The Centers for Medicare and Medicaid Services (CMS) announced that on December 31, 2023, it would end its 5-year pilot of the Emergency Triage, Treat And Transport program known as “ET3.” ET3 enabled ambulance service providers to transport a patient to an alternative destination and/or provide treatment on the scene by paramedics or via telemedicine. CMS is ending the program because of disappointing participation and intervention numbers. According to CMS data, there were 151 total ambulance companies enrolled, but by June 30, 2023, only 64 had billed for medical interventions. Of the 2,379 patients served under ET3, only 165 had been transported to an “alternative destination” like urgent care.
Misaligned incentives: According to Alan Ayers, President of Experity Consulting, the challenge with ET3 was that payment went to ambulance operators, which represented a misalignment of incentives because the decision maker was the paramedic, yet reimbursement focused on transportation. Additionally, eligibility was limited to fee-for-service Medicare patients. In 2021, the “ET3 Improvement Program” provided $34 million in 2-year grants for 40 municipalities operating 911 call centers to add a nurse triage line and refer non-emergent callers to “community resources,” including urgent care. The “improvement” was that the ambulance would never be summoned in the first place.
“The incentives really should have gone to providers,” says Ayers. “There are only a few integrated health systems with emergency departments and urgent cares that also have their own ambulance services. For everyone else, the receiving urgent care would only receive Medicare payment for the patients. And ambulance arrivals would introduce a whole set of complex issues including the inability or refusal to pay, higher-acuity patients taking more time and disrupting throughput, inappropriate triaging of patients in need of admission, and even the logistics of moving stretchers through the hallways. While intuitively a way to increase urgent care volume and reduce total health costs, many urgent care providers saw significant risk in accepting the patients with ambulance arrivals.”