How Agility is providing solutions in health insurance


Since its inception in 1995, Agility has grown its global footprint across Asia Pacific, Africa, Middle East and more recently, entered the UK market. Providing risk management software solutions to the health funding and broader insurance industry, Agility assists its customers to adapt to the challenges that an evolving health insurance market brings, whilst leveraging modern technologies and deploying Best Practice guidelines and algorithms.

Neels Barendrecht, CEO of Agility Risk Solutions in Asia and the UK, said that 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 on its source code owned technology in South Africa, the company started to export 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 could be an A to Z-type solution, it could be modular if they have very specific needs, it could be a process of refining and enhancing intellectual property over time. There’s an array of models that we assist our insurance and funding customers with.”

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

Not your standard “software-off-the-shelf”

Despite the company being founded in the 90s, Barendrecht stressed that it is not bogged down by a legacy system. “Our most recent version of software was built on Artificial Intelligence and is Rule Based. It was developed and enhanced over the past ten years to allow for even better management of big data at a highly granular level of data fields. This is the legacy that the Agility solution is managing out of the traditional ways of work: Ensuring highly granular datasets that are effectively and speedily managed within big data structures.”

This is a key differentiator. Chantal Viljoen, Agility Risk Solutions’ technology director, echoed Barendrecht’s sentiment 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 various levels of maturity in different markets. We use AI technology to enhance Best Practice guidelines, as well as clinical and other rules that are applied across claims.”

“Our entity-based architecture allows us to have a ’single version of the truth’, thereby ensuring that it does not 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 making sure that individuals are duly cared for and not merely linked to the principally insured’s health status. It also greatly improves speed to market.”

Further still, demonstrating that Agility’s offering is not just your standard off-the-shelf software product, Viljoen said the system’s built-in intelligence enables its customers to invest in a knowledge-based system. “We really look at a customer’s market, investigate its unique anomalies, and cater to it within the intellectual property that is embedded in the application. This includes clinical, actuarial, risk modelling and various other forms of IP that has been developed and refined over the past 27 years”.

Applying AI

According to Barendrecht, AI has become somewhat of an overused jargon word in the industry, that 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. That is not real ‘integration’. Integration is when your whole applications and all modules are on the same platform and architecture.” The same applies to AI, he continued, “A lot of people quote AI as being part of their solution, but when you go under the hood, that’s not really what’s happening. It has almost become a marketing jargon, rather than a true definition.”

Real adoption of AI is when it is applied to “do risk management in a totally different way,” Barendrecht said. Agility does this by applying AI as a first line of entry to better predict risk, whilst applying machine learning to claims management.

According to Viljoen, the insurance market places a big focus on managing 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 proactive management of these FWA risks. “We don’t claw back any monies or fraudulent activities afterwards. We apply AI as a front to claims and as a first line of entry. This allows us to better predict risk, as well as outcomes, whilst preventing FWA by proactively applying clinical, actuarial and benefit rules. This means that FWA claims are declined in advance.”

Pressures in the health insurance market

Turning to the health market specifically, the COVID-19 pandemic has caused knock-on effects that are likely to persist for some time. Dr Jacques Snyman, Agility’s medical director said first and foremost, people are more sensitive to health and their health needs because of COVID-19.

“This is for two reasons. Firstly, it focused people’s attention on chronic conditions – e.g. diabetes, cardiovascular diseases and so forth – as they were more severely affected by COVID-19. We are also seeing a significant post-COVID impact on chronic diseases, entailing a worsening disease state. This is putting an additional cost burden on healthcare funders, providers and hospitals.”

Another significant trend that is affecting the market, albeit not directly attributable to the pandemic, is the rise in consumer expectations. Consumers have become increasingly accustomed to accessing general services 100% online from their mobile devices, which raises a concern that consumer expectations could become unrealistic.

Both Snyman and Barendrecht agreed that this is a multifaceted issue that brings with it both positives and negatives.

According to Snyman, the emergence of Telemedicine, for example, could be highly 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 could reduce costs, it also means that the service is easier to abuse.”

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

Overall, though, Snyman said if the digitisation of medicine is guided correctly, it will be a good thing.

Technology driving 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 incidence of certain diseases is increasing globally. Diabetes is a good example. The point prevalence of diabetes increased by 49% from 1990 to 2019. The impact on treatment cost is similar due to better molecules and the ability to prolong life expectancy. However, not treating diabetes to guideline goals 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 the cost of care by 4.4% per year in patients suffering type 2 diabetes mellitus ” Snyman said

This has a knock-on-effect on other diseases. It is often the case that the treatment, specific condition or disease puts the patient at risk for another. An example would chronic immune suppression that is used to treat auto-immune diseases, which may increase the patient’s infection risk. Moreover, Snyman said as our ability to treat illnesses improves, we are living longer lives, and hence “recruiting” diseases 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, Snyman continued, but this also puts a burden on the insurance environment. As a result, consumers need to start spending on insurance at a younger age to subsidise costs when they are older. Unfortunately, the contrary is detected in many markets, especially where employers moved away from subsidising healthcare cover.

Finding solutions

It has been asked how an entity with its foundation in the South African healthcare market has made 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 across the globe with unique and custom-made solutions.

Barendrecht says that the South African market probably covers the most extensive benefits at both inpatient and outpatient level. “What we call medical schemes, which you would call health insurance, health plans or health funds in other parts of the world, cover up to physiotherapy, psychology and occupational therapy. You would typically not find these being covered elsewhere in the world from a private health insurance perspective.”

What that does, Barendrecht said, is it makes cover quite expensive. However, it allows the patient’s health to be managed better from primary, through to secondary and tertiary care. Elsewhere in the world, health insurance typically covers hospitalisation primarily, only catching the patient when they are sick already. This means the intervention that can be done from a preventative aspect is very limited and mostly not being funded 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 which other parts of the world do not have. As a result, the global market is very keen to understand how they can go down that continuum of care.”

“It is this deep understanding of health risk management across the full continuum of care that has led Agility to its award-winning solutions. It’s probably something that South Africans are very well known for – finding solutions.  South Africa is a country of extremes. High quality private healthcare provision, whilst an over-populated and, in some instances, poor public healthcare delivery system. If you can learn between the private and public health care sector, like we have, you can build unique solutions and create out of the box thinking. And that is exactly what we take to other parts of the world to help our customers build impactful solutions, because that’s what we’ve done. And that’s what we have done since inception.”

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