Treatment in Place- How EMS is Bringing Care Home
Written by Melissa Kroll, MD
Historically, we expect the EMS system to bring the patient to care. We expect that when we call 911, the EMTs and paramedics will provide treatment while transporting us to the Emergency Department. However, since the early 2000s, there has been a growing movement to use EMS systems and our paramedics in a different way. Mobile Integrated Health programs utilize community paramedics, paramedics who’ve had additional training, to provide more care in the home. These programs range from discharge follow-up visits in the home, scheduled visits to reduce readmissions, and providing in-home treatments on an urgent basis to keep the patient in the home.
Interest in these innovative programs has grown, but growth has been limited secondary to reimbursement challenges. Until recently, EMS was reimbursed by mileage, with a modifier to differentiate basic care to advanced care. This meant that any care or treatment a patient received on scene was not reimbursed, including complex care such as managing a cardiac arrest.
In 2019, CMMI announced the Emergency Triage, Treat, and Transport Program (ET3). The ET3 model aimed to reduce cost and increase quality of care by: 1) providing the appropriate level of care safely and at the right time, allowing for person-centered care with increased options; 2) encouraging the appropriate utilization of services; and 3) increasing the efficiency of the EMS system and allowing it to focus on high-acuity cases.[i],[ii] For the first time, Medicare was reimbursing EMS for transportation to alternative destinations and treatment in place (performed with a telehealth consult). Unfortunately, the ET3 pilot stopped early, after only two years. CMS cited low EMS participation, difficulty building successful partnerships during the COVID pandemic, and overall low claim volume as reasons the program failed. However, this pilot project did show that paramedics were successful at providing treatment in place and alternative destination without increased mortality or cost.[iii],[iv]
Since this pilot, new treatment in place and alternative destination programs have grown throughout the United States. In Missouri, Medicaid has approved reimbursement for treatment in place and alternative destination for patients with mental health disorders and substance use disorders. This allows EMS systems to directly bring patients to mental health urgent cares and call substance use disorder counselors to the patient’s homes. While volumes are low overall right now, programs like these could help alleviate the boarding and overcrowding crisis in Emergency Departments.
We expect an expansion of these types of programs in the next several years. The Rural Health Transformation Grant in Missouri has provided nearly $40 million[v] to EMS systems, with the development of Mobile Integrated Health programs and improved integration of EMS with hospital systems specifically named as a priority. This creates an immense opportunity to design systems that can keep patients in their homes.
These expanded programs will need better training, expanded protocols, increased training and better integration with Emergency Departments. Emergency Physicians are ideal for providing training and oversight for these systems. Additionally, increased connections allow for possible telehealth evaluations and treatments, an alternative/additional service that Emergency Physicians can provide. These services will need appropriate reimbursement to be sustainable. Now is the time to collaborate with our local EMS systems to advocate for meaningful reimbursement so we can provide better care for our patients.
[i] Emergency Triage, Treat, and Transport Model (ET3) Request for Applications (RFA). Centers for Medicare and Medicaid Services.
[ii] Emergency Triage, Treat, and Transport (ET3) Model. Centers for Medicare and Medicaid Services. https://innovation.cms.gov/innovation-models/et3. Accessed July 2, 2020.
[iii] Centers for Medicare & Medicaid Services. Emergency Triage, Treat, and Transport (ET3) Model: Final Evaluation Report. Published January 2025. Accessed July 1, 2026. https://www.cms.gov/priorities/innovation/data-and-reports/2025/et3-model-final-eval-rpt
[iv] National Association of Emergency Medical Technicians. The Case for EMS Reimbursement: Treatment in Place (TIP). Published 2025. Accessed July 1, 2026. https://naemt.org/docs/default-source/emshd-2025/naemt-case-for-reimbursement-tip-2025.pdf