March 27, 2019

At a Glance: HHS Emergency Triage Treat and Transport Payment Model

What was announced?

On February 14, 2019, the Center for Medicare and Medicaid Innovation (CMMI) within the Department of Health and Human Services announced a new payment and service delivery model called Emergency Triage, Treat, and Transport (ET3). This voluntary CMMI payment initiative will be a 5-year program that seeks to allow Medicare beneficiaries to receive the right care at the right time and place and includes payments for alternatives to emergency department transport, including the use of telemedicine to treat patients in place.

What are the model’s goals?

The ET3 model seeks to reduce expenditures while preserving and enhancing quality of care through three goals:

  • Provide person-centered care. Deliver safe care at the right time and place.
  • Encourage appropriate utilization of services.
  • Increase efficiency in the EMS system so that EMS may better focus on high-acuity cases.

What will be covered?

Currently, CMS pays ambulance providers to transport beneficiaries who call 911 to the emergency department and a few other select locations. Under the ET3 model, CMS will expand payment for participating ambulance suppliers and providers to

  • Transport an individual to a hospital emergency department or other destination covered under the regulations
  • Transport to an alternative destination such as a primary care office or urgent care clinic
  • Provide treatment in place with a qualified care practitioner, either on the scene or using telehealth

CMS will pay participants as a telehealth originating site at a rate equivalent to the base BLS ambulance rate for transport or for treatment in place with a qualified provider (Physician, NP). Qualified providers that treat patients in place will be able to bill for these services separately and will be eligible for an increased payment rate during non-business hours. Funding for local governments or other entities to develop medical triage lines to manage low-acuity complaints. Starting in year 3 of the program, participants also will have the opportunity to earn up to an additional 5% in model payments based on performance quality measures.

When will the ET3 payment model start?

A Request for Applications (RFA) will be released in the summer of 2019. Participants and the Notice of Funding Opportunity will be released by Fall 2019. The cooperate agreement awards will be available to participants in early 2020. CMS encourages those interested in the ET3 model to begin making cooperative agreements with local governments, its designees, or other entities that operate or have authority over one or more 911 dispatches.

How could ET3 benefit telemedicine use for emergencies?

CMMI released only limited information on the ET3 model, and many questions need to be answered before the full impact of the ET3 innovation can be fully appreciated. Although a role for telemedicine was specifically mentioned in the published materials, CMMI needs to clarify telemedicine documentation, collaboration, coding, and other requirements. Currently, CMS has many restrictions on billing for telemedicine services including if the patient is in a healthcare shortage area, Metropolitan Statistical area (MSA), or a CMS approved origination site. Potentially, the ET3 program could expand Medicare payments to qualified providers for unscheduled emergency telemedicine care in association with a licensed ambulance on a 911 call.  However, it is also possible the current limitations on telemedicine could remain in place. Additionally, the level of collaboration that will be required between physicians, physician assistants, nurse practitioners, EMS providers, EMS directors, and government agencies is not defined. More details will likely be made available by CMMI when the Request for Applications occurs this summer.

Where can I find more information?

Current information, including fact sheets and webinar information, is available on the CMS Innovation Center website or by e-mail.

Michael Baker, MD, FACEP