ET3 - A New Care Paradigm
How the CMS Innovation Center's ET3 Initiative transforms the role of EMS and ambulance operators in patient care
The CMS Innovation Center’s long-awaited Emergency Triage, Treat and Transport Model (ET3) is scheduled to go live next month. ET3 proposes a much-needed paradigm shift in the role of EMS and ambulance operators within the healthcare continuum, while illustrating how the combination of technology (e.g. telemedicine) and intuitive protocols makes healthcare work better.
The Problem
In 2017, the US registered 139mm emergency department visits, of which 14.5% were patients who arrived via ambulance.
Source: CDC 2017 Emergency Department Data
Many ED visits are unnecessary (an extreme example being the “frequent-fliers” who consistently call in for non-emergencies). Excluding “super-users,” a significant number of visits are low acuity patients showing up to the ED when they could have been treated in lower acuity settings. Unnecessary visits drive ED overcrowding and higher cost of care.
Source: CMS Webinar: Emergency Triage, Treat, and Transport (ET3) Model - Overview
The present Medicare reimbursement system for ambulance operators creates a significant misalignment of incentives which exacerbates the problem:
Since Medicare was established in 1965, ambulance suppliers have been reimbursed for the transport of beneficiaries to and between hospitals, dialysis clinics, and skilled nursing facilities (SNF). As the scope of practice of the emergency medical technician expanded, CMS updated the reimbursement policy to account for the level of care provided while en route. Though the current rule includes eight separate levels of service, the model still requires the transport of a beneficiary to one of the aforementioned locations to qualify for reimbursement. When someone calls 911 for a non-acute event, there is a financial incentive for suppliers to transport them to an ED when alternative care by EMS providers may result in higher quality patient-centered care at a significantly lower cost.
Source: EMS Innovation White Paper, 2013 (emphasis added).
The CDC’s annual emergency department data further illustrates the pain that is being felt as a result of this misalignment across EDs nationwide:
Long wait times:
Many patients with non-urgent issues showing up to the ED*:
A lot of ED visits (e.g. minor injuries) could be easily triaged in another setting (e.g. a telemedicine visit):
Source: CDC 2017 Emergency Department Data. Note - of the interesting nuggets in the data here, my favorite is the >800k annual ED visits for “effects of foreign body entering through natural orifice.” Ouch.
Bringing the ED to You
ET3 lays out new protocols for dealing with 911 calls, emphasizing triaging patients in lower acuity, lower cost settings:
Source: CMS Webinar: Emergency Triage, Treat, and Transport (ET3) Model - Overview
Whereas in the past, ambulance operators were reimbursed only for transporting a patient to a high acuity setting, ET3 offers reimbursement for:
Telemedicine intervention at the point of 911 call (i.e. 911 dispatch operator loops in a clinician to interact with patient on the phone)
Telemedicine intervention “in-place” at the point of ambulance pickup (i.e. EMTs loop in a clinician at the patient’s home)
Transport to lower acuity settings (i.e. ambulance takes the patient to an urgent care center instead of a hospital ED)
Shifting these low-acuity patients out of the ED offers benefits for all stakeholders:
Hospitals can focus on the higher acuity patients (who are likely to generate more revenue downstream for the health system)
Payors see significant cost savings as patients are treated in lower cost settings
Burden on ER docs and staff is eased by diminished crowding (ER clinicians have some of the highest “burnout” rates across specialties)
Ambulance operators can generate additional revenue streams by providing in-place care
Patients get the right care faster, yielding better outcomes
The Way it Should Work
There will be challenges in implementing this new model of care:
Implementation will require re-engineering already complex workflows for 911 operators; e.g. 911 dispatchers will have to determine eligibility and coverage status on the line with the patient (who might be panicking during a medical emergency)
People with private/commercial or no health insurance would need to be layered into this paradigm eventually; this further expands the challenge of determining eligibility for the ET3 protocols
Patients may be reluctant to participate. If a patient insists on going to an ED, it’s not clear that ambulance operators would have a mandate to steer the patient to a lower cost setting
Operators might have liability issues if they steer patients away from the ED and it turns out that the patient really did have a highly acute issue (e.g. a patient may describe symptoms that a clinician deems innocuous, which may end up being a significant health issue)
The above challenges highlight a need for technology that can connect disparate silos of information to surface critical patient information to each decisionmaker in this chain. For example, 911 operators would benefit from technology that automatically indicates what, if any, coverage a caller has to seamlessly determine eligibility. If a clinician could review a patient’s health record while the ambulance is headed to the patient’s home, the process of triaging the patient’s issue could be meaningfully expedited. While this level of interoperability may take time to realize, it will be the key to unlocking smooth collaboration between these entities.
In a system that often feels unintuitive, ET3 feels like an example of healthcare working the way it should. It will be interesting to see how the selected participants fare in the program’s inaugural year.
Related stuff I read:
Gary Ludwig for FIREHOUSE Magazine - EMS: Ambulance Companies: A History Lesson
Marc Eckstein for Health Affairs - The Ambulance Industry Struggles To Go The Distance
(*) Emergency Severity Index mapped out as a decision tree:
Source: Emergency Department Triage: An Ethical Analysis
Please don’t sue me:
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