NEMT Market Disruption Spells Opportunity for Hospitals and EMS Agencies

Written by Christa Lassen-Vogel, Sr. Manager of Marketing Communications, ZOLL Data Systems | Jul 29, 2021 5:15:00 PM 

(6 min read) Non-emergency medical transport (NEMT) is a growing, multi-billion-dollar industry. According to Frost & Sullivan, the total addressable NEMT market in the U.S. will surpass $12B by 2023, expanding at an estimated annual rate of 6.2%¹

This space is evolving rapidly, making some tectonic shifts that are here to stay. Here’s how ZOLL® Data Systems sees the NEMT market disruption, along with our advice to emergency medical services (EMS) agencies and hospitals on how to successfully navigate it.

NEMT Today

The skyrocketing growth in the NEMT market is propelled by an aging U.S. population and increased efforts to remove individual barriers to accessing healthcare. Patient access to care has become a hot button as education increases about the environmental and social determinants of health (how physical and social environments influence racial, ethnic, and socioeconomic disparities — including transportation for medical care — in health and wellbeing). Most recently, the obesity epidemic, opioid crisis, and COVID-19 pandemic have further heightened awareness around the importance of NEMT for vulnerable patient populations.

As the demand for patient transportation increases, existing NEMT inefficiencies and gaps are placing strain on healthcare systems. For example:

  • Up to 7 million people miss or delay medical appointments each year due to transportation issues.²
  • Missed appointments cost U.S. healthcare $150 billion annually.²
  • 12.2% of adults with disabilities cannot get a ride to the doctor.²
  • 80% of the eligible NEMT population does not require specialized vehicles, but may need specialized care.²
Transport Disruption 

In the past, ambulances were the primary, if not only, option for all transport from one medical facility to another. The urgent need for more NEMT services has pushed hospitals, in particular, to find a wider variety of transport options that are more cost-effective for non-emergency patients.

Specifically, transportation network companies (TNCs) Uber and Lyft have partnered with healthcare providers and managed care organizations (MCOs) to provide NEMT services. At the same time, new, technology-based companies are entering the industry with ride-booking software. These platforms integrate with TNCs, providing hospitals with a NEMT “marketplace” where they can efficiently search, book, and track trips for patients who do not require specialized vehicles to the next point of care.

The confluence of the increased NEMT demand and new market players like the TNCs and ride-booking platforms has effectively disrupted the market. Hospitals in many areas now have an increased number of transportation options, which is diverting some business to non-EMS sources.

Meanwhile, the financial investment in the NEMT market continues to grow. Uber and Lyft have created healthcare transportation divisions, and technology companies are successfully securing funding to accelerate build-outs of their platforms. All signs point to this market disruption continuing at a rapid clip.

Lower Costs and Higher Patient Satisfaction for Hospitals

Recent changes to the NEMT landscape are a huge benefit for hospitals and healthcare systems. As the ones who often schedule the NEMT, hospitals need as many options as possible to ensure patients receive the proper care after being released — and now they have them.

Ride-booking platforms, like Roundtrip, simplify end-to-end NEMT management for hospitals. These systems integrate directly with electronic medical records (EMRs) and allow hospital staff to access a broad network that includes both their contracted vendors and other TNC options. Ride requestors can determine patient eligibility and benefits, choose between multiple transportation options, and order a ride with one click…all from an access point within the tools they are already using. Dashboards offer real-time ride status, so patients know when their ride will arrive and what’s happening next.

The result is that hospitals are able to move patients in and out quickly, while maintaining a high quality of care. Additionally, it ensures that ambulances are reserved for emergency response.

“Health systems are starting to look at patient transportation as a comprehensive program not as a vendor contracting exercise with local transportation companies,” says Kevin Mehalick, head of business development at Roundtrip. “Leading health systems that have large care networks, and even integrated health plans, are treating transportation as a revenue enabler, not just an expense line item.”

