Case Studies - InnovaCare Health
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Case Studies

At InnovaCare Health, we specialize in improving the health of populations that have traditionally proven uniquely challenging for healthcare organizations – specifically, those with high rates of dual-eligible beneficiaries. Our 20-year track record demonstrates continued success in entering new communities, thriving in difficult markets, and enhancing medical margins through a wide range of strategies.

The Market: Puerto Rico is one of the nation’s top-10 Medicare Advantage (MA) markets, with a growth rate of 2.5 percent annually. It is also one of the largest markets for dual-eligible beneficiaries, with more than 50 percent of Medicare members also eligible for Medicaid.

The Situation: When we partnered with San Juan-based MMM Healthcare in 2004, we began building physician relationships across the island, analyzing existing data and structuring new, value-based contracts. With 100,000 dual-eligible members depending on us, we had to get this right – quickly.

The Outcome: Today, InnovaCare manages nearly half a million lives on the island. We have built the MA market leader in Puerto Rico, with a 34 percent market share, as well as the top plans in terms of profitability and Medical Loss Ratio (MLR). Most importantly, our members are seeing the benefits of the InnovaCare way:

Earned 4.5 star ratings for two largest Medicare/MA plans

36% decrease

in bed days per 1,000 members from 1,902 (2006) to 1,219 (2016)

23% increase

in generic dispensing rate from 67 percent (2006) to 90 percent (2016) 

Today, we have built and manage an MA network that includes:

1,935

primary care providers

4,100

specialty care providers

50

hospitals

26

independent practice associations

Additionally, MMM Healthcare has been continuously recognized as one of the Mejores Patronos en PR (Top Employers in Puerto Rico) by El Nuevo Día, the island’s largest newspaper.

The Market: As a practicing physician, Richard Shinto, M.D., recognized the unmet need for operational expertise among physician groups and payers in a changing market. Value-based care was coming – and those who adapted first would have the advantage. Dr. Shinto founded InnovaCare, and its predecessor companies, to help healthcare organizations manage the health of complex patient populations with quality, affordability and efficiency.

The Situation: Over two decades, the leadership team of InnovaCare Health has worked together to build successful, sustainable models in a number of states. With each diverse market our team has entered, we have developed networks of engaged physicians, implemented the latest technologies and added to a track record of proven success, helping partners evolve their business into more efficient, value-based models.

The Outcome: We achieved efficient outcomes in every market we entered, managing care for hundreds of thousands through a progressive, value-based model.

California:

  • Built network of 545 PCPs, ~3,300 SCPs, 23 hospitals and 14 IPAs (12 owned)
  • Improved medical margin by 7.7% over seven years
  • Reached five-year exclusive contracts with ~84% of PCPs

Arizona:

  • Built network of 164 PCPs in less than two years

Missouri:

  • Built network of 108 PCPs in one year and assumed full risk within one year of entry

Illinois:

  • Maintained a stable PHO network of 13 PHO/IPAs

Tennessee:

  • Built network of 104 PCPs in one year

Totaling these and the other markets we have entered, InnovaCare improved medical margins by an average of 4.25 percent in the first year and developed networks averaging 136 PCPs within two years.