Sun Life’s High-Cost Claims and Injectable Drug Trends Analysis offers critical insights for self-funded employers managing health benefits. Based on 60,000 stop-loss claims from a database of 6 million members, the report reveals that 87% of employers faced at least one high-cost claim between 2019 and 2022. Rising medical costs and evolving coverage have contributed to a growing number of claims.
Trends in High-Cost Claims
High-cost claims are becoming more frequent and expensive. In 2023, there were 32 claims exceeding $3 million—double the number from the previous year. Nine of these claims surpassed $5 million, highlighting the increasing prevalence of catastrophic medical costs. Congenital anomalies accounted for half of these $3 million+ claims, often stemming from birth-related conditions that require lifelong care.
Overall, 72% of stop-loss reimbursements originated from just 10 high-cost conditions, with 92% tied to the top 20. Employers must consider these concentrated risks when designing benefit plans and allocating resources.
The Role of Injectable Drugs
Injectable drugs are another major cost driver, with the top 10 drugs each exceeding $10 million in total spend. Keytruda, a cancer treatment, continues to dominate, accounting for nearly $70 million in 2023 alone. Among the top 20 drugs, 11 are used primarily for cancer treatment. Other notable additions include Enhertu and Tecentriq, as well as high-cost drugs like Tepezza, Ultomiris, Krystexxa, and Rylaze—all averaging over $400,000 per treatment. These drugs’ high costs are partly due to their recent FDA approval and patent-protected status.
Top Medical Conditions Driving Costs
Malignant neoplasms (solid tumors) remain the leading condition, with double the medical spend of the next highest category, cardiovascular disease (CVD). Notably, CVD rose to the #2 spot, surpassing blood cancers (Leukemia, Lymphoma, and Multiple Myeloma) for the first time in 12 years. This shift underscores the growing health burden of lifestyle factors, congenital heart defects, and potential post-COVID complications. CVD-related claims have risen by 33% since 2020, outpacing overall increases in medical claim costs.
Newborn/infant care climbed to the #3 position in 2023. This category saw an average claim cost of $470,800, with the highest single claim exceeding $11 million. Other significant cost drivers include orthopedic/musculoskeletal conditions and congenital anomalies, which often result in multimillion-dollar claims due to their long-term health implications.
Implications for Employers
Sun Life’s data highlights the importance of proactive health benefits management. Employers must navigate rising costs associated with conditions like CVD, cancer, and newborn care, as well as the growing impact of high-cost injectable drugs. Understanding these trends can help employers design sustainable health plans that balance cost control with quality care for employees.
By leveraging insights from comprehensive claims analysis, employers can better prepare for high-cost risks and implement solutions to mitigate financial exposure.
Conclusion
The rise in high-cost claims and multimillion-dollar medical expenses underscores the need for informed decision-making in employee benefits management. Generous Benefits supports employers in navigating these complexities, offering tailored solutions to optimize health plans while prioritizing employee wellness.
