The ER Is Not a Primary Care Backup Plan. We Built One Anyway, and the System Let Us.

America’s emergency departments are absorbing millions of visits that belong in primary care offices. MedFlorida’s founder explains how access failure became a structural policy choice.

POLICY  ·  DR. MAZIN SHIKARA  ·  MEDFLORIDA MEDICAL CENTERS

Consider a patient with hypertension who wakes up one morning with a headache and a blood pressure reading of 168 over 104. She has a primary care physician, technically. Her last appointment was eleven weeks ago. The next available slot is nine days out. The after-hours line went to voicemail. She goes to the emergency department.

The emergency department gives her a medication adjustment, runs a workup that finds nothing acutely alarming, and sends her home with instructions to follow up with her primary care doctor. The visit costs several hundred dollars more than an office visit would have. No one in the emergency department knows her baseline. No one there will be managing her blood pressure in six months.

This is not an edge case. It is the operating model of American primary care, and Dr. Mazin Shikara has been watching it play out across South Florida for nearly two decades.

Access Is a Clinical Variable, Not a Scheduling Preference

The policy framing around healthcare access tends to treat it as a logistical problem: how do we get more patients into primary care offices more efficiently? That framing understates what access failure actually does clinically.

A 2023 Commonwealth Fund analysis found that patients unable to secure timely primary care were nearly twice as likely to seek care in high-cost settings for non-emergent conditions. That number has a dollar figure attached. It also has a clinical one. Emergency departments are designed to stabilize acute presentations. They are not designed for the longitudinal knowledge of a patient that makes chronic disease management effective.

When a patient with type 2 diabetes arrives in an emergency department with an elevated A1C, the ER physician manages the immediate presentation. What they cannot do is understand that the patient’s numbers have been trending upward for eight months, that her previous medication was changed due to a side effect, and that she recently started a new job with a schedule that has disrupted her eating patterns. That contextual knowledge lives in primary care, if the patient has a primary care relationship that functions.

Delayed access erodes those relationships. Patients who cannot reach their primary care provider when they need to do not simply wait patiently and reschedule. They seek care elsewhere, accumulate fragmented records across multiple systems, and gradually lose the continuity that makes primary care clinically effective in the first place.

“What patients ask for is rarely complicated. They want to be seen when they’re sick, understood when they’re worried, and followed when their condition doesn’t resolve in a week.”

DR. MAZIN SHIKARA

What MedFlorida Built and Why

When Dr. Shikara founded Medical Consultants of Florida in 2007, the organization that would become MedFlorida Medical Centers, same-day appointments and walk-in availability were not marketed as differentiators. They were operational requirements derived from a simple observation: patients in South Florida’s Medicare and Medicaid population, many of them elderly, many managing multiple chronic conditions, many without reliable transportation or flexible schedules, could not navigate a system that required them to plan healthcare appointments weeks in advance.

MedFlorida opened three locations simultaneously in St. Lucie, Jupiter, and Boynton Beach. Courtesy transportation was part of the model from the beginning, addressing a barrier that rarely appears in clinical guidelines but routinely derails care plans. In-house laboratory and diagnostic services meant that a patient who came in with a concern could leave with answers rather than referrals to outside facilities that might take days to schedule and weeks to report.

None of this required a technology platform or a venture-backed growth strategy. It required an operational commitment to proximity, physical and temporal, between a patient’s symptom and a clinical response.

The model has expanded to nineteen primary care locations across Florida, with three more opening in early 2026, plus ten Xpress Urgent Care sites, serving a patient population that includes a significant proportion of Medicare and Medicaid beneficiaries. The demographics are not incidental. These are the patients who most consistently fall through the access gaps in American primary care and who most directly bear the cost, in health and dollars, when those gaps are not closed.

The Economics of Access Investment

Here is the financial reality that makes access-oriented primary care structurally precarious: the current reimbursement system does not pay for availability. It pays for encounters.

Maintaining same-day appointment slots requires holding capacity that may not fill on a given day. Walk-in availability requires staffing flexibility that generates overhead whether or not patients walk in. Courtesy transportation is a direct expense with no billing code. In-house diagnostics require capital investment and ongoing operational costs.

Under fee-for-service reimbursement, all of these investments are costs without corresponding revenue lines. They generate clinical value, reduced downstream emergency department utilization, better-managed chronic disease populations, higher patient retention, but that value accrues to payers and to the broader health system, not to the primary care practice that created it.

Healthcare economists have been making this argument for years. Value-based payment models, which theoretically align incentives toward longitudinal outcomes rather than transaction volume, are the structural solution. In practice, their implementation has been uneven. Many primary care practices operate in markets where fee-for-service remains the dominant payment model even as value-based contracts are nominally available. The transition creates a period of maximum financial pressure: practices are asked to invest in access and continuity infrastructure while still being primarily compensated for volume.

MedFlorida navigates this by operating across a mix of Medicare Advantage, Medicaid managed care, and commercial payers, with some contracts that reward outcomes and utilization patterns. It is not a clean solution. It is a managed tension.

What Policy Would Actually Help

The conversation about primary care access in American health policy tends to cycle through familiar proposals: more primary care residency slots, medical school loan forgiveness, telemedicine expansion, community health center funding. These are legitimate interventions. They are not sufficient.

The structural problem is that the payment system continues to undervalue the services that prevent expensive downstream care. A primary care visit that successfully manages a hypertensive patient’s blood pressure and avoids a future hospitalization generates, for the primary care practice, a modest evaluation and management billing code. The hospital that would have treated the eventual stroke generates substantially more revenue. The incentives point in the wrong direction.

Meaningful reform would do three things. First, create payment models that explicitly reward primary care practices for measurable reductions in high-cost downstream utilization, not through complex quality metrics that generate administrative burden, but through direct recognition of outcomes. Second, fund access infrastructure, same-day capacity, extended hours, transportation support, as a reimbursable service rather than a charitable investment. Third, reduce administrative overhead through prior authorization reform, which would return physician hours to patient care at no capital cost.

None of these proposals are new. The political will to move them from policy discussion to payment reality has been the persistent obstacle.

In the meantime, practices like MedFlorida keep absorbing the patients that the access gaps produce, and emergency departments keep treating blood pressure headaches that should have been a phone call.

ABOUT THE AUTHOR

Dr. Mazin Shikara is the founder, President, and CEO of MedFlorida Medical Centers, a multi-location primary care network operating across Florida since 2007. He completed training at the University of Baghdad College of Medicine, postgraduate training as a Member of the Royal College of Physicians in England, and residency in internal medicine at Flushing Hospital Medical Center in New York. He is board-certified in internal medicine by the American Board of Internal Medicine.