The Emergency Triage, Treat, and Transport (ET3) Model: The Future of EMS
The Emergency Triage, Treat, and Transport model—known universally to the EMS profession as ET3—has become a hopeful harbinger for the way EMS will operate in the future. The Centers for Medicare & Medicaid Services (CMS) describes ET3 as “a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare Fee-for-Service (FFS) beneficiaries following a 9-1-1 call.” Translating that into operational-speak, the model will allow beneficiaries to access the most appropriate emergency services at the right time and place.
Core Objectives and Operational Pathways
The ET3 model aims to improve quality and lower costs by reducing avoidable transports to the emergency department (ED) and unnecessary hospitalizations following those transports. The program envisions that alternative pathways will open, with patients getting care in the right place at the right time, the first time. The model will also encourage local governments, their designees, or other entities that operate or have authority over one or more 9-1-1 dispatch centers, to establish a medical triage line for low-acuity 9-1-1 calls.
Under ET3, while CMS continues to pay for transport to a hospital ED, it also pays participants for:
- Transport to an alternative destination partner such as a primary care office, urgent care clinic or community health center.
- Initiating treatment in place with a qualified health care partner at the scene or via telehealth.
Economic Impact and Efficiency Data
There was hope that the model would lead to the removal of the perverse EMS incentive in the U.S. whereby payment only happens when a patient is delivered to the emergency department. According to a 2019 CMS presentation, for example, 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 ED would save $560 million a year in Medicare costs, according to their numbers.
The following table outlines the potential impact and scale of the ET3 model based on CMS data:
| Metric | Data Value |
|---|---|
| Potential Annual Medicare Savings | $560 Million |
| Transports Treatable in Lower-Acuity Settings | 16% |
| Initially Approved Agency Applications | 184 |
ET3 in the Real World: Implementation at Empress EMS
Hanan Cohen, director of mobile healthcare at Empress EMS in Yonkers, New York, operates a functioning ET3 program. Empress was one of the earliest implementers, and despite being very near Ground Zero for the U.S. COVID outbreak, they remain cautious ET3 enthusiasts. “We figured out early on that treatment in place with qualified health care practitioners would certainly have the lion’s share of the volume of patients,” says Cohen. Currently, nearly all of Empress EMS’ low-acuity patients are being served by treatment-in-place with a qualified health care practitioner along with a member of the EMS team, whether an EMT or paramedic dispatched to a low-acuity call.
The Role of Telehealth and COVID-19 Adjustments
COVID brought about another change that affected ET3. With hospitals experiencing severe pressure, the American Rescue Plan Act of 2021 gave CMS the funding for a Treatment in Place (TIP) waiver program. This allows ground ambulance services to seek reimbursement for not transporting a patient, providing the EMS service is acting within local COVID treatment protocols. In the view of many, this proved the case for ET3; EMS doesn’t need a multi-year trial to prove what we’d achieved with this change—namely that if we stop automatic ED transports, patients get what they need and we get paid for our time. In fact, there’s no question that the pandemic only accentuated the need for telehealth, which has become a vital link for so many patients to the health care system.