Cancer still tops high-cost health claims but muscle and orthopedic conditions are making surprise surge: Sun Life report

Rhea-AI Summary

Sun Life's 13th annual high-cost claims report reveals significant increases in healthcare expenses, with million-dollar stop-loss claims rising 29% this year and 61% over four years. Cancer remains the top cost driver, generating $1.2 billion in spending across 5,000 claims in 2024. Orthopedic/musculoskeletal conditions have surprisingly entered the top three categories, with $1.18 billion in total spend. The report analyzes over 65,000 health claims from 3,000 employers between 2021-2024. Notable findings include a 70% increase in congenital anomaly claim costs since 2021, with the highest claim reaching $12 million. In drug categories, uncategorized drugs, including gene therapies, have emerged as a significant cost driver, with two members receiving treatments totaling $6.8 million. Keytruda leads as the costliest cancer treatment at $84.4 million in spend.

Positive

• Comprehensive analysis of 65,000 health claims provides valuable insights for healthcare cost management
• Sun Life's position as the leading independent stop-loss provider demonstrates market leadership
• Company offers dedicated programs and resources to help improve healthcare outcomes while managing costs

Negative

• Million-dollar stop-loss claims increased significantly by 29% this year and 61% over four years
• Cancer treatment costs remain extremely high at $1.2 billion in spending
• Emergence of high-cost gene therapies adding significant expense to healthcare costs
• 70% increase in congenital anomaly claim costs since 2021 indicates rising healthcare expenses

Insights

Healthcare Industry Analyst

Sun Life's report reveals alarming healthcare cost trends with million-dollar claims up 29% annually, highlighting significant business challenges and opportunities.

Sun Life's 13th annual high-cost claims report reveals concerning trends that will impact both the company's operations and the broader healthcare landscape. The 29% year-over-year increase in million-dollar stop-loss claims and 61% growth over four years signals significant pressure on self-funded employer health plans—Sun Life's core customer base. With 63% of covered U.S. workers in self-funded plans according to KFF, these escalating costs directly affect Sun Life's risk exposure and pricing strategies.

The report identifies cancer as the dominant cost driver, generating $1.2 billion in spending across approximately 5,000 claims—triple the cost of cardiovascular conditions. The surprising emergence of orthopedic/musculoskeletal conditions in the top three categories with $1.18 billion in total spending represents a strategic pivot point for Sun Life's underwriting and risk management approaches.

Particularly noteworthy is the 70% increase in average costs for congenital anomaly claims since 2021, with a single claim reaching $12 million. This exponential growth in ultra-high-cost claims will likely accelerate premium adjustments for Sun Life's stop-loss insurance products.

The emergence of "uncategorized drugs" as a high-cost category, driven by gene therapies totaling $6.8 million for just two members, signals a transformative shift in the cost structure of healthcare that will reshape Sun Life's actuarial models. With eight of the ten highest-cost drugs used primarily for cancer treatment and Keytruda alone accounting for $84.4 million in spending, the company faces mounting pressure to develop innovative cost containment strategies.

Sun Life appears to be positioning its clinical engagement programs and PinnacleCare service as strategic solutions to these cost challenges, potentially creating new revenue streams while addressing customer pain points. The data clearly demonstrates the company's deepening role in healthcare cost management beyond traditional insurance functions—a necessary evolution in a market experiencing unsustainable medical inflation.

13^th-annual high-cost claims analysis highlights soaring healthcare expenses with cancer, cardiovascular and musculoskeletal leading the way

WELLESLEY, Mass., June 4, 2025 /PRNewswire/ -- Sun Life, the nation's leading independent stop-loss provider for self-funded employers, today released its 13th annual high-cost claim and injectable drugs trend analysis, examining more than 65,000 health claims from 3,000 employers between 2021 and 2024. Overall, million-dollar stop-loss claims are on the rise, increasing by 29% this year when looking at claims-per-million-covered employees, and are up 61% over the past four years. 

"Sun Life's annual high-cost claims report illustrates the escalating nature of healthcare costs and the growing financial burden on employers and the healthcare system," said Jen Collier, president of Health and Risk Solutions, Sun Life U.S. "By analyzing our clinical data annually, we are able to create solutions with targeted interventions and personalized care navigation that can have a significant impact on both health outcomes and cost containment."

