Author(s): John Montes. Published on March 1, 2019.

Paradigm Shift

A new federal pilot program could usher in a new age of EMS care—and a new NFPA guide is ready to assist

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In June, NFPA will release NFPA 451, Guide for Community Health Care Programs, and the timing couldn’t be better.

That’s because in February, the United States Department of Health and Human Services announced a new emergency medical services payment pilot program that could transform how EMS systems operate across the country, and may lead to wider adoption of community paramedicine programs.

The announced move has to do with Medicare—the federally run insurance program for adults aged 65 and older—and how it pays for ambulance services. Under current rules, if a Medicare patient calls 911 for unscheduled emergency ambulance services, EMS providers are only paid if the patient is transported to a hospital emergency room. This leaves EMS providers with few options, and leads to many avoidable ER trips in cases where onsite care or a trip to a doctor’s office may have been more appropriate and cost effective.

The shortcomings of this system led the Centers for Medicare & Medicaid Services (CMS) to introduce the new payment model called “Emergency Triage, Treat, and Transport” (ET3 for short) to help expand treatment options. Beginning early next year, Medicare will launch a 5-year pilot program that will pay selected providers not just for transport to the ER, but also for treating patients at the scene or remotely through telehealth-type portals. It will also allow some emergency ambulance providers to transport patients to locations besides the ER, such as 24-hour-care clinics or a primary-care doctor’s office.

“This model will create a new set of incentives for emergency transport and care, ensuring patients get convenient, appropriate treatment in whatever setting makes sense for them,” said Health and Human Services Secretary Alex Azar.

Nearly all EMS-affiliated associations have advocated for something like the ET3 model for years to improve efficiency and patient outcomes. But as with any significant change to the status quo, there are questions and logistical hurdles to address. For instance, now that there are options, how will providers make the right call about how to treat patients or where they take them? How should protocols and training for dispatchers and others in the EMS system be altered to accommodate this paradigm shift?

That’s where NFPA 451 comes in. The new guide offers all EMS systems a template for setting up local programs that meet the requirements outlined in the ET3 model. The process requires applicants to undertake a detailed evaluation of their community’s health care needs, and provide information about how the EMS system will implement strategies to reduce waste and improve patient outcomes. NFPA 451 outlines how to achieve those critical goals through cooperation among all facets of the health care system, including 911 providers, hospitals, insurers, primary care physicians, and others. The guide arrives just as many EMS providers are considering how to set up their systems to work within the new program. CMS will begin taking applications this summer and will launch the ET3 pilot early next year; visit for more information.

NFPA 451 promises to retain its value long after that, however, even for providers who aren’t selected for the pilot.

The ET3 launch is just the beginning of a long journey that I suspect will lead to fundamental changes in how we receive and deliver health care. As Medicare explores the possibility of accepting and promoting health care models outside of traditional hospital settings, other insurers should eventually follow. A door has opened that will lead to better and more efficient outcomes for patients. NFPA 451 will help ensure that transition is smooth and efficient for providers as well.

JOHN MONTES is specialist, Emergency Services Public Fire Protection, at NFPA. Top Illustration: Michael Hoeweler