Triaging low acuity 911 calls to telehealth services may save money…and emergency department visits.
It seems like an eternity since leaders in Emergency Medical Services (EMS) began calling for the decoupling of EMS triage, response, assessment and treatment from the requirement to transport. The perverse incentive to transport not only increases emergency department (ED) utilization, but also undermines efforts to invest in quality of care and integrate EMS into the healthcare system.
In 1997, Keith Neely published a seminal article describing a vision for EMS in which there would be multiple options at each decision point in a 911 call. The 1996 EMS Agenda for the Future and the 2006 Institute of Medicine Report: “EMS at the Crossroads” both described a future where EMS finances would be “linked to value” and “permit payment without transport.”, At long last, in February 2019, the dreams of Keith Neely and so many others in EMS came to fruition.
The Center for Medicare & Medicaid Innovation (CMMI), an entity created by the 2010 Affordable Care Act, announced a new voluntary, five-year model payment program. Under the program, participating EMS agencies responding to a 911 call will receive equivalent reimbursement for transport to either an ED, to an appropriate alternative destination (i.e. urgent care centers, primary care offices or behavioral health centers) or for performing treatment in place, either via telehealth or on-scene by a “qualified healthcare practitioner.” Additionally, local governments or other entities with authority over 911 dispatch centers will be eligible to apply for funding to develop medical triage lines for low-acuity 911 calls with the potential of avoiding the EMS response altogether.[iv]
Change of the tide
The Emergency Triage, Treat and Transport (ET3) program represents a sea-change for EMS. It signals the federal government’s interest in EMS as a gateway to the healthcare system, and shows a willingness to test new payment models and to encourage innovation. It builds upon some preliminary evidence from several recent demonstration projects, some of which were funded by CMMI’s Healthcare Innovation Awards.
Perhaps the most significant influence to the design of the ET3 program were the community health programs developed by Regional EMS Authority (REMSA) of Reno, NV. REMSA used CMMI funding to develop three innovative programs: alternative destinations, nurse health line and a community health prevention program. The nurse triage program was particularly successful, generating an estimated $5.8 million in savings by avoiding more than 4,000 ED visits and achieving 96% patient satisfaction rates. The alternative destination program was modestly successful as well as generating $1.8 million in savings by avoiding over 1,400 ED visits.[v]
Another strong influence on ET3 was the Houston Emergency TeleHealth And Navigation (ETHAN) program, which utilized telehealth to provide treatment on scene. It produced only modest rates of ED avoidance or transport to alternate destinations, but reported a 44-minute reduction in EMS task time on low acuity calls by treating patients in place via telehealth and referring the patient to non-emergent transport.[vi] A number of other projects, including one by the Los Angeles Fire Department and a project funded by CMMI healthcare innovation award in Mesa, AZ, have experimented with deploying nurse practitioners as part of the 911 system to provide treatment on scene.
The implications of ET3 for the future of EMS are significant. Long overdue cleavage of reimbursement from transport may help unleash a lot of pent up innovation. The program rather overtly encourages partnerships between EMS and urgent care centers and telehealth networks. Potentially, it also broadens the opportunity for EMS to implement point-of-care lab testing in the field or decision support applications. Additionally, ET3 might stimulate improved bidirectional communication pathways and/or sharing of outcome information between EMS and hospitals or other healthcare provider networks. Perhaps it opens the door to stronger collaborations and treatment paradigms for hospice and palliative care patients.
Despite this nearly boundless potential for the EMS profession and industry to reinvent itself, a number of important issues need to be addressed to make sure this model can realize its anticipated value and move from demonstration project to Medicare policy.
Three steps of ET3
First, EMS agencies and their medical directors will need to come up with protocols, procedures and training to safely identify appropriate patients for ET3 model alternative destinations or treatment in place. This will need to be done despite the lack of pre-existing evidence-based protocols for doing so.
Second, it will be extremely difficult to implement the model without other payers (Medicare Advantage plans, state Medicaid programs and commercial payers) getting on board. EMS agencies and their partnering telehealth providers and alternative destinations will need to either accept all patients, including the uninsured or find alternative strategies that maintain compliance with EMTALA and maintain the public trust in 911.
Third, EMS regulatory structures in at least some states and municipalities will have to demonstrate new-found flexibility and open-mindedness to accommodate agencies wishing to participate in the model payment program.
One of the greatest limitations of the program is its limitation to 911 calls only. This severely limits the opportunity to partner with hospitals, health systems or accountable care organizations that have spent the last few years developing a myriad of unique partnerships with EMS. These partnerships help to support coordinated emergency care and other initiatives, sometimes referred to as mobile integrated healthcare or community paramedicine. Hopefully, CMMI is not finished with exploring the opportunities for innovation within EMS and will revisit these models in future programs.
At present, EMS agencies that have applied and their partners in urgent care, primary care and telehealth, are eagerly awaiting CMMI’s announcement of first-round program participants. When the announcement comes, and the official launch date of program implementation is announced, it will be as if a gun went off at the start of a track and field event.
The race will be on to bring to life on a grand scale the vision of Keith Neely and so many other legendary leaders of the EMS profession. We stand upon the precipice of change. Let’s take the leap. Let us show the world that we can fly.
 Neely KW, Drake MER, Moorhead JC, Schmidt TA, Skeen DT, Wilson EA: Multiple options and unique pathways: A new direction for EMS? Ann Emerg Med December 1997;30:797-799.
 Emergency Medical Services Agenda for the Future. Washington, D.C.: National Highway Traffic Safety Administration; 1996.
 Emergency Medical Services At the Crossroads. Washington, D.C.: Institute of Medicine; 2007.
[iv] Emergency Triage, Treat, and Transport (ET3) Model. Washington, DC. Center for Medicare & Medicaid Services, 2019. https://innovation.cms.gov/initiatives/et3/. Accessed February 14, 2019.
[v] A Model for Better Community Health. Reno, NV. Regional EMS Authority (REMSA); 2017.
[vi] Langabeer JR, 2nd, Gonzalez M, Alqusairi D, et al. Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to Urban Emergency Departments. The Western Journal of Emergency Medicine 2016;17:713-20.