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Innovating for Value: Leaders Share Insights from their Experiences in Value-Based Care

We would like to extend our deep appreciation to the executives who participated in the

interviews, for sharing your knowledge, insights and experiences with us and your peers.

Participants can be found at the end of this paper.

Authors: Cindy Lee, Greg Maddrey, Giselle D’Agostino

White Paper Title

Innovating for Value:Leaders Share Insights from their Experiences in

Value-Based Care

In this time of regulatory uncertainty, leading healthcare providers are

continuing to transform their organizations and pursue value-based payment

models because they believe healthcare is too expensive. These providers are

disrupting themselves by creating new care and operating models to meet the

tenets of affordability and accessibility.

This paper shares real-life lessons and insights from leaders across nearly 20

such organizations pursuing value-based care.

We interviewed more than 30 executives from 19 innovative provider organizations to understand their

experiences in value-based care. Represented organizations include academic health systems, integrated delivery

networks, community hospitals and large multi-specialty groups. All have participated in at least one Centers for

Medicare and Medicaid Services (CMS) accountable care organization (ACO) model – including Pioneer, Medicare

Shared Savings Program (MSSP) and NextGen ACO programs – and a couple of these organizations were very

early adopters, initiating their journey in clinical integration ahead of these CMS initiatives.

The size of the Medicare populations under management today for these organizations ranges from 12,000 to

150,000 lives, with shared savings distributions exceeding $30 million. Many of these organizations are also

managing commercial lives in an upside only or upside/downside risk sharing arrangement, and several have scaled

to more than 500,000 total lives within value-based models.

Defi nition of Value:

We use the terms value and

value-based care in a broad

sense, to apply to a range

of models from upside-only

shared savings to bundles

all the way to full risk.


Page 2

Motivations for Pursuing Value-Based Care

From our conversations, two themes emerged as the primary motivators for pursuing value-based care:

1. It is the right thing to do. Some organizations are driven by a deep-seated philosophical perspective that alternative payment models are in

fact how healthcare should be fi nanced – i.e., providers should be paid for managing care/health, rather than on a

transactional basis. These organizations tend to believe that providers must pursue value-based payment models

with the perspective of burning the “fee for service boats” to enable innovation and not be hampered by old world

economics. This is not to say they expect to move fully to a capitated or risk based payment; but rather, that the

payment model should not create disincentives for providing care in the lowest cost care setting appropriate.

These organizations often cited a very strong leader who has spearheaded the charge toward this goal, enabling

the organization to make some “big bets” in infrastructure (e.g., care management, primary care, analytics/

infrastructure). Generally, these organizations believe healthcare has become too expensive and that providers are

in the best position to right the ship.

2. There is a business opportunity.Some organizations are pursuing alternative payment models because they see a strategic opportunity to secure and

grow their market position and fi nancial future. For example, several providers used Medicare ACO programs as a

way to create greater integration with independent primary care physicians. Others that were relatively low cost in

their markets saw an opportunity to secure savings from total cost of care contracts with commercial managed care

organizations, given many of these contracts establish targets using a blend of market and actual provider historical

cost trends. These organizations appear to be taking a more tempered and deliberate approach to infrastructure

investments and scaling lives with the intent to maintain a balanced portfolio of payment models.

Most of those interviewed specifi cally elected to participate in a CMS ACO program as a “test case” to acquire access to

longitudinal claims data, build value-based clinical capabilities and related infrastructure and gain relevant experiences.

While these organizations hoped to earn some shared savings, many did not have specifi c fi nancial expectations when

entering into the program (excepting those that pursued NextGen).


Evaluating Impact and Investment Return and the Role of ScaleEven with a clear motivation and specific strategy to move to value, many

leaders reflected that the actual pursuit of value-based care is challenging

because it requires a deliberate decision every day to operate differently,

typically in the absence of immediate feedback or results. In other efforts that

provider systems pursue (e.g., strategic growth, operational efficiencies) the

leading indicators are clear. For value-based care, however, the feedback loop

is more akin to research and development where the experiment and expected

results are continuously tweaked, and at times scrapped and reinitiated, to

make progress.

