Earlier this year, the Department of Health and Human Services (HHS) announced a new Center for Medicare & Medicaid Innovation (CMMI) payment model for community paramedicine. Designed to reduce unnecessary use of emergency departments (ED), the Emergency Triage, Treat and Transport (ET3) model will test new emergency ambulance service payments in fee-for-service Medicare for “treatment in place” and for transporting Medicare beneficiaries to alternative treatment destinations other than EDs. As part of its multipayer alignment strategy, CMMI will also encourage ET3 model participants to partner with other payers, including state Medicaid agencies.

This brief provides an overview of what’s driving this policy shift, Centers for Medicare & Medicaid Services (CMS) guidance on the topic, and its implications for stakeholders.

What’s Driving the Policy?

Traditionally, people who call 9-1-1 are taken by ambulance providers to EDs, regardless of whether the ED is the most appropriate and cost-effective setting for the person’s care. This means increased healthcare costs, overcrowding of EDs, and a lower quality of care for patients, especially those who need behavioral health treatment at a crisis center or primary or preventive care, rather than an ED visit.

Community paramedicine—a relatively new and evolving model of care—seeks to overcome these challenges by enabling qualified paramedics to provide services beyond their traditional emergency response and transport roles, regardless of whether they ultimately transport the patient to an ED.1 Community paramedicine can vary from place to place. Models of care may include expanding paramedics’ scope of care to provide primary care/preventive services in place; providing transport services to locations other than EDs, such as to a behavioral health center; and providing additional services such as ongoing care management, connecting individuals to community-based services that address the social determinants of health, and/or referring patients to medical services that they and EDs do not provide (such as long-term care or palliative care).

Community paramedicine programs are frequently designed with a specific access challenge in mind. For example, in rural communities where healthcare service gaps are often caused by shortages of primary care providers and long travel times to the nearest clinics, community paramedics can help fill access gaps by providing primary/preventive care in place, when appropriate. Other community paramedicine programs seek to address “ED boarding”—that is, “boarding” patients in the ED while awaiting an inpatient bed, a problem that is commonly linked to a lack of behavioral health treatment capacity. To help tackle this problem, paramedicine models may seek to triage care for individuals with behavioral health needs in order to route them to the most appropriate and timely care setting.

But achieving widespread implementation has been challenging. Most payers have not yet established mechanisms to pay paramedics for services provided without transport, and, even in geographic areas where some do, a lack of alignment from payer to payer makes it difficult for ambulance providers to perform and be compensated for community paramedicine (ambulance providers rarely know a person’s coverage status when triaging and responding to a 9-1-1 call). Like most other payers, fee-for-service Medicare reimbursement currently does not support coverage of community paramedicine services, paying only for ground ambulance services to certain covered destinations, typically high-cost, high-acuity sites of care like EDs.

CMMI Encourages States to Align Medicaid Policies with ET3 Model

Announced in February, the ET3 model is a voluntary, five-year model scheduled to take effect on January 1, 2020. Under ET3, CMS will pay participating Medicare-enrolled ambulance service providers and hospital-owned ambulance providers to transport beneficiaries to an alternative setting or to provide care in place. These providers will still be paid to transport a beneficiary to the same locations permitted by Medicare regulations today—hospitals, critical access hospitals, skilled nursing facilities, and dialysis centers. Local governments and other entities that operate 9-1-1 dispatches also have an opportunity to access cooperative agreement funding to create a medical triage line, used to screen callers for medical triage services prior to ambulance initiation.

Recognizing the importance of multipayer participation in the ET3 model, CMS in August issued an Informational Bulletin to states describing the flexibilities that they have to structure Medicaid transportation services to align with the ET3 model design.

Unlike Medicare, state Medicaid agencies may use statutory and regulatory authorities to reimburse paramedics participating in community paramedicine models like ET3. States may, for example, submit a State Plan Amendment recognizing licensed paramedics as providers of services furnished on the scene without transport; alter state regulations that restrict emergency transport to certain destinations; and/or seek waivers of statewideness, comparability, and/or freedom of choice, depending on their community paramedicine program design. The Bulletin also highlights the flexibilities that Medicaid managed care organizations have to pay for alternative destinations or on-site care, even if such allowances are not included in the Medicaid state plan (i.e., through “in-lieu of” services)2. To guide states’ processes, the Bulletin includes a series of questions that states should consider during program design and implementation.

Conclusion

Although CMMI has yet to make similar efforts to promote alignment with private payers or Medicare Advantage plans, some states, local governments, and commercial payers have already established reimbursement for community paramedicine programs. In 2012, Minnesota became the first state to allow paramedics to bill Medicaid for community paramedicine services,3 and at least four other states—Arizona, Georgia, Wyoming and Nevada—have followed suit, and 14 states reimburse for at least some “treat and no transport” calls.4 Similarly, commercial plans have begun to roll out community paramedicine programs in targeted areas5 and report improvements such as reduced hospital admissions, fewer ambulance transports and fewer ED visits.6

Nonetheless, one of the major challenges that community paramedicine providers face is funding; many providers rely on grant funding and/or self-fund the program as a strategy to bring down overall spending in risk-based care models. The ET3 model may stimulate interest among a broader swath of private and public payers, increasing the potential for community paramedicine to grow its footprint as a solution for lowering healthcare costs and addressing access challenges.

1 Such services are typically provided by an advanced paramedic, often referred to as a community paramedic, who has received additional training to provide services such as health assessments, chronic disease monitoring and education, medication management, immunizations and vaccinations, laboratory specimen collection, hospital discharge follow-up care, and minor medical procedures.

2 Services or settings that a state determined are medically appropriate, cost-effective alternatives to state plan services or settings covered in the Medicaid managed care contract between the state and MCO.

3 Minnesota Session Law, Chapter 169—S.F.No. 1532, available at: https://www.revisor.mn.gov/laws/2012/0/Session+Law/Chapter/169/#laws.0.1.0.

4 National Association of EMTs, Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey, 2018, available at: http://www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-survey-2018-04-12-2018-web-links-1.pdf?Status=Temp&sfvrsn=a741cb92_2.

5 Journal of Emergency Medical Services, Turning the Corner: New Economic Models are Changing the Face of EMS Delivery, 2018, available at: https://www.jems.com/2018/03/21/turning-the-corner-new-economic-models-are-changing-the-face-of-ems-delivery/.

6 Blue Cross Blue Shield, Health at Home with Community Paramedicine, 2018, available at: https://www.bcbs.com/the-health-of-america/articles/health-home-community-paramedicine.