Industry experts project there will be significant increases in NEMT efficiency and patient satisfaction as a result of the market disruption. One study found that rideshare-based transportation service can increase show rates to primary care for Medicaid patients.³ Also, Lyft has published case study data showing a 40% decrease in emergency room (ER) utilization for one Medicaid plan and a decrease in wait time from 28 minutes for a traditional NEMT ride to just seven minutes for a Lyft for a health insurer.4Especially noteworthy, it is estimated that hospitals achieve a 30-70% total annual net savings on ride costs when using modern NEMT (TNCs and digital networks).5

Translating the Market Disruption for Agencies

The NEMT market disruption creates concerns for some EMS agencies, but it also presents opportunities that should not be ignored. To stay competitive and develop new revenue sources, agencies must embrace and respond to this disruption.

Agencies benefit from building stronger relationships with hospitals, and by doing so, can capture a bigger share of the growing NEMT market to complement their existing service offerings.

Translating the Market Disruption for Agencies

The NEMT market disruption creates concerns for some EMS agencies, but it also presents opportunities that should not be ignored. To stay competitive and develop new revenue sources, agencies must embrace and respond to this disruption.

Agencies benefit from building stronger relationships with hospitals, and by doing so, can capture a bigger share of the growing NEMT market to complement their existing service offerings.

Growing NEMT Market

It’s important to remember that more than 20 million Americans gained health coverage through the Affordable Care Act (ACA)6, and 20% of the U.S. populationwill be 65 or older in the next 10 years. In short, the need for emergency transport is projected to increase dramatically, and progressive EMS agencies will recognize that ambulances must be used more judiciously to respond efficiently to emergencies.

EMS agencies will still have contracts in which hospitals name them as the provider of choice. These relationships will not be usurped by the new technology platforms and TNCs. Rather, transport requests will be automatically fed into an agency’s dispatch system, where they can accept or decline, therefore maximizing their resources as they see fit. Viewing ride demand data by time of day, day of week, and level of service can inform scheduling decisions and strategic placement of crew and vehicles. Agencies without vendor contracts can pick up incremental business by joining the ride-booking marketplace, where they will be visible as transport options. Previously, hospitals only had access to a limited number of contracted vendors, but the marketplace creates more choices, as well as more opportunities for EMS agencies.  

The future of NEMT is now. Savvy EMS agencies will see the market disruption as a chance to expand business and will take steps to adapt quickly. By seizing the moment and being an active participant with additional value to offer hospitals, agencies will reap benefits with expanded services that make the best use of their human and vehicle resources.

Conclusion

The impact of the NEMT market disruption is almost entirely positive. It gives hospitals and agencies new pathways to achieve growth and efficiency, while providing patients with more customized care and a more satisfying experience.

As the market continues to evolve, ZOLL®Data Systems offers advanced technology to help you stay ahead of the changes. ZOLL Dispatch is a data-rich call taking and computer-aided dispatch (CAD) solution that offers integration with Roundtrip, the leading digital transportation marketplace for better health outcomes.

Resources

¹ Inchaustegui, Nicolas. “The Next Level of Care: Transportation Network Companies’ Disruption of Healthcare Mobility.” Frost & Sullivan website, Oct. 1, 2020,http://www.frost.com/frost-perspectives/the-next-level-of-care-transportation-network-companies-disruption-of-healthcare-mobility/. Accessed 19 July 2021.

² “Non-emergency Medical Transportation (NEMT) in North American Healthcare Mobility.” Frost & Sullivan website, 2020, store.frost.com/non-emergency-medical-transportation-nemt-in-north-american-healthcare-mobility-2020.html. Accessed 19 July 2021.

Chaiyachati, Krisda H. Hubbard, Rebecca A. Yeager, Alyssa. Mugo, Brian. Shea, Judy A. Rosin, Roy. Grande, David. “Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program.” National Center for Biotechnology Information, U.S. National Library of Medicine website, June 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC5975142/. Accessed 19 July 2021.

“New Data Shows Lyft is Improving Access to Care For Millions of Medicaid Recipients.” Lyft website, Aug. 19, 2020, www.lyft.com/blog/posts/research-improving-access-to-care-medicaid. Accessed 19 July 2021.

