$3 million+ medical claims more than doubled from 2015 to 2018
Patients with $1.5 million or more in claims rose 54%
WELLESLEY, Mass. (June 12, 2019) – Specialty drugs, extended hospital stays and complex treatments are major cost drivers in million-dollar+ claims, according to the Sun Life 2019 High-cost claims and injectable drug trends report. The report analyzed nearly 37,000 high-dollar medical cases in its database from 2015 to 2018. In total, Sun Life currently has approximately 2,300 U.S. employer clients that cover more than 4.7 million people.
The costliest condition driving these claims is cancer, with injectable drugs contributing significantly to the total cost. All of the top five high-cost injectable drugs are most frequently used to treat cancer. These include radiation and chemotherapy drugs, but other cancer treatments are emerging that may point to changes in the treatment landscape.
“There are incredible steps forward in medical care, where we are seeing better survival rates and quality of life for patients,” said Dan Fishbein, M.D., president of Sun Life U.S. “Self-funded employers should understand medical cost trends and their key drivers. While we see other factors contributing to high-cost claims, including complicated surgeries and long hospital stays, specialty drugs continue to be a major factor in the increasing frequency and size of million-dollar and multi-million-dollar claims.”
According to the report, in 2018 the conditions most likely to result in claims exceeding $3 million per person were organ transplants, cancer and related treatments, and congenital anomalies. These patients experienced a combination of complicated procedures, advanced life-sustaining treatments and other complications requiring extended in-patient stays. The number of patients with more than $1.5 million in claims went up 54 percent, from 46 in 2015 to 71 in 2018, and the number of patients with more than $3 million in claims rose 140 percent, from five in 2015 to 12 in 2018.
Other key findings from the report include:
- Age factor: 64 percent of million-dollar+ patients were under 40 years of age.
- Injectable drugs: The highest injectable-drug charges for a single patient in 2018 were for Soliris, used to treat blood disorders, at $1.8 million, and Erwinaze, which treats cancer, at $1.7 million. The top 10 highest-cost drugs are all used for either cancer or blood disorders.
- Frequency vs. severity: Injectable drugs for more common diseases such as cancer typically generate high costs because they are frequently prescribed; other drugs accumulate high costs because the medication itself has a high average cost.
- Emerging treatments: New gene therapies could cure diseases with just one dose, but they come at a high cost – a new drug from Novartis that cures spinal muscular atrophy will cost just over $2 million per patient.
According to the annual Kaiser Employer Health Benefits Survey, 61 percent of covered workers in the U.S. are in a self-funded health plan. Employers who self-fund purchase stop-loss insurance to protect against high-dollar claims. Sun Life U.S.’s research shows that 85 percent of self-funded employers saw a stop-loss claim in any given policy year, and, over a four-year period, 22 percent had at least one member with a claim of more than $1 million.
Sun Life uses clinical expertise to analyze claims and identify opportunities to reduce claims costs for employer clients. Cost and clinical management approaches include identifying improper prescription amounts and/or billing errors, and finding centers of excellence or alternative treatments, which may result in better patient outcomes and a more comfortable, convenient treatment setting.
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Sun Life is a leading international financial services organization providing insurance, wealth and asset management solutions to individual and corporate 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, 2019, Sun Life had total assets under management of C$1,011 billion. For more information, please visit www.sunlife.com.
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In the United States, Sun Life is one of the largest group benefits providers, serving more than 60,000 employers in small, medium and large workplaces across the country. Sun Life’s broad portfolio of insurance products and services in the U.S. includes disability, absence management, life, dental, vision, voluntary and medical stop-loss. Sun Life employs approximately 6,000 people in its U.S insurance and asset management businesses. 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, please visit www.sunlife.com/us.
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