The Rise of Virtual-First Healthcare: Its Access, Equity, and Cost

Virtual-first health plans and provider groups are emerging as new care delivery models, offering patients convenience at a lower cost. These plans, however, raise questions about continuity, health equity, and regulatory oversight. This article examines how virtual-first health plans are transforming care pathways, payer strategies, and investment trends, while outlining guardrails to ensure quality and access.

Virtual-first care refers to insurance products, provider groups, or care models where digital methods are the default point of entry. Patients are expected to start virtually for most non-emergency needs. Virtual providers handle referrals and guide patients to physical locations. Integration with primary care and specialty networks is prioritized. Ideally, these models reduce fragmentation by guiding patients through a selected network. Examples include virtual-first health plans from national insurers, startups offering digital primary care subscriptions, and hybrid systems that combine telehealth with brick-and-mortar clinics.

Virtual-first care is rapidly expanding. Unlike traditional telehealth, an adjunct to in-person care, virtual-first health plans and provider groups design their models around digital front doors. Members begin with video, phone, or asynchronous chat encounters, with in-person services coordinated when clinically necessary. This approach is attractive to payers, employers, and investors because it promises lower costs, improved patient satisfaction, and better navigation of fragmented health systems. For patients, it offers convenience and immediacy. Yet the shift to virtual-first care raises critical questions about access, equity, continuity of care, and oversight. As the model scales, health leaders and policymakers must understand both its opportunities and its pitfalls.

Implications of Virtual-First Care

For many patients, virtual-first care reduces barriers such as travel, scheduling delays, and geographic shortages of clinicians. Individuals in rural areas, people with mobility limitations, or those balancing multiple jobs may find it easier to seek care when the first step is virtual. Some models also provide extended hours, faster response times, and triage that connect patients to the right level of care. However, access gains are not universal.

Virtual-first models assume broadband access, digital literacy, and comfort with technology. Populations most in need of care, such as older adults, low-income individuals, and non-English speakers, may face new hurdles if in-person options are reduced or if digital platforms are not designed to be inclusive. Another key concern is whether virtual-first pathways fragment relationships with existing primary care providers. Patients might have episodic digital encounters that meet immediate needs but do not establish long-term continuity. Without safeguards, care could become transactional rather than relational, weakening preventive and chronic care management. 

Virtual-first care has the potential to both reduce and widen disparities. Positive equity impacts include increasing behavioral health access in communities facing clinician shortages, offering multilingual platforms or culturally competent care navigation, and lowering transportation costs that mainly burden low-income households. However, equity risks involve excluding patients without reliable broadband or devices; algorithms that triage care might reinforce existing biases; and narrow networks could limit access to local providers familiar with patients’ cultural or community contexts. The outcomes for equity will depend on design choices, such as whether systems provide alternatives for those who are digitally excluded populations and whether quality metrics capture disparities in experience and outcomes. 

From the insurers’ perspective, virtual-first models are attractive because they can reduce unnecessary emergency department visits and redirect patients to lower-cost settings. Digital triage tools help determine which patients require in-person services, potentially avoiding costly overutilization. Additionally, virtual-first plans often feature value-based payment structures with capitated or bundled arrangements, aligning incentives to manage the total cost of care.

From the provider and system perspectives, virtual-first care can streamline workflows by utilizing asynchronous visits, nurse triage, or AI-enhanced tools, thereby reducing costs. But reimbursement remains uneven. While some insurers cover virtual-first encounters as equivalent to in-person visits, others pay less, creating sustainability challenges.

In terms of cost implications, from the patients’ perspective, there may be lower out-of-pocket costs when virtual visits substitute for urgent care or specialist consultations. Yet, there are risks associated with overusing the convenience of digital access, leading to higher visit volumes without improving outcomes and ultimately raising total costs. The challenge lies in balancing ease of entry with clinical appropriateness. Table 1 summarizes the implications of virtual-first care.

