Six Things Fire Chiefs Need to Know About ET3

The Centers for Medicare and Medicaid Innovation (CMMI) created shock waves in the EMS world in February with the announcement of the Emergency Triage, Treat, and Transport (ET3) program. As you may have heard, ET3 has the potential to revolutionize how the Center for Medicare and Medicaid Services (CMS) reimburses fire/EMS agencies for care provided to Medicare beneficiaries. As you consider whether ET3 is right for your agency, the IAFC wants to highlight some key pieces of information for EMS leaders: 

What is ET3 and How Will It Work? 

ET3 is a pilot program that will test whether patient satisfaction can be increased and overall Medicare spending decreased by paying EMS agencies to either transport patients to alternative destinations or provide treatment in place (TIP) without transport. The ET3 program is scheduled for a 2020 launch and will run through 2025. It is important to note that CMMI only will reimburse fire/EMS agencies under ET3 for services provided to Medicare fee-for-service (FFS) beneficiaries, not Medicare Advantage or Medicaid beneficiaries. 

Who Can Participate and How Much Will CMMI Pay? 


All Medicare-enrolled ambulance suppliers and providers are eligible to apply to participate in ET3. Fire departments that provide EMS first response without transport (even at the ALS level) are not eligible to participate. The ET3 application portal has not yet opened. However, CMMI recently released an RFA that provides details on how they plan to evaluate applications. One of the biggest components that CMMI hopes to see in successful applications will be EMS agency partnerships with other healthcare providers and payors in their community. While CMMI can only extend their ET3 pilot to Medicare FFS beneficiaries, they certainly don’t want ET3 to develop in a Medicare-only silo.  

CMMI plans to reimburse agencies at either the BLS-emergent or ALS Level I rate, depending on the care provided to the patient. Regardless, Medicare’s medical necessity requirement will remain in place for all services rendered to patients. CMMI also has stated that if a patient is eligible for either ET3 option (alternate destination or treatment without transport) but insists on being transported to a hospital, then the CMS medical necessity rules will remain in place. 

What are the Requirements to Participate in ET3? 

All ET3 participants must provide a “transportation to alternative destinations” option. In these instances, the patient must be transported by ambulance to a destination such as an urgent care clinic or a primary care provider’s office. Agencies applying to join the ET3 model will need to describe their partnerships with local alternate destinations to show that they have access to a partnering alternative destination 24/7. This coverage may be achieved using multiple alternative destinations, open at different times. 

The TIP opportunity is optional for ET3 participants. Any agency offering a TIP option must incorporate consultation with a “qualified healthcare provider (QHP)” either in-person or via a two-way voice and video communication. Medicare defines eligible QHPs as physicians, physician assistants, and nurse practitioners. Paramedics, nurses, and EMTs do not qualify as QHPs. These consultations are intended to be brief and to confirm that the treatment decisions for the patient are appropriate. As in the alternative destinations option, ET3 applicants must demonstrate their partnerships with QHPs are established in such a way that a partnering QHP is available 24/7.  

Lastly, CMMI encourages ET3 applicants to design programs that combine alternative destination and TIP options. A blend of these options can be used to achieve coverage for an entire 24-hour period.  For example, a fire department could partner with an urgent care clinic from 0800-2359 and then with a QHP to provide a TIP option from 0000-0759 when the urgent care clinic is closed. 

Regardless of the treatment decisions made, the patient remains the final decisionmaker on where they are transported (even if they choose an emergency department for a low-acuity condition). Fire/EMS agencies will be required to continuously monitor the patient’s condition while providing care and to transport the patient to a hospital if their condition worsens.  

What Challenges Exist for ET3 Participants? 

Since the ET3 program reimbursement opportunities are available only for Medicare FFS beneficiaries, fire departments must accurately identify a patient’s payor. While CMMI plans to ask applicants how they will identify patients’ payors, they are open to a range of ideas and solutions.

Rural fire departments interested in the TIP option also may face challenges in facilitating the voice/video consultation with a QHP. Limited connectivity for smartphones and other devices may make it hard to provide this consultation.  The IAFC is actively working with CMMI to discuss ways to ease these challenges. IAFC members with thoughts or recommendations are encouraged to contact the EMS Section.  

Support for Triage Lines 

CMMI also plans to include a funding opportunity to help up to 40 agencies establish a nurse triage line as part of their 911 answering point. CMMI’s interest in supporting nurse triage lines came after their review of the results that similar triage lines in New York City, Washington, DC, and other cities have achieved in diverting non- and low-acuity calls from the 911-system. CMMI plans to require that these awards will be available only to the agency which operates the 911 answering point in a given jurisdiction (even if this is a law enforcement agency). Additionally, the awardee must be located in a jurisdiction which has an EMS agency providing either the alternative destination or TIP option for Medicare FFS patients. CMMI hopes to release more information on these awards in 2020. 

Where Can I Learn More About ET3? 

CMMI has made several resources available on the ET3 Program website. In addition to the RFA, CMMI has released webinars, a frequently asked questions document, and several fact sheets. Anyone considering applying to the ET3 program is strongly encouraged to review these resources. 

The ET3 Program is complex initiative by CMMI that could produce voluminous data and results that could help us finally improve CMS reimbursements. Make sure to keep watch for more updates from the IAFC as CMMI releases additional details on the ET3 program.

Mike McEvoy, PhD, NRP, RN, CCRN, is the EMS chief for Saratoga County, N.Y., and chair of the EMS Section. Evan Davis is the IAFC's government relations strategic manager and liaison to the EMS Section.   

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