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Becker’s Healthcare Podcast
Brett Maxfield, MS, CRNA and President and CEO of Maxfield Healthcare Solutions
00:22:09
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- [00:00]
A
Hello, this is Francesca Matthews with the Becker's ASC Review podcast. I'm thrilled to be joined today by Brett Maxfield, CRNA President and CEO of Maxfield Healthcare Solutions. Brett, thank you so much for being here today.
- [00:13]
B
Hey, my pleasure, Francesca. Thanks for having me.
- [00:15]
A
Yeah, of course. To start us off, could you please introduce yourself and tell us a little bit about your background?
- [00:20]
B
You bet. Yeah, absolutely. So my name is Brett Maxfield. As you mentioned, I am A by licensure, crna, but that's not really what I do anymore. So life has kind of evolved and changed a little bit. So I originally that was the plan was to be a CRNA and do anesthesia and life kind of changed a little bit. So about 15 years ago I had some pretty significant health issues and had to kind of transition careers. And so out of that necessity, the consulting firm was born. And so I transitioned from doing bedside anesthesia to now I do a whole bunch of different things kind of all under the umbrella of that healthcare solutions. So I guess kind of just naming things off. I own a multi specialty surgery center in Southeast Idaho. And then with the consulting firm I help to supply, manage direct aid train, multitude of different things with about 400 to 450 different surgery centers and office based surgical practices worldwide. So we're in all 50 states and expanded internationally. In addition to doing that, I also am a member of the board of directors for Quad A. I'm also the president of the Idaho Ambulatory Surgery Center Association. I am an international surveyor for Quad A. I'm the chair of the practice committee for the American association of Nurse Anesthesiology. And yeah, that kind of covers pretty much all my professional life. So I like to stay busy. I'm kind of all over the place and rarely home. So it's kind of a fun life.
- [02:00]
A
Yeah, quite the background there. Thanks for sharing that. I always love to talk with people who have kind of a wide range of experiences. I feel like it's always interesting jumping just right into questions here. What are the top three trends that you're following in healthcare and ASCS today?
- [02:17]
B
You know, there's a couple. Obviously the thing when you talk about ASCs, the thing at everybody's forefront of their mind right now is the cost involved and how it's just our reimbursement's going down and our expenses are going up, you know, and when you stratify those costs post pandemic, the first thing that hit us was the cost of supplies. You know, the supply chain got disrupted, supplies went up and quite honestly, we were hoping that things would come back down. And I don't know if the actual expense has stayed that high or if people just realized like they often do, that hey, you know, people pay these prices and just kept things high. But you know, that was the first wave to hit us. The next wave to hit us was the anesthesia shortage. So I think that doing what I do, working in the consulting field, I saw a big, big, big uptick in demand for my services post pandemic because a lot of the people that were deemed non essential decided that they weren't going to let the hospitals determine their livelihood. And so they said, you know, we're taking this out of your hands. And they, they started reaching out to people like me and creating office based surgical practices, ambulatory surgery centers, things like that, which most of the hospitals didn't care because it was, you know, again, the ones they deemed non essential. So this was the plastics, the podiatry, things like that, you know, pediatric dentistry. I think what they failed to realize though was that when those people left the hospital, it also meant they were going to take anesthesia with them. And then a lot of these things, especially for CRNAs, my background, the opportunity to leave and do your own thing was significantly more lucrative with a better lifestyle than staying at the hospital. And so I think that was an unforeseen result of that kind of push to deprioritize the non essential providers was the hospitals didn't realize they were going to lose a big chunk of their anesthesia. So obviously that's another big one that we're watching right now. And then the newest, latest entry into the mix is AI. AI is definitely something that as we integrate it more, see it more in play, it's definitely going to change things within the ASC realm. And so those are kind of the big things we're watching right now is those different trends kind of seeing what's happening, kind of watching a little bit to see what's still coming out. Again, being kind of on a 30,000 foot view of things with what I do, it's been interesting to see which specialties have also kind of taken off in that ASC world. So, you know, the last five years we've seen a huge uptick and a lot of stuff that used to be mainly just hospital based, you know, the vascular areas, the, you know, as things come off the inpatient only list, we're seeing more of those GYN specialties leave again and you know, it'll be interesting. I'm We've got a healthcare crisis right now. We've got an affordability crisis. This government shutdown really kind of brought that to light and kind of brought to light how ridiculous a lot of this stuff is. You know, for an example, my family of five pre Affordable Care act paid about $800 a month in premiums to, for our insurance, you know, for a barely moderate plan, like a silver level type plan. And as soon as the Affordable Care act, it did anything, passed, did anything but make things affordable, like for my family, it jumped from $800 a month to $2,500 a month to where now we're sitting close to I think $4,000 a month for that same silvertype plan. So anyway, we're watching all those different things. I think you're gonna see some big changes coming. I think we're gonna have to see some big changes coming there because the average person making $46,000 a year cannot afford to make a $48,000 a year health insurance payment. It's ridiculous. So there's going to be some changes coming and there have to be. So those are kind of things we're keeping our eye on, watching what's happening. And a lot of it circles around that finance component.
