Dr Richard Shinto on Managing Disparities in Health Care Services Amid the Pandemic

Despite limited resources to combat the coronavirus disease 2019 pandemic, collaborative efforts among the government, health plans, and providers in Puerto Rico exemplify how care can be better optimized in communities in the United States impacted by disparities in health care services.

Despite limited resources to combat the coronavirus disease 2019 (COVID-19) pandemic, collaborative efforts among the government, health plans, and providers in Puerto Rico exemplifies how care can be better optimized in communities in the United States impacted by disparities in health care services, said Richard Shinto, MD, MBA, CEO of InnovaCare Health.


AJMC®: Hello, I'm Matthew Gavidia. Today on MJH Life Sciences News Network, The American Journal of Managed Care® is pleased to welcome Dr Richard Shinto, CEO of InnovaCare Health.

Great to have you on, Rick, can you introduce yourself and tell us a little bit about your work?

Shinto: Hi, Rick Shinto, I'm the CEO of InnovaCare Health. We're a health care organization, we have health plans and provider groups, predominantly in Puerto Rico and in Florida. [I'm a] physician by background and been running this company for more than almost 20 years.

AJMC®: As a provider of health care services in Puerto Rico and Florida, can you speak on any differences in managing care between these 2 areas, particularly in addressing health care disparities amid the pandemic?

Shinto: That's an interesting question, and just to get started here, we have a large operation in Puerto Rico and we’re building a large operation in Florida, and my background has been always in California. So, what really jumped out to me quickly when I went into Florida is that they have a strong infrastructure with a lot of clinics. Hospital systems are strong, they have their own clinics, the providers have all consolidated into clinics, and so it's a more robust health care system. As you can also expect, there's a lot more providers there. So, the big difference is a robust health care system with a lot of providers.

In Puerto Rico, as you know, due to the attrition of physicians off the island, a lot of the younger ones that go off the island for postgraduate training don't return—we have a more limited number of providers and as a result of that, during the pandemic, the government and the health plans and the provider networks had to strategize together to address where there might be inadequacies in care.

One of the things I talked to people about is I think having run health care companies across the United States, Puerto Rico has been the only place I know where the health plans, the government, the providers, and the hospitals try to work together. They have regular meetings; when they go to Congress they have a consistent message and a consistent story. That's kind of what happened during the pandemic, if you think about it.

Puerto Rico was hit with an infection from a cruise ship, and as a result of that, the government knew they didn't have an adequate number of hospital ICU [intensive care unit] beds and ventilators, and so they immediately shut down the island. Then they came to the health plans to see how the health plans could support that whole initiative of shutting down the island. I think we did a pretty good job.

I mean, if you think about it, today we probably have 73,000 infections and maybe 950 deaths—there’s over 3 million people here. So, I think we've done a pretty good job. Even today, the island still still runs with curfews and mandatory masks, and it's because the government wants to ensure in the health care system that we have reduced numbers and prevalence of infection, because they know that the health care system cannot absorb the number of infections and potential deaths that may occur if it started to increase.

So, I think they've done a good job, and again, the difference between the 2 is a robust health care system, a lot of clinics—Puerto Rico, fewer number of physicians, not as robust of a health care system, but more alignment between the providers, the payers, and the government.

AJMC®: To build on top of what you just said, what lessons do you think your organization has learned on the COVID-19 pandemic based on your experience managing care in Puerto Rico?

Shinto: It's interesting, Puerto Rico has gone through a lot of natural disasters. A few years ago, we were devastated by a category 5 hurricane, so much of the one you just saw hitting Nicaragua, and that one went directly through the island.

Now, why do I tell you that story? Because after that hurricane, the island reacted very quickly. For example, a company like ours partnered with Bacardi rum, and then we were able to go across the island and provide water, food, and medical care. The island was very resilient in reacting to natural disasters because they've had to live through them. So we've always been able to handle some of those, even the earthquake, we were able to handle that, but on a pandemic, it's different.

