A medical call to 911 usually results in an ambulance at the door and a trip to the hospital. The Centers for Medicare and Medicaid Services, however, is proposing a new model that it promises will lower costs, improve quality of care, and allow patients to receive care at the right place, not necessarily the ED.
They call it Emergency Triage, Transport, and Treat (ET3), and say the plan will reduce the number of unnecessary trips to the emergency department and instead take patients to a clinic or doctor's office or even set up a telemedicine appointment in their home. CMS will release a request for applications this summer, decide who meets the criteria in the fall, and implement it in early 2020. (https://go.cms.gov/2L2JnET.)
It's good that the federal government is looking at things through modern eyes, said David Persse, MD, the director of Houston's EMS and Public Health Authority. “EMS is evolving at an impressive pace, but it is limited in how to evolve depending on how we get paid,” he said. “As the payment model becomes more contemporary, it allows us to become more creative and decrease cost.”
Experts warn that the devil is in the details, which won't be clear until the request for application is made. One of the unresolved factors is how paramedics will decide who needs to go to the hospital. One study, for instance, found that EMTs tend to undertriage patients.
Michael M. Neeki, DO, of Arrowhead Regional Medical Center in Colton, CA, found in a prospective, double-blind analysis of 503 ED patients that paramedics assessed 251 as emergent, 178 as urgent, and 74 as neither. (West J Emerg Med. 2016;17: 690; http://bit.ly/2KQk0WH.) Emergency physicians considered 296 of those same patients emergent, 148 urgent, and 59 neither. They agreed 71.8 percent of the time.
Room for Error
That leaves considerable room for error, said Dr. Neeki. “If you miss one MI, the liability of that financially and in terms of safety is considerable. You could have dynamic changes in a patient during transport. Who is responsible for that?”
Dr. Neeki said he considers ET3 to be on the right track with appropriate training for paramedics and careful definitions of other parts of the plan. “The business of medicine is about caring for patients, not financial benefit,” he said.
Douglas K. Tan, MD, the president of the National Association of EMS Physicians, agreed, noting that the program will require more training about protocols and appropriate chief complaints and more engaged medical direction. “The whole purpose is to allow Medicare beneficiaries the most appropriate care,” he said.
It will also raise a whole host of dilemmas. “Where does traditional EMS begin and ET3 take over?” asked Dr. Tan, an associate professor of emergency medicine at Washington University School of Medicine in St. Louis, MO. “When does the high-risk refusal [to be transported] patient become an ET3 telemedicine patient? That's a question we haven't answered yet and will have to better define before program initiation.
“The engaged medical director will have to say when you should call the emergency department as usual or when you should call the Medicare-enrolled health care provider with a question about the patient's condition,” he said.
When triage indicates a lower-level health care facility, how will the EMS personnel know the best place to take patients? “It can't be a random urgent care center or clinic,” Dr. Tan said. “That facility must have an agreement with participating ambulance services to accept patients.” That will require considerable coordination between clinics and the EMS service to outline the capabilities of clinics or doctors' offices, their ability to take different kinds of patients, how many they can accept each day, and what payment arrangements exist. “Part of that has to include follow-up care,” said Dr. Tan. That will make it possible for patients to get into a system for regular care.
“The physician director has to make sure we remain patient-centered and that metrics are included,” said Dr. Tan. “For example, was the patient treated in an emergency department within a certain number of hours after an ET3 encounter? Performance metrics in terms of patient satisfaction are important. If it is something all patients hate, then there is something wrong.”
Some worry, he added, that busy EMS services will be bogged down by the treat-in-place proviso, using telemedicine, and ensuring follow-up.
Lack of Oversight
That has not been the experience of Dr. Persse, however, who pioneered a telehealth program called ETHAN (Emergency Telehealth and Navigation) funded by the Texas 1115 Healthcare Transformation Waiver program. It allows EMS providers to care for patients who need something other than transport to a hospital.
ETHAN gets patients to the right level of care, and tablets allow physicians in the Houston 911 call center to communicate directly with patients and to schedule appointments with clinics, exchange health information, and set up transportation. Patients can still opt for ED transport.
ET3 also will use qualified health practitioners to provide treatment. Patients who call 911 can talk to a triage professional or have an ambulance dispatched. On the scene, EMS determines if the patient should be transported to a hospital or another facility or receive treatment on-site or via audio or video conferencing.
Julio Lairet, DO, the chair of the ACEP EMS committee, said everyone agrees that strong medical oversight is required. He expressed concern about ET3's perceived reliance on qualified health care practitioners, who are not defined.
Dr. Tan added that it must also be determined who will oversee and credential practitioners in these cases. “We don't want a cottage industry to pop up as ‘medical control are us.’” He said he expects more caveats to arise as more is learned about the program. “I'm excited to see the potential,” he said. “I think we will learn quite a bit in the next five years as these roll out. It brings more responsibility, and requires more oversight to make sure it's done right, and the patient always comes first.”
Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.