- [06:15]
A
Yeah, absolutely. I think, I think the shutdown and a number of things in the last year. So I've kind of done that like behind the curtain effect. So yeah, all totally relevant topics there. What are you most excited about right now?
- [06:30]
B
You know, honestly, the thing I am most excited about has to do with that AI. I think it's a tool that we want to be a little bit doomsday. We have to be a little bit careful and not trust too much in AI because we don't want things to suddenly end up that we have no idea how to do things without AI. But on the flip side, there's some really cool opportunities there. There's some real opportunity, especially on the revenue cycle side of things, to see where a lot of this inefficiency that happens, this back and forth, the stupidity of we're going to deny, deny, deny and then approve with no changes. You know, just that stupidity that happens there. The ability to control costs a little bit better within your systems, the ability to really honestly with AI have almost immediate input from your quality assurance programs. You know, looking at things like, hey, let's plug in all this surgeon's data. We've got a guy who claims that he takes two hours to do this particular surgery, but survey says AI tells us you're three and A half hours. So guess what, buddy, you're not scheduling for two hours anymore. Your cases are scheduled for three and a half. Increasing efficiency, decreasing patient dissatisfaction with wait times, things like that. I think there's a lot of potential with AI application within the ASC field.
- [07:50]
A
Yeah, absolutely. And it's something that's interesting to me. Just I know that like within the ASC field, the use of technology is kind of fragmented or I noticed there's some large gaps, you know, a lot. There are plenty of ASCs that are still, you know, don't have EMR systems. And then there's. I just wrote an article not too long ago about a totally AI powered ASC going up on the east coast. So I think that's something really kind of being reconciled within the industry right now.
- [08:15]
B
Well, I think for ASCs and especially the office based surgical practices, a lot of times these EMRs are just price so high that they price themselves out of a client. And so I think that's something we're gonna have to see kind of, you know, balancing itself out and reconciling itself that as we drift to the technology driven side, you're gonna have to see some of these disruptors enter into the market that bring things that offer the same quality at an affordability price point where a lot of these places can get in. You know, I know speaking from experience, a lot of the practices that I work with have that issue where they would like to have that, they would like to have that gathering ability at their fingert, but it's just so cost prohibitive that it really makes it difficult. And you know, again, coming from the anesthesia background, I can tell you as an anesthesia provider, I hated EMRs. You know, you want to slow me down and make me inefficient, give me an emr. That's a great way to do it. So I'm kind of a dinosaur. You know, technology is not my best friend. I'm not a 20 something who's grown up with an iPad or an iPhone in their hand their whole life. So that could be part of my problem. I readily, you know, acknowledge that could be one of my limitations. But you know, at the same time, we'll see how that all plays out. And if we can eliminate some of those inefficiencies that make practitioners not want to use those.
- [09:33]
A
Absolutely. Yeah. No, hear you there. On the dinosaur aspect, I'm honestly in my 20s and sometimes still feel like I'm not really with it as far as all the technology, like the way that Some of these kids are. But how are you thinking about growth over the next 12 months?
