What Are Hospital Alternative Destination Sites?

If you work in the prehospital and emergency care industry, you’ve been hearing talk about Emergency Triage, Treat, and Transport (ET3) for a while now. This pilot program – facilitated by the Centers for Medicare and Medicaid Services (CMS) – is an experimental 5-year payment model that provides greater flexibility, reduces costs, and increases efficiencies for Medicare beneficiaries following a 9-1-1 call.

Initially set to roll out in early 2020, ET3 worked with more than 200 participating agencies to enact a two-pronged approach for helping Medicare beneficiaries access the “most appropriate emergency services at the right time and place.” The program would allow participating ambulance agencies to choose from two new options (in addition to typical transport to the ED): transport to an alternative destination or on-scene, “treatment in place” with a qualified health care practitioner, either in-person or via telehealth technology.

With the onset of the Novel Coronavirus Disease (COVID-19) health emergency, CMS decided to delay the start of the ET3 Model from May 1, 2020, until January 1, 2021, allowing its selected participants to more fully focus on responding to the pandemic.

What is ET3?

Medicare currently only pays for emergency ground ambulance services only when beneficiaries are transported to a limited number of covered destinations. According to the CMS, this creates an incentive to transport beneficiaries to high-acuity, high-cost settings (e.g., hospital emergency departments), even when a lower-acuity, lower-cost setting may more appropriately meet an individual’s needs. For example, the U.S. Departments of Health and Human Services and Transportation estimates that Medicare could save $560 million per year by transporting individuals to doctors’ offices rather than a hospital ED.

How Does ET3 work?

ET3 organizers hypothesize that a revised payment model not only has the potential to lower Medicare costs but also improve the quality of care by reducing avoidable transports to the hospital ED and reducing avoidable inpatient admissions. During this 5-year program, ET3 will pay participating ambulance agencies to add two additional treatment options to their services, based on the patient’s presenting symptoms. These include:

• Transport to an alternative destination
• On-scene “treatment in place” with a qualified health care practitioner, either in-person or via qualified telehealth technology

What is An Alternative Destination Site Under the ET3 Program?

Participating agencies will be expected to align with their local resources to meet the requirements of the ET3 program and ensure that at least one of the non-ED options is available at all times. Alternative destination sites must be enrolled in Medicare or employ or contract with Medicare-enrolled practitioners.

• Federally Qualified Health Centers: These locations are community-based facilities that provide care on a sliding fee scale to underserved patients. They include programs such as Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Health Centers for Residents of Public Housing. They must meet stringent requirements and receive funds from the U.S. Health Resources & Services Administration.
• Physicians’ Offices: Primary care physicians may be the most appropriate health care provider for a patient who has called 9-1-1. A primary care physician is typically a specialist in Family Medicine, Internal Medicine, or Pediatrics who provides continuing responsibility for a patient’s comprehensive care over time, including chronic, preventive, and acute care in both inpatient and outpatient settings. The structure of the primary care practice may include a team of physicians and non-physician health professionals.
• Behavioral Health Centers: These locations focus on treating mental, social, and physical illness of patients; they may be freestanding for-profit/non-profit entities, state institutions, or a department within an acute care hospital. Outpatient services may include partial hospitalization, chemical dependency programs, intensive outpatient facilities, and general clinics. Inpatient facilities may include psychiatric hospitals/units, residential treatment centers, and substance abuse programs.
• Urgent Care Centers: For illnesses and injuries that are not life-threatening but need care within 24 hours, Urgent Care facilities are a good option. Often open during extended hours, urgent care physicians and health care providers can examine and treat patients suffering from a wide range of symptoms that are not necessarily ED-level emergencies. If more care is needed, they will direct the patient to follow-up with the proper provider in the appropriate timeline.

COVID-19 Allowances

As part of the ET3 roll out, CMS issued temporary regulatory waivers and new rules to increase flexibility in response to COVID-19, including broadening the list of allowable destinations for ground ambulance transports. While there must still be a medical necessity for ground ambulance transport, covered transports will temporarily include:

• Alternative sites determined to be part of a hospital
• Critical access hospital (CAH) or skilled nursing facility (SNF)
• Community mental health centers
• Federally qualified health centers (FQHCs)
• Rural health clinics (RHCs)
• Physician offices
• Urgent care facilities
• Ambulatory surgical centers (ASCs)
• Locations furnishing dialysis services when an ESRD facility is not available
• The beneficiary’s home (for a COVID-19 patient who is discharged from the hospital to be under quarantine)

During the first year of the program, ET3 participants will be allowed to transport beneficiaries to these covered destinations, although they will not be considered “ET3 Model Interventions.” However, they will help ET3 Participants begin implementing the new model despite the COVID-19 public health emergency.

Monitoring and Feedback

CMS acknowledges that the ET3 model will require “robust monitoring,” both on the part of participants and the CMS. Agencies will be expected to report on requested metrics regularly, and the CMS will be monitoring additional statistics to ensure the new model inadvertently creates no adverse outcomes.

Additionally, participants will be expected to participate in “learning communities” and activities, such as webinars, interviews, and in-person meetings, to ensure feedback is being received and best practices shared.

Utilizing an efficient ePCR tool like ESO Electronic Health Record (EHR) is one way ET3 participants can ensure they meet all reporting requirements needed to remain compliant with their ET3 participation. In addition to time-saving features and digital forms that make documentation in the field more efficient and accurate, ESO EHR also offers powerful built-in analytics that makes it easy to quickly output reports and view metrics. These features also make it easier to get reimbursed promptly and help document the trends relating to transport to new destinations covered under the ET3 program.

View an introductory video on ESO EHR or download the one-page product overview now.