A Doctor May be Coming to You Virtually in an Ambulance

Posted by Jon Savage on Aug 21, 2019

CMS’s Emergency Triage, Treat, and Transport (ET3) Model

Each year there are approximately 240 million calls into the 9-1-1 emergency system of which it is estimated that about 20% or nearly 5 million of which are non-emergencies.  There is an obligation to respond to these calls on the part of the Police-Fire-EMS personnel.  For these non-emergencies, it takes needed personnel out of commission to be ready to respond to true emergencies, it costs the system money, and it could easily end up costing the person calling in for a non-emergency reason a fair amount of money too.  

Medical transports to the hospital result in charges of several hundred dollars to $1000+ from the EMS service and the hospital charges generally will run in the thousands, even for a relatively minor visit.  For payer systems, including Medicare and Medicaid, this becomes a large financial burden.  A white paper put out by Health and Human Services(HHS) in conjunction with the Department of Transportation(DOT) suggested that if 15% of the Medicare patients were transported to a doctors office instead of the ER, Medicare could save about $560 million per year.  They estimate the saving would be even greater if the patient was treated in place.  

Ambulance systems generally have no incentive not to transport these patients.  They are not trained to make a diagnosis, so making the decision to not take them to the hospital is fraught with risk.  From a financial perspective, the EMS system is set up currently such that they are reimbursed for transportation to the hospital.  There is little to no reimbursement to bring them to an urgent care center or to take them to a walk-in primary care clinic.  In the age of telemedicine, patients can be seen and examined right where they are by a doctor or other medical or behavioral health provider using secure video technology combined with digital stethoscopes and cameras.  However, utilization of this convenient, cost-effective service is low partly because of the lack of financial incentive for EMS to engage in it.

Good news!  Those days are coming to an end.  This year the Centers for Medicare and Medicaid Service(CMS) announced its Emergency Triage, Treat, and Transport (ET3) Model.  During the initial pilot launch of this model, EMS providers will be reimbursed for either transporting to “alternative” sites of care such as a clinic or urgent care or obtaining “treatment in place” for the patient such as a telehealth encounter for non-emergency patients.  Under this pilot model, the ambulance service will be paid the same as they would have been paid to take the patient to the hospital.

Does this work?

Let’s take a look at one program, now in its fourth year of existence as an example.  Houston Fire and its EMS telemedicine program have now managed over 20,000 non-emergency patients.  In the most recent year of analysis, it is estimated they saved over $1.7 million in direct costs to the system.  Non-emergency transports have been cut by about 80% which has also resulted in returning the ambulances back into service an average of 44 minutes faster.  All of this comes at no reduction in patient satisfaction or increase in patient mortality.

A few more ET3 details

The ideal model to carry out an effective EMS telemedicine program engages several stakeholders in the patient care system.  There are four recommended partners in the ET3 model but not all four need to be involved for an approved or successful program.  Those four stakeholders include:

  1. 9-1-1 dispatch systems including local governments or other entities that operate them
  2. Ambulance services
  3. Alternative site participants(Telehealth providers, clinics, urgent care centers)
  4. Payers (More effective if more than Medicare such as Medicaid and commercial insurance is on board)

There are some transport volume requirements for applicants.  To apply to participate, the model must be in a state with at least 15,000 Medicare Fee For Service(FFS) emergency transports in 2017.  Bonus application points are given if the model occurs in one or more counties where at least one of the counties had 7,500 Medicare FFS transports in 2017.

Care on Location’s Role

Care on Location’s EMS Telehealth program is a perfect partnership for this innovative ET3 care model.  Care on Location builds the telemedicine backpacks and cases for the back of the ambulances or at the patient’s side while also maintaining the secure HIPAA-compliant software connection with patient and EMS crew on one end and an experienced Emergency Medicine trained provider on the other end.  We have been involved in the telehealth space for years and understand federal policy, billing, coding, and technology.  But more importantly, as emergency medicine trained providers, we know how to work with ambulance crews and provide safe, cost-effective care.

Care on Location is seeking other interested parties to partner in being part of this advancement in making our health system a more efficient and effective one.

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