#United States #Sun Life #Healthcare Costs #Wellesley #orthopedic conditions

Sun Life's Annual High-Cost Claims Report

Sun Life recently shared its 13th annual high-cost claims report, shedding light on the escalating costs in the healthcare sector. The analysis, derived from over 65,000 health claims submitted by 3,000 self-funded employers from 2021 to 2024, emphasizes a significant upward trend in million-dollar claims. This year, claims per million covered employees saw a 29% increase, and over the last four years, there has been a staggering 61% rise.

Key Findings

The report reinforces the staggering reality of healthcare expenses, particularly highlighting cancer as the foremost cost driver. Cancer care accounted for a colossal $1.2 billion through around 5,000 claims in 2024, more than tripling the expenses of the second-largest category, cardiovascular conditions. Despite their dip in rankings, blood cancers, including leukemia and lymphoma, still rank within the top five, collectively affecting approximately 900 individuals annually.

In a startling development, orthopedic and musculoskeletal conditions have surged, marking their entry into the top three costly categories for the first time. Although each claim averages $116,000—less than cancer-related claims—its prevalence is second only to malignant neoplasms, cost totaling $1.18 billion during the reporting phase. The rise in orthopedic claims underlines a growing need for strategic interventions in this area.

The report also noted a dramatic uptick in congenital anomaly claims, which have risen by 70% since 2021. With over 450 reported cases, the average claim cost reached $335,000, with one individual case soaring to approximately $12 million. This surge emphasizes the importance of early diagnosis and treatment in managing costs effectively.

Injectable Drug Costs

On the topic of injectable drugs, an emerging category—'uncategorized drugs'—has claimed a significant spot among these high-cost treatments, partially attributed to gene therapies. This category encapsulates a range of new medications and compounded formulations used in clinical trials, showing a surprisingly low average treatment cost of $5,900. However, due to two members accessing gene therapies totaling $6.8 million, this category ranked as the 16th highest in expenses.

Notably, eight of the ten highest-cost medications are primarily used in cancer treatment, with Keytruda marking the highest singular expenditure at $84.4 million. Additionally, Durvalumab has newly joined this list due to its sharp utilization spike among patients.

Healthcare Impacts and Solutions

Dr. Miles Varn, Chief Medical Officer at Sun Life, remarked on the compounding pressures of chronic conditions, medical advances, drug spending, and delayed medical care facing employers. "To address these challenges, we engage members early in their health journey, optimizing care access through targeted solutions. This approach not only improves health outcomes but also fosters more sustainable financial implications for employers."

As a leading stop-loss provider, Sun Life supports self-funded employers by covering high-cost claims, which are becoming increasingly burdensome. A report from KFF indicated that 63% of U.S. workers have plans funded by their employers, underscoring the necessity for comprehensive healthcare solutions.

Conclusion

Sun Life’s findings reveal a critical landscape of healthcare costs continuing to intensify across various sectors. While cancer remains the leading culprit, the rise of orthopedic and congenital claims signals an urgent need for focused intervention strategies. As healthcare expenses push these self-funded employers towards the edge, proactive measures will be essential to mitigate these costs and enhance care access for employees.

For further insights, join Sun Life's webinar on high-cost claims and injectables scheduled for June 5, featuring key executives from the company, including Jen Collier and Dr. Miles Varn.