There is an old saying in health care: “no margin, no mission”. The perspective was not originally meant to be harsh. Instead, it was intended to remind employees within many non-profit systems that mission cannot be pursued unless adequate finances keep the doors open. Money must be considered. A positive “margin” (i.e. revenue exceeds costs) must be achieved. If not, the organization cannot survive very long.
I’ve never much liked the expression, I must admit. Sure, there is truth behind it. But so is there truth to “no food, no life” and you don’t hear too many people saying the obvious about food in countries that aren’t experiencing a famine. It is simply understood. It’s an inherent part of the basic rules of sustainability.
And yet I’ve heard the margin mantra all too often in my career, especially in the past decade. Usually it’s mentioned by a finance person, or a new health system administrator. Typically it’s spoken to physicians, nurses, and other clinicians when a new administration is planning on making some cuts, offered soberly as if the people taking direct care of patients never themselves had to balance their own checkbook or bank statement. There are a lot of health care MBAs out there who seem to think that clinical staff don’t understand the necessity of budgets, operating margins, and cost containment. It must be something those folks are taught in business school. “Doctors don’t care about spending,” they must hear. “Careful or they’ll break the bank whenever they can.” Why else would a non-clinician sigh, hold his hands as if standing in a pulpit, and prophetically declare “No margin, no mission” in response to questions from clinicians about spending?
Please. The person making the most money in the health system is preaching about the importance of margin to staff who are about to be told that their nurse-to-patient ratios are too high? This isn’t about margin at all. It’s about how much margin. Which is a different thing entirely.
Not all hospital administrators or health organization chief finance officers are like this; I’ve met some good ones, people who don’t think about the “bottom line” as a set of spreadsheet numbers or financial goals. However, it’s scary how many actually do. The percentage of people running health care in this country that sit in offices separated from where people get care and pass judgment on waste and cost-effectiveness is frightening.
“What does he do out there?”
That was the question that a CEO once asked about me when, as chief medical officer, I used to walk through the hospital once or twice a day, often before the sun was up or well after it had set. This person didn’t ask me. No, he asked my retiring predecessor.
“What did you tell him?”
My friend shook his head. His eyes looked sad. “You should keep your options open,” he told me.
Ah, my options. Yes. Indeed, I kept them open. A few months later, after tolerating more than a few childish outbursts and lectures about the importance of budget cuts in a system that had operating margins well above the norm, I exercised the one that made the most sense: I left. Any place that wanted me to “choose which side I was on” (i.e. doctors or administration) was not a place that understood why it was there.
No margin, no mission? How about this: no mission, no meaning.
It is seductive, the margin argument, as it is – to a degree – logical, practical, and pragmatic. Margin pays bills. Margin replaces equipment. But who decides in the margin world what count as funding priorities? Who gets to say how much margin is needed to feed savings and investment portfolios rather than after-hour and weekend nurse-patient ratios? It can be shocking, even shameful, how quickly perspective can be lost on what matters when the view to meaning is distorted by the thick and opaque lens of margin.
Mission gets forgotten. Morale sinks. People suffer.
It’s no wonder that there is surging interest in something better, something that makes more sense. ‘Medicare for All’ isn’t some communist plot to destroy health care companies. It is a rational response to the lunacy of what we get when margin motivation goes unchecked. It is a reasonable request for balance in a so-called ‘health care system’ that seems uncertain why it exists in the first place.
Does ‘Medicare for All’ really have a chance in our current political climate? Is it even the right solution? I don’t know. But maybe the debate will help clear some cobwebs from our collective thinking. Why is it we have even developed a system of care delivery in the first place? Do we deliver care in order that it can be financially sustainable or do we do so because we actually want to help each other heal?
No margin, no mission? Left unchecked, that pithy maxim is a Faustian bargain, in disguise. Because, when it comes to health care, margin without mission can be meaningless.