“Mission-driven” should be more specific

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“I’m interested in healthcare because…”

I frequently chat with people that are looking for their next healthcare job and want to know companies they should join. When I ask what they’re looking for in their next job, basically everyone says some combination of the same thing.

• “I’m looking for a role where I can have ownership.”
• “I’m trying to be somewhere where things are less chaotic. I’m fine with chaos, just not the chaos at [insert last company].”
• “Honestly I’d love to work for a second time founder this time around.”
• And almost every single time….“I want it to be mission-driven”. 

But what does mission-driven actually mean?  90% of the time when I follow up and ask, it’s one or more of the following.

• “I want to work at a company that’s helping underserved populations.”
• “I want to be at a company that’s helping move to value-based care.”
• “I want to improve access to care.”
• “I’d like to be at a company that’s working on social determinants of health.”

I think these motivations are great! They come from a good place of generally wanting to help people. But, it might be worth getting a bit more specific. 

Mission and business models

The issue with healthcare is that there are no silver bullets to solving these problems. Every proposed solution creates tradeoffs that are downstream of their business model. A few examples:

• Value-based care companies eventually have to do some form of rationing to keep costs under control.
• Increasing access to care is great but how are you getting more clinicians to see them? Are you increasing your costs? Are you forcing clinicians to see more patients quickly? Are you using a modality that’s scalable but probably not as good as in-person care with a doctor, even if it’s more accessible?
• Social determinants companies generally have to take a cut; would it just be better if that money went straight to patients instead?
• A hospital-at-home company makes it possible for hospitals to offer inpatient level care in a patient’s home, which is more convenient for them and expands the number of patients they can see. But they charge the same amount as an inpatient stay, which the patient ends up paying in some way. Is that better? If they work with a payer instead, then the payer will likely do everything they can to make sure the patient doesn’t escalate to the high cost hospital in the area. Is that better?
• Companies that provide accreditation keep a minimum set of standards that companies have to have if they’re doing things like taking care of patients or handling data, but it makes it more expensive for new, potentially competitive companies to get started.

Every company will tell you their version of mission-driven. The hospitals will say they’re the ones that actually care for patients, but they also are the ones costing the most. The payers will say they’re the only ones trying to reduce costs, but you’ve heard all the horror stories people have with their insurance company. And every single middleman has their own spiel about how their mission is to improve healthcare (but specifically in a way that works for their business).

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Creating your own theory of change

So…what mission are you talking about when you say “mission-driven”? Most of these companies have missions at odds with each other.

If you want to work at a company that’s mission-driven or helping make healthcare better, you should try to form your own theory about what will make a better healthcare system. Think through which tradeoffs you’re okay with - what would result in a net-benefit to the system? 

If you don’t have your own theory, you’ll end up just agreeing with the version of mission-driven that a company tells you. And probably a salary cut for the pleasure of it.

I recommend narrowing in on some specific part of healthcare to improve when trying to craft your theory of change. A lot of people expect one company to fix healthcare when it encompasses a million problems. The “what will fix healthcare” statement ends up paralyzing a lot of people when they don’t see a clear wedge. Focus on a more specific problem that a company can actually have some control over and enact change.

Your theory statement should probably be disagreeable, otherwise you haven’t thought hard enough about what the tradeoffs actually are. Examples of theories (not saying I believe these, just examples):

• “I believe we should have AI primary care that’s totally automated for routine care. It’d make care more accessible and cheaper, and would free primary care physicians to do more complex cases. However this will likely miss a certain % of diagnoses that need a face-to-face visit.”
• “I think we should be doing MRIs or lab tests every 3-6 months and we think that will catch more diseases earlier. However, it might lead to increased downstream costs, anxiety, or unnecessary follow up care and complications.”
• “Increasing the capacity of hospitals is the most important thing we can do because they deliver the highest quality of care for X disease. This will likely lead to higher costs because care done in a hospital setting is always more expensive, but that’s worth it for this disease state.”
• “We sell patient engagement solutions to X. We think that personalization and data-driven campaigns are an important part of getting patients to do important things like get flu shots, checkups, etc. that will improve their health. However, this is going to be a six-figure plus contract to support the staff needed to carry out this campaign, which will be paid by hospitals who will need to raise prices (indirectly) to pay for this.”

All of these theories can be disagreed with - but they present an understanding of a solution and what costs and issues there might be with it. Every single healthcare company you want to work for has their version of this statement, even if it’s not as explicitly laid out as I’ve done here. It’s just baked into their business model.

Questions To Ask 

Once you have a good sense of what your theory of change or idea of “mission-driven” is and know which companies are good fits, it’s important to look at those companies to see if what they say their mission is actually aligns with what they do.

Below are some questions that might help you figure out the alignment. Some of the answers can be found online, talking to investors of the company, or most likely during the interview process. Even asking one or two of these should give you a sense of what you’re walking into.

