ET3 or Not, EMS Needs a Better Reimbursement Model

Gil Glass

Chief Executive Officer, US
Inspired by a product that makes a difference and motivated by a talented staff, Gil has a passion for using technology to help communities.

You don’t need me to tell you that not every patient for whom an ambulance is called belongs in the hospital. And yet we know that too often, that’s exactly what happens.

According to a 2019 Centers for Medicare & Medicaid Services (CMS) presentation, 16% of Medicare fee-for-service emergency ambulance transports to a hospital could have been treated in a lower-acuity setting. What’s more, appropriately transporting people to a doctor’s office rather than an emergency department (ED) would save $560 million a year in Medicare costs.

So why isn’t this happening? Because Medicare primarily pays for emergency ground ambulance services only when a patient is transported to a limited number of covered destinations, like hospital EDs. Incentives drive behavior, after all, and few things are more incentivizing than getting paid.

Remember ET3?

You may recall that a few years ago CMS attempted to re-align these incentives. The agency announced a new, voluntary payment model called Emergency, Triage, Treat, and Transport (ET3). The goal was to test the idea that giving ambulance crews more flexibility in determining what destination, if any, was needed for the patient, would provide better care for the patient and would cost less for Medicare patients.

Under ET3, while CMS would continue to pay for transport to a hospital ED, it would also begin paying participants for transport to an alternative destination partner such as a primary care office, urgent care clinic or a community health center, or to initiate treatment in place with a qualified healthcare partner at the scene or via telehealth. When ET3 was first announced, there was genuine excitement about what a game-changer this could be for the industry.

Unfortunately, COVID hit and the program start was delayed. Ultimately, though, there were 184 agencies whose applications were approved. While ET3 is continuing for those agencies for the duration of the five-year program, it won’t affect national reimbursement policy as was originally hoped.

An Idea Whose Time Has Come 

While the ET3 program won’t have the impact we’d hoped, that doesn’t mean the idea didn’t have merit. Or that our industry shouldn’t be coming up with solutions that align the ways in which we’re reimbursed with what’s best for our patients. In a time when healthcare expenses continue to rise, an approach that ensures patients get the right care at the right place and also cuts costs—well, that’s something to consider very seriously.

It’s easy to see how a mentality of “take the patient to the ED because that’s how we get paid” limits innovation. I believe that an ET3-type initiative that focuses on the patient rather than the payment must be pushed to the forefront—not just from the EMS side but also by those who work in hospitals. They also have skin in this game, as many struggle to recruit and retain the necessary staff to care for an influx of patients. It’s easy to imagine how much pressure on hospitals could be relieved if a sizable percentage of patients could be better treated in a more appropriate and less costly setting.

The bottom line is that we need our colleagues in healthcare and elsewhere to view EMS as much more than just transport, that they are a critical part of the healthcare ecosystem—not just for Medicare and Medicaid patients but for all patients, regardless of payer.

What Innovation Might Look Like

It’s not enough to simply raise the question of how we get reimbursed for alternative destinations, though. That’s why I’ve given a lot of thought to what the solution might be. (And if you haven’t already, read the EMS Agenda 2050 document, which addresses this in detail.) As the CEO of a software company, you won’t be surprised to hear that I believe creating a people-focused system (patient, caregivers, community) requires, among other things, the right technology tools. The good news is that those already exist.

These solutions make the routing, scheduling and resourcing of EMS teams, vehicles and equipment easier. They enable seamless, real-time collaboration and data exchange between triage nurses, physicians, dispatchers, telecommunicators, and EMTs/paramedics. In short, the right technology provides the critical foundation to implement an innovative triage, treat and transport initiative. Not in 2050, not next year or even next month. Today.

At Logis, we built our computer-aided dispatch (CAD) platform, called Intelligent Decision Support (IDS), for a range of public safety organizations—EMS, the fire service and mobile integrated healthcare. But while the role of those who use it may differ, IDS and the solutions that work off this foundation share a single goal: to make the entire process more informed, efficient, cost-effective, and safer. This should be the case whether you’re a patient, a provider, or a public safety professional.

One of our customers, MedStar Mobile Healthcare, in Fort Worth, Texas, was one of the first organizations to sign up for CMS’ ET3 program. Now, when a patient calls 911 and the trained 911 telecommunicator has determined the caller doesn’t need to go to an ED, they’re immediately offered to be seen by a qualified healthcare 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. MedStar’s model is a proof-of-concept that could and should be adopted more widely.

We Need People and Processes, Too

We all know that even the best technology can only take you so far. A modern model for alternative destination emergency response and reimbursement requires creating a partner network that also includes EMS organizations, health plans and healthcare providers, like MedStar’s collaboration with local doctors. Again, this isn’t a future state but a program that some healthcare organizations are successfully operating today.

The last essential element? Skilled professionals tasked with putting the new model in place. Triage nurses who can help determine the right destination during a 911 call. EMTs ready to deliver the right treatment on-site or en route to the appropriate destination. Trained telecommunicators able to book appointments with the right healthcare professional during a 911 call. Each of these, and others beyond, will be critical.

The failure of the federal ET3 program to institutionalize change should not be the end of the effort to dramatically improve emergency response. We need to get patients the right care when and where they need to while still ensuring EMS professionals are compensated for the work they do. There’s too much at stake not to try.

When we put the patient—not payment—at the center of everything we do and leverage technology to deliver care and find efficiencies and savings, there’s no limit to what we can achieve.

If you’re looking for your next computer-aided dispatch system or want to talk about any Logis products, we’d love to start a conversation.

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