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Cancer tops stop-loss claims, transplant costs jump

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Cancer once again topped the list of costliest stop-loss catastrophic claims, but the cost of transplants is growing rapidly, according to a report by Sun Life Financial Inc.

Between 2012 and 2015, self-insured employers covered by Sun Life stop-loss insurance paid $5.3 billion of a total $9 billion in medical charges after discounts. Those employers received $2.3 billion in stop-loss claims reimbursements, Sun Life said in the fourth annual report, “Top Ten Catastrophic Claims Conditions,” released last week.

The top 10 costliest conditions represented 53% of the total claims reimbursed, Sun Life said.

Self-insured employers buy stop-loss insurance to protect themselves against costly medical claims. A stop-loss claim is one that exceeds the stop-loss insurance deductible.

Different forms of cancer took the top two spots on the list of catastrophic claims conditions that received the most reimbursement under Sun Life stop-loss insurance during the four-year period. Cancer has remained at the top of the list for the past four years of the report.

Sun Life paid out $618 million in stop-loss reimbursements between 2012 and 2015 — 26.6% to total stop-loss claims — for cancers, including malignant neoplasms, like breast and brain cancer, and blood cancers, such as leukemia, lymphoma and multiple myeloma, according to the report.

Cancer claims reimbursement rose to 28% of total stop-loss claims reimbursements in 2015 from 24.3% in 2012, the report showed.

Not only is cancer a prevalent condition, but new cancer treatment and high-cost medications are driving costs, said Lisa Hundertmark, Wellesley, Massachusetts-based senior manager of claims services and clinical resources for Sun Life.

“Advancements in medication used as well as treatments such as transplantation are adding to the cost that it takes to take care of somebody with cancer,” Ms. Hundertmark said. Plus, “a good majority of (cancers) will require things outside of just medications. It can be surgeries, radiation therapies, transplantations,” and drugs to boost patients' immune systems, she said.

The report also showed that 45% of the 20 highest cost intravenous medications in 2015 were used to treat cancer. The top 20 intravenous medications represented $54.5 million, or 7.6%, of total stop-loss claims reimbursements, Sun Life said.

The costliest medical conditions covered by Sun Life stop-loss insurance also included chronic and end-stage renal disease at No. 3, followed by congenital abnormalities, premature births, transplants, congestive heart failure, cerebrovascular disease, pulmonary collapse or respiratory failure, and septicemia.

Transplants were the sixth highest-cost condition during the four-year period, up from No. 11 in Sun Life's previous survey, which looked at the costliest conditions between 2011 and 2014. Transplants, including kidney, liver, lung, bone marrow and stem cell, represented $62.2 million in stop-loss claims payments between 2012 and 2015, or 2.7% of the total reimbursements.

The average charge for a transplant during the four-year period was more than $253,000, according to the report.

“We're utilizing transplants for different diagnoses than we have in the past,” which is increasing the claim reimbursements, Ms. Hundertmark said. Transplants, once reserved for treating leukemia and lymphoma, are now being used to treat conditions like sickle cell, multiple sclerosis, and other types of cancers, like brain cancer, she said.

The report also showed that the number of claims exceeding $1 million jumped 25% during the 2012-2015 period, compared with the 2011-2014 period. The increase was driven by higher prevalence of cancers, transplants and kidney disease, Sun Life said.

Though just 2% of stop-loss claimants hit the million-dollar reimbursement mark, those claimants account for 18.5% of total stop-loss claims reimbursements, according to Sun Life.

Sun Life stop-loss insurance covers 1,979 policyholders representing 5.2 million individuals.