Complex, costly conditions: Having a care team is essential

Complex, costly conditions take an enormous toll on those who have them — and on their family members. The four condition categories — cancer, musculoskeletal issues, cardiac conditions and renal disease — account for $455 billion in annual health care spending.1

Not surprisingly, nearly nine out of 10 employers are concerned about costs related to complex conditions.2 Individuals suffering from these conditions are also concerned about costs, but they’re struggling to understand and manage them after diagnosis.

The health care system is confusing and complicated in general. Adding in a complex condition makes it even harder to navigate. People with complex and chronic conditions tend to have complicated care plans and need help finding and coordinating high-quality care.

Benefits of a care team

Having the right care team in place can help members navigate the overwhelming health care system and feel better supported. Advocacy and care management programs are two big pieces of the team that work together.

Advocacy representatives help employees:

  • Address benefit navigation, including coverage.
  • Get help with a claim.
  • Find the services they need.
  • Find in-network providers.
  • Understand their treatment options.
  • Make the best decisions for them and their families.

Care management (CM) nurses help employees:

  • Understand where they are in the treatment process.
  • Answer any clinical-related questions.
  • Understand the whole picture, including lifestyle changes, diet and stress management.
  • Discuss medications they’re taking.
  • Decide which screenings and monitoring are best for them.
  • Receive support on an ongoing basis.
  • Identify and help close gaps in care.

Regardless of program, advisors and nurses take a compassionate, empathetic approach when helping an employee or their family member. It’s not just about answering questions and explaining services. They truly care about supporting each person on an individual basis. For individuals dealing with a complex, costly condition, that level of support and care is vital.

Achieving the quadruple aim for complex, costly conditions

In order to measure success of advocacy and CM programs, we need to look at the quadruple aim. Cost, quality, employee experience and provider experience all come in to play. Consider the following questions relating to each topic.

Cost: Did the advocacy representative and CM nurse provide education and support that ultimately delivered cost-effective results?

Quality: Was the employee directed to a Center of Excellence (COE), quality provider and/or the best possible evidence-based treatment? Is the employee compliant with their medication and treatment regimen?

Employee experience: Does the employee recommend the provider and/or COE they visited? Did they feel supported by the advocacy rep and CM nurse? Did the advocacy rep and CM nurse make health care easier to understand?

Provider experience: Did the support from the advocacy rep and CM nurse help ensure an efficient and effective appointment with the provider?

Advocacy program success

A recent Optum study, “Ten Years of Health and Well-being at Work,” includes responses from 500 U.S.-based employers related to workplace well-being. This research features a section on advocacy programs.

We learned that today, about 43% of all employers offer advocacy services, with jumbo employers offering 46% and medium employers offering 35%.3

Employers who have contracted with these services are reporting success. In fact, employers rate the following as highly successful areas4:

  • Improved health outcomes: 65%
  • Increased employee productivity: 65%
  • Increased utilization of appropriate benefits and services: 65%
  • Increased employee satisfaction with benefits: 62%
  • Streamlined benefits navigation: 61%
  • Simplified access to services: 58%

Consider an advocacy and care management approach when supporting employees with complex, costly conditions. Visit to learn more.

To learn about other well-being at work topics, including behavioral health, women’s health and complex, costly conditions, download the e-book.


About the author

SerxnerSeth - Full shotSeth Serxner, PhD, MPH
Chief Health Officer, Optum

Seth Serxner, a national expert on behavior change, program design and measurement, brings the breadth of his experience in academia, industry and consulting to his role as chief health officer at Optum.

His versatile skill set ensures processes and outcomes that improve health for clients in all markets. His deep knowledge of behavior change, population health and measurement allows him to visualize and deliver on program innovation.

He is a published author with over 25 years of experience in health and productivity management. He holds a master’s in public health and a doctorate from the University of California, where his research focused on health promotion and disease prevention in social ecology.


Optum. “Complex, costly conditions” white paper. 2019.
Optum. “Ten Years of Health and Well-Being at Work” e-book. 2019.

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