Research based on Sun Life’s high-cost claims data also shows:
- Million-dollar+ claims increased 37% from 2018 to 2021
- Highest-dollar claims were due to combinations of in-patient hospitalization, injectable/specialty drugs, comorbid conditions and complicated surgeries
- Highest-cost claim in 2021 was $6.23 million, for hemophilia
- High-cost mental health claims increased 21% from 2020 to 2021
Sun Life U.S. has released its 10th annual report on high-cost medical claims, analyzing its stop-loss claims data and medical trends from 2018 – 2021. COVID-19 rose to a top 10 costliest condition in 2021, with the highest-cost COVID-19 claim reaching $1.75 million. Other categories of medical claims, including cancer and mental health claims, showed increases as well. The report reviewed nearly 50,000 Sun Life member claims from more than 2,800 self-funded employer clients around the country, providing research and data indicative of U.S. healthcare trends. The rise in claims over the study period are the result of increases in underlying medical claims cost as well as changes to Sun Life’s book of covered business.
According to the Kaiser Foundation’s annual report on employee benefits, 64 percent of employees in the U.S. are enrolled in self-funded health plans. As the largest independent stop-loss provider in the U.S., currently covering 5.3 million lives, Sun Life covers high-dollar claims for employers who self-fund their employee health plans. Sun Life also provides members with health advisory and care navigation services through its Health Navigator solution, powered by PinnacleCare.
“From COVID-19 to mental health, new treatments and healthcare trends are continuously emerging and evolving, and self-funded employers need guidance as they consider health plan designs and how to best support their employees’ health,” said Jen Collier, senior vice president of Sun Life U.S. Health and Risk Solutions. “Compiling this research every year allows us to understand and provide analysis and insights on the evolution of clinical and drug treatments and trends for the highest-cost diagnoses. This helps employers understand how to anticipate the potential frequency and costs of claims, as well as assess risk factors and improve health outcomes. When we arm our clients with the best information and expertise, they can make the best decisions for the health of their employees.”
Other key takeaways from the report:
Two years of COVID-19
- In 2021 COVID-19 was a top 10 condition with a total spend of $114 million; in the four-year ranking for 2018-2021, COVID-19 was still in the top 20 despite only having claims for two of the four years.
- COVID-19 claims that were severe enough to breach stop-loss deductibles averaged $231,300, with the highest claim at $1.75 million.
- COVID-19 also contributed to the cost of care for two members with primary conditions of sepsis with a total spend of over $3 million each.
Mental health claims on the rise
- Total spend on mental and behavioral health claims rose by 22% in 2021; the average cost per claim remained relatively flat at $68,300, indicating that the increase was mostly due to more members having high-cost mental health claims, not higher costs of care.
- Depressive disorders saw the most significant growth at 85%, while sleep/wake disorders rose by 68%, and alcohol- and opioid-related claims increased as well.
Multi-million-dollar claims continue to rise
- From 2020-2021 the number of million-dollar+ claims increased by 21% and increased 37% from 2018-2021 (adjusted for changes in number of covered lives)
- In 2021 the conditions with the most frequent million-dollar+ claims were cancer, complications around newborn/infant care and COVID-19.
- The $6.23 million claim for hemophilia was driven almost entirely by injectable drug costs.
- The highest-cost claim driven primarily by in-patient care was for $5.43 million, for a congenital anomaly (condition present at birth), with a comorbidity of septicemia.
- Ten members had claims over $3 million in 2021, for conditions including hemophilia, sepsis, cancer, burns, and complications around newborn/infant care.
- Cost drivers for these claims include extended in-patient hospitalization, complicated surgeries, injectable drugs/Rx treatment, and comorbidities such as COVID-19, kidney failure, or cardiac complications.
Medical vs. Rx/pharmacy costs
- Claims for three conditions – malnutrition, transplant and hemophilia – had at least 70% of total costs from drugs.
- The cost of conditions like COVID-19 or complications around newborn/infant care were driven almost entirely by medical spend (not pharmacy), largely due to in-patient hospitalization.
Cancer trends
- The highest-cost cancer claim in 2021 was $5.41 million, driven by a combination of in-patient care, complicated surgeries, and injectable drugs.
- Cancer has dominated the list of costliest conditions for ten straight years, due to both overall cost and frequency of claims.
- Eleven of the top 20 costliest injectable drugs are used to treat cancer.
Sun Life’s high-dollar claims report also offers employers guidance on optimizing care and improving health outcomes which can result in cost savings as well. Care navigation, site of care changes, expert claims review, and employee wellness programs can all help reduce the cost of care while improving the member’s medical journey.
Sun Life’s recent webinar presenting additional insights from the report is available to view here.