An excellent summary of the issues related to CMS’ Emergency Triage, Treatment and Transport (ET3) model in Health Affairs on June 23, 2025.
For each patient enrolled in the ET3 mode, the average Net Savings to Medicare (NSM) is shown below. Treatment in Place (TIP) models are patient-centric models that have the potential to save hundreds of millions of dollars to the Medicare program.
A summary of the economic case for EMS TIP programs can be found here.
We encourage EMS and stakeholders to support current legislation that changes Medicare’s EMS payment model to reimburse for TIP and MIH.
H.R. 2538 - Comprehensive Alternative Response for Emergencies (CARE) Act of 2025 (TIP Bill)
H.R. 4011 – Community Paramedicine Act of 2025
Learning From The Failure Of A CMS Emergency Medical Services Model
Erik Blutinger, Alexander J. Ulintz, Kevin Chason, Nicholas Gavin
June 23, 2025
https://www.healthaffairs.org/content/forefront/learning-failure-cms-emergency-medical-services-model
Barely one year after the eruption of the global COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) launched an exciting initiative for Medicare fee-for-service beneficiaries. The Emergency Triage, Treat, and Transport (ET3) Model afforded one of three outcomes for every patient encounter: ambulance transport to a covered destination (that is, a hospital emergency department), ambulance transport to an alternative destination (for example, urgent care), or treatment in place (emergency medical service [EMS] on scene with telehealth physician consult). The program—a voluntary, five-year payment model covering prehospital services beyond emergency stabilization and transportation—sought to answer a critical question: Is there a better way to deliver acute, unscheduled care to older adults in the community without defaulting to expensive, intensive care settings?
However, CMS abruptly announced the death of ET3 in 2023. Another planned aspect of the model, which would have provided up to $34 million for local emergency communications centers to establish or expand medical triage lines, was canceled prior to implementation after CMS received fewer than 30 applications.
The recent publication of CMS’s final report provided insights into the limited participation and other challenges that prevented the model from flourishing, but the current landscape leaves EMS agencies, emergency departments, and other key stakeholders stuck in a current of costly prehospital acute care services while trying to paddle upstream toward value-based care. This article examines the forces that led to an early termination of ET3 but laid the groundwork and set the trajectory for value-based care and EMS-led innovation.
What ET3 Was Trying To Solve
Over the past two decades, the EMS community has realized that person-centered, value-based care could look very different than the traditional model of transporting all patients to an emergency department. “Community paramedicine” programs, which emerged in the 1990s, filled critical health care gaps in rural America. This concept gained momentum in the 2010s after passage of the Affordable Care Act spurred an interest in value-based models. Several state Medicaid programs reimburse for community paramedic services, and some EMS systems have launched programs funded by local taxpayers or agreements with providers and payers. In 2019, EMS Agenda 2050 envisioned systems of care, integrated with EMS, that allowed the right level of care in the right setting to be delivered to the patient, with reimbursement for the value of the service provided. This broader concept—extending EMS beyond its transport function and expanding its patient navigation function in coordination with health systems and community services—is increasingly known as “mobile integrated health” (MIH). The dream of MIH, however, was often limited to grant-funded pilot programs, including some supported by the Center for Medicare and Medicaid Innovation.
Historically, Medicare primarily has paid emergency ground ambulance services for transporting individuals to expensive facilities such as traditional hospitals, critical access hospitals, dialysis centers, and skilled nursing facilities. As a result, when calling 9-1-1, beneficiaries typically get taken to a hospital emergency department rather than a destination or outcome that, in some cases, may align better with their medical needs and personal preferences for receiving care outside of the emergency department.
The misalignment between the services that EMS provides and reimbursement solely for its transportation function leads to inefficiency and potentially unnecessary Medicare spending. The downstream consequences of this model are significant: high costs of care in intensive settings, emergency department overcrowding, longer EMS wait times during an emergency. Moreover, EMS agencies, already running on thin margins, are often not reimbursed for the emergency response, acute care, medications, and supplies used if a patient does not want—or does not need—transportation to a reimbursable destination.
Recognizing these inefficiencies, EMS agencies have long advocated for alternative care models, leading to experimental programs such as ET3.
