Physicians criticize proposed partnership between CVS, Mass General Brigham

Primary care physicians and the Senate's health care point person are questioning a proposed partnership between Mass General Brigham and CVS that the two companies say will address gaps in comprehensive primary care access.

"My first reaction was, this is not what we think about when we think about primary care," Sen. Cindy Friedman, co-chair of the Health Care Financing Committee, told the News Service. "I'm kind of blown away." 

MGB and MinuteClinic's primary care practice are seeking state regulatory approval for a clinical affiliation that the companies say will help lower health care costs and provide primary care access for those who presently lack it. About 80 advanced practice providers (APPs) currently staff 37 CVS MinuteClinic sites in Massachusetts, according to papers filed with the Health Policy Commission on June 6. The proposal does not involve opening more clinics or hiring more staff, and MGB does not plan to invest funds into the partnership. 

"Extending primary care to a business such as CVS through MinuteClinics, which typically only have nurse practitioners in them, would be a little concerning because it would seemingly remove the physician from the equation," primary care physician Dr. Chris Garofalo said.

Garofalo is a partner at Family Medicine Associates of South Attleboro, where he's worked for 21 years.

"I appreciate that we need to have more primary care clinicians of all types," Garofalo added. "When you leave the physician out of it — I'm not so sure that's the direction we should be going in. It's really important to have everybody there who is doing the roles that they are best trained for." 

Nurse practitioners are able to practice independent of physicians in Massachusetts. Clinicians at MinuteClinic primary care sites would "manage end-to-end care with a focus on prevention that includes regularly scheduled health maintenance visits, recommended screenings and addressing existing chronic conditions," according to CVS. Services would include same-day access, extended hours and virtual care. The term "advanced practice provider" encompasses nurse practitioners and physician associates.

Massachusetts is grappling with a primary care crisis. CVS has previously said that many of the patients at its MinuteClinics "either don't have a primary care provider or have not seen one in years." A Health Policy Commission report named provider burnout and patient access barriers as major reasons behind the sector's decline. A task force is developing recommendations for sector investments, standardized data reporting requirements and workforce solutions.

Beacon Hill Democrats have said that addressing the primary care crisis is a session priority, though more than seven months into the session no single legislative proposal has emerged or been tapped as a path forward. 

Friedman called the MGB-CVS proposal "misleading."

"I don't understand how a single person sitting in a CVS, where the MinuteClinics are, is providing 'primary care.' To me, what they're talking about is just urgent care," Friedman said. "We spent all of this energy and research on what makes primary care [what it is], and it's fundamentally the relationship between a patient and provider in a place where many of your health care needs can be met, and also where you can find wellness and preventative medicine. We have systems in place for collaborative care. That isn't going to happen in a CVS."

Physician associated and nurse practitioners are viewed by some as part of the formula needed to help fill gaps in access. Under the proposal, each clinician would support a patient panel of about 1,500 patients, which is expected to add capacity for up to 120,000 patients statewide.

"I think it's highly doubtful that an APP would be able to carry a [full] patient panel of 1,500 and still feel like they could do it adequately. Quite honestly, our situation has shown that that is not possible without a good, robust system — and that's what we're really lacking right now," said Brigham and Women's primary care physician Dr. Zoe Tseng. 

Tseng has been with Brigham and Women's for 11 years and is one of the nearly 200 MGB doctors who recently voted to join a new primary care physician union. She has scaled back to caring for only a partial panel of patients, but said she still often has to work more than 40 hours each week because of the volume of work required on the administrative end of primary caregiving. 

Tseng and others who spoke with the News Service questioned how the proposal would create "team-based" care, and whether clinicians who have staffed primarily in urgent care settings would be able to provide adequate primary care.

"In their proposal, they didn't really talk about who would be working in collaboration with these APPs. They don't have the same training as physicians. Who is helping them to train up to do primary care in a way that is leading the core principles of primary care?" Tseng said, referring to the sector's "4Cs" framework. "Unless it's proven to work, I don't know why they're rolling it out in such a large capacity. It really risks putting primary care in a more fragmented state than it already is."

