Health and Healthcare

Multimillion-Dollar Medical Claims Continue to Skyrocket

Jon C. Ogg

Published: June 12, 2019 1:15 pm

Last Updated: January 6, 2020 3:47 am

Whether you were in favor of or against the Affordable Care Act, aka Obamacare, it is likely of little surprise that the cost of health care has continued to rise. What also has risen handily is the number of ultra-high cost claims among individual covered by insurance claims. These high single medical claims can wreck even the healthiest group plans from year to year.

Sun Life Financial has released its annual view on individual claims. It’s no longer just claims rising with $1 million in annual costs tied to the health care of one person. Now the group is even tracking a rise in the incidence of claims that are $3 million or more.

With a coverage group of about 2,300 U.S. employers covering a total of more than 4.7 million people, Sun Life gets some insight into where the costs are going. It also should be noted that these are self-funded cases where the company’s reinsurance contracts are being used. Cited for the rapid rise in ultra-high claims are specialty drugs, extended hospital stays and complex treatments.

The Sun Life 2019 high-cost claims and injectable drug trends report was said to have analyzed nearly 37,000 high-dollar medical cases in its database from 2015 to 2018. The number of $3 million-plus claims was shown to have risen 140% from 2015 to 2018 alone, and patients with claims of $1.5 million or more also rose by 54% within that same period of time (the original release by Sun Life noted 104% on $3M claims and ‘doubled’ on $1.5M claims).

Cancer continues to be the costliest condition, and the injectable drugs are acting as a significant contributor to the total cost of care. Sun Life even showed that all the top five high-cost injectable drugs are most frequently used to treat cancer, including radiation and chemotherapy drugs. Other cancer treatments also are emerging that may point to changes in the treatment landscape. The top 10 highest-cost drugs are all used for either cancer or blood disorders.

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. Adding to the costs were a combination of complicated procedures, along with advanced life-sustaining treatments and complications requiring longer in-patient stays.

While the actual numbers of incidents of high costs are relatively low, there is an implication here with all rising costs that the per-patient costs are going to grow much higher when dealing with larger population groups. The number of patients with more than $1.5 million in claims went up 54%, from 46 in 2015 to 71 in 2018. The number of patients with more than $3 million in claims rose 140%, from 5 in 2015 to 12 in 2018.

Now compare this to last year’s report. Sun Life said in June of 2018 that the number of patients with million-dollar-plus claims rose 87%, from 104 in 2014 to 194 in 2017. Most charges then ranged from $1.0 million to $1.5 million and came to over $935 million in paid charges.

Several statistics were used in the Sun Life study as well:

• Some 64% of million-dollar-plus patients were under 40 years of age.
• The highest injectable-drug charge for a single patient in 2018 was for Soliris, used to treat blood disorders, at $1.8 million.
• The second highest was Erwinaze as a cancer treatment at $1.7 million.
• New gene therapies could cure diseases with just one dose, but they come at a high cost as a new drug from Novartis that cures spinal muscular atrophy will cost just over $2 million per patient.
• Sun Life U.S.’s research showed that 85% of self-funded employers saw a stop-loss claim in any given policy year. Over a four-year period, 22% of self-funded employers had at least one member with a claim of more than $1 million.

Dan Fishbein, president of Sun Life U.S., said:

There are incredible steps forward in medical care, where we are seeing better survival rates and quality of life for patients. 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.

Breast cancer was the most common type of cancer, and it came with the highest total cost. Lymphocytic leukemia was the cancer condition with the highest average cost. Within the top 20 highest-cost injectable drugs, the majority of the cancer treatment high-cost injectables were from Herceptin, Neulasta, Perjeta, Avastin and Keytruda.