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The new healthcare drive – More care, less risk

31 May 2010 Agility GHS-Africa

With the landscape of healthcare constantly changing, it has become increasingly important for medical schemes and their administrative risk managers to think “out of the box” and establish new and innovative ways for addressing the challenges of managing risk while still providing world-class care to their members.

One such administrator is Agility Global Healthcare Solutions (Agility GHS), international healthcare player and administrator to several global health insurers including a part as new administrator and risk manager to Resolution Health Medical Scheme (RHMS) since December 2009, an open scheme which has experienced tumultuous times in recent years. Agility is focused on alternative thinking when it comes to managed healthcare practices and prides itself in being the first administrator in the country to apply a “more care, less risk” rationale to their administrative practices.

“People throughout the world are facing lifestyle-related illnesses on an unprecedented scale with as much as 56% of South African medical scheme members displaying at least one or more healthcare risk factors, and as many as 20% could be at high risk from chronic disease”, says Mike Collier CEO of Agility GHS. “Effective management of risk in healthcare funding is not a series of point solutions but rather the application of a holistic framework of interventions. Agility GHS believes that the future of managed healthcare lay within proactive interventions, and has developed a Patient Driven Care (PDC) programme which has rewritten the rules of disease management.”

“At the heart of PDC is a proactive, fully integrated healthcare campaign focused on keeping members with high risk profiles healthier by making available the appropriate benefits for their specific condition in a structured, timely fashion,” says Collier. “This proactive allocative framework ensures optimal buy-in from providers and patients and both are now not frustrated by tedious applications and paperwork as this is done online and approvals can be updated real-time and mostly without the need for human intervention.”

By monitoring compliance and disease severity to establish treatment protocols within the benefits made available, Agility GHS reduces the onset of acute episodes, hospitalisation, disability and relapse. “Although this means an initial greater expenditure in medical costs, this is completely offset by a significant reduction in event rates for most serious chronic conditions. Healthier members translate directly into lower healthcare costs”, says Collier.

Online, real-time services are also a key focal point for Agility GHS says Collier. Highly automated systems feature an unprecedented amount of embedded business and clinical knowledge and most pre-authorisation requests are handled online in real time through an easy to use portal accessible by members and providers. “Agility is currently phasing in real-time claims capability for optical and dental service providers using terminal technology”, says Collier. Outpatient claims are also handled online in real-time where the provider knows exactly what will be paid, all whilst the member is present at the point of care.

“Not only do these automated, real time processes provide for more efficient administration and an improved member and service provider experience, but they also create more accurate and complete data which in turn allows for better risk management.’

Streamlined processes and new advanced technology have certainly impacted on the administration of Resolution Health Medical Scheme. Since AgilityGHS-Africa was appointed as administrator to the Scheme in December 2009 steps have been taken to integrate the existing service delivery models and ensure risk management is done on a “one version of the truth” system and process. Unnecessarily outsourced processes have been reintegrated, which has had a knock-on effect of increasing margins within the Scheme. In the period December 2009 to February 2010, RHMS has experienced improved financials with an R15m operating surplus and a 2% increase in its solvency levels. In addition, ever increasing non-healthcare costs have been averted and contained and further savings are expected in this area as a result of the new integrated processes implemented. Scheme claims ratios are also expected to subside slightly in coming months.

In addition to the many challenges facing medical scheme administrators is the current trend of over payment prevalent in closed schemes says Collier. The underlying reasons for this are:

  • Business processes are characterised by a large manual component because real time, on-line, higher automation systems are not yet prevalent;
  • The perceived value of large administration brands are fully priced in the closed schemes costing models;
  • Economies of scale have not been realised or simply have not flowed down to closed schemes.

“Agility GHS has the powerful combination of the latest generation technology, clinical intellectual property, global experience and local knowledge to offer administration and managed care models at significantly reduced rates,” says Collier.

 
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