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Resources to Drive Performance and Profitability:

Chronic Condition    Total Number of ED Visits by Chronic

Asthma                       1,441,083

Behavioral Health       5,700,937

COPD                            691,650

Diabetes                      2,107,471

Heart Failure                    70,092

Hypertension               4,105,027

Total ED Visits           23,982,070       

Levers and Causes to Reduce Preventable Admissions

Many ED visits and hospitalizations could be prevented with a cross-continuum care management strategy that is focused not only on clinical management but also on social determinants and behavioral health needs. The study identifies the following as causes and levers:

  • Lack of knowledge on how to manage their disease
  • Improper use of medications
  • Inability to engage in effective self-care
  • low adherence rates
  • Lack of access

Successful Strategies

Keys to success include an intense focus on engaging patients and meeting their needs through shared goals, aligned incentives, transparent care plans and integrated technology to support workflows across all sites of care, as well as a strategy to identify patients who would benefit the most using population segmentation/risk stratification algorithms.

• Care Management Vision/Strategy/Infrastructure

  (Provider engagement, payer contracts, leadership and governance)

• Patient Engagement and Activation

  (Care planning based on patient’s needs and goals)

• Population Segmentation/Risk Stratification

  (Ability to define, stratify and target at-risk populations)

• Multidisciplinary Care Coordination

  (Cleary defined roles and responsibilities, care transitions)

• Technology and Analytics

  (Access to information across the continuum)

Emergency Triage, Treat, and Transport (ET3) Model: New Solution Being Tested

The Center for Medicare and Medicaid Innovation’s (Innovation Center) Emergency Triage, Treat, and Transport (ET3) Model is a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare beneficiaries following a 911 call.

Under the ET3 model, the Centers for Medicare & Medicaid Services (CMS) will pay participating ambulance suppliers and providers to:

1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations,

2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or

3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth.

The model will allow beneficiaries to access the most appropriate emergency services at the right time and place. The model will also encourage local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches to promote successful model implementation by establishing a medical triage line for low-acuity 911 calls. As a result, the ET3 model aims to improve quality and lower costs by reducing avoidable transports to the ED and unnecessary hospitalizations following those transports.

 Why CMMI Developed a Model for Emergency Medical Services (EMS) Innovation?

Currently, Medicare regulations only allow payment for emergency ground ambulance services when individuals are transported to hospitals, critical access hospitals, skilled nursing facilities, and dialysis centers. Most beneficiaries who call 911 with a medical emergency are therefore transported to one of these facilities, and most often to a hospital ED, even when a lower-acuity destination may more appropriately meet an individual’s needs.

"The Center for Medicare and Medicaid Innovation’s (Innovation Center) Emergency Triage, Treat, and Transport (ET3) Model is a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare beneficiaries following a 911 call."

In addition, a range of EMS innovations across the care continuum has been instituted throughout the country. The ET3 Model builds upon design components and lessons learned from such innovations as well as several EMS-related Innovation Center Health Care Innovation Award (HCIA) recipients.

How Does the ET3 Model Transform the Ambulance System?

With the support of local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches, ambulance suppliers and providers will triage people seeking emergency care based on their presenting needs. The model aims to ensure Medicare Fee-For-Service beneficiaries receive the most appropriate care, at the right time, and in the right place. Beneficiaries who receive treatment from alternative destinations may also save on out-of-pocket costs. An individual can always choose to be brought to an ED if he/she prefers.

What Are the Model’s Goals?

The ET3 model aims to reduce expenditures and preserve or enhance quality of care by:

Providing person-centered care, such that beneficiaries receive the appropriate level of care delivered safely at the right time and place while having greater control of their healthcare through the availability of more options.

Encouraging appropriate utilization of services to meet health care needs effectively.

Increasing efficiency in the EMS system to more readily respond to and focus on high-acuity cases, such as heart attacks and strokes.

How Will the Model Achieve These Goals?

The ET3 Model aims to achieve these goals through three core features:

 1. Quality-Adjusted Payments for EMS Innovations

• Provide new payment options for transport and tratment in place of calling 911

• Tie payment to performance milestones to hold participants accountable for quality.

2. Support Aligned Regional Markets

• Make cooperative agreements available to local governments

• Focus funding

3. Enhanced Monitoring and Enforcement

• Build accountability though monitoring of specific quality metrics and adverse events

• Include robust enforcement to ensure patient safety and program integrity.

Who Can Participate in the Model?

The key participants in the ET3 Model will be Medicare-enrolled ambulance service suppliers and hospital-owned ambulance providers. In addition, to advance regional alignment, local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic areas where ambulance suppliers and providers have been selected to participate in the model will have an opportunity to apply for cooperative agreement funding.

Together, ambulance suppliers and providers will focus on direct services, while local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches will create a supportive structure to ensure successful and sustainable delivery of those services.

Who is Eligible for the Model Interventions?

Any individual who calls 911 and is connected to a dispatch system that has incorporated a medical triage line under the model would be screened for eligibility for medical triage services prior to ambulance initiation. Upon arriving on scene, participating ambulance suppliers and providers may triage Medicare FFS beneficiaries to one of the model’s interventions upon ambulance dispatch following a 911 call. As part of a multi-payer alignment strategy, the Innovation Center will encourage ET3 Model participants to partner with additional payers, including state Medicaid agencies, to provide similar interventions to all people in their geographic areas.

How may Medicare Beneficiaries and their Families Benefit from the ET3 Model?

Participating ambulance suppliers and providers will have greater flexibility regarding where and how a beneficiary receives care following an emergency. By paying for ambulance transport to new destinations or treatment in place for beneficiaries with lower-acuity needs, beneficiaries will gain new ways of accessing care settings during an emergency. As a result, the model may allow beneficiaries to avoid hours spent in the ED as well as reduce exposure to hospital-acquired conditions.

 How will Funding be Awarded?

The Innovation Center anticipates releasing a Request for Applications (RFA) in Summer 2019 to solicit Medicare-enrolled ambulance suppliers and providers. Once participants have been selected and announced, the Innovation Center anticipates issuing a Notice of Funding Opportunity (NOFO) in Fall 2019 for up to 40 of two-year cooperative agreements, available to local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate.

The Innovation Center anticipates utilizing a phased approach with up to three rounds of RFAs, up to two releases of NOFOs, and staggered performance start dates. The staged approach across multiple application rounds is designed to advance key design elements of the ET3 Model and optimize overall impact, including regional uptake of its innovations and multi-payer alignment. 

What is the Model Timeline?

The ET3 Model will have a five-year performance period. The anticipated start date is January 2020. The performance period for all participants, regardless of start date, will end at the same time; thus, only applicants selected through the first RFA will participate for the full five years.

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