Maryland reinvented how it pays hospitals. Primary care was left underfunded

Ask almost anyone in Maryland how long it takes to get a new primary care appointment, and you’ll hear the same answer. Months, if you can find a doctor taking patients at all. That’s a strange thing to be true in a state the rest of the country studies as a model for controlling health care costs.

Maryland really is different. Since 2014, our hospitals have been paid under global budgets, a fixed amount of revenue set each year by the Health Services Cost Review Commission (HSCRC) instead of a fee for every admission and test. The idea is elegant. If a hospital no longer profits from filling beds, it has reason to keep people healthy and out of the hospital in the first place.

By several measures it worked. Maryland holds down hospital spending, keeps employer premiums comparatively low and posts solid numbers on preventable admissions and emergency room visits. In the Commonwealth Fund’s 2025 scorecard, the state ranks seventh in overall health system performance.

This isn’t a story about failure. It’s a story about something we left half-finished.

Global budgets changed how hospitals get paid. They didn’t build the primary care system the whole design depends on. You can’t keep people out of the hospital without somewhere for them to go instead. That somewhere is primary care, and family medicine in particular, because they are far more likely to practice the kind of broad outpatient care that provides access to the whole family and keeps communities well.

Look at where the doctors come from, and the gap is hard to miss. Maryland trained 28 new family medicine residents in 2014; in 2024, it trained 27. During those same years, Virginia and Pennsylvania substantially grew their training pipelines, including new programs aimed at rural and underserved communities. Maryland rebuilt the way we pay for hospital care and never made the matching investment in the people who deliver care everywhere else.

The state’s own data tells the rest of the story. Maryland’s most recent primary care investment analysis found that primary care spending didn’t rise between 2021 and 2023. It fell for some Medicare populations and stayed flat for others. The analysis flagged a cluster of ZIP codes, concentrated in Baltimore City and parts of western and southeastern Maryland, where the most disadvantaged neighborhoods get less primary care investment.

Global budgets may not have caused this shortfall, but they didn’t help. Residency growth depends on federal Medicare funding caps, faculty, training sites and choices made by medical school leaders. The payment model, on its own, didn’t push hospitals to build family medicine capacity.

A global budget rewards a hospital for cutting avoidable admissions this year. A new residency or a community clinic takes years to pay off, and the savings leak out across other hospitals, other insurers, and the state’s overall cost calculation. For a safety-net hospital in a low-income community with little spare capital, the math rarely closes. The hospital gets told to reduce preventable hospital use while leaning on an insufficient workforce and a limited number of underfunded clinics.

On Jan. 1, Maryland moved from its Total Cost of Care model into the new federal AHEAD model. For the first time, the state has committed to setting annual primary care investment targets, beginning in 2027. It is an admission that the old model underdelivered on exactly this.

Public reporting alone won’t change a hospital’s spending. The state should tie targets to actual financing, and weight the money toward underserved communities, rather than letting a rising statewide average cover up local gaps.

It should set a specific goal for new family medicine residency positions, and protect that funding from the annual pressure to show a one-year drop in admissions, because training a family physician takes longer than a budget cycle.

It should give community health centers and independent practices a defined way to share in the savings their work creates under a hospital’s global budget. And it should measure what actually matters to a patient, which isn’t dollars spent but whether you can get an appointment, keep the same doctor, and find one in your ZIP code.

Maryland embarked on a bold experiment to reduce hospital spending, and it worked. We haven’t yet built the primary care infrastructure that payment reform was supposed to make possible.

As AHEAD takes shape, Maryland will need to decide whether to finish the job. For the Marylander still calling around for a doctor who will see them, that decision isn’t abstract. It’s the difference between a system that looks good on a national scorecard and one they can actually feel is working.