Our Take
Gene therapies and specialty drugs are real cost drivers, but the real story is comorbidity: employers funding siloed disease treatment when the math favors whole-person care.
Why it matters
Self-funded employers are seeing their largest claims double down on preventable conditions. Obesity and diabetes are the root risk factor for cancer, MSK, and cardiovascular disease—three of the four highest-cost diagnoses. The window to act on prevention is closing faster than claims are rising.
Do this week
Finance, HR, and Medical: map your top 20 highest-cost claimants by comorbidity profile (obesity + diabetes + cancer, for example) before Q1 budgeting closes so you can pilot integrated MSK and diabetes management in that cohort.
Expensive claims are rising fast and clustering around preventable conditions
Million-dollar-plus health claims increased in frequency by 46% from 2022 to 2026, according to Sun Life U.S.'s High-Cost Claims and Injectable Drug Trends report, which analyzed more than 70,000 high-dollar claims from self-funding employers (company-reported). Three drivers dominate: secondary (comorbid) conditions, long inpatient hospitalizations, and injectable drugs.
The most expensive single treatment is Elevidys, a gene therapy for Duchenne muscular dystrophy, averaging $3.6 million per patient. Blood cancers carry the highest multimillion-dollar claim burden, with an average of $5.45 million in 2025; one leukemia patient's claims reached nearly $8 million.
But the composition of high-cost claims has shifted. Orthopedic and musculoskeletal (MSK) conditions have only recently joined cancer and premature birth as top drivers of $3-million-plus claims, suggesting both rising severity and new therapeutic options. Liver disease spending grew 43% in 2025 alone, with an average per-patient cost of $230,000.
Comorbidities are the structural problem your siloed coverage ignores
The Sun Life analysis identifies strong connections between three high-cost condition clusters: cancer paired with cardiovascular disease and chronic kidney disease; and orthopedic/MSK conditions paired with the same trio. The shared risk factors are consistent: age, obesity, diabetes, and inflammation.
This is not new pathology. It is the expected outcome of untreated metabolic disease. Yet most employer health plans treat cancer, cardiovascular disease, MSK, and kidney disease as separate conditions requiring separate specialists, separate authorization workflows, and separate cost centers. The claim data suggests this approach is failing.
A secondary finding matters equally: orthopedic/MSK conditions and cancer are now the most frequent drivers of both high-dollar medical claims and short-term disability claims. That means the same preventable conditions are cascading into lost productivity alongside medical spend.
Employers have one lever that works: GLP-1 access. Obesity and diabetes are the upstream risk factors for the three most expensive claim clusters. Broadening coverage of GLP-1s—and tying them to whole-person care workflows rather than standalone pharmacy benefits—can reduce the incidence of cancer, cardiovascular disease, and MSK severity. The time horizon for preventive payoff is 2 to 4 years. The cost of delayed action is geometric.
Audit your comorbidity mapping before year-end planning
Most employers can identify their top 100 claimants by diagnosis. Few can identify them by comorbidity pattern. Request a comorbidity report from your claims administrator or TPA by December 15. Ask specifically for: members with diabetes plus cancer, members with obesity plus MSK, and members with multiple chronic conditions triggering both medical claims and short-term disability claims in the same plan year.
Use that map to design your 2025 pilot. Don't launch a new disease-management program. Instead, integrate your MSK and diabetes support services—physical therapy, nutrition counseling, metabolic labs—into a single engagement pathway. Measure two outcomes: claim cost per patient in the cohort over 24 months, and disability claim frequency.
If you're not yet offering GLP-1 coverage, or offering it only through narrow pharmacy tiers, treat that as a separate, urgent decision: GLP-1 access at scale (meaning no prior auth, tiered copay, or BMI thresholds) is now a cost-containment lever, not a wellness nice-to-have.