Table 1. Implications of Virtual-First Care

	Benefits	Limitations
Patients		Patients
	Reducing barriers of travel, scheduling delays, and geographic shortages of clinicians, mobility limitations, balancing multiple jobs.	Fragment relationships with existing primary care providers.
	Faster response times and triage connecting patients to the right level of care.	Patients may receive episodic digital encounters that address acute needs but fail to build long-term continuity.
	Lower out-of-pocket costs when virtual visits substitute for urgent care or specialist consultations	While some insurers cover virtual-first encounters as equal to coverage of in-person visits, other insurers pay less, creating sustainability challenges.
Insurers		Insurers
	Reducing unnecessary emergency department visits and redirecting patients toward lower-cost settings.	Equity risks exclude patients without reliable broadband or devices.
	Digital triage tools help to reduce unnecessary emergency department visits and redirect patients toward lower-cost settings.	Algorithms that triage care may replicate existing biases.
	Determine which patients require in-person services, potentially avoiding costly overutilization.	Narrow networks may limit access to local providers familiar with patients’ cultural or community context.
	Feature value-based payment structures with capitated or bundled arrangements, aligning incentives to manage the total cost of care.
Providers and Health Systems
	Streamline workflows by using asynchronous visits, nurse triage, or AI-enhanced tools.	Care could become transactional rather than relational, undermining preventive and chronic care management.
		Older adults, low-income individuals, and non-English speakers may experience new obstacles if digital platforms are not designed inclusively.
		Risks of overusing the convenience of digital access, leading to higher visit volumes without improving outcomes, and raising total costs.

Market and Investment Trends

The past five years have seen rapid growth in investment into virtual-first platforms. Venture-backed companies have developed national networks for primary care, behavioral health, women’s health, and chronic disease management. Insurers are increasingly embedding these offerings into benefit designs, promoting them as lower-cost options for employers. Key trends include:

• Startups are partnering with health systems to blend digital and in-person services.

• Specialty care in diabetes, musculoskeletal health, or dermatology is provided mainly through online services.

• Large employers are offering virtual-first plans as part of their cost-saving benefit packages.

• Mergers and acquisitions are created with the aim of building comprehensive digital-first ecosystems.

While investor enthusiasm is strong, questions remain about long-term sustainability, patient retention, and differentiation once virtual care becomes ubiquitous.

Regulatory and Policy Considerations

Regulation lags behind innovation. Policymakers face several questions: Many virtual-first models operate nationally, challenging state-based licensure frameworks. Regulators should evaluate not only physical provider networks but also the accessibility and inclusivity of digital networks. Insurers should be required to reimburse virtual encounters at the same rate as in-person visits. Additionally, since current quality metrics are designed for in-person encounters, new measures are required for virtual-first settings, including continuity, patient satisfaction, and digital equity. Increased reliance on digital platforms heightens concerns about consumer data use and protection. Establishing clear guardrails is essential to protect patients while allowing innovation to thrive.

Implementing Virtual-First Care

To realize the benefits of virtual-first care without deepening inequities, stakeholders should adopt the following guardrails.

1. Ensure that patients can seamlessly access in-person care when needed, avoiding “digital-only” silos.

2. Collect and report outcomes by race, ethnicity, language, geography, and socioeconomic status.

3. Allow members to opt into or out of virtual-first pathways, respecting individual preferences.

4. Invest in multilingual interfaces, user-friendly platforms, and outreach to digitally underserved populations.

5. Incorporate virtual-first care into longitudinal patient records and primary care relationships.

6. Support value-based payment models that reward quality and outcomes rather than visit volume.

Conclusion

Virtual-first care represents a significant evolution in healthcare delivery, moving beyond telehealth as a supplement to positioning digital encounters as the starting point of care. For payers, it offers pathways to lower costs; for patients, it promises convenience and quicker access. Yet the model introduces new challenges around equity, continuity, and oversight. The future of virtual-first care will depend on careful policy design, responsible investment, and commitment from payers and providers to prioritize inclusivity and quality. Without such guardrails, the model risks becoming a two-tiered system that improves access for the digitally enabled while marginalizing others. Executed well, however, virtual-first care could become a cornerstone of value-based, patient-centered health systems.

Additional Readings

• Ellner A, Basu N, Phillips RS. From revolution to evolution: early experience with virtual-first, outcomes-based primary care. Journal of General Internal Medicine. 2023 Jun;38(8):1975-9.

• Noble M, Chen F, Linke S, Dall TM, Napoleone J. Modeling the Economic Value of Cardio-metabolic Virtual-First Care Programs. American Journal of Managed Care. 2024 May 2;30.

• Potter J, Watson Gans D, Gardner A, O’Neill J, Watkins C, Husain I. Using virtual emergency medicine clinicians as a health system entry point (virtual-first): cross-sectional survey study. Journal of Medical Internet Research. 2023 Aug 3;25:e42840.

• Schwamm LH, Estrada J, Erskine A, Licurse A. Virtual care: new models of caring for our patients and workforce. The Lancet Digital Health. 2020 Jun 1;2(6):e282-5.

• Whitehead DC, Mehrotra A. The growing phenomenon of “virtual-first” primary care. JAMA. 2021 Dec 21;326(23):2365-6.

• Zaleski AL, Guan X, Thomas Craig KJ, Junk C, McGill AT, Gordon H, Verbrugge DJ, Caya K. An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payor. BMC Health Services Research. 2025 Jul 29;25(1):994.