MinuteClinic clinicians "are board-certified, highly trained medical professionals who are well-positioned to address gaps in comprehensive primary care access," CVS said in a statement. The company added that nurse practitioners are qualified to do much of what physicians can, like diagnose and treat illnesses, order, perform and interpret medical tests, and refer patients externally. 

Boston University health, policy and law professor Dr. Alan Sager called the proposal "more primary care smoke and mirrors."

"We'd need to rely on experienced, salaried NPs who are already providing primary care — but they're not sitting in drug stores providing episodic relief," he said.

Trade and advocacy groups are waiting for more information. Executive Director of Health Care For All Amy Rosenthal said in a statement that the organization is "interested in learning more about where these (new) clinics will be located and look[s] forward to a Health Policy Commission analysis related to cost." 

According to an MGB spokesperson, the affiliation will expand access statewide with "a particular focus on regions with demonstrated provider shortages and high avoidable [emergency department] use in areas such as Worcester and Bristol counties as well as Western Massachusetts." 

Massachusetts Medical Society President Dr. Olivia Liao wrote in a statement to the News Service that "careful consideration" is needed for any proposal that could improve primary care access. 

"We believe patients receive the best possible care when they are served by a physician-led team, supported by other health professionals," Liao wrote. "While we welcome creative ideas to expand primary care access, we must also focus on lasting solutions: rebuilding our primary care workforce through payment and policy reforms that reduce physician burnout, attract new graduates into the field, and ensure our health system remains strong and sustainable for the future."

Health Policy Commission regulators must vet the proposal. After additional paperwork is filed, the agency will launch a 30-day review process. While the HPC cannot block transactions, it can call on other state agencies to consider action to do so. 

CVS said it expects a decision from the Health Policy Commission sometime during the fourth quarter of 2025.

MGB patients could receive in-network primary care at MinuteClinics should the affiliation be approved, which would offer "enhanced access" to MGB hospitals, specialists, diagnostic and radiology facilities, and specialty labs for comprehensive care coordination, according to CVS. Patients could be referred to an MGB specialist or hospital for coordinated care if deemed necessary. 

"If MGB starts adding more people into the specialist system, they're just going to decrease access for everybody. It's just going to make wait times even longer," Brigham and Women's Faulkner primary care physician Dr. Andrew Cooper Warren said. 

"What it does do is let MGB claim now that for every one of those 80 advanced practitioners, they can tack on a 1,500-person patient panel and add those patients to their [accountable care organization]," Warren said. "This allows MGB to say, 'Oh, guess what? We just expanded by X number of patients' to the insurance companies, and then get paid for those people without actually spending any of their money."

CVS called the move a "strategic evolution" of the MinuteClinic care model. Friedman said the potential for increased referrals to the MGB system "is a potentially good business model not necessarily for the patient, but for the system."

"It's the continuation of the consolidation of health care and it's not working for anybody. Except for businesses who are in the business of health care," the Arlington Democrat said.

Asked what she sees as a better solution to improve Massachusetts' struggling primary care sector, Friedman suggested several systemic overhauls.

"Get rid of the administrative burden and pay primary care practices enough that they can stay in business. That simple. You want to do something else? Pay for residents to go into primary care," Friedman said.

Friedman has filed a bill (S 867) for three sessions that would put into place primary care spending requirements, develop recommendations to stabilize the sector's workforce, and create a different payment and coverage model. The bill was reported out favorably by the Committee on Health Care Financing in June and sits in Senate Ways and Means, where it died last session.

"It's just so upsetting to me that this is what people think of when they think about primary care. This is not primary care," Friedman said of the proposed partnership. "Primary care, to me, is family medicine, and it happens the minute you're born until the minute you die. It provides a foundation for health care." 

MinuteClinic already offers in-network adult primary care to some Aetna members in certain markets in places including Texas, Georgia, South Florida, North Carolina, Connecticut, Tennessee, New Jersey, California, Washington, D.C., Virginia and Maryland, according to CVS.