How Agility offers solutions in health insurance

Since its inception in 1995, Agility has grown its global footprint across Asia Pacific, Africa, the Middle East and recently entered the UK market. Agility provides risk management software solutions to the health finance and broader insurance industry, helping its clients adapt to the challenges of an evolving health insurance market while leveraging modern technologies and implementing best practice guidelines and algorithms.

Neels Barendrecht, managing director of Agility Risk Solutions in Asia and UK, said Agility has always placed a strong focus on owning its technology, and this philosophy remains today.

Following the incorporation of its own managed care company and administrator of its source-owned technology in South Africa, the company began exporting its technology to other parts of the world in the early 2000s. The first countries it engaged with since 2003 were Hong Kong, Malaysia and Australia and Dubai in 2011.

Barendrecht explained: “We build solutions for our customers. It can be an A to Z type solution, it can be modular if they have very specific needs, it can be a process of refining and improving intellectual property over time. It are a number of models that we help our insurance and financing customers with.”

Although the company’s roots, and much of its business, are in healthcare, it has also ventured into risk management solutions in group life, disability and critical illness to ensure that the wider continuum of healthcare is properly addressed, managed and integrated. . “Our primary focus is on effective management of human capital and productivity. This is achieved through improved quality of care and better provision of health services to employers, while ensuring the right care at the right level for consumers, said Barendrecht.

Not your standard “off the shelf” software

Despite the fact that the company was founded in the 90s, Barendrecht stressed that it is not locked into an older system. “Our latest version of the software was built on artificial intelligence and is rule-based. It was developed and improved over the last ten years to provide even better management of big data at a very detailed level of data fields. This is the legacy that the Agility solution manages out of the traditional ways of working: Securing highly detailed data sets that are efficiently and quickly managed within large data structures.”

This is a key differentiator. Chantal Viljoen, director of technology for Agility Risk Solutions, echoed Barendrecht’s stance that the company is not dependent on legacy or fragmented systems. She said the company’s solution is integrated yet modular. “This is to accommodate the different levels of maturity in different markets. We are using AI technology to improve best practice guidelines as well as clinical and other rules applied across claims.”

“Our entity-based architecture allows us to have a ‘single version of the truth’, ensuring that it doesn’t become a legacy health, life or other insurance class system. Instead, it operates across insurance classes and products with ease. This is quite important if you want to ensure integration across classes and products, while ensuring that individuals are well cared for and not just tied to the health status of the primary insured. It also greatly improves speed to market.”

Viljoen said the system’s built-in intelligence enables customers to invest in a knowledge-based system. “We really look at a customer’s market, examine its unique anomalies and accommodate that within the intellectual property embedded in the application. This includes clinical, actuarial, risk modeling and various other forms of IP that have been developed and refined over the last 27 years”.

Using AI

According to Barendrecht, AI has become something of an overused jargon word in the industry, which is used too loosely. “It’s similar to the word ‘integration’. Everyone uses the term integration when they’re really just transferring data between systems. It’s not real ‘integration’. Integration is when all the applications and all the modules are on the same platform and architecture.” The same goes for AI, he continued, “A lot of people cite AI as part of their solution, but when you get under the hood, that’s not really what’s going on. It’s almost become marketing jargon, rather than a true definition.”

Real use of AI is when it is used to “do risk management in a completely different way,” Barendrecht said. Agility does this by using AI as a first line of entry to better predict risk, while applying machine learning to claims management.

According to Viljoen, the insurance market has a large focus on handling fraud, waste and abuse (FWA). However, this is done retrospectively and leads to reactive clawbacks, thereby damaging the relationships between all stakeholders in the continuum.

Agility’s solution focuses on proactively managing these FWA risks. “We do not take back any money or fraudulent activities afterwards. We use artificial intelligence as a front for claims and as a first line of entry. This allows us to better predict risk, as well as outcomes, while preventing FWA by proactively applying clinical, actuarial and benefit rules. This means that FWA claims are rejected in advance.”

Pressure in the health insurance market

Regarding the healthcare market specifically, the covid-19 pandemic has caused consequences that are likely to persist for some time. Dr Jacques Snyman, Agility’s medical director said primarily that people are more sensitive to health and their health needs due to COVID-19.

