Thinking About Applying for CMS’ New ET3 Model?

The EMS community has been buzzing since the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) announced the Emergency Triage, Treat and Transport (ET3) Model. CMS has conducted a national press conference and three webinars explaining the model. Although many aspects of the program are still in development, the main tenets of the model have been well articulated and ambulance services will likely become eligible to apply by mid to late summer. Given the ambitious timeline communicated by CMS, it’s not too early to begin thinking about considerations if you are evaluating whether or not to apply for this voluntary Alternate Payment Model (APM).

We couldn’t be more pleased that CMMI has announced the ET3 project, as we believe this to be a patient-centered initiative that will undoubtedly improve patient care and create efficiencies for EMS and hospital systems.

On March 25, 2019, the National Association of Emergency Medical Technicians (NAEMT), the International Association of Fire Chiefs (IAFC) and the National Association of EMS Physicians (NAEMSP) conducted a webinar sponsored by ESO Solutions and FirstWatch, to begin educating agencies on what they should be considering now if they plan on applying for the ET3 APM.

The salient points of that webinar are outlined in part one of this two part article series. The next article will provide responses to the most frequently asked questions regarding the ET3 model. (To view a recording of the ET3 webinar, go to

Clinical Considerations

First, let us begin by stating and offer the following for EMS physicians to consider as the application for–and implementation of–ET3 pilot programs progresses:

Assurance of Quality and Patient Safety:
The EMS physician or physicians who serve as medical directors for EMS systems have traditionally been responsible for credentialing personnel who function within the system. The ET3 pilot contemplates allowing on-scene telemedicine as well as transportation to alternative sites. Our first priority is to do no harm as we work to assure patient safety; we would, therefore, be strongly in favor of utilization of the traditional credentialing pathways for any clinician or provider who seeks to participate in the ET3 program. In this way, reporting of outcomes, assurance of availability, and performance improvement activities can be readily implemented. The absence of such a defined and practiced credentialing process could result in a situation where clinicians and providers unfamiliar with EMS scope of care are rendering medical opinions, leading to less than ideal outcomes for patients. Obviously, we support a public and transparent process for this credentialing such that there is not an undue restriction of markets or overly burdensome processes.

Appropriate Differentiation of Traditional EMS vs. ET3 Utilization:
Many EMS and EM physicians participate routinely in online medical direction for a host of critical patients, as well as those who are refusing transport. In many cases, these patients may be better served by telemedicine, inclusive of two-way video communications. At what point would a high-risk refusal patient in the traditional EMS sense become an ET3 telemedicine encounter? These and similar issues identify concepts that should be considered prior to program initiation.

Appropriate Accounting for Actual and Perceived Conflicts of Interest:
Whether the telemedicine provider is an EMS physician or provider in another facility, there undoubtedly will be patients who have an ET3 telemedicine encounter who may be appropriately referred for transport by EMS or as a follow up at some point in the future. We must assure appropriate alignment of incentives and transparency to prevent unintended consequences.

Appropriate Performance Metrics
We are all keenly interested in patient safety, quality of care and cost accounting. The ability to track and report metrics and measures that demonstrate safety, experience of care, effectiveness and efficiency will be crucial. Assure you have processes in place that can evaluate and report key performance metrics. In the early discussions with CMS and CMMI, we provided examples of metrics such as:

  • Treatment in an ED within 6, 12, or 24 hours of an ET3 encounter, inclusive of outcomes from the second encounter (Patient Safety Measure);
  • Repeat EMS visit within 6,12, or 24 hours of an ET3 encounter, inclusive of outcomes from the second encounter (Patient Safety Measure);
  • Patient satisfaction and/or family satisfaction (Patient Experience Measure);
  • Total task time for EMS for non-transport, alternative transport and ED transport (Operational Efficiency Measure);
  • EMS personnel and other clinician and provider satisfaction scores (Practitioner Satisfaction/Balancing Measure); and
  • Pre- and post-implementation transport ratio (Economic Efficiency Measure).

Operational Considerations

Currently Licensed Ambulance Providers:
Eligibility for this model is limited to ambulance providers and suppliers that are currently licensed and are participating with the Medicare program, as evidenced by the agency having a National Provider Identification (NPI) number with Medicare. Participation in this model means you will be eligible for Medicare reimbursement for providing treat in place, or transport to alternate destination services to Medicare Fee For Service (FFS) beneficiaries. Reimbursement eligibility for either of these two patient outcomes only applies if an ambulance responds to a 9-1-1 call for EMS assistance. A first response unit only, even if the first response agency is the same provider as the ambulance, will not be a reimbursable service under this model.