Rochlin, Danielle H. Lee, Chuan-Mei. Scheuter, Claudia. Milstein, Arnold. Kaplan, Robert M. “Economic Benefit of ‘Modern’ Nonemergency Medical Transportation That Utilizes Digital Transportation Networks.” U.S. National Library of Medicine website, March 2019, pubmed.ncbi.nlm.nih.gov/30676791/. Accessed 19 July 2021.

“Chart Book: Accomplishments of Affordable Care Act.”Center on Budget and Policy Priorities website, March 19, 2019, http://www.cbpp.org/research/health/chart-book-accomplishments-of-affordable-care-act. Accessed 19 July 2021.

7 “Older People Projected to Outnumber Children for First Time in U.S. History.” United States Census Bureau website, March 13, 2018, www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html. Accessed 19 July 2021.

Emergency Triage, Treat, and Transport (ET3) Model

The Centers for Medicare & Medicaid Services released a detailed fact sheet detailing the Emergency Triage, Treat, and Transport (ET3) model. It provides significant details on the scope of the project and key benchmarks – Michael Shabkie 

Emergency Triage, Treat, and Transport (ET3) Model
The Center for Medicare and Medicaid Innovation’s (Innovation Center) Emergency Triage, Treat, and Transport (ET3) Model is a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare beneficiaries following a 911 call. Under the ET3 model, the Centers for Medicare & Medicaid Services (CMS) will pay participating ambulance suppliers and providers to:

  1. Transport an individual to a hospital emergency department (ED) or other destination covered under the regulations
  2. Transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic),
  3. Provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth.

The model will allow beneficiaries to access the most appropriate emergency services at the right time and place. The model will also encourage local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches to promote successful model implementation by establishing a medical triage line for low-acuity 911 calls. As a result, the ET3 model aims to improve quality and lower costs by reducing avoidable transports to the ED and unnecessary hospitalizations following those transports.

Why develop a model for emergency medical services (EMS) innovation?
Currently, Medicare regulations only allow payment for emergency ground ambulance services when individuals are transported to hospitals, critical access hospitals, skilled nursing facilities, and dialysis centers. Most beneficiaries who call 911 with a medical emergency are therefore transported to one of these facilities, and most often to a hospital ED, even when a lower-acuity destination may more appropriately meet an individual’s needs.

An earlier White Paper by the U.S. Departments of Health and Human Services and Transportation found that Medicare could save $560 million per year by transporting individuals to doctors’ offices rather than a hospital ED; taking into account avoided inpatient hospitalizations and opportunities for treating in place may garner further savings and quality of care improvements. Thus, there is great opportunity for improvement in care quality and reduction in costs to the Medicare program through innovation in emergency medical services (EMS).

In addition, a range of EMS innovations across the care continuum has been instituted throughout the country. The ET3 Model builds upon design components and lessons learned from such innovations as well as several EMS-related Innovation Center Health Care Innovation Award (HCIA) recipients.

How does the ET3 model transform the ambulance system?
With the support of local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches, ambulance suppliers and providers will triage people seeking emergency care based on their presenting needs. The model aims to ensure Medicare Fee-For-Service beneficiaries receive the most appropriate care, at the right time, and in the right place. As depicted in the figure below, the model may help make EMS systems more efficient and will provide beneficiaries broader access to the care they need. Beneficiaries who receive treatment from alternative destinations may also save on out-of-pocket costs. An individual can always choose to be brought to an ED if he/she prefers.

This flow chart outlines how emergency health care needs of Medicare beneficiaries would be addressed following a 911 call, and the new services under the ET3 model.  At the top of the chart is “911 call received.” After the 911 call is received an ambulance service is initiated OR a health care professional discusses health concern(s) with the individual via a medical triage line. The medical triage line that connects an individual with a health care professional is a new service under the ET3 model.  If an ambulance is initiated, one of two things could happen. One, the ambulance could transport the individual to receive additional care, either to another care facility like urgent care, or to a covered destination like the emergency department. OR two, the ambulance arrives, but does not transport the individual. In this second scenario, as part of the ambulance care team, a qualified health care practitioner (either on site or through audio or video conferencing) provides treatment in place. The ambulance transporting the individual to another care facility like urgent care is a new service under the ET3 model as is treatment in place either on site or through audio or video conferencing via a qualified health care practitioner.