The type of preparation is different. The PPE [personal protective equipment], we didn't have adequate supplies of that, and staffing a number of physicians. What happened is that in natural disasters, we could react quickly. And now what we've learned in this disaster, we need to understand how to react towards pandemics or different types of disasters that maybe not necessarily are something related to climate.

AJMC®: In looking at this current public health emergency, as well as those to come, what do you perceive as an unmet need in care delivery that warrants intervention? And how can we better prepare ourselves for the next pandemic or public health emergency?

Shinto: I've had a lot of discussions about this, both with CMS and with legislators. The reimbursements on the island are significantly lower than the states and the territory, since it's not a state, is not well represented. The amount of federal support for health care is much lower.

As a result of that, for physicians to be able to live and provide care, and to have an income, there's some sacrifices that have to be made. Some of those might be in the quality of their offices.

In the case of what's going on right now, it's inadequate PPE preparation. And I tell you that story, because one of the things that happened in the disasters, the natural ones, was FEMA [Federal Emergency Management Agency] and federal support. We really didn't get it, you hear about it, but we really didn't see it. And as a matter of fact, our company really focuses on supply chain. With or without disasters, we focus on supply chain.

When that pandemic started back in March, we were already ordering PPE and we were already ordering COVID-19 testing, but as soon as it started to come in, FEMA came in and they took everything. And so the island couldn't receive it, but it was distributed in the United States. These are the inequities that bother me a lot, because we do a lot down here to try to make do with what we have, and even in certain difficult situations where we could use more support, we're not getting in. And so one of the things in the question you're asking me is, how can we look at it differently?

Well, one is I think there needs to be more recognition to the health care system in Puerto Rico, better reimbursements, and more federal support when we need it in times of emergencies like this one.

AJMC®: Lastly, do you have any other concluding thoughts?

Shinto: Well, the only thing I would like to tell you, and it’s what I just spent a few minutes talking to you about is it's interesting about disparities, social disparities, and ethnic disparities, but let me tell you a story.

One of the things I learned very quickly in Puerto Rico is that Puerto Ricans have learned really to take care of each other, even when they don't have what they need. And one of the things you see in the health care system, the providers really don't go around looking at your insurance card, they just take care of you. One of the reasons I think that is, is because the island has learned to exist with limited supplies and it's just been generational.

So, parents, fathers, kids—the doctors just took care of the patients, and now they just take care of patients. You don't see the levels of discrimination under any conditions, they just take care of patients. And I think that's something that all of us need to learn. I think the other thing that we need to learn about the island is it doesn't make sense for the health care providers, the health plans, and the government to all fight each other.

And one of the things, although we fight down on the island, there is basic alignment. You see it in disasters. As soon as it hits, everybody lines up. We saw it in the States, it hit, everybody lined up to take care of everything, but more so on the island because they've learned to live with such little supplies.

So, when I think about it, is there a concluding thought to that? I think we all need to kind of look at Puerto Rico and the health care system, and we need to understand how the politics, the government, the hospitals, the health plans, and the providers can all learn to work together because in the end, the one that benefits the most from all that are the patients. And you look at the socioeconomic level of Puerto Rico and everybody's doing okay under some pretty tough conditions with regard to reimbursements to the island.

So, I mean, it's something I've learned. I've been here for more than 15 years. I practiced in California, I know what we’ve dealt with in California—I know what we’ve dealt with across the United States, but I see, although there's tension, there’s underlying alignment between these different organizations, which I think is good—something we should all learn. And actually, you could start seeing it. When you look at a per capita cost of care in Puerto Rico, as compared with the United States, we're like half the cost.

So, that's why some of the different organizations start looking at Puerto Rico and say, how are you able to manage your cost of care at half the cost of the United States? So, I think that'd be my concluding thoughts about what I've experienced down here, and what these disasters have shown us about some of the disparities and how Puerto Rico has reacted.

AJMC®: To learn more, visit our website at AJMC.com. I’m Matthew Gavidia, thanks for joining us!