Million-dollar+ claims rose from 109 claims per
million members in 2019 to 158 claims per million in 2022
WELLESLEY, Mass., May 17, 2023
/PRNewswire/ -- Sun Life U.S., the largest independent provider of
medical stop-loss insurance in the country, has released its
11th annual High-cost claims and injectable drug trends
analysis report, analyzing its extensive claims database and
highlighting trends in healthcare and medical costs. Sun Life's
claims data showed that million-dollar+ claims increased 45%, from
109 claims per million covered members in 2019 to 158 claims per
million covered members in 2022. Million-dollar+ claims appeared
across a broad range of medical conditions, from more common
diagnoses like cancer to less common conditions like hemophilia.
Depending on the condition, contributing factors included long-term
hospitalizations, specialty drugs, treatment of comorbid
(secondary) conditions and complicated surgeries.
"This research provides valuable insights into the trends that
contribute to rising healthcare costs, which helps shape our
approach to new benefit solutions and services that help people
access the care and coverage they need," said Jen Collier, president, Health and Risk
Solutions, Sun Life U.S. "We want employers to be as informed as
possible when making their health plan decisions so they can
provide the best plans for their employees that help improve health
outcomes while managing their medical spending."
As a stop-loss provider, Sun Life covers high-dollar claims for
employers who self-fund their employee health plans. According to
KFF, an independent non-profit organization focused on national
health issues, 65% of covered workers in the U.S. are in a plan
that is self-funded. Sun Life's high-cost claims report provides
insights that help self-funded employers understand the unique
health needs of their employees. This year's report examined 55,000
stop-loss claims from 2019 to 2022, analyzing the overall
highest-cost medical conditions and the implications of increasing
costs amid physician shortages that reduce access to care.
Report highlights
- Injectable drugs continue to be key drivers of high-cost
claims; the majority are used to treat cancer. Total Sun Life
stop-loss reimbursements for cancer from 2019 to 2022 were
$1.5 billion.
- The most frequent diagnosis among orthopedic and
musculoskeletal conditions was spinal stenosis, a narrowing of the
spinal column resulting from arthritis. Orthopedic/musculoskeletal
conditions are also a leading cause of short- and long-term
disability. Total Sun Life stop-loss reimbursements for this
condition were $339 million during
the four-year period.
- Cardiovascular disease, which includes heart disease and
stroke, represents more U.S. total health spend (12%) than any
other diagnostic group, according to research from The American
Heart Association. Total Sun Life stop-loss reimbursements during
the four-year period were $444
million.
- Newborn and infant care, which includes premature birth or
complications during birth, continued to be among the highest-cost
conditions, predominantly due to long-term hospitalizations. Total
Sun Life stop-loss reimbursements from 2019 to 2022 were
$338 million in this condition
category.
Medical vs. Rx spend
- Treatment of many conditions included both medical (hospital or
clinic-based care) and Rx/drug spend.
- Conditions like newborn/infant care and COVID-19 were almost
entirely made up of medical spend, while conditions like hemophilia
were heavily based on Rx spend.
- Medical spend can still include drugs administered in a
clinical setting, while Rx spend includes injections, patches or
oral medications.
- Certain drugs may have higher costs when administered in a
clinical setting, compared to when the patient can administer the
drugs at home. Many Sun Life members who have transitioned to more
convenient, home-based infusions saw their claims lowered by tens
or even hundreds of thousands of dollars.
"While we closely follow the cost trends associated with
injectable drugs, we are pleased to see new innovative drugs and
treatments coming to market that will save and improve the lives of
people facing major medical conditions," said Dan Fishbein, M.D., president of Sun Life U.S.
"Our job as a medical stop-loss provider is to help absorb these
high costs so self-funded employers are protected and can continue
to offer comprehensive benefits to their employees. Availability
and cost of treatment can be barriers to healthcare access, so we
are constantly looking for ways to help members get the care they
need when they need it."
Sun Life's Health and Risk Solutions business, which provides
stop-loss coverage, also offers Health Navigator powered by
PinnacleCare, a healthcare navigation service that offers personal
care advisors to help people access the right diagnoses,
treatments, and care for their needs.
Sun Life's annual high-cost claims report analyzes a rolling
four years of medical claims data from a member database of 5.5
million people, covered by 2,800 self-funded employer clients. Sun
Life is the largest independent stop-loss provider in the U.S.
according to data from the National Association of Insurance
Commissioners. An independent stop-loss provider does not sell
medical claim administration services.
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, 2022, Sun Life had total assets under management of
C$1.36 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 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 U.S. and affiliated
companies in asset management employ approximately 5,500 people in
the U.S. 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
Devon Fernald
Devon.Portney.Fernald@sunlife.com
781-800-3609
Anjie Coplin
Anjie.Coplin@sunlife.com
781-446-1693
Connect with Sun Life U.S.
https://www.facebook.com/SLFUnitedStates
https://www.linkedin.com/company/sun-life-financial
https://twitter.com/SunLifeUS
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SOURCE Sun Life U.S.