What are the model’s goals?
The ET3 model aims to reduce expenditures and preserve or enhance quality of care by:

• Providing person-centered care, such that beneficiaries receive the appropriate level of care delivered safely at the right time and place while having greater control of their healthcare through the availability of more options
• Encouraging appropriate utilization of services to meet health care needs effectively.
• Increasing efficiency in the EMS system to more readily respond to and focus on high-acuity cases, such as heart attacks and strokes.

How will the model achieve these goals?
The ET3 Model aims to achieve these goals through three core features:

1. Quality-adjusted payments for EMS innovations. Provide new payment options for transport and treatment in place following a 911 call Tie payment to performance milestones to hold participants accountable for quality

2. Support for aligned regional markets. Make cooperative agreements available to local governments, its designees, or other entities that operate or have authority over one or more 911 dispatches acting on their behalf in regions where selected model participants operate Focus funding on the establishment of medical triage lines to ensure appropriate use of EMS resources and advance multi-payer adoption to support overall success and sustainability.

3. Enhanced monitoring and enforcement. Build accountability through the monitoring of specific quality metrics and adverse events Include robust enforcement to ensure patient safety and program integrity

Who can participate in the model?
The key participants in the ET3 Model will be Medicare-enrolled ambulance service suppliers and hospital-owned ambulance providers. In addition, to advance regional alignment, local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic areas where ambulance suppliers and providers have been selected to participate in the model will have an opportunity to apply for cooperative agreement funding.
Together, ambulance suppliers and providers will focus on direct services, while local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches will create a supportive structure to ensure successful and sustainable delivery of those services.

Ambulance Suppliers and Providers will support EMS innovation by transporting Medicare beneficiaries to currently covered destinations (e.g., ED ) or alternative destinations, and by providing treatment in place with a qualified health care practitioner (on site or via telehealth). Local Governments, its designees, or other entities that operate or have authority over one or more 911 dispatcheswill promote successful model implementation by establishing a medical triage line for low-acuity calls received via their 911 dispatch system.

Who is eligible for the model interventions?
Any individual who calls 911 and is connected to a dispatch system that has incorporated a medical triage line under the model would be screened for eligibility for medical triage services prior to ambulance initiation. Upon arriving on scene, participating ambulance suppliers and providers may triage Medicare FFS beneficiaries to one of the model’s interventions upon ambulance dispatch following a 911 call. As part of a multi-payer alignment strategy, the Innovation Center will encourage ET3 Model participants to partner with additional payers, including state Medicaid agencies, to provide similar interventions to all people in their geographic areas.

How may Medicare beneficiaries and their families benefit from the ET3 model?
Participating ambulance suppliers and providers will have greater flexibility regarding where and how a beneficiary receives care following an emergency. By paying for ambulance transport to new destinations or treatment in place for beneficiaries with lower-acuity needs, beneficiaries will gain new ways of accessing care settings during an emergency. As a result, the model may allow beneficiaries to avoid hours spent in the ED as well as reduce exposure to hospital-acquired conditions.

How will funding be awarded?
The Innovation Center anticipates releasing a Request for Applications (RFA) in Summer 2019 to solicit Medicare-enrolled ambulance suppliers and providers. Once participants have been selected and announced, the Innovation Center anticipates issuing a Notice of Funding Opportunity (NOFO) in Fall 2019 for up to 40 of two-year cooperative agreements, available to local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate.
The Innovation Center anticipates utilizing a phased approach with up to three rounds of RFAs, up to two releases of NOFOs, and staggered performance start dates. The staged approach across multiple application rounds is designed to advance key design elements of the ET3 Model and optimize overall impact, including regional uptake of its innovations and multi-payer alignment.

What is the model timeline?
The ET3 Model will have a five-year performance period. The anticipated start date is January 2020. The performance period for all participants, regardless of start date, will end at the same time; thus, only applicants selected through the first RFA will participate for the full five years.

Resources and Support
For more information on the ET3 Model, please visit: https://innovation.cms.gov/initiatives/et3/. If stakeholders have questions on the ET3 Model, they can send an email to ET3Model@cms.hhs.gov.