Virtual-first means that patients will use telehealth as the first option for primary care services. This is a rapidly increasing strategy of delivering primary care that is becoming particularly popular with insurers and patients. Perhaps it isn't specifically stated as the primary motivation, but definitely an underlying rationale for the growing phenomenon of “virtual-first” primary care is to cut costs (11, 12). Health plans and insurers are interested because the cost savings are substantial and the virtual-first plans are priced up to 20% lower than other traditional plans offered by the same insurer (12).

The encounter can be provided by a primary care physician or other primary care professional. Evidence suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians (13). It would follow that if an underlying motivation for virtual-first primary care is to decrease costs then decreasing labor costs by using nurse practitioners rather than physicians to deliver primary care would be consistent with this strategy. Consequently, the use of primary care physicians to deliver virtual-first primary care would likely be less attractive than non-physician providers to the corporation in this new healthcare delivery system.

An additional feature of the new virtual-first and artificial intelligence healthcare delivery system is the extensive use of decision making based on a presenting complaint and medical history without a physical exam. Virtual visits for primary care are structured primarily with a patient talking to a provider without a physical exam or biomarker data. This strategy still requires a human provider, and their affiliated labor costs, to elicit the presenting complaint and take the history. Some health systems may use electronic portals where patients answer questions with branching logic to move toward a differential diagnosis or need for additional biomarkers. The creation of the algorithm with the corresponding accompanying questions for the patient is based on input from experts and pattern recognition. This information can be collected through an electronic interface without the need to pay a provider to collect the medical history face-to-face. This would decrease the labor costs for collecting the data.

For example, both Rory (https://www.hellorory.com/) for women's health and Roman (https://www.getroman.com/) for men's health provide prescription medication through online visit portals. They begin with a modified medical history collected through a series of self-report questions and branching logic. These modules have different questions based on the chosen ailment (e.g., allergies, erectile dysfunction, inadequate eyelashes). The patient can do everything totally through the interface without a video interaction with a healthcare provider. A video chat with a healthcare provider happens only in states with laws requiring it. In this structure, healthcare labor costs, and the need to employ primary care physicians is clearly minimized.

This brings us back to the Luddites. If the decisions for modifying the healthcare system around new technology is driven by the desire of insurers and health systems to decrease costs, particularly labor costs, then the resulting system will likely need fewer and fewer primary care physicians. The Luddites wanted to produce high-quality goods but they also wanted higher trained workers to be used, valued and paid accordingly.

It is unclear whether the use of virtual-first primary care without a physical exam provided by nurse practitioners or other health professionals, or online visits without human interaction will lead to better or worse health outcomes. That is an open question and a needed focus of research. Nevertheless, this technology driven change in the delivery system will likely lead to fewer primary care physicians. Oh, and what happened to the Luddites? The factory owners prevailed.

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