“This is for two reasons. First, it focused people’s attention on chronic conditions—eg, diabetes, cardiovascular disease, and so on—as they were hit harder by COVID-19. We’re also seeing a significant post-COVID – impact on chronic diseases, which leads to a worsening of the disease state. This places an additional cost burden on health funders, suppliers and hospitals.”

Another significant trend affecting the market, although not directly attributable to the pandemic, is the increase in consumer expectations. Consumers have become increasingly accustomed to accessing general services 100% online from their mobile devices, raising concerns that consumer expectations may become unrealistic.

Both Snyman and Barendrecht agreed that this is a multifaceted issue that brings with it both positive and negative aspects.

According to Snyman, the emergence of telemedicine, for example, can be very beneficial. “Telemedicine makes it easier to access doctors’ advice, which makes it easier to get advice before you actually need to see a doctor in person. While this may reduce costs, it also means that the service is easier to abuse.”

It can also create some unrealistic expectations in patients, continued Snyman. There are “health-seeking” behaviors and “treatment shopping,” both of which are not always healthy, and can make discussions between patients and clinicians more difficult.

Overall, however, Snyman said that if the digitization of medicine is managed properly, it will be a good thing.

Technology drives costs

Technology can be a double-edged sword when it comes to the health insurance market. “We are becoming increasingly aware of the shift in the burden of disease. The prevalence and occurrence of certain diseases is increasing globally. Diabetes is a good example. The point prevalence of diabetes increased by 49% from 1990 to 2019. The effect on treatment costs is similar due to better molecules and the ability to extend life expectancy. However, not treating diabetes to guideline targets can cost a funder even more. Every 1% increase in the disease marker HbA1c increases the risk of cardiovascular death by 25%. In turn, this increases care costs by 4.4% per year in patients suffering from type 2 diabetes mellitus, Snyman said

This has a negative effect on other diseases. It is often the case that the treatment, the specific condition or the disease puts the patient at risk for another. An example would be chronic immunosuppression used to treat autoimmune diseases, which can increase the patient’s risk of infection. Also, Snyman said, as our ability to treat disease improves, we live longer lives, and therefore “recruit” disease with age. “In that sense, medical technology is driving costs, because we want to live longer.”

The industry is willing to spend on new medical technology, continued Snyman, but this also puts a strain on the insurance environment. As a result, consumers must start spending on insurance at a younger age to subsidize costs when they are older. Unfortunately, the opposite is being discovered in many markets, especially where employers moved away from subsidizing health coverage.

Finding solutions

It has been questioned how an entity with its foundation in the South African healthcare system has had such an impact in global markets. The answer lies within the unique format and structure of the South African healthcare industry. Agility built a unique solution within this complex environment and has in turn assisted market players worldwide with unique and tailor-made solutions.

Barendrecht says that the South African market probably covers the most comprehensive benefits at both outpatient and outpatient levels. “What we call medical schemes, which you would call health insurance, health insurance or health funds in other parts of the world, covers physiotherapy, psychology and occupational therapy. You won’t usually find these covered elsewhere in the world from a private health insurance perspective.”

What that does, Barendrecht said, is that it makes coverage quite expensive. However, it means that the patient’s health can be managed better from primary, through to secondary and tertiary care. Elsewhere in the world, health insurance usually primarily covers hospitalization, only covering the patient when they are already ill. This means that the intervention that can be done from a preventive aspect is very limited and mostly not financed by the individual from their own pocket.

“This is also why we are so data-rich. We have a lot of data available to us that other parts of the world don’t have. As a result, the global market is very keen to understand how they can move down that continuum of care.”

“It is this deep understanding of health risk management across the entire continuum of care that has led Agility to its award-winning solutions. It is probably something South Africans are very famous for – finding solutions. South Africa is a country of extremes. Private healthcare by high quality, while an overcrowded and, in some cases, poor public healthcare system. If you can learn between private and public healthcare, as we have, you can build unique solutions and think outside the box. And that’s exactly what we take to others parts of the world to help our customers build effective solutions, because that’s what we’ve been doing. And that’s what we’ve been doing since the beginning.”

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