EP445: Can a Primary-Care-Only Practice Survive in 2024? With Tom X. Lee, MD

Tom X. Lee, MD — who founded One Medical and Epocrates and now leads Galileo — joins Stacey Richter to answer a question so many primary care leaders are asking: can a primary-care-only practice actually survive in 2024? Dr. Lee names what he calls the "paradox of primary care" — the fact that the most common way to make primary care financially sustainable is to drive downstream specialty volume, which is exactly the outcome good primary care is supposed to prevent — and lays out what it actually takes to escape that trap: enlightened leadership with a value mindset, paired with real service-operations chops. WHAT YOU'LL LEARN ✅ What Dr. Lee calls the "paradox of primary care" — how the most common path to primary care profitability (driving downstream specialty volume) directly undermines what good primary care is supposed to achieve ✅ Why Dr. Lee believes enlightened leadership combined with strong service operations, not just funding, is what actually separates a pure-play primary care practice that survives from one that doesn't ✅ Where hidden waste actually lives in a primary care practice — often busywork, redundant clicks, and tasks that could be automated or handled by a nurse navigator instead of a physician ✅ Why open access to care isn't enough on its own, and why "access, sure, but access to what?" explains why retail clinics struggled to become longitudinal primary care destinations ✅ Dr. Lee's message to payers and policymakers about what it would actually take to help primary care find its "productive middle" between fee-for-service and value WHY THIS MATTERS Primary care's central bind is structural: the organizations that own primary care practices usually make more money the more specialty and downstream care gets used, which means truly effective primary care can end up cannibalizing its own parent organization's revenue. Escaping that bind, according to Dr. Lee, isn't about picking a side between fee-for-service and value-based care — it's about building the leadership and operational discipline to find a productive middle, whether a practice is independent, direct primary care, or embedded inside a larger system. Getting the incentives wrong at the payer and policy level, meanwhile, keeps making that middle harder to reach. MENTIONED IN THIS EPISODE EP438 with John Lee, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction. 07:02 What is the paradox of primary care? 09:19 Why is it hard to run an independent primary care practice? 10:01 What are the barriers to running an independent primary care practice? 10:41 Can you have fee for service and value? 12:25 "Value is more about a mindset." 13:22 What hidden waste is there in a primary care practice? 15:11 What do you need to have a value-focused mindset? 17:14 Why does access precede quality? 18:20 Why have retail clinics failed in being longitudinal primary care destinations? 20:29 What is a longitudinal primary care destination and why does it matter? 23:48 What are the nuances of a service business that make them challenging for managers? 24:35 How do you find the balance between fee for service and value? 31:17 EP438 with John Lee, MD. 32:14 How can you invest in quality without a value-based contract? 34:19 How do you address the trade-off between fee-for-service finances and investing in value-based care? 35:36 Where is the "productive middle"? 36:27 Dr. Tom Lee's message to payers. 39:55 Dr. Tom Lee's message for policymakers.