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Create an ET3 System Now
The Emergency Triage, Treat, and Transport model—known universally to the EMS profession as ET3—has become a hopeful harbinger for the way EMS will operate in the future. The Centers for Medicare & Medicaid Services (CMS) describes ET3 as “a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare Fee-for-Service (FFS) beneficiaries following a 9-1-1 call.”
Translating that into operational-speak, the model will allow beneficiaries to access the most appropriate emergency services at the right time and place. The model will also encourage local governments, their designees, or other entities that operate or have authority over one or more 9-1-1 dispatch centers, to establish a medical triage line for low-acuity 9-1-1 calls. As a result, the ET3 model aims to improve quality and lower costs by reducing avoidable transports to the emergency department (ED) and unnecessary hospitalizations following those transports.
Under ET3, while CMS continues to pay for transport to a hospital ED, it also pays participants for transport to an alternative destination partner such as a primary care office, urgent care clinic or community health center, or to initiate treatment in place with a qualified health care partner at the scene or via telehealth.
Right Care, Right Place
When ET3 was first announced in July 2019 as a trial, there was genuine excitement about the significant change this could mean for the industry. There was hope that the model would lead to the removal of the perverse EMS incentive in the U.S. whereby payment only happens when a patient is delivered to the emergency department. The program envisions that alternative pathways will open, with patients getting care in the right place at the right time, the first time.
Applications from 184 agencies had been approved when COVID hit, delaying the program’s start. As a result, a number of people and partners moved on or changed focus. COVID brought about another change that affected ET3: With hospitals experiencing severe pressure and
This was just more evidence to a case that had already been
ET3 in the Real World
The
Hanan Cohen, director of mobile healthcare at Empress EMS in Yonkers, New York, operates a functioning ET3 program. Empress was one of the earliest implementers, and despite being very near the New Rochelle area—Ground Zero for the U.S. COVID outbreak—they remain cautious ET3 enthusiasts. “We figured out early on that treatment in place with qualified health care practitioners would certainly have the lion’s share of the volume of patients,” says Cohen.
Time has proved them right. In fact, there’s no question that the pandemic only accentuated the need for telehealth, which has become a vital link for so many patients to the health care system, he continues. Currently, nearly
A vision of the future is also on display at MedStar Mobile Healthcare in Fort Worth, Texas—one of the first agencies to sign up for ET3. MedStar has led the nation not only in developing patient-centered, in-home care but has elegantly demonstrated system cost savings and the value of such services to patients as well as insurance payers.
When an on-scene EMS practitioner has determined the caller doesn’t need to go to an ED, the patient is immediately offered to be seen by a qualified health care practitioner through a telemedicine program MedStar has set up with a local physician group. After that consult, the patient may be offered treatment in place or transportation to an urgent care center. The MedStar crews have done over 1,200 ET3 interventions to date and 92.8% of them have been treated in place.
As Matt Zavadsky, MedStar’s chief strategic integration officer, will tell anyone who listens to one of his many talks, “You don’t have to be formally involved in ET3 to run the same
Both EMS systems and insurers are highly motivated to avoid unnecessary transports and hospital stays; that makes a compelling opportunity for partnerships. Says Empress EMS’ Cohen, “You must show the value, which I believe EMS has done over and over again, and be reimbursed at a price that’s appropriate to your value.”
EMS agencies, he continues, should partner with insurers who reimburse us for the level of service we provide and see the value of treating the patient in place or delivering them to an alternate destination that's more appropriate for the patient and able to care for them at a lower cost with the same level of care.
Whether you’re launching an ET3 program or building a case to partner with a payer, technology plays a major role. The systems and solutions that handle your data are what will make the routing, scheduling and resourcing of EMS teams, vehicles and equipment much easier. Many systems are already available to enable seamless, real-time collaboration and data exchange between triage nurses, physicians, dispatchers, telecommunicators, and EMS practitioners. The right technology provides the critical foundation to implement an innovative triage, treatment and transport initiative.
So Far, So Good?
It’s probably too soon and too complicated to weigh in on the success of ET3. After all, it debuted—to quote Matt Zavadsky again—in “2019 BC: Before COVID.” The pandemic created the conditions to accelerate alternative models of patient treatment and transport along with an explosion of telehealth services. It also turned the evolution of the ET3 model into a revolution of rapid treatment strategies that have enabled us to cope and survive. But with a little work and the right systems in place, every organization can create a similar program, Cohen notes. “The heavy lift is on the individual EMS agency, which is responsible for engaging payers, educating the payers and hopefully getting a contract or a working agreement to pay for the same services that Medicare has outlined in the ET3 program.”
If ET3 can be replicated with the aid of data and partners, could we call it “mission accomplished”? The approach cannot be for local arrangements to provide local solutions, but to create an entire system and change to our industry. A national solution that changes federal reimbursement rates is absolutely necessary.
We need the proven results of the ET3 trial so we can roll this out across the country, says Cohen. We don't need to go through continuous drawn-out negotiations, he adds. “We just need to change the payment profile on the system, and they can pay for it starting tomorrow.”
Gil Glass has more than three decades of EMS experience spanning the EMS profession—from paramedic and comm center manager to director of operations, chief operating officer and general manager. Today he serves as CEO of Logis Solutions, a company that uses CAD and decision-support technologies to help public safety organizations serve their communities.
Rob Lawrence is director of strategic implementation for the ambulance service PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts. He is also the part-time executive director of the California Ambulance Association. He previously served as chief operating officer of the Richmond (Virginia) Ambulance Authority.
Comments
Finally, a possible solution to EMS units waiting sometimes hours to have their patients triaged in a local ED. Turnaround times have been a consistent problem for every EMS manager and hopefully this may be a viable solution! We shall see.
—Pete Hosey