I opened a primary care practice. Now I see why doctors are giving up.

When I opened an independent family medicine practice, I believed I was creating the kind of care patients say they want: A physician who knows them, listens and has enough time to think.

Instead, I learned why so many primary care doctors are leaving.

The problem is not that physicians have stopped caring. It is that the system asks us to accept enormous responsibility while paying mainly for brief, billable encounters.

A patient may spend 20 minutes in my office, but the work rarely ends there. I review laboratory results, answer messages, refill medications, read hospital records, coordinate referrals, appeal denials and complete forms. Much of that work is unpaid or poorly compensated.

Meanwhile, an independent practice must pay rent, employees, malpractice insurance, electronic medical record fees and billing expenses regardless of delayed payments or missed appointments.

The financial prescription is always the same: See more patients, shorten visits and move faster.

But patients are not becoming simpler. Good primary care requires time. Yet taking that time can reduce revenue and put the practice at risk.

Maryland should care about this because our emergency departments are already strained. Maryland’s emergency-room stays have historically been among the longest in the nation. And a substantial share of emergency-department use involves problems that are non-emergent, primary-care treatable or potentially avoidable with timely outpatient care.

When patients cannot get timely primary care, the emergency room becomes the default. That is expensive and frustrating for patients who may wait hours for a problem a family physician could have addressed earlier. Strengthening primary care is not simply about helping doctors. It is part of solving Maryland’s hospital-access problem.

Maryland’s AHEAD model recognizes this connection and seeks to invest more in primary care. But it also illustrates our tendency to respond to complexity with more complexity: quality measures, reporting requirements and multiple program pathways. Large health systems can hire teams to manage those obligations. Small independent practices often cannot.

Maryland should also test something simpler, a marketplace insurance designed to work with direct primary care.

Under direct primary care (DPC), patients pay a physician a transparent monthly membership for routine and ongoing primary care. The practice does not submit an insurance claim for every visit, phone call or message. The physician is paid to care for the patient over time rather than maximize billable encounters.

The accompanying marketplace plan would remain real insurance, covering hospitalization, specialists, emergency care, prescriptions, imaging and other major expenses. Government subsidies could focus on making that insurance affordable, while patients pay their DPC physician directly.

Imagine an eligible Marylander paying about $100 monthly for DPC and no more than $100 for subsidized insurance. The state could then measure whether better access and continuity reduce emergency visits, hospitalizations and total insurance spending. If improved access and continuity reduce avoidable emergency visits and hospitalizations, those savings should eventually be reflected in lower premiums and lower taxpayer subsidies. 

Maryland already has the regulatory tools to test this. The state could pursue this through a Section 1332 waiver, or as a pilot administered through the Maryland Health Benefit Exchange. 

The principle should be simple: Primary care must be accessible to patients, sustainable for physicians and financed in a way that rewards continuity rather than volume.

I opened my office because I still believe in community-based family medicine. I now understand why doctors sell to larger systems, reduce clinical work or leave primary care entirely.

If Maryland wants stronger primary care and fewer patients relying on emergency departments for problems that could have been managed earlier, it should be willing to test financing models that make it easier — not harder — for family physicians to remain in practice.