Where the cheap telehealth patients actually come from

The most expensive patient you will ever get is the one you win in an ad auction, because to get them you had to outbid everyone else who wanted them. The cheapest patient is the one who never entered an auction at all.

That is the whole case for distribution, and it is the lever most telehealth founders never build because it is slower and less legible than turning on ads. This is the companion to a point made elsewhere on this site: two things make a patient cheap to acquire, differentiation and distribution. Differentiation is its own subject. This is the distribution half, and distribution comes in three kinds that are not remotely equal. You can own it, you can borrow it, or you can rent it from the company that makes the drug you prescribe. Only one of the three compounds, and only one of the three cannot be taken away from you.

Why is a distribution patient cheaper than an ad patient?

An auction sets the price of attention to the highest bid. When you buy a patient through Meta or Google, you are not paying what the patient is worth to you. You are paying what the patient is worth to the best-funded bidder in your category, because that is who you had to beat. In a category with a venture-backed incumbent, that price only goes one direction.

A patient who reaches you some other way, through a piece of content they trusted, a doctor who referred them, an employer who put you in front of them, never entered that auction. There was no second bidder to outpay. The cost of acquiring them scales with the work you did to build the route, not with whatever your richest competitor decided to spend this quarter. That is the entire economic difference, and over a few years it is the difference between a business that compounds and one that rents its growth at a rising rate.

What does owned distribution look like?

Owned distribution is any audience or referral base that belongs to you. An email list. A body of content that ranks and keeps working. A reputation in a specific community. A referral relationship with clinicians who send you patients. The defining property is that no one can switch it off.

It has one real cost, and it is the reason founders skip it: it lags. An audience built today pays out in two or three quarters, not this week, and there is no dashboard that makes the first months feel productive. That lag is exactly why it has to start before you feel ready for it. Every month you delay owned distribution is a month you will later have to buy patients at auction prices because you have no other route.

This is why the advice, when a founder has real constraints, is almost always to start the owned channel immediately and in parallel with everything else, rather than after the paid engine is working. The paid engine never stops needing to be fed. The owned channel, once built, feeds itself.

In practice, starting is smaller than most founders expect.

From Pranay Parikh, MD, founder of Off-Label:

"I tell them to start with organic, and the easiest organic is just them in front of a camera. They can do it with their iPhone. They don't even need a camera, just an extra microphone. Start on Instagram. It will be choppy at first, but it feels more authentic. Talk about building the business, why you are doing what you are doing, and just get people to know you. Eventually you build a team around it, get editors and the rest, but I would do a minimal viable product first: get some engagement, get friends and family to follow and repost, and make it as authentic as possible."

What does borrowed distribution look like, and why isn't it a moat?

Borrowed distribution is renting someone else's audience. This is the whole category of B2B partnerships and affiliate deals, and it is genuinely valuable, so long as you are honest about what it is.

The clearest recent example is Ro's placement in Planet Fitness's member perks program. Planet Fitness describes that program in its own annual report as a channel where "brands and third-party retail partners" pay it "fees and commissions" to put offers in front of its members. That is a distribution channel that never touches an ad auction, sitting in front of a very large membership, paid on a commission basis so its cost tracks results rather than a competitor's bid. If you can strike a deal like that, strike it.

But two features make it a channel, not a moat. First, it is not exclusive: the same perks program carries other weight-loss and telehealth brands, including Ro's direct competitors. You are one logo among several, not the only door. Second, and more important, it can be taken away, because it was never yours.

The proof of that ran in public last year. In April 2025, Novo Nordisk enabled several telehealth companies, including Hims & Hers, LifeMD, and Ro, to route patients directly through its NovoCare Pharmacy. Two months later, in June 2025, Novo terminated the Hims & Hers collaboration, citing concerns about the company's compounding and marketing practices. Whatever the merits of that specific dispute, the mechanics are the lesson. A distribution channel that someone else controls is a channel they can close, on their timeline and their reasons, after you have built part of your business on it.

Borrowed distribution is worth having. It is not worth mistaking for something you own.

What happens when the company that makes the drug owns the channel?

There is a third case, and it is the one telehealth founders in the GLP-1 space are living through right now.

The manufacturers are building their own direct-to-patient channels. Eli Lilly launched LillyDirect in January 2024, offering patients access to independent telehealth providers and direct home delivery of Lilly medicines. Novo Nordisk launched NovoCare Pharmacy in March 2025 as a direct-to-patient delivery option for cash-paying patients. Lilly described its self-pay offering as removing "third-party supply chain entities" so patients could buy directly. That phrase is worth reading twice, because in a lot of cases the third-party supply chain entity being removed is an independent telehealth company.

Be precise about what the manufacturers have taken and what they have not. They now own the pharmacy, the fulfillment, the pricing, and increasingly the patient's front door. They have not taken the prescriber. Lilly is explicit that the clinicians on its platform exercise independent medical judgment. So the squeeze does not fall on every telehealth company equally. It falls hardest on the ones whose entire value was access, connecting a patient to a drug and getting it shipped. If that was your product, the maker of the drug now offers it directly, and the Hims termination shows they can decide who else gets to.

The telehealth company that survives this owns something the manufacturer cannot supply: a real clinical relationship, a specific patient population it reaches better than anyone, a reason the patient came to it rather than to the drug. Which is to say, differentiation or owned distribution. The companies with neither are discovering that they were a front-end, and that front-ends are replaceable.

So which one should you build first?

Owned, and starting now, because it is the only one of the three that both compounds and cannot be revoked, and because it takes the longest to pay off.

That does not mean ignore the other two. Borrow a channel if you can get one, and take the near-term patients it brings, as long as you never let it become your only route. Plug into a manufacturer channel if the economics work, with clear eyes about who can close it. But the owned channel is the one that decides whether, in three years, you are a business with its own demand or a business still paying auction prices for every patient because you never built an alternative. The founders who win this are not the ones who found the cleverest partnership. They are the ones who started building something that was theirs before they were forced to.

Frequently asked questions

How do you get telehealth patients without paid ads?

Through distribution, which is any route to a patient that does not run through an ad auction. It comes in three forms: owned (an audience, content, or referral base you control), borrowed (a partnership or affiliate deal that rents someone else's audience), and manufacturer channels (direct-to-patient programs run by the drug maker). Owned distribution is slower to build but compounds and cannot be switched off.

Is a partnership like Ro and Planet Fitness a good distribution strategy?

It is a good channel and a poor moat. Planet Fitness's perks program is a commission-based way to reach a large membership without bidding in an ad auction, which is genuinely valuable. But it is not exclusive, and it belongs to the partner, who can add competitors or end the arrangement. Use borrowed distribution for reach; do not mistake it for something you own.

Are drug manufacturers going to replace telehealth companies?

Not entirely, but they are reshaping the game. LillyDirect and NovoCare Pharmacy let manufacturers own the pharmacy, fulfillment, pricing, and patient front door directly. They have not taken over prescribing, which stays with independent clinicians. The companies most exposed are those whose only value was drug access; those with a genuine clinical relationship or a distinct patient population can still compete and even plug into these channels.

What is the difference between owned and borrowed distribution?

Owned distribution belongs to you and cannot be revoked: your email list, your content, your referral relationships, your reputation. Borrowed distribution is rented from someone else: a partner's audience, an affiliate placement, a manufacturer's channel. Borrowed distribution is faster to access but can be changed or ended by its owner. Only owned distribution compounds into a durable acquisition advantage.