• What is the company business model and where do they derive the MOST of their margin? Some companies will have certain high revenue but low margin businesses that are meant to prop up their higher margin business. This dynamic can drive very different cultures, missions, and ethos between departments within companies especially as they grow.
• Is the stakeholder they sell to and the process the company is enabling one that aligns with your idea of mission?
• What is the one north star metric for the company? Is this consistent across everyone you talk to? Does that metric track with what you think will make healthcare better?
• How are promotions done internally for your team? Is it tied to some metric related to whatever you think will make healthcare better? For certain roles this won’t really be applicable since they’ll be focused on keeping the company running.
• If you talk to people at the company, can they name a scenario where the mission of the company was in conflict with the objectives of the company at the time? How did the company handle it?
• Does the company talk about patient stories on their site? When you ask an employee about a patient the company helped, do they have a good answer? You can tell quickly if the company shares these stories frequently or not, which is a signal.

Conclusion and random thoughts

“When everyone is mission-driven, no one is mission-driven.”

The poet, me

I used to just move past the “mission-driven” thing when people said that’s what they’re looking for. But now, I’m becoming increasingly convinced that this is one of the biggest sticking points between companies and their employees because neither party actually defines this. And when things start going sideways for a company, suddenly the mission-driven piece and the sustainability of the business come into direct conflict with each other.

So if you’re thinking about getting a job in healthcare, try to have a sense of what solutions you think would make healthcare better before you start looking around. It’ll not only narrow down your search but you’ll also have a great reason to tell the company about why you want to join. 

I also want to add a big caveat to this whole post - I think it’s totally fine to be in healthcare for non-mission reasons. A lot of people are in healthcare because it’s a stable job and pays decently. I’m largely in it because I find the field to be intellectually interesting more than trying to serve any specific mission. This post is meant to serve as a more rigorous thought exercise to figure out what mission means if it’s a priority for you.

A few random, related thoughts that didn’t fit above:

• Most people want to join mission-driven companies but also don’t want to take a big salary cut. This is why they look at mission-driven companies in healthcare and climate tech but not education. Nothing wrong with that, but it’s worth just being honest with yourself about it. People are way more willing to accept a company's mission when it coincides with a much higher paycheck. Just figure out what level of tradeoff you’re making between personal compensation and mission-drivenness you’re comfortable with before you actually get an offer.
• I think companies would be better if they included their theory of change and their specific version of a better healthcare system as part of the interview process to see if candidates agree with it. You should want candidates who aren’t good fits to leave earlier in the process if they don’t agree with your version “mission-driven”. 
  • Most companies are not willing to be opinionated about this for fear of losing good candidates, but a ton of discord can happen later if not everyone is aligned on what the north star of “better healthcare” is.
  • For example, Forward has a pretty strong theory of change on their mission page. They think health insurance is the problem and insist on doing cash pay + relying on automation/software. A lot of people will disagree with it, but the portion that do agree will strongly agree and be unified in that belief.

• One thing I like about my finance and e-commerce homies is that I know exactly what drives them. They want money! Their motivations are as clear as day, so I know to interact with them with that baseline knowledge. One thing that can be frustrating in healthcare is that everyone’s motivations are wildly different and not as clear. This is particularly annoying in two areas.
  • One is to see people motivated entirely by money use their mission-driven angle as a ruse to get people to work alongside them, and then take advantage of that belief. For example - hiring people at lower pay because they want to improve something in healthcare, while actually enriching themselves and not caring about the actual company outcome.
  • The second is that major sales decisions are made based on whether your internal champion is excited about the same mission as you. Not only is that very hard since it’s not exactly written out, but it can also introduce a certain bias. For other businesses, it’s pretty straightforward - they have a KPI they care about and you help them there. For healthcare, that map of influence is way less clear.
• A common trope is that you have to be mission-driven to start a company in healthcare, and some people get dissuaded because they’re not extremely passionate or have a personal experience with a healthcare problem. I’ve seen a lot of successful companies get started by people interested in healthcare just from an intellectual perspective. Part of it is that they’re more willing to pivot from one idea to another because they’re not anchored to a personal experience and work on unsexy parts of healthcare that may not be as obviously mission-driven. Obviously there’s no one way to be successful as a founder, but the popular narrative over-indexes on mission-driven founders. It shouldn’t be a reason someone DOESN’T start a company.
• A lot of times, adherence to the mission is directly related to how much control and involvement the original founder(s) have in the company. Once investors have more leverage and say, the tension between mission and business increases. Inevitably as a company grows the mission part becomes more diluted since the founder presence is felt less and the investor presence is felt more, so if you deeply care about the mission, I’d target early stage companies.

By the way, everything above includes Out-Of-Pocket! At the end of the day, Out-Of-Pocket is a cost to companies that pay to sponsor, attend events, buy courses, etc. Those costs may not directly increase costs to patients, but they do increase costs to the healthcare system in some capacity. My belief is that the increased cost to the system is worthwhile if it means less people make the same mistakes reading my posts, more good talent enters healthcare, and good companies get started via the Out-Of-Pocket ecosystem (co-founders meeting, ideas generated, etc.).

It could totally be wrong! But that’s the operating theory of change. I have more specific ones about improving the healthcare system, which you can find out if you take the healthcare 101 course :). 

Thinkboi out,

Nikhil aka. “Mission-driven impossible”

Twitter: ​@nikillinit​

IG: ​@outofpockethealth​

Other posts: ​outofpocket.health/posts​

Thanks to Jay Rughani and Jake Fishbein who read drafts of this

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