full five years. CMS anticipates utilizing a phased approach with up to three rounds of RFAs, up to two releases of NOFOs, and staggered performance start dates to encourage regional uptake and the multi-payer model.

Review the preview of the RFA, watch the ET3 webinar, or visit the FAQ page for more information.