EP481: Seriously, IRL, What Does “No Margin, No Mission” Even Mean? With Benjamin Schwartz, MD, MBA

Last week, I announced I was on a tear to really get to the bottom of no margin, no mission. How do we, in real life, operationalize these very sort of inspirational but kind of vague words?

This conversation is largely me grilling Dr. Ben Schwartz on what no margin, no mission means to him, and how do you systematically pull it off? So, yeah, real softball kind of question. I’m joking, which is why I could not have been more appreciative of Dr. Ben Schwartz for taking on this challenge and coming back on Relentless Health Value to discuss.

For a full transcript of this episode, click here.

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Because here’s the thing: If you wanna do a start-up or you wanna do something in healthcare involving mission and margin, it is (but not always) a trade-off. It is often at least conceived that the more mission, the less margin. This trade-off is more likely, actually, going to be true and is often true when there are perverse incentives, such as stuff like the sicker the population is, the more money everybody makes.

From provider organizations to carriers to PBMs (pharmacy benefit managers) and, yeah, pharma to even brokers, consultants who are often paid a percentage of “shared savings” or get a little kicker for every prescription written, like, how common apparently it is for some big PBMs to pay employee benefit consultants for every single script that gets written—something like, what, $7, hypothetically.

But back to shared savings. You know, never forget shared savings go up when trend goes up. Rebates go up when list prices go up. This is always true.

And so, mission and margin only travel together if someone is creative, innovative, knowledgeable, dedicated, and has enough energy to force these two terms to align amidst a whole lot of countervailing industry norms, policies, shareholder fiduciary interests, and just some deeply ingrained culture.

I really liked how Anthony Stanowski put it in a recent Modern Healthcare article he wrote: “We often hear the phrase, ‘No margin, no mission.’ And it’s true—a system without financial viability cannot sustain itself. But the reverse is also true: Without mission, margin devolves into a utilitarian calculation of which procedures yield the highest returns, which drugs deliver the most measurable ‘value,’ or which population segment is most important to attract.”

So, with all that said, here’s what I’m up to, listeners. This is going to be a series where we talk about achieving mission success and if and/or how mission can fit into any given business model. Especially business models that we talk so often about on this podcast, which (from a mission standpoint, at least) could be labeled as bad, not so good, not so good for keeping patients (or people who really don’t want to become patients) healthy.

So, what I’m gonna do periodically is invite guests to come on Relentless Health Value to have this conversation with me. This started with the show last week with John Lee, MD (Take Two: EP438). I really wanna pick a few of your big brains about what it takes to run a healthcare practice or a business that is actually in that sweet spot, in the zone where mission and margin are balanced.

How can we get ourselves so situated as a business or as an industry or an ecosystem so that those who are able to balance mission and margin come out as winners? That is my goal.

Okay, I wanna talk about a complication now, a complication that is even more deep rooted than the whole perverse incentives thing. What’s even below that? Because why is it—you know, that Charlie Munger quote, Warren Buffett’s partner, who famously said, “Show me an incentive, and I’ll show you an outcome”—why is that even true in the first place? It’s not like, if there’s an incentive, then I must act in accordance to that incentive. Where does this come from, that if there’s a perverse incentive that the outcomes then are also perverse?

And this might be TMI philosophical, but yeah, here we are. So, let’s just go there for 45 seconds, why don’t we?

So, it’s important, I think, to recognize that monetary success is the bedrock of a lot of people’s self-esteem. I just listened to Scott Galloway, who’s an interesting cat. He has a podcast. He’s got several podcasts. And one of them, he went on at some length about how we so often measure, again, our self-worth by our literal worth. Like, every dollar we put in our pocket is like a quantitative increase in our value as a human being. And Scott Galloway continues, few people, even billionaires, feel they have enough money.

And again, I’m getting probably TMI philosophical here, but this thought really stuck with me. And I’ve been thinking about it for a week, just in terms of what this means for healthcare in this country. You know, if our basic value system is tied to increasing our net worth—and we often think that’s okay, even if it comes at the expense of personal relationships or our own health but also if the business is a healthcare business—me self-enriching in profiteering ways will negatively impact other people’s health.

But margin has become a cultural norm—the shoving of margin forward that mission just does not have, especially at the corporate level, 10,000 feet from any bedside of any patient. And I’m saying this with some emphasis. Of course, there is the Hippocratic Oath, for sure. But as far as laws go, the only maybe structural or legal framework around mission that I could find anyway is fiduciary responsibility.

