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EF: Can you elaborate on the role that you are playing in accessing healthcare?
NB: We consider healthcare from all angles of the value chain, but the technology we use—which employs artificial intelligence and rule-based software—underpins everything we do. It is a fresh approach that is innovative. Healthcare is a very complex insurance class. It differs from general insurance, long-term insurance, or short-term insurance. It has millions of claim lines and touch points and is quite complicated in terms of coding, schema, and tariffs.
There are different levels of care, and if you do not have the right technology or are still using legacy systems, you will not be able to manage new ways of doing things with a flexible and agile solution. Healthcare is a field of research that is always evolving. You will lag behind if you do not continue to follow that evolution.
We offer various solutions through technology. Technology is the enabler of our solutions. The biggest challenge in the markets that we serve, is technology without embedded intellectual property, whilst also not allowing for various models and scenarios. These legacy technology bases still require extensive development whilst the R&D is lagging behind. Our approach is around conducting research and development for the embedded intellectual property that is integrated into the technology and ensuring that it is a bespoke solution tailored to a customer.
Our system even differs for each market. Countries, clients, insurers, regulations and modeling differs. Even accommodating different currencies, different languages and distinct alphabets become challenging to legacy and other systems. Most technology solutions are built around a specific customer or environment with little to no opportunity for exporting these across clients and markets.
We have designed our solutions to be portable and exportable, allowing us to deploy them to new markets and clients whilst also transferring our knowledge that was built over a period of almost three decades simultaneously. Due to its complexity and evolving nature, the healthcare industry is a more social setting where you must collaborate and share.
Life insurance is one of the insurance classes with an easier modeling process. Healthcare is an open system. There are other factors at play. The recent pandemic clearly illustrated the need for healthcare systems to be adaptable.
The Agility continuum of services includes technology solutions, risk management, administration, as well as marketing and distribution across a wide spectrum of services and products relating to healthcare and employee benefits.
Some of our most notable outcomes achieved across markets include:
· A significant decrease in hospital readmission rates
· effective management of fraud, waste and abuse proactively
· Reduction in operational costs for our insurance clients (as much as 50%)
· effective management of high-risk patient pools
· Establishing provider networks and panels to integrate fully with risk management protocols and guidelines
· enhanced marketing and distribution strategies through effective technology
As far back as 1999, Bill Gates compared healthcare operations with the military. Lots of people in the backroom ran around like soldiers, endeavouring to manage metadata and volumes of information. To a large extent and unfortunately, there are a lot of health insurers out there still operating in that fashion. , The challenge that Agility took on to solve is to move into the next generation where you trust your technology to enhance the deployment of IP and reduce your soldiers. It is not about moving paper around, but it is about intelligent decision-making.
EF: What do your customers require the most?
NB: There are two facets. The first is understanding what your customers want, and the second is providing them with the appropriate solutions. For example, the market continues to handle authorisations in the traditional manner. In our setting, electronic authorization is possible. You do not even need to pick up the phone because we can execute electronic authorizations and integrate business-to-business with hospitals. Furthermore, as part of a silo approach, the majority of authorisations are not integrated with the claims, making the need for authorisations obsolete! It also excludes the ability to apply case management and other interventions at the point of payment.
Integration is crucial. If a system is not properly integrated, it becomes a waste of time and money. Coupled with a more granular capturing and management of data, the Agility solutions assist our customers with enhanced risk management abilities.
EF: What are your priorities for 2023?
NB: COVID-19 and its restrictions had some adverse impacts on our business, but this assisted the business with becoming more agile and being able to attend to enhanced solutions.
We have expanded into new markets in the United Kingdom, Africa and various regions of Asia. To date, we have done work across roughly 16 nations worldwide, including Africa. We have a lot of experience and knowledge in the industry, so we know what works and what does not. In 2023, we want to aggressively expand the company into those markets.
EF: What do you believe to be the biggest market opportunities?
The integration of products and services remains a unique feature of Agility, allowing integration on the same technology platform, whilst ensuring integrated strategic rollouts. This unique feature of Agility has proven to assist our customers with creating unique products and product offerings, whilst the marketing and distribution of these products coincide effectively as part of the strategy.
Agility is therefore confident that this true integration, not only within healthcare but also auxiliary services and products will continue to provide us with opportunities to serve our customers in a unique manner.
EF: You have been using AI to add value to your processes. How do you think AI, such as ChatGPT, and other new technologies will impact the industry?
NB: Technology is going to continuously enhance what we are doing. In our world, there is a combination of human and machine learning. You can never only have machine learning. For example, determining the protocol for asthma or diabetes and deciding what kind of medicine to use requires a human element. That is why we have the rules engine combined with AI. It is human learning combined with machine learning. We have a panel of specialists from every specialization and on a worldwide basis that assists us with the continuous enhancement of our clinical IP. The machine learning then applies specific trends and outcomes achieved through the combination of machine and human learning.
This is a very interesting environment due to the impact of different stakeholders in this space. AI is really valuable in terms of the big data that you have to work with. However, I cannot see AI as a stand-alone solution. Human IP needs to guide the direction that AI goes. We do not want algorithms to be applied incorrectly.
EF: Agility is going to be celebrating its 30th anniversary soon. Apart from a great experience in the sector, what are you going to celebrate as something that has changed the history of healthcare?
NB: We have done a couple of innovative things over the years.
We are the pioneers in South Africa in terms of putting provider networks in place and directing them to work under a new model. Our partnership approach has proven to be the correct approach since 1996.
During the 1990s, we built a provider network of 12,000 providers and it remains one of the biggest provider networks in South Africa. This network has evolved over time and taken it to the next level of sharing the risk with providers and different models of provider integration. That is one of the major achievements that has enabled us to save our health insurers and medical schemes a tremendous amount of money.
Secondly, I believe we were the first health insurance system in South Africa to deploy AI in our solution (and pioneered this in many of the other markets that we play as well). The adoption of innovative technology has been one of our proudest achievements. "Knowledge Objects" is the group’s established software development entity that operates at arm’s length from the rest of the Agility companies.
We are also proud of what we have achieved in terms of integration. We are excelling at integration in whatever market we operate in. Integration of all the administration, operational, and risk management into one platform or architecture is unique. The next step we are taking is to put all the insurance classes onto one platform to enable us to have a 360-degree view of our customers. We have already integrated medical schemes, health insurance, top-up cover (gap and co-pay), and rewards programs on the same platform.
This integrated platform provides a 360-degree view of the customer and helps determine how we can improve their well-being.
Although this next stage is a challenge, we are forging ahead. In order to overcome this challenge, we have to have knowledge and expertise across a wide variety and a wide spectrum of different disciplines and classes of insurance, but the end result is worth it.
EF: Is there any final message you want to deliver to the audience through our platform?
NB: In South Africa, National Health Insurance (universal cover through one risk pool managed by the State) is now top of the agenda. It is important that we remain resilient in terms of our approach. We should not just bow to NHI, but we should acknowledge the principles of universal coverage. It is the modeling of how this outcome is achieved and the funding mechanisms that should be of concern.
The unfortunate (or fortunate?) dilemma of healthcare all over the world is that the modeling and delivery become political in nature. Elections are won through healthcare policies as we have witnessed many times all over the world. The emotions of the people should not be exploited over and above realism with funding and sustainability. I want people to remain calm and levelheaded about healthcare and not lose sight of the real outcome – this is about the generations to follow and not about us!