The hidden cost of ‘free’ telehealth: Why independent primary care pays the price

Commercial insurers and self‑insured employers are increasingly steering patients toward zero-dollar copay telehealth and low‑copay urgent care, effectively devaluing longitudinal primary care while shifting clinical risk and unresolved problems back onto independent practices already struggling with rising overhead and stagnant reimbursement. Independent primary care groups can push back by reframing themselves as the “continuity hub” of care, redesigning their own telehealth and urgent access offerings, and renegotiating payer and employer relationships to align incentives with comprehensive, relationship‑based care.

Insurers’ ‘free care’ comes at a price

As insurers race to advertise “free” virtual visits and lower copays at urgent care centers, independent primary care physicians say they’re being left to clean up the mess. From misdiagnosed conditions to fragmented chronic disease management, the promotional telehealth model increasingly sends patients back to community practices with more complex problems — but no additional resources to solve them.

Commercial plans and large self‑insured employers now routinely waive copays for telehealth delivered by their own contracted vendors and carve out lower cost‑sharing tiers for urgent care chains. Those same benefit designs often fail to offer comparable support for visits with patients’ established primary care physicians, even when the issues originate in virtual encounters that never fully resolved the problem.

How benefit design sidelines continuity

Telehealth has demonstrated that it can substitute for some in‑person visits and lower per‑encounter spending, which is why payers have embraced it as a cost‑control tool. But benefit design rarely differentiates between one‑off encounters and relationship‑based primary care that manages multimorbidity, social drivers of health and long‑term risk.

When a sore throat, rash or medication refill can be handled instantly by a remote clinician who has never met the patient, the insurer saves money on that single episode — while the primary care practice loses the revenue and the opportunity to reinforce continuity of care. Over time, that erosion of acute visit volume and evening/weekend coverage can undermine the financial model that supports the fixed overhead of community practices.

Independent clinics, which often operate on thin margins, have invested in their own telehealth capabilities without seeing a commensurate increase in their fee schedules to compensate for platform fees, information technology (IT) support, workflow redesign and staff time spent onboarding patients into virtual care. Their costs typically go unreimbursed when payers treat telehealth as a cheaper alternative rather than an integrated component of comprehensive primary care.

Clinical fallout: Cleaning up after ‘free’ telehealth

Primary care clinicians have long worried that direct‑to‑patient telehealth and retail urgent care would fragment care and erode the continuity that underpins good outcomes. During the COVID-19 pandemic, practices struggled with triage rules, visit‑type protocols and safe boundaries for what could reasonably be handled virtually, especially for acute symptoms.

Insurers and employer plans, however, continue to market virtual care as a frictionless solution for nearly any concern, from respiratory infections to behavioral health, often with limited integration into the patient’s medical home. When those encounters fall short, patients almost inevitably end up back in their primary care office.

This creates a worrisome two‑step pattern: a brief, low‑copay virtual visit with a remote clinician, followed days later by a longer, more complex visit with the primary care physician to reevaluate, order tests, reconcile medications and repair frayed trust. While the free telehealth encounter gets the headlines, it is the community practice that carries the harder work of diagnosis, care coordination and chronic disease management — often without additional payment or recognition in quality programs.

Hidden costs and growing strain

For large health systems, telehealth implementation has been underwritten by scale — enterprise platforms, centralized IT and dedicated virtual teams. Independent primary care practices face the same expectations from patients and payers but must build and support virtual care with far fewer resources.

For primary care clinicians, uncertain reimbursement and complex payer rules have emerged as major barriers to sustainable telehealth use. There are hidden costs, such as staff spending significant time troubleshooting patient video connections, clinicians toggling between telehealth and in‑person visits with minimal guidance, and uncompensated work documenting and coordinating care after these external virtual encounters with insurers’ supported vendors.

Insurer carve‑outs that reserve zero-dollar copays for vendors’ telehealth products and low copays for contracted urgent care centers have the practical effect of steering patients away from their own doctors for initial episodes of care. When those episodes are incomplete or fragmented, the independent practice is left with responsibility for risk, follow‑through and liability — but not the volume or revenue that makes their operations sustainable.

Reclaiming telehealth for continuity

Primary care physicians are not powerless in the face of these trends, but they will need to rethink both strategy and messaging to defend continuity‑based care. First, practices can reclaim telehealth as a continuity tool rather than a stand‑alone convenience service. Clear triage rules, written visit‑type protocols and clinician training on virtual communication help ensure that virtual encounters reinforce long‑term relationships instead of replacing them.

Independent groups can prioritize video and phone visits for follow‑ups, chronic disease check‑ins and medication management, where an existing relationship and shared record make remote care safer and more efficient. For acute issues, they can offer same‑day access — including structured virtual slots — but maintain guardrails around high‑risk symptoms, insisting on in‑person evaluation when necessary to protect patient safety and diagnostic accuracy.

Push payers and employers on benefit design

Second, physicians can press payers and self‑insured employers to align benefit design with continuity of care, not just low per‑encounter cost. That means advocating for equivalent or better coverage of virtual visits when they are delivered by the patient’s own primary care practice, rather than reserving zero copays solely for external vendors.

Within accountable care organizations and other value‑based contracts, practices can use claims data to show how fragmented telehealth and low‑copay urgent care can increase downstream utilization and risk while integrated primary care telehealth supports better chronic disease control and reduces avoidable emergency room visits and hospitalizations. Self‑insured employers, particularly those focused on productivity and absenteeism, may be receptive to evidence that a strong relationship with local primary care reduces total cost of care more reliably than transient vendor‑driven encounters.

Communicate the value of continuity

Third, independent practices can refine their own pricing and communication strategies around virtual care. While they cannot make every telehealth encounter free, they can incorporate remote touchpoints into direct primary care models where feasible.

Just as important is creating a clear narrative for patients. Through portals, email campaigns and in‑office signage, practices can explain why seeing “your own doctor” matters: the ability to recognize subtle patterns, avoid duplicative testing, manage medications safely, and address behavioral and social factors over time. Patients who have experienced fragmented care often respond strongly to a message that contrasts one‑off virtual visits with comprehensive, team‑based primary care built on a longitudinal relationship.

Keep a seat at the policy table

Finally, independent primary care must remain active in policy discussions on telehealth reimbursement and network design. Without clearer standards, insurers will continue to experiment with preferred pricing and carve‑outs that favor their own virtual products over local practices, widening digital divides and exacerbating inequities in access. Persistent engagement with regulators, payers and employer coalitions can help ensure that telehealth supports — rather than undermines — the community‑based primary care infrastructure that millions of patients still depend on.

Insurers and self‑insured employers may view zero-dollar telehealth and low‑copay urgent care as patient‑friendly innovations, but for independent primary care practices, these benefit designs are quietly hollowing out the economic and clinical foundation of longitudinal care. If primary care is to remain viable outside consolidated health systems, independent practices will need to reclaim telehealth as an extension of the medical home, demand benefit designs that reward continuity rather than fragmentation, and make a clear, public case that one’s own doctor is not a luxury add‑on to the system but the central organizing force that keeps care safe, efficient and sustainable over time.

Robert Resnik, M.D., MBA, is a board-certified internal medicine physician practicing in Cary, North Carolina. He earned his medical degree from Eastern Virginia Medical School in Norfolk and completed his residency at East Carolina University in Greenville, North Carolina. He also holds an MBA from Duke University in Durham, North Carolina.