CMS is taking prior authorization for frequent, non-emergency ambulance transportation nationwide and launching a model that pay ambulance services for taking patients to nonhospital facilities.
CMS is making two important changes to ambulance service payment that are designed to cut down on the use of ambulances for nonemergency transport and direct care for nonemergency patients away from hospital emergency departments.
The federal agency announced yesterday that it was expanding the prior authorization program for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. The program established a variety of prior authorization requirements for RSNAT ambulance services, defined as ambulance transportation for a person that occurs three times or more during a 10-day period or at least once per week for three weeks or longer. It has been piloted in two sets of states, and an outside evaluation by Mathematica found that it reduced RSNAT use and expenditure by over 60% and that the number of ambulance companies providing RSNAT services decreased by about half.
The second change is the launching of the voluntary Emergency Triage, Treat and Transport (ET3) model, which will allow the participating ambulance services to bill CMS for transporting patients to facilities other than the traditional destinations of hospitals, nursing homes and dialysis centers that make the ambulance ride reimbursable. The ET3 model also includes provisions for reimbursement of care delivered at the scene and avoiding ambulance transport altogether.
“It is representative of Medicare no longer chasing down bad utilization,” Michael Phillips, an account manager at Archway Health, a Boston healthcare consulting firm, said about ET3. “It is trying to prevent it before it happens.”
“They are basically taking the low acuity transport and giving them the alternative of taking
them someplace else that is more in line with the services they need,” added Phillips. The ambulance services will be required to have arrangements with the alternatives to the hospital emergency departments. “It can’t just be, ‘Who is your PCP?” said Phillips.
Phillips said ET3 could help with so-called frequent fliers, some of whom might, for example, have a substance abuse problem that would be bettered care at facility for people with substance abuse problems that at a hospital.
ET3 was put on hold because of COVID-19, but the first performance year is now scheduled to start in January 2021.
ET3 has lost some of its novelty factor. Because of COVID-19 and the declaration of public emergency, CMS has expanded the list of allowable destinations for ambulance transports. But that expansion is temporary and tied to the duration of the COVID-19 public health emergency declaration.
The evaluation of the RSNAT prior authorization program focused on the impact of the program on Medicare beneficiaries with end-stage renal disease, severe pressure ulcers, or both, because beneficiaries with those conditions make up disproportionate share of RSNAT users. The evaluation showed that prior authorization decreased Medicare expenditures for beneficiaries with end-stage renal disease but not for those only with pressure ulcers. Prior authorization can be impediment to timely care, but Mathematica evaluators said they did not see any impact on quality or access to care.
According to the evaluation, the prior authorization resulted in savings of about $550 million that are related to RSNAT. But they cautioned that savings realized in what was in effect a pilot program may not be seen in a nationwide program because some of the states in the program had high baseline rates of RSNAT use and therefore presented a greater opportunity for cutting back on it.
Phillips says it bodes well for ET3 that “major players” such as Boston’s Public Health Commission, Mayo Clinic Ambulance and Philadelphia’s Fire Department have been accepted into the program, although it is known yet whether they took the next step and signed a participation agreement.
Phillips said “COVID is going to be the proverbial X factor” with ET3. It’s possible that some nonhospital sites already have some experience dealing with patients arriving by ambulance because of the pandemic and CMS’ relaxation of the rules about where ambulances could take patients and still be paid.
ET3 does not include any downside risk but does make a 5% bonus available to participants who meet certain quality metrics.
“I'm curious to see if the (5%) incentive will be a strong enough incentive to keep participants aligned with the goals of the program, particularly if there's any consternation among the alternate sites of care. I'd imagine this will be relatively new for them too, which could lead to some implementation headaches.”