Cancer costs are still rising—and so are million-dollar-plus medical claims

Since 2010, cancer has consistently topped Sun Life’s annual list of high-cost claim conditions. With the American Cancer Society having predicted 1.7 million new diagnoses last year, it should be unsurprising (if no less sobering) that 2019 was no exception.

The latest stop-loss report from the financial services company shows cancer in the top two spots, making up 26% of stop-loss reimbursements. Chronic/end-stage renal disease rounds out the top three conditions. Diabetes was the second costliest condition associated with chronic/end-stage renal disease. Transplants and congenital anomalies (conditions present at birth) also ranked high on the list.

Cancer also holds the top six positions on the list of 20 high-cost injectable drugs, with another cancer treatment (Yervoy) coming in at number nine. According to the report, $306.2 million was spent on injectable medications in 2019, with $185.6 million (61%) attributed to the top 20 on the list. Five cancer drugs⁠—Herceptin, Opdivo, Neulasta, Keytruda, and Avastin—made up 27% of the total injectable drug cost overall.

Zolgensma, a gene therapy approved last year for the treatment of spinal muscular atrophy, had the highest average cost at $2.2 million per member.

From 2016 to 2019, the report states, 24% of employers had at least one member with over $1 million in claims. Claims between $2 million and $3 million rose 44% and those totaling $3 million or more doubled. Of the 14 members in the $3 million or more category, most of the main contributing conditions were congenital anomalies, cancer conditions, and genetic disorders. Most of the patients in this category had a combination of complicated procedures, advanced life-sustaining treatments or other complications requiring extended in-patient stays. For four of those members, high-cost drugs played a crucial role in the final tally.

The report also notes that 46% of million-dollar claims were for patients under the age of 20, with 71% of the $3 million+ claims for patients under 12. The leading high-cost claim was congenital anomalies for those under age two. Cancer was the most common claim category for ages 2-19, and hemophilia was the leading condition for ages 20-39.

The report took COVID-19 into account as well, noting that while many coronavirus claims did not breach the stop-loss deductible level, stop-loss claims seen to date had hospitalization stays between 3 and 35 days. The highest hospitalization cost for one patient, according to the report, exceeded $190,000.

“We fully support the expansion of life-saving drug treatment options that are becoming available to patients with cancer and other serious medical conditions. It’s also important to note that this trend of increasing costs will continue, and the trillions of dollars spent on healthcare are the responsibility of employees, their families and the businesses where they work,” said Jen Collier, R.N., senior vice president, Stop-Loss & Health at Sun Life U.S.