MANCHIN, CAPITO, MILLER, MOONEY URGE CMS TO ADOPT TREAT-IN-PLACE MODEL IN WEST VIRGINIA

Letter

Dear Administrator Brooks-LaSure,

We write to you to ask you to review the proposal submitted by the West Virginia Office of
Emergency Medical Services (OEMS) and the West Virginia Hospital Association (WVHA)
along with a small coalition of emergency medicine physicians, EMS providers, and payers to
explore a statewide, multi-payer demonstration to address the workforce challenges faced by
West Virginia hospitals and Emergency Medical Services (EMS) providers. The Center for
Medicare and Medicaid Innovation (CMMI), or "Innovation Center," was authorized under the
Affordable Care Act (ACA) and tasked with designing, implementing, and testing new health
care payment models to address growing concerns about rising costs, quality of care, and
inefficient spending. We feel that the proposal submitted by the coalition of providers in West
Virginia warrants a closer review by the Centers for Medicare & Medicaid Services (CMS) and
CMMI.

During the Public Health Emergency (PHE), the Centers for Medicare & Medicaid Services
(CMS) provided greater flexibility allowing EMS to treat certain conditions at the scene or
transport patients to an alternative site of care. However, this flexibility appeared to have limited
impact in West Virginia due to several factors such as in rural communities where there are no
alternatives sites of care while in urban areas the alternatives sites were not prepared for an
ambulance presenting at their facility. Beyond the CMS flexibilities, the Center for Medicare and
Medicaid Innovation (CMMI) launched the Emergency Triage, Treat, and Transport (ET3)
voluntary, five-year payment model to provide greater flexibility for Medicare Fee-for-Service
(FFS) beneficiaries following a 911 call. West Virginia chose not to participate in the ET3
demonstration, and one barrier noted was the requirement to transport patients to an alternative
site of care. However, Kanawha County West Virginia EMS did participate in the community
paramedicine model allowing EMS to provide basic services in the community.

The treat-in-place option that the coalition is exploring is built upon an effort in western
Pennsylvania that focused on three conditions that can be treated in place following a 911 call
and following narrow protocols developed by EMS. The effort in Pennsylvania was unsuccessful
because only one payer participated, so EMS had to have different processes for patient's based
on their insurance status. As a result, the coalition has focused on one model for EMS with a goal
of securing most payers agreeing to participate in the treat-in-place option, so EMS has one
statewide protocol and billing process.

Additionally, we are aware that CMS decided to end the ET3 Model on December 31, 2023,
which is two years prior to the original agreement. We feel that a statewide model, such as the
coalition is proposing, warrants review despite that lower than anticipated projected interventions
from the ET3 Model. By utilizing a multi-payor state model, CMS would be best able to receive
robust quantitative and qualitative date to review the models' efficacy.

After receiving initial support for the treat-in-place option from the coalition and three statewide
payers (Highmark, Public Employee Insurance Agency (PEIA), and Medicaid) OEMS has
started drafting protocols for three conditions:

* Diabetes -- Hypoglycemia Evaluation
* Asthma/COPD Evaluation
* Seizure Evaluation

Based on preliminary data for these three conditions, about 15,000 patients sought care in West
Virginia hospitals' emergency departments but were not admitted as inpatients in 2022.

Furthermore, EMS 2022 data shows that symptoms of these conditions prompted 64,777 calls of
which 49,061 were transported for additional care, while 4,136 were treated at the scene or
released for other transportation. It is important to note that the planned EMS services for the
treat-in-place option is within the current scope of practice of EMS. In addition to the services
provided by EMS, part of the protocol will be to advise the patient to follow-up with their
primary care provider to ensure continuity of care.

If Medicare would participate in this demonstration, West Virginia would be able to advance a
statewide demonstration that all EMS providers could participate in while having the payers for
approximately 75 percent of the patients that EMS treats included in the demonstration. This
would be a major step forward in advancing an improved model that better utilizes limited EMS
and hospital staff while ensuring quality patient care and saving approximately $3 million in
unnecessary emergency room visits. Furthermore, this model could be replicated nationwide,
especially in rural communities with limited health resources.

We appreciate your review of this matter, and look forward to hearing from you regarding your
consideration of the coalition's proposal.

Sincerely,

Source