Cancer Leads as Top Cost Driver

Cancer once again tops the list as the most frequent and costly condition, with malignant neoplasms (solid tumors) generating $1.2 billion in spending across approximately 5,000 claims in 2024—triple the cost of the second-leading condition, cardiovascular. While blood cancers (Leukemia, Lymphoma, Multiple Myeloma) moved down one spot, they remain in the top five categories with nearly 900 members experiencing a high-cost claim annually.

Additional Key Findings:

Orthopedics/Musculoskeletal (Ortho/MSK) conditions are increasing in frequency, placing the category in the top three for the first time.

• While the average cost is lower than most categories at $116,000, it is second in claim frequency only to malignant neoplasms.
• The total spend in the category is $1.18 billion for the reporting period.

The average cost for congenital anomaly claims increased 70% since 2021.

• More than 450 members experienced a congenital anomaly with an average claim cost of $335,000.
• The highest-cost claim in this category in 2024 was approximately $12 million.

Uncategorized drugs' have emerged as one of the highest-cost categories among injectable drugs, driven in part by gene therapies.

• This category encompasses newly approved medications, compounded formulations, and drugs used in experimental treatments during clinical trials.
• Even though the average treatment cost is relatively low at $5,900, two members received gene therapies totaling $6.8 million in 2024, catapulting the category to #16 on the list.

Eight of the 10 highest-cost drugs are primarily used in the treatment of cancer.

• Keytruda was the costliest cancer treatment and the highest overall drug with $84.4 million in spend.
• Durvalumab was added to this year's list due to a spike in utilization over the four-year and one-year views, with 78 members using the drug in 2024.

"As a physician, I am keenly aware that factors such as chronic conditions, medical advancements, drug spend, and delayed care are putting pressure on employers and their workforces," said Dr. Miles Varn, chief medical officer, Sun Life U.S. and head of PinnacleCare. "Through Sun Life's dedicated programs and resources, our clinical team can engage members early in their healthcare journey – helping to close care gaps by finding appropriate care and services – ultimately improving the outcomes for individuals while creating more sustainable costs for employers."

As a stop-loss provider, Sun Life covers high-cost claims for employers who self-fund their employee health plans. According to KFF, an independent non-profit organization focused on national health issues, 63% of covered workers in the U.S. are in a plan that is self-funded.

To learn more, register for Sun Life's High-Cost Claims and Injectables webinar on June 5 featuring Jennifer Collier, Sun Life's president of Health and Risk Solutions, Dr. Miles Varn, chief medical officer, Mike Huppert, AVP, Actuarial and Risk Management, and Ryan Murphy, assistant vice president, Health Capabilities and Strategic Growth.

About Sun Life
Sun Life is a leading international financial services organization providing asset management, wealth, insurance and health solutions to individual and institutional Clients. Sun Life has operations in a number of markets worldwide, including Canada, the U.S., the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China, Australia, Singapore, Vietnam, Malaysia and Bermuda. As of March 31, 2025, Sun Life had total assets under management of $1.55 trillion. For more information, please visit sunlife.com.

Sun Life Financial Inc. trades on the Toronto (TSX), New York (NYSE) and Philippine (PSE) stock exchanges under the ticker symbol SLF.

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. Sun Life employs more than 8,300 people in the U.S., including associates in our partner dental practices and affiliated companies in asset management. 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.).

Media contact:
Anjie Coplin
Anjie.Coplin@sunlife.com
469-938-1050

Connect with Sun Life U.S.

https://www.facebook.com/SLFUnitedStates   
https://www.linkedin.com/company/sun-life-financial  

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SOURCE Sun Life U.S.

FAQ

What are the top high-cost health claims in Sun Life's 2024 report?

Cancer (malignant neoplasms) leads with $1.2 billion in spending, followed by cardiovascular conditions, and orthopedic/musculoskeletal conditions ranking third for the first time.

How much have million-dollar stop-loss claims increased according to Sun Life (SLF)?

Million-dollar stop-loss claims increased by 29% in 2024 and have risen 61% over the past four years.

What is the most expensive drug treatment in Sun Life's 2024 report?

Keytruda was the costliest cancer treatment and highest overall drug with $84.4 million in total spend.

How much did congenital anomaly claims increase in Sun Life's report?

The average cost for congenital anomaly claims increased 70% since 2021, with the highest single claim reaching approximately $12 million.

What is the significance of orthopedic conditions in Sun Life's 2024 health claims report?

Orthopedic/musculoskeletal conditions reached the top three categories for the first time, with $1.18 billion in total spend and the second-highest claim frequency after cancer.