Sun Life releases annual report on highest-cost medical claims; cardiovascular disease rises to second place

"Our extensive claims database allows us to provide guidance to our self-funded clients so they can understand how to best manage their health plans and costs, while ensuring they can choose additional solutions that drive the best care for their employees," said Jen Collier, president, Health and Risk Solutions, Sun Life U.S. "Additionally, the data informs our health and risk product development team as they create solutions and programs that directly support the health and wellness of our members, regardless of whether their condition has resulted in a high-cost claim."

One of the most notable observations in this year's report is that cardiovascular disease (CVD) moved up to the second spot of highest-paid claims, surpassing blood cancers for the first time in the company's 12 years of reporting. The average cost for CVD claims increased 33% since 2020, which is higher than the increase in average cost across all medical claims. Malignant neoplasm (solid tumors) continues to hold the top spot with double the medical spend of CVD.

"There are various factors that can contribute to cardiovascular disease, including congenital heart defects, aging and lifestyle risk factors such as smoking and obesity. More recently, there is evidence that post-COVID-19 infection and long COVID increase the risk of cardiovascular complications," said Dr. Miles Varn, Sun Life's chief medical officer and head of PinnacleCare. "Sun Life has dedicated teams and clinicians committed to using our data and expertise to remove barriers to health care so our members can achieve optimal health care outcomes."

Other key takeaways from the report:  

Medical cost trends

• 72% of all stop-loss reimbursements came from the top 10 high-cost medical conditions and 92% came from the top 20 conditions.
• Newborn/infant care disease/disorder claims rose by an average of $100,000 from 2022 to 2023, with an annual average cost of $470,800. The highest claim for this condition was $11.5 million.
• Orthopedics/musculoskeletal conditions came in at #4 in the single year for 2023 reimbursements. It has the highest number of individual members with a high-cost claim compared to any other top 20 condition, besides solid cancers (#1); it also has more utilization than other conditions, but a lower average cost at just over $100,000.

Multimillion-dollar claims continue to rise

• All top 20 claim categories experienced at least one million-dollar+ claim; the highest cost claim this year was for newborn/infant care at over $11 million.
• In 2023, a notable change occurred in the $3 million+ category, with 32 claims—nearly double the number of such claims from 2022.
• Of the 32 claims over $3 million, half were related to a diagnosis of congenital anomaly. While these claims are often associated with birth/early years, they can have implications on the health of an individual for their entire lifetime.

Monitoring trends in injectable drugs

• The top 10 injectable drugs all had more than $10 million in total spend. Keytruda has claimed the top position for the past four years and totaled nearly $70 million in spend in 2023 alone.
• Of the top 20 drugs, 11 were used primarily in the treatment of cancer; Enhertu and Tecentriq are new additions to the list.
• Four drugs on our top 20 list had an average cost over $400K: Tepezza, Ultomiris, Krystexxa and Rylaze. All four of these drugs received their FDA approval within the past six years and are currently under patent, which tends to result in a higher average cost.

Sun Life, the largest independent stop-loss provider in the U.S., covers high-dollar claims for employers that self-fund their health plans. In 2023, the Health Benefits Survey by KFF, an independent nonprofit organization focused on national health issues, found that 65% of employees in the U.S. who receive health benefits from their employer are enrolled in self-funded plans.  Since 2011, Sun Life has published the high-cost claims and injectables report as a tool to better understand cost drivers and healthcare trends.

Register for Sun Life's High-Cost Claims and Injectables webinar on June 5 featuring Jennifer Collier, Sun Life's President of Health and Risk Solutions, Mike Huppert, VP, Actuarial & Risk Management, and Lisa Hundertmark, Director of Clinical Services who will provide additional insights from the report.

About Sun Life

Sun Life is a leading international financial services organization providing asset management, wealth, insurance and health solutions to individual and institutional Clients. Sun Life has operations in a number of markets worldwide, including Canada, the United States, the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China, Australia, Singapore, Vietnam, Malaysia and Bermuda. As of March 31, 2024, Sun Life had total assets under management of $1.47 trillion. For more information, please visit www.sunlife.com.

Sun Life Financial Inc. trades on the Toronto (TSX), New York (NYSE) and Philippine (PSE) stock exchanges under the ticker symbol SLF.

Sun Life U.S. is one of the largest providers of employee and government benefits, helping more than 50 million Americans access the healthcare and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. Sun Life employs more than 8,500 people in the U.S., including associates in our partner dental practices and affiliated companies in asset management. Group insurance policies are issued by Sun Life Assurance Company of Canada (Wellesley Hills, Mass.), except in New York, where policies are issued by Sun Life and Health Insurance Company (U.S.) (Lansing, Mich.). For more information visit our website and newsroom.

Media Contacts:
Anjie Coplin
Sun Life U.S.
[email protected] 

Devon Fernald
Sun Life U.S.
[email protected]

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SOURCE Sun Life U.S.