Sun Life 11th annual High Cost Claims Report: Insights and strategies to help you lower your risk of the top serious conditions

Sun Life publishes an annual research report focused on the highest cost health insurance claims. The data in the report is drawn from Sun Life’s stop loss claims, a type of insurance employers who self-fund their health insurance plan purchase to protect against the financial impact of very high cost health insurance claims. This year’s report included data from over 55,000 members, $5.5 billion in reimbursements, and over $12 billion in total cost over the past 4 years.

 Dr. Miles Varn, Sun Life VP, Chief Medical Officer, and Head of PinnacleCare, shared his insights about the latest report and what steps you can take to lower your risk of developing the serious health issues covered in the report.

 PinnacleCare (PC): If you look at five year trends, this is the first year where cardiovascular conditions moved ahead of blood cancers. What do you think may be driving this change?

Dr. Miles Varn (MV): There’s strong evidence from a recent, carefully designed study by the Veteran’s Administration that the increase in cardiovascular issues, including heart attack, heart failure, and arrhythmia, is a side effect of COVID infection. Researchers looked at a cohort that wasn’t infected with COVID and a cohort that had COVID infection. Those who were infected had a substantially higher risk for heart attack, heart failure, and arrhythmia for at least a year post-infection. The increased risk not only affected people with prior cardiac conditions, but even those who never had a cardiac risk pre-COVID infection were at about a 30% higher risk of a cardiovascular event post-infection. The study’s limitations are that participants were primarily male and older, but the data is still eye-opening.

PC: Do you think deferred care also is playing a part?

MV: I think it’s primarily post-COVID risks, but deferred and delayed care probably are accelerating or adding to the incidence and prevalence of cardiovascular disease.

PC: The cost of drugs that are administered in a clinical setting like a hospital is significantly higher than when the same drugs are administered at home or on an outpatient basis. Why is that?

MV: Health systems mark up the cost of administering the drug, so they charge a much higher fee. Patients who are prescribed injectable medications can potentially lower their out-of-pocket costs by asking their doctor if there’s an option to receive the medication as an outpatient or at home.

PC: What factors have the potential to increase the amount of time you spend in the hospital and the cost of your care?

MV: Comorbidities (other diseases or health problems) can have a negative impact on the length of your hospital stay. When someone has multiple health problems, there’s an increased risk of complications and a slower pace of healing. For example, if you’re healthy person and are hospitalized with pneumonia, you’re likely to do better than someone with heart disease, diabetes, or chronic kidney disease, because those conditions weaken your immune system and have a negative impact on your heart, lungs, kidneys, and other organs.

PC: Another topic addressed in the report is healthcare access. What factors are making it more difficult for people to access the care they need?

MV: There are several components contributing to this issue. One is a shortage of providers and the other is the fact that costs for healthcare staff have gone up dramatically, making it difficult for some health systems, especially small systems and ones in rural areas, to hire the people they need or even to continue to operate. As hospitals are forced to close, that puts additional strain on the remaining hospitals.

In the northern U.S., there are staffing shortages in a wide range of specialties, from nursing to anesthesia. In the southern U.S., an increase in population that’s larger than what was predicted means there’s increased demand for care. But health systems didn’t build for this swell in population, so there are not enough hospital beds and clinic space to serve all the patients.

Unfortunately, the issue is likely to get worse because Baby Boomer-age physicians are retiring, but since there has been no increase in the number of residency spots in the U.S., retiring physicians aren’t being replaced quickly enough. We’ve covered the increased demand for physicians with immigration in the past, but that’s been cut off during COVID and because the number of green cards available for skilled workers are limited.

PC: Looking at the top conditions in the Sun Life report, what steps do you recommend that people take to manage their risk for serious health conditions?

MV: In terms of cancer, get the recommended screenings at the recommended intervals so you can focus on early detection, because many types of cancer can be more effectively managed when diagnosed earlier. There are also lifestyle changes that can positively impact your health and lower your risk for a wide range of conditions including heart disease and cancer. Those changes include eating a healthy diet, getting regular exercise, reducing stress, and getting an adequate amount of good quality sleep.

PC: If you are diagnosed with a serious condition, especially some of the more complex ones, what steps should you take when seeking care?

MV: You want to be treated in a medical center that treats a high volume of patients with your condition and is a leader in the treatment of the condition in terms of having the latest treatment approaches, fellowship trained physicians, and access to clinical trials of new treatments. If you’re diagnosed with a complex condition, seek a second opinion from a specialist with significant experience treating the condition. All these steps can help ensure you’re receiving an accurate diagnosis and the most appropriate treatment plan.