PEOPLE throughout the world are facing lifestyle-related illnesses on an unprecedented scale with as much as 56 percent of South African medical scheme members displaying at least one or more healthcare risk factors.
This is according to Mike Collier, CEO of Agility Global Healthcare Solutions, who warns that as many as 20 percent could be at high risk from chronic disease.
"Effective management of risk in healthcare funding is not a series of point solutions but rather the application of a holistic framework of interventions. 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'.
"They have to establish new and innovative ways for addressing the challenges of managing risk while still providing world-class care to their members."
Agility GHS is an international healthcare player and administrator to several global health insurers.
In December last year it assumed the role of new administrator and risk manager to Resolution Health Medical Scheme, an open scheme which has experienced tumultuous times in recent years.
Collier says, "We focus on alternative thinking when it comes to managed healthcare practices and pride ourselves in being the first administrator in the country to apply a 'more care, less risk' rationale to our administrative practices.
"We believe that the future of managed healthcare lies within proactive interventions. To this end we have developed a Patient Driven Care programme which has rewritten the rules of disease management."
At its heart, he explains is a proactive, fully integrated healthcare campaign. It focuses on keeping members with high risk profiles healthier by making available the appropriate benefits for their specific condition in a structured, timely fashion.
"This proactive allocative framework ensures optimal buy-in from providers and patients who are not frustrated by tedious applications and paperwork. All this is done online and approvals can be updated real-time and mostly without the need for human intervention," he says.
By monitoring compliance and disease severity to establish treatment protocols within the benefits made available, the administrator 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 according to the CEO. "Highly automated systems feature an unprecedented amount of embedded business and clinical knowledge. 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. 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.
"While these automated, real time processes provide for more efficient administration and an improved member and service provider experience, they also create more accurate and complete data. This, in turn, allows for better risk management."
Loraine Tulleken: Business Report, 28 May 2010