Telehealth Required for Treat in Place:
CMS articulated many times that any beneficiary who calls 9-1-1 should have the opportunity to be seen by a qualified healthcare practitioner (QHP). In Medicare terms, a QHP is a person or entity that is eligible for reimbursement for telemedicine or telehealth services, such as a physician, physician assistant or nurse practitioner. CMS has previously defined telehealth services as an interactive audio and video telecommunications system that permits real-time communication between the QHP and the beneficiary.1 The QHP will be eligible for Medicare reimbursement for services provided to Medicare FFS beneficiaries under the ET3 model. This means that to be eligible for reimbursement under an approved ET3 model, you will need to have the technology and processes in place to facilitate real time audio and video communications from the scene of the ambulance response. To assist the reimbursement process for the ambulance agency and the QHP, it’s likely there will need to be some process that links the patient encounter by the ambulance crew with the telehealth services provided by the QHP.

No Telehealth Requirement for Alternate Destinations:
Ambulance transport to alternate destinations will not require a telehealth intervention, meaning that this patient outcome could be “protocolized” to the level that your agency’s medical director authorizes. For example, a protocol that includes a list of inclusion, and more importantly, exclusion criteria for alternate destination could be established by your medical authority.

Dispatch Agency Reimbursement:
Under the proposed ET3 model, select dispatch centers operated by local governmental authorities that provide medical triage services will also be eligible for funding. This will be limited to dispatch agencies that provide dispatch services for an ambulance agency that has been approved and enrolled in the ET3 model under the alternative destination or telehealth programs. CMS hasn’t yet identified the financial model the reimbursement would follow and understands that reimbursing only for FFS beneficiaries may not provide enough funding to fully implement call triage in all dispatch centers.

Financial/Community/Regulatory Considerations

Is This Allowed in Your Operating Area?:
Some state or local regulations may not allow ambulances to transport to alternate destinations from 9-1-1 responses. Similarly, there may be local or state rules that preclude the ability for EMTs and paramedics from offering alternate dispositions. Knowing whether or not an ET3 model is even legal in your area is a crucial step early in the ET3 model implementation evaluation process. If it’s not, begin conversations with those who can either change the rules, or in some cases, have the ability to grant a special waiver to facilitate the implementation of an ET3 service delivery model.

Financial Triage:
EMTs and paramedics generally don’t engage in extensive financial eligibility discussions on the scene of a 9-1-1 call. Since reimbursement for ET3 services will be limited to Medicare FFS beneficiaries, agencies will need to determine the best way to educate field crews how to identify eligible patients. Our advice (and CMS’ desire) is that agencies attempt to work with other payers in their service area (e.g., Medicare Advantage, Medicaid, commercial) to adopt similar models. This will make it easier to implement the model in larger patient populations, perhaps all patients, regardless of payer source. A great way to start this process is to get a payer report from your billing department, identify your largest payers, and begin those discussions. It is also possible that multi-payer integration for ET3 services will be an evaluation criteria for ET3 model approval.

Partner Engagement:
There are numerous stakeholders who may be impacted if your agency is approved for the ET3 model. Hospitals may be concerned about a reduction in Medicare or other payer beneficiaries coming to the ED by ambulance. Have conversations with them early to explain the model and seek their input. Under the ET3 model, you need a network of alternate destinations to transport, or refer patients to–without this referral network, success could be elusive. Engagement by community clinics, urgent care centers and large physician practice groups will be crucial to the ET3 model. Finally, due to the potential patient care and economic risk of the model, assure your medical director and governing body are appropriately involved during this crucial step.

Demonstration of Value:
The bottom line to this model is to prove to CMS and other payers that we can safely navigate patients to care locations other than an ED. It may be advisable for you to take a deep dive into your current transport ratio and the types of patients that fall into the payer categories who might be eligible for dispositions other than a transport to the ED. For example, if your transport ratio is already low because you have an operating MIH-CP program that includes protocols that facilitate enhanced alternate destinations, getting the ratio lower may be a difficult task. Further, if you have a unique patient demographic with an appropriately high transport ratio, it may be similarly difficult to safely reduce that ratio.

These are very interesting times for EMS and the patients and communities we serve. The ET3 model is something many of us have been advocating for years, even decades. Appropriately implementing the model in your service area is absolutely essential to change the value proposition for EMS.

In the next article in this series, we will attempt to provide guidance on some of the most frequently asked questions regarding implementation of the ET3 model.


1. Medicare Learning Network. (January 2019.) Telehealth Services. Centers for Medicare and Medicaid Services. Retrieved April 4, 2019, from

Figure 1: Payer Mix Analysis: Analyzing your payer mix breakdown could help you identify the potential the percentage of your patient transports by payer type.

Figure 2: Transport Outcome Analysis:
This type of analysis would be helpful to determine a baseline for measuring any changes from pre and post ET3 implementation.

Figure 3: Primary Impression analysis for patient contacts and transport outcomes:
This type of analysis could potentially assist with the development of protocols and estimates for potential pre and post implementation patient outcomes.
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Brent Myers, MD, MPH, FACEP, FAEMS, is the president of the National Association of EMS Physicians (NAEMSP) and the chief medical officer for ESO Solutions.

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