Combined telemedicine-first and direct primary care as a promising model of healthcare delivery.

Telemedicine is comparable in quality to in-person care, adequate for many primary care concerns, acceptable to patients, and can overcome barriers to care. However, patients are reluctant to pay the same for telemedicine as in-person care and uncertainty about future payor reimbursement makes it risky to base a clinical practice primarily on telemedicine. Physical exam-supported information collection and relationship-building are limited in telemedicine, but can be mitigated through remote patient monitoring and ample access to a provider and clinical team. Subscription-based direct primary care models disconnect payment from episodes of care, which can support enhanced communication between the patient and care team and support time for asynchronous tasks such as remote patient monitoring data review. A "telemedicine first, direct primary care" model in which most care is provided through telemedicine and financed via subscription would retain the convenience of telemedicine, mitigate relationship-limiting deficiencies due to the lack of physical contact, and provide a stable revenue stream to support a telemedicine-based approach to care. Paired with specialist access via eConsults and options to refer to in-person care when necessary, this model would support telemedicine as the foundation for practice and connect underserved populations to primary and specialty care.