Integrated Administration & Disease Management

Agility Health has, at all times, regarded administration as an integral part of medical scheme risk management. In contrast, most administrators regard their service as a stand-alone commodity to execute processes – a view that is causing an increasing amount of concern amongst the broader healthcare market.

Our approach places an inherent focus on superior risk management and innovation. This philosophy ensures that our systems and operations function in a unique, risk orientated fashion that allows client schemes to achieve clear competitive advantage. 

We pride ourselves on the following differentiating administration capabilities:

a) Boutique administration functionality

All schemes are administered independently as a boutique service to client schemes and their members, employers, providers and intermediaries. At the same time, Agility Health ensures that its clients fully benefit from its combined client footprint using the economies of scale principle to ensure maximum gain, impact and advantage across its client base.

b) Global knowledge and models

All clients become part of a global family that participate in some of the most innovative healthcare modelling, technology, and risk management solutions available to the global healthcare industry. Agility Health’s footprint (both annuity and project management solutions) spans five continents with operational offices in three of these, and further representation in two more.

c) Integrated administration and managed care offering

The Agility Health offering is based on the philosophy that administration and managed healthcare delivers one key capability – proper risk management of the medical scheme. Our clients experience the benefit of a seamless administration and managed care service unmatched by any other industry player. Cutting-edge technology sits at the heart of Agility’s philosophy with all administration and managed care services provided on one platform and rendered by integration experts across various disciplines. Highly automated intelligent processing, effective clinical risk management and high quality reporting are all unique benefits for our clients. 

A Patient Driven Care ™ approach

Known as Patient Driven Care™ (PDC™), Agility Health’s clinical risk management framework is a proprietary concept developed by the company’s clinical and risk modelling team. All PDC™ touch points support a single objective: to reduce disease or catastrophic events per patient to ultimately enhance overall wellbeing while driving down associated healthcare costs.

Agility Health’s managed care philosophy places the patient at the very centre of every intervention. This member-centric capability enables superior management of every disease, therapeutic or diagnostic entity as well as the distinctive combinations that make the health risk and wellness of an individual unique.

Industry-leading technology significantly enhances Agility Health’s already impressive managed care capabilities. Expertly deployed by its team of Personal Health Coordinators (PHCs), the proactive management of patient risk becomes a seamless, near automatic and natural process. Embedded algorithms and protocols further enable the process by managing PHC workflow allocation and ensuring timeous intervention and benefit allocation as required.

Agility believes that an integrated risk management philosophy can only be achieved with a truly integrated end-to-end administration and managed care system. It is this unwavering commitment to seamless integration that allows schemes  to achieve  their objective of ensuring that members receive timeous access to the necessary and most effective care during an event.

More importantly, our approach empowers patients and providers to keep the member healthy through prevention, ultimately leading to fewer catastrophic events. Agility Health's PDC™ philosophy identifies risk in the insured population and focuses on high risk patients. These patients are intensively managed to improve clinical outcomes and reduce unnecessary healthcare costs. Low risk patients are monitored by automated processes. This results in significantly lower costs for member and medical scheme alike. 

Hospital Management

Agility Health’s Hospital Management solution differs to that of the traditional administrator philosophy where of the majority of hospital utilisation and authorisation is done reactively as opposed to proactively. This approach is further aggravated by the manual processing of all authorisations with approximately 80% of requests requiring some form of human intervention, ultimately translating into unnecessary member and provider frustration and laborious administrative processes.

Agility Health’s unique administration system eliminates many of the archaic processes. This results in substantial cost savings for clients and a significantly-improved member experience.

Our team of highly qualified Personal Health Coordinators (PHCs) manage all hospital utilisation and authorisation requests with a 24 hour, 7 day a week, year-round service offering. Remote submissions from doctors’ rooms are received and processed on the same sophisticated platform used by the PHC team, thereby ensuring a single version of truth. The pre-authorisation process is similarly sophisticated and streamlined as a real-time solution available telephonically, via email or fax, or as an industry-first automated e-authorisation function to both members and providers. 

Pharmacy Benefit Management (PBM)

Our Pharmacy Benefit Management (PBM) offering, known as PharmacyPower™, is an extension of the patient specific care continuum where an intelligent real time rules process drives consistent decision-making per patient. Importantly, the system takes all historic patient knowledge into account and is seamlessly integrated into Agility Health’s overall Patient Driven Care™ (PDC™) approach.

PharmacyPower™ expertly combines PBM technology with proven clinical interventions that are customised to the South African market. Its inherent flexibility enables the system to easily cater to a scheme’s unique needs and specific risk tolerance in a highly automated, real-time environment.

Due to the system’s intelligent benefit entitlement allocation, maximum clinical gain is ensured for money spent while the system’s superior automation significantly lowers the demand for human intervention and ensures more consistent rule application. PharmacyPower™ also boasts unique web-based access to chronic medicines, patient- and disease-specific, which naturally drives the Drug Utilisation Review (DUR) process and near eliminates inconsistencies in the allocation of medicine.

Simply stated, PharmacyPower™ represents the most efficient and flexible solution to manage pharmaceutical claims and control costs whilst promoting the highest level of patient care.

Disease Management

Managed care, as provided by Agility Health, is flawlessly integrated with the Patient Driven Care (PDC™) programme. The programme is unique in the South African healthcare industry and one of very few programmes worldwide that maximises the benefit to both scheme and member via stringent control of both clinical and financial risk across all disciplines and episodes, whilst ensuring best possible health outcomes for the member.

Its focus is on nudging beneficiaries and providers to the correct behaviour to timeously maximise clinical outcomes. This is made possible by the unique real-time risk assessment performed by the system which risk-rates all users at various touch points - be it at an employee health day or any other provider contact. At-risk individuals are identified and their profiles are escalated to the Personal Heath Coordinator (PHC) team for timeous intervention.

PHCs coordinate the care of individuals who need it most through continuous consultation processes with both the beneficiary and clinical care provider.

Systems and care paths are i based on individual member’s disease severity, behavioural patterns, co-morbidities and lifestyle.  These are introduced in collaboration with the professional network provider. At Agility Health, managed care is about the patient, member or employee and not just about the approval of access to benefits in a static algorithm.

This rich data environment also allows Agility Health to enter into first-to-market risk sharing agreements with product providers where they supply either pharmaceuticals or devices within a risk transfer model such as a compliance programme or taking financial risk for clinical events of beneficiaries exposed to their products. 

The holistic care focus of PDC™ reduces waste, optimises care and drives down both clinical and financial risk.