ET3, Organization Design And Operational Dynamics
The prehospital community was excited to have a path toward sustainably offering patients a customized care path rather than defaulting to sometimes unnecessary transportation to an intensive and expensive care setting. In March 2021, CMS unveiled a list of 184 public and private ambulance providers and suppliers selected to participate. Enthusiasm grew as the groundwork was laid for a paradigm shift in prehospital medicine.
Overall, model participants were afforded generous flexibility for tailoring their own care pathways. New care protocols were built from an early stage. Communities stood up new structures for building novel interventions and new procedures even in places such as New York City, whose Fire Department of New York organized weekly meetings with major health systems to discuss recommended “best practices.”
New protocols and procedures also were greeted with overwhelming optimism by the EMS community and patients in parts of the country. Interest in out-of-hospital care is high especially when telehealth becomes a new option for patients to receive care in the comfort of their homes. With ET3’s goals of person-centered care, increased efficiency in the EMS system, and growing technological capabilities in the out-of-hospital environment, systems were willing to invest, build new protocols, and develop new policies for meeting consumer demand.
Several barriers, however, impeded overall progress and acceptance of ET3. The lack of cultural acceptance, high administrative costs, and challenging care coordination seemed to limit potential outcomes. Implementation challenges quickly became apparent, as participation rates lagged, and adoption—even among highly motivated participating agencies—was hindered. According to CMS, from January 1, 2021, to December 30, 2023, 147 EMS agencies participated in the model but only 72 (49 percent) submitted a claim for these services. The number of unique Medicare and Medicaid beneficiaries who received an ET3 intervention was 2,964, suggesting an average of 41 patients per provider. There were also many more treatment-in-place interventions (3,144) than transports to alternate destinations (253).
ET3 could have demonstrated significant cost savings by diverting preventable emergency department visits through treatment in place with telehealth or transport to alternative destinations such as urgent care. The program, however, was canceled early, partially attributable to delays in implementation and slow uptake of systemwide interventions.
Why ET3 Failed
Out-of-hospital care is popular yet often associated with costs and limited resources. The final report underscores the administrative, operational, and reimbursement complexity that EMS systems face when implementing innovative programs, even with federal and community support. Significant barriers prevented model participation in most local health care Marketplaces: Many health systems and departments rely upon fee-for-service, volume-driven care models versus programs with value-based care elements such as ET3 that was intended to reduce emergency department volume and inpatient admissions. Value-based care programs have faced their fair share of challenges in health care but still represent an aspirational goal in the United States, to blunt the long-term trajectory of ever-rising health care costs.
The post-public health emergency era has introduced changing policy, payment, and coding surrounding virtual health care visits. Major health stakeholders are struggling to predict future health trends especially now that COVID-19-era–related policies are no longer in effect. After COVID-19, many health systems have not experienced healthy operating margins, prompting executives to “think twice” about alternative care models that have yet to prove long-term financial sustainability.
Onward And Upward
So, what now?
Despite the premature closure of the ET3 pilot, the national appetite for value-based care beyond the four walls of a clinic or hospital continues to grow, as does innovation in MIH. Future efforts should: Balance local flexibility in program design with clear federal reimbursement structures that are feasible for small MIH programs to participate in; integrate MIH into existing value-based payment infrastructure, including broader insurance participation beyond Medicare; and support rigorous evaluation of similar MIH programs that continue to flourish across the country.
Data will require prioritization, too. The collection and comparison of systematic data is indispensable for meeting individualized community needs as it pertains to areas such as billing procedures, EMS payment model structuring, and cultural acceptance of new home-based technologies. Future partnerships with private payers may also help with the acquisition, accessibility, and overall processing of patient-level data. It is difficult to understand care delivery without data—a key pillar to any future program that aims to replicate parts of ET3.
There is no innovation and creativity without failure. ET3 failed due to problems with program implementation, resource allocation, financial incentives with ongoing focus on fee-for-service arrangements, and cultural acceptance within both EMS and its health care partners. But the program should be considered a landmark success for its ability to pioneer new ideas with good intentions in EMS. The model’s challenges have provided valuable lessons for policy makers and health care systems to reopen the door for sustainable, value-based EMS care for years to come.
