A new payment model by the Center for Medicare and Medicaid Innovation (CMMI) hopes to reduce low-acuity hospital visits by allowing ambulance care teams to provide care and transportation based on a patient’s health needs rather than rigid Medicare guidelines.
The Emergency Triage, Treat, and Transport (ET3) Model is a voluntary, five-year payment model that allows Medicare-enrolled ambulance service suppliers and hospital-owned ambulance providers, with the support of local governments, their designees, or other entities that operate 911 dispatches, to determine what level of care a Medicare beneficiary needs and then either transport the patient to an appropriate care site (which can include a hospital emergency department, as well as a primary care doctor’s office or an urgent care center) or treat the patient onsite by a qualified health care practitioner, either on the scene or connected using telehealth.
“This model will create a new set of incentives for emergency transport and care, ensuring patients get convenient, appropriate treatment in whatever setting makes sense for them,” said HHS Secretary Alex Azar, in a prepared statement announcing the model. “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.”
Shift in Policy
The new payment model represents a significant shift in policy for EMS services because Medicare currently pays only for transportation to hospitals, critical access hospitals, skilled nursing facilities, and dialysis centers. And most beneficiaries who call 911 are transported to emergency departments, regardless of their health needs.
In addition to providing care in more appropriate settings, the potential cost savings range anywhere from $560 million, based on a white paper by the U.S. Departments of Health and Human Services and Transportation, to $1 billion, based on a comment by Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma, who said at a press conference that 19 percent of Medicare fee-for-service beneficiaries could be treated at home or in another, cheaper facility for their emergency needs rather than being treated in an ED. The ET3 model also includes a built-in value-based incentive, enabling participating ambulance suppliers and providers to earn up to a 5 percent payment adjustment in later years of the model based on successfully performing quality measures.
The cost savings for Medicare beneficiaries themselves would also stem from avoiding unnecessary trips to the ED, but according to Adam Boehler, director of CMMI who’s shepherding the model, copayments for ambulance transport will remain the same regardless of where they’re taken.
Not the First
Interestingly, CMMI is not the first to use triage and telehealth to reduce low-acuity ED visits and reduce ED spending by diverting patients to more appropriate places of care. In fact, one emergency physician group has been doing the same thing themselves since 2014.
Wake Emergency Physicians PA (WEPPA) is a private practice group of 102 doctors and 65 PAs operating in nine emergency departments through North Carolina. In 2014, the group started their own telemedicine service called RelyMD, which is 100% owned and staffed by the group.
While RelyMD started out as more of a typical tele-urgent care, that wasn’t the real reason the service was created.
“We started looking at telemedicine in the pre-hospital setting to avoid unnecessary EMS transport,” said WEPPA’s Bobby Park, MD, in a recent Emergency Physicians Monthly article. “The diversion rate of people going to the emergency department is around 10 to 20 percent of the visits that we see, based on survey data.”
RelyMD currently contracts with self-insured companies and hospitals, along with Medicaid, in an attempt to lower the number of avoidable ED visits and reduce overall costs.
“Every single one of our hospital partners has stayed on as clients year over year because they get a return on their investment,” Park said. “If they spend X, they typically save two to three times X.”
ET3 Timeline
As for Medicare’s new ET3, as many as 30 percent of Medicare beneficiaries could be affected by the new payment model, which is expected to begin in January 2020. CMMI will release a Request for Applications (RFA) in Summer 2019, and those Medicare-enrolled ambulance suppliers and providers that are selected will be announced in Fall 2019. Two subsequent rounds of Request for Applications will be offered once the program is up and running, with rolling start dates for those participants. The program will end at the same time for all participants, with the end date currently slated for December 31, 2025.
CMMI also will provide funding for two-year cooperative agreements for up to 40 local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate.
CMS hopes other payers, including Medicaid and commercial plans, will also participate in the voluntary model, especially since anyone who calls 911 and is connected to a dispatch system in the payment model will be screened for eligibility for medical triage services prior to ambulance initiation.
For more information, review the following resources about Medicare’s new ET3 payment model:
- CMS’s Emergency Triage, Treat, and Transport (ET3) Model Fact Sheet
- CMS’s Press Release: “HHS launches innovative payment model with new treatment and transport options to more appropriately and effectively meet beneficiaries’ emergency needs”
- FierceHealth’s “CMS launches new model for paying ambulance crews—even if they don’t transport to the ER”
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