- [09:50]
B
You know, as far as growth goes, it's an interesting time for growth. A lot of it. I'm seeing a little bit of hesitation in the kind of. In the ASC market, kind of waiting to see what happens with our economy. You know, there's been so much. There's been so much partisan politicking that it just makes me want to vomit when it comes to that kind of stuff. They, you know, if people would just do what's best for the country instead of what's best for themselves, that would be amazing. But that's an aside because of a lot of what's going on. I've seen people either going headfirst into the, hey, it's good now we've got to go. Let's do this as quick as we can before it goes away. And I've also seen even more to the other side where it's, hey, I'm not sure how certain the future looks. Let's be cautious. Let's kind of hold off on some of these projects. But really, honestly, where a lot of the growth that I see coming is we've had this exodus, right? So we've had all these people were deemed non essential during the pandemic, step out and take their services to other locations. They have then in turn seen the benefit of, dang, you know what, it's kind of nice to collect a facility fee when I own an asc, as a podiatrist, as a plastic surgeon, as a reproductive specialist, whatever it may be. And they're seeing that as an additional revenue stream. So what we're now starting to see on the growth side is that hospitals have gotten smart and said, oh, shoot, we kind of messed up there. And so I've had several opportunities recently where an opportunity has presented itself to kind of incorporate these surgery centers back into hospitals. And the hospitals, especially some of the larger hospital systems, have gotten smart and realized that, hey, you know, here's an example. We've got one that's close enough to be an hopd. They start out that path and go, hey, yeah, we can make hpd. We could generate these hospital rates. We could, you know, have that extra revenue coming in. But then they take a pause and they go, okay, but what are we going to do? We're going to alienate these surgeons again that we've just worked hard to kind of get back in. So I've actually seen an interesting trend in the growth where a lot of these Hospital systems are actually purchasing ASCs with the intent of keeping them just an ASC, not an HOPD, for the purpose of being able to have an investment mechanism to get surgeons, primary care physicians, things like that incorporated into the hospital system and buying into the hospital system, kind of essentially allowing them some legal loyalty there. Who knows how long it'll be before somebody in the government decides that, you know, while they can take kickbacks and bribes again, we can't let the physicians do that, so let's ban it. But for now, that's looking like possibly an avenue for growth for quite a few of the smaller ASCs and OBs.
- [12:44]
A
Yeah, definitely the laughing at your bribe comment because. Yeah, let's be honest. Yeah, no, for sure.
- [12:51]
B
Pull back the curtain there and just say the truth. I mean, the ASCs were originally, you know, when they first started coming around, everybody had to have a certificate of need. And basically the intent there was, hey, the American Hospital association is afraid, you know, these are going to come in the OR is the only place where a hospital really generates any money. These ASCs are going to pop up everywhere in every corner and cripple everybody. That didn't happen. So as the states have gotten smart to that and realized that they've gone through and kind of a lot of the states have started removing these certificate of need areas. So there's a couple things happening with this and I want to address this one a little bit. You know, you've still got some of these places where quite honestly it's a bribe, you know, like let's call a spade a spade. You know, in Chicagoland area when you build an asc, you have to find the right person, you have to pay them the right amount, and then suddenly you get a certificate of need. It's not an honest process. And it's not just Chicago, it's New York. It's, you know, even Alaska. I mean, I had an opportunity present where literally a converted Jiffy Lube was being offered as a surgery center because it had a certificate. The building itself was in a horrible area. It was a trashy building, but because they had the certificate of need, they were asking a ridiculous amount for it. Because again, you have to pay off the right people, grease the right wheels, which is wrong. So we've now the pendulum swings each way. It can't swing too far the other way. I think the thing that will prevent kind of that fear, that original fear, and honestly the original fear was that if these pop up everywhere, they're going to be unregulated they're going to be unsafe. We're going to have patients dying all over the place. That's a legitimate fear. The United Arab Emirates is an example I'll use. Right now. They've got a huge growth happening and so rather than creating this false bribery system they've, that we have going on, they basically just said, hey, you know, fine, go out and do your thing, set up, but you have to be able to get accredited. And so that kind of covers both. Hey, it fills the need. And hey, we also are assuring that it's safe because you have to go through an approved accrediting agency to make sure that your, you know, what you're doing there is legit, it's safe. We're not going to have, you know, somebody's garage in Miami with silicone being injected into a buttocks from Home Depot. Right. So anyway, again, I'm a little biased. I'm with Quade, so there is some bias. I see the value in accreditation agencies and organizations, but the data is there too. When you look at accreditation accredited versus non accredited facilities, your morbidity and mortality drop off pretty significantly from the random pop ups that are just, you know, by the seat of your pants type thing versus the ones that are doing things right. So anyway, there you go. There's my little soapbox for a minute there.
- [15:48]
A
We love, we love a soapbox here. Is there anything else that I haven't touched on that you think is important in this conversation?
