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November 22, 2021

The Growing Phenomenon of “Virtual-First” Primary Care

Author Affiliations
  • 1Mass General Brigham, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
JAMA. 2021;326(23):2365-2366. doi:10.1001/jama.2021.21169

In October 2021, UnitedHealth Group announced the launch of a lower-premium “virtual-first primary care” plan in which enrollees receive longitudinal care from a telehealth-only physician for most of their primary care needs.1 This announcement closely followed similar virtual-first initiatives introduced by Humana, Aetna, and many regional plans in the last year. Doctor on Demand, a telehealth company supporting many of these plans, has raised $75 million in venture financing and announced that they are recruiting 1000 more clinicians to support virtual primary care services.2 Firefly Health, which provides virtual-first primary care services, has announced that it will be offering its own health plan.

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2 Comments for this article
"Virtual-First" With or Without "Profits-First"?
Robert Vinetz, MD, FAAP | California Physicians Alliance (CaPA)
Virtual-first care, if based on the for-profit health insurance model, is certain to exacerbate the fragmentation, disintegration, and high cost of healthcare, rather than promote its coordination, integration, affordability and quality.

A huge red-flag warning in the virtual-first approach is the authors’ observation that "Health plans clearly see a market opportunity; new enrollees likely to embrace a virtual-first product will be younger and more highly educated people who, on average, use the health care system the least. By preferentially enrolling healthier people and therefore having enrollees with lower health care expenditures, the plan can be profitable regardless of whether
the plan leads to improved care."

This is a classic example of a profit-first value system with a strategy of “cherry picking“ and “lemon dropping:" picking the patients who will yield the most profit and dropping or excluding patients whose care risks those profits. Patients who need care the most are unwanted or considered as residue to be picked up, if at all, by someone else (think Medicare, Medicaid, charity, or “their own bootstraps“).

As a society, we need to decide whether everyone deserves and receives healthcare or whether we continue the wealthy world's highest-cost system of risk-pool fragmentation, segregation, and profits before people. If we choose the universal "everybody in nobody out" system, the virtual-first visit must be made consistent with the values of that patients-first system and only then, if eventually shown to help rather than to harm, should it be a "virtual-first option."

Virtual Medicine: The Benefits of Concise Electronic Medical Records
Marc Rendell, M.D. | The Rose Salter Medical Research Foundation
Whitehead and Mehrotra are commended for increasing awareness of the trend to telemedicine for initial care (1). They have well summarized potential advantages but leave out one important aspect of the appeal of current telemedicine platforms: ease of use. The need for efficient digital interactions has promoted concise EMR programs, far less onerous than the present day systems in use in hospitals and outpatient clinics. Let us state the reality: programs such as Epic and Cerner and Allscripts are challenging, time consuming, and take away from the doctor patient interaction. Complexity of data entry and redundancy are burdensome for the physician. Telemedicine platforms such as MDLive, Teladoc, and Amwell have moved the focus back to the essential functions of medical care. These programs are efficacious and less onerous than the current day in person platforms. Physicians and patients both prefer electronic medical record programs that are secondary to the medical interaction rather than occupying the primary effort of the physician.

(1) Whitehead DC, Mehrotra A. The Growing Phenomenon of “Virtual-First” Primary Care. JAMA. Published online November 22, 2021. doi:10.1001/jama.2021.21169