And you know the only entity with fiduciary responsibility to patients or members? Plan sponsors, right? No, the boards of nonprofit health systems don’t have fiduciary responsibility to patients. Not TPAs (third-party administrators) or ASO (administrative services only) leaders as far as most courts seem to have determined so far. Not PBMs. None of these entities has any legal obligation to patients, members, or the communities they serve.

Dave Karlander was talking about this recently. Any health system or any of them talking about fiduciary responsibility, legally what that means is a responsibility to margin it up, for better or for worse, even as a nonprofit.

Alright, massive spoiler alert: So, if you don’t wanna hear this, skip ahead. But I just need to give you a heads-up of my big “holy smokes, blew my brain” moment of reckoning that cropped up in this conversation with Dr. Ben Schwartz. And it became so clear toward the end.

Where this conversation winds up is we circle the whole way back from whence we came: trust. That if you want to trust that no mission, no margin is gonna wind up a trade-off situation, like in a place that you can trust, then you have to trust the person who is making that call. So, it all comes back to trust.

So do listen to this episode, even though I just ruined the suspense. But, hey … that’s what I do.

And with that, here’s my conversation with Dr. Ben Schwartz. Also, read his bio on the Web site. He just got a brand-new job at Commons Clinic, so congratulations, Dr. Schwartz. His new job is not being an orthopedic surgeon full-time. He will be SVP, Care Services and Strategy, over there at Commons Clinic.

Also mentioned in this episode are Anthony Stanowski; John Lee, MD; Scott Galloway; Dave Karlander; Keith Passwater; Havarti Risk; Commons Clinic; Yashaswini Singh, PhD; Beau Raymond, MD; Rishi Wadhera, MD, MPP; Doug Geinzer; Scott Conard, MD; Andreas Mang; Peter Hayes; and Matt McQuide.

Related episodes: INBW42 with Stacey Richter; EP477 with Stacey Richter; EP474 with Yashaswini Singh, PhD; EP326 with Rishi Wadhera, MD, MPP; EP391 with Scott Conard, MD; EP419 with Andreas Mang; EP475 with Peter Hayes 

You can follow Dr. Schwartz on LinkedIn and read his blog on Substack. 

Benjamin J. Schwartz, MD, MBA, is a physician executive and fellowship-trained orthopedic surgeon with nearly two decades of experience in musculoskeletal care. After 17 years in clinical practice—including leadership roles in a private equity–backed MSO—he’s now transitioning from the operating room to executive leadership, focused on building scalable, patient-centered specialty care models.

Ben recently accepted the role of senior vice president of care services and strategy at Commons Clinic, a tech-enabled, value-based specialty care platform backed by leading healthcare investors. In this role, he will help shape the company’s clinical strategy, care delivery infrastructure, and multisite growth initiatives. He officially begins this position in fall 2025 and is currently supporting Commons in a consulting capacity.

Ben serves as chair of the Practice Management Committee for the American Association of Hip and Knee Surgeons and has advised multiple early-stage health tech start-ups. He is widely known for bridging the gap between frontline clinical practice and system-level innovation.

His writing appears in The Surgeon’s Record, where he explores the intersection of healthcare delivery, business strategy, and physician leadership.

Ben is passionate about reimagining musculoskeletal care through thoughtful integration of technology, operational excellence, and a renewed focus on the doctor-patient relationship.

08:50 Sister Irene Kraus and the origin of no margin, no mission.

10:01 Margin and mission versus profit and profiteering.

12:45 Stacey’s manifesto (EP400).

13:01 What is the broad mission within healthcare?

14:12 What is mission drift within healthcare?

15:54 EP474 with Yashaswini Singh, PhD.

17:26 Why do we struggle with balancing margin and mission?

20:47 EP455 with Beau Raymond, MD.

20:52 How does value vary?

23:18 EP326 with Rishi Wadhera, MD, MPP.

23:53 What needs to happen to balance margin with mission?

28:29 Why does everything come down to trust?

28:33 EP391 with Scott Conard, MD.

30:30 EP419 with Andreas Mang.

32:21 What are the “vectors of change” to create balance between mission and margin?

32:43 EP475 with Peter Hayes. 

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479), Justin Leader (Take Two: EP433), Andreas Mang and Jon Camire (EP478), Stacey Richter (EP477), Charles Green (Bonus Episode), Ann Lewandowski, Peter Hayes, Yashaswini Singh