- [15:54]
B
You know, that's a good question. There's a lot. You know, as we're talking about growth, I think there's more opportunity for growth. I think that's a really important thing for people to understand is that healthcare is in need of disruptors right now. I think that the trend to ASCs, as long as it's done the right way, is definitely that potential disruptor. I had an opportunity to speak and I won't say the state, but I was meeting with basically the healthcare panel within the state government. So senators and representatives had a discussion with them, had a good lunch. We were Talking about how ASCs get reimbursed versus hospitals and HOPDs and these people who are making the decisions about things like Medicaid reimbursement and you know, hospital policy, healthcare policy for the state. As we got talking with them, it became very clear that they didn't really know how any of that works. You know, one of the specific examples we use was we talked about how in an asc, a true asc, your CPT code is kind of the ceiling. So if you're having code, you know, whatever for a bunion correction, you know, I can't think of the code off the top of my head. But anyway, with that code, if they say, hey, for this code we reimburse you $6,000. That's it, period. That's the end of the statement. So you get $6,000, and that's what you get reimbursed for any hardware, any facility fees, paying your staff, paying for medications, paying for anesthesia, you know, all that kind of stuff outside of the anesthesia, professional fees are paid with that facility fee, with that one CPT code versus in the hospital where that's kind of your floor instead of your ceiling. So you start with that. Then you get to charge for nursing fees and facility fees and, you know, medication administration fees and all kinds of, you know, your dme, all that kind of stuff gets added on top. So when we started talking about that, it became very clear that they had no idea that's how it worked. They had no idea why it was that ASCs were cheaper. They just thought maybe we charged less, you know, on the goodness of our heart or something, right? So as we discussed this, about 15 minutes into the conversation, one of the state senators says, hey, can we regulate, can we, can we mandate that anything that can be done in ASC is done in asc? I kind of just looked at him and laughed, roll my eyes and say, hey, you're the government. Do whatever you want. You know, you guys can do whatever you want to do. And they kind of discuss that quite a bit about, hey, how do we require that if this is an ASC potential that we send that, they have to at least evaluate that as a spot first before they go to the hospital to have it done. So theoretically, one 15 minute conversation with the right people within the government could have saved this particular state literally hundreds of millions of dollars in Medicaid fees and could have generated additional revenue for these ASCs. You know, it just, you know, all the while saving taxpayers money and saving patients money and throwing things into a system that's, you know, a little bit more efficient, I guess, would be the best way of putting it. You know, I use the example this is. This has been quite a few years ago, but I was doing anesthesia for a ob GYN surgeon and he came in and he did a robotic hysterectomy. And then he, he left and came back to do something small like a bladder sling or something like that. But anyway, got it done, took him out, hit, said hi to the patient, rolled the patient to the. The hysterectomy patient out to the recovery room, went out. I saw the patient, brought him back, got him up, got him hooked up. We were ready for surgery. I called the surgeon, said, hey, we're ready. Come on in. You know, we're good to go. He's like, hey, what do you mean you're good to go? I'm at lunch. I'm like, yeah, dude, it's been 15 minutes. Get your butt in here. It's time to go. And he's like, hey, I'm used to this hospital. He's like, I thought I had time to go eat. I'm actually at a restaurant. And we're like, dude, you saw this patient, you signed off, you said it was ready. We're in the or. And so just that kind of. That inefficiency, you know, eliminating things like that, you know, just. I've got all kinds of anecdotal stories from that, from my previous anesthesia career where there's just a lot of inefficiency that can be eliminated and where we can, through some of these other methods, again, looking at AI, at ways to eliminate. Hey, this particular anesthesia provider is able to get a patient in and get him asleep in this amount of time. Hey, this particular surgeon can get this exact same procedure done in one third the amount of time that the other partners there at the surgery center can. What's he doing differently? Let's bring him in and have him maybe train with the others, you know, so I just. I see a lot of potential for growth, for efficiency, for progress there. And I think as we do that, as we become more efficient, it'll have ripple effects as long as administration treats things ethically. So that's a whole other, like, a whole different side quest here, if you will. I just look at it as, you know, treat your people right, treat people, and they're gonna do their best for you. I've always tried to live with that as far as the areas where I've been director and manager, and it really has paid off. You know, I've had some just incredible employees who are just willing to absolutely go to bat for me. And it's because they know that on the flip side, I am 100% on board to do the same for them. That, you know, if it doesn't seem fair to them, if it doesn't seem fair to me, then it probably isn't fair. We need to make a change type thing. And I just. I wish we had a little bit more of that. In this world of kind of corruption and greed, you know, who, what health insurance CEO really needs to be taking in 350 million a year, you know, while I don't. Another soapbox. Yeah.
- [21:44]
A
I was like, well, we've got many. We can get a whole series of podcasts about that.
- [21:48]
B
Don't even get me started.
- [21:49]
A
But absolutely. Well, that is all I have for you today. Brett, thank you so much, so much for joining us today. It has been a pleasure speaking with you, and I look forward to connecting with you again in the future.
- [22:00]
B
Hey, my pleasure is all mine. Thank you so much, Francesca. Good to hear from you again.
- [22:04]
A
Yeah, absolutely.