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Emergency Triage, Treatment, and Transport

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 Since the beginning of Emergency Medical Services (EMS) in the 1960s, ambulances have operated in a “you call, we haul” process. The 1965 Social Security Act included ambulance transportation as a covered benefit, therefore, Medicare pays ambulance providers for transportation to hospital emergency departments, skilled nursing facilities, and dialysis appointments. For years, much of EMS has operated in this model. 


EMS_Blog_VithalaniReports by the National Highway Traffic Safety Administration’s (NHTSA), Emergency Medical Services Agenda for the Future (1996) and EMS Agenda 2050 (2018), detail the necessity for EMS to move away from this practice and develop patient navigation pathways that include treatment in place, as well as transportation to alternative sites of care. Despite this, little has been done nationwide, other than the relatively recent development of Mobile Integrated Healthcare-Community Paramedicine. Much of this lack of movement, however, has been due to dearth of availability of funds for these types of programs.

In 2013, the U.S. Department of Health and Human Services and Department of Transportation released a whitepaper regarding alternative payment models for EMS systems. In it, they outlined various approaches that move away from the current standard not only of EMS payment, but also navigating patients away from emergency departments, estimating an annual savings of $560 million.

ET3 Model

On Feb. 14, 2019, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare & Medicaid Innovation (CMMI) announced a new payment initiative for EMS – the Emergency Triage, Treat and Transport (ET3) Model. This voluntary alternative payment model will allow ambulance agencies and regional 911 centers to participate in new pathways to treatment for Medicare fee-for-service patients.

Enrolled EMS agencies will be able to develop processes for treating patients in place, after being evaluated by a Medicare-qualified health care professional on scene, or via video telehealth. They also may institute pathways for patients to be transported to locations for care other than a hospital emergency department, such as an urgent care clinic, physician’s office, sobering center, etc. In both instances, EMS would be paid for services they provide.

Local governments, or their designees, that run 911 communication centers will be able to apply to develop and manage processes for medical triage of low-acuity patients. These processes would allow patients the triage and navigation prior to the dispatch of an emergency medical resource, such as an ambulance. For example, patients could be sent to their primary care physician’s office or urgent care center via taxi or ride-sharing services, ordered by the medical triage line at the communication center.

Services will be encouraged to maintain high quality of care, with an additional 5% payment available based on pre-determined quality metrics.

Moving forward

Compared with other CMS/CMMI projects, the timeline for these initiatives is fairly aggressive. CMS will release their Request for Application for ambulance providers in summer 2019, and for local government communication centers in the fall.

Many EMS organizations already have begun developing their planned processes in anticipation of application releases. In one informal poll of social media-active EMS physicians, 16 of 25 (64%) of respondents stated their EMS agency would be applying and already have begun planning to do so. Further, three others (12%) stated they were not planning on applying, with the remaining six (24%) either unsure of their plans or unclear on the details of the ET3 model. In another survey of major metropolitan EMS medical directors (the “Eagles Coalition”) who were asked about planned participation in ET3, 19 (44%) of 43 respondents said their agency is planning on applying for the ET3 program. Another 11 (26%) were “ET3-curious,” and the remaining 13 (30%) were not interested in applying at this time.

There are many more considerations to be had prior to these programs going live. Clinically, agencies must develop processes to appropriately train and credential EMS providers for this new model of health care delivery. Both CMS and individual agencies must develop and begin to measure their outcome- and process-based performance measures to ensure appropriate quality assurance of these programs as they begin.

Operationally, the biggest consideration must be whether to attempt to implement these projects solely for Medicare fee-for-service patients or for all 911 callers. For the latter to be financially feasible, EMS agencies will need to work with other payers to sign agreements mirroring that of ET3; something CMMI states is a primary goal for the model. Further, many EMS agencies do not routinely employ, or have telehealth agreements with, qualified health care professionals other than their EMS medical director, nor is there a standard infrastructure for performing or documenting telehealth visits.


The ET3 Model already has proven to be a groundbreaking leap in the right direction toward aligning EMS as a true part of the health care field. As programs begin and outcomes are measured, hopefully it will be the first steps of many.

Veer Vithalani, MD, is the interim medical director for the Emergency Physicians Advisory Board in Fort Worth, which provides medical direction and oversight to the MedStar Mobile Healthcare System; as well as an attending emergency physician & the EMS director for the JPS Health Network. He is a fellow of the American College of Emergency Physicians and the National Association of EMS Physicians.

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