The goal of value-based care models is theoretically straightforward: to identify the factors (clinical conditions, utilization

patterns, social/environmental factors) that contribute to utilization of high cost items (e.g., hospitalizations, emergency

rooms) that could be avoided through behavioral modification of the provider and/or beneficiary/member. The challenge

in executing against that goal is multifold. Designing, deploying and evaluating the impact to shape the right intervention

is incredibly difficult: what should the intervention be and for whom, and when, how and how frequently should

the intervention be applied. Data delays prove for many providers a perennial challenge to evaluating impact. More

fundamentally, isolating the contributors to reductions in utilization is particularly elusive given the number of variables

that are being moved at the same time, plus the added noise of how to factor in the consideration for a natural regression to

the mean that would have caused a reduction in utilization even with no intervention. There are many predictive algorithms,

both home grown and commercially available, that attempt to assist in this effort. However, the efficacy of each is highly

debated and even for those where there is agreement, the algorithm only accomplishes half the equation of identifying which

members/patients may require an intervention but not what intervention will be most effective and in what context.

With this level of complexity, many organizations shared their desire for scale to attain a sufficient base of lives on which to

“practice” to refine the analytic and clinical models. Yet the investments required to venture into value- based care models

are sizeable, creating the proverbial chicken-egg conundrum of how much to invest ahead of returns. Leaders also cited

questions of how to measure returns given some investments, such as care management, may benefit the organization

more broadly - while other infrastructure investments may be considered foundational. With the challenges of containing

and evaluating those value-based care-specific investments and associated returns, versus others without as clear of a

delineation, some organizations said pursuing value-based care has to be an intentional shift in the enterprise’s overall

strategy, in particular for more commodity services. In doing so, an organization can think a bit more freely about the

investment requirements akin to other capital investments.

Leaders also generally believed scale in the number lives under management to be important due to the transformational

change that is required in clinical practice to succeed in value-based models. For example, they noted that a meaningful

portion of a given physician’s practice must be impacted to garner the requisite attention to shift practice patterns. In

addition, a large base of ‘like’ populations (i.e., commercial, Medicare, Medicaid) enables economies of experience across

practices to understand which interventions were effective. And finally, a larger population base helps support technology

and resource investment requirements.

... the actual pursuit

of value-based care is

challenging because it

requires a deliberate

decision every day to

operate differently.


Innovating Care Through Myriad ModelsEven with the complexities of assessing the true effectiveness of any new care model, some organizations have developed

a model of care that they believe is effective and scalable across their enterprise. We have profiled four such models below.

While highly variant in design, each entity has demonstrated efficacy through medical spend reductions and the ability

to scale across its organization. These examples reinforce that there is no one answer for how care models should be

structured to succeed in value, but rather, should be a function of each organization’s culture, network structure including

physician organization and to some degree, ability to invest.

Integrated Academic Model: An Academic Health System (AHS) built a Center for Population Health to coordinate a variety of programs and

resources to support the movement to value, spanning support for primary care practice redesign, integrated

care management for complex patients, post-acute care (PAC) coordination, home-based care and patient

engagement tools. This organization recently conducted a study to understand the efficacy of their integrated

care management program by comparing members who qualified for and participated in the program against a

cohort that qualified but did not participate due to lack of capacity.

ResultsThe study found that beneficiaries who participated in the care management program experienced a reduction in

emergency department (ED) visits by 6 percent, hospitalizations by 8 percent and Medicare spend by 6 percent.

The study also found that the longer a member was in the care management program, the better the results. At

program initiation, the care manager assesses the beneficiary to design the appropriate care program, and on an

ad hoc basis seeks to provide patients with alternate ways to interact with their providers and encourages the use

of lower acuity sites when appropriate.

This program has been expanded across this AHS’s community partners and found to be equally successful. As a

next step, the Center is expanding to work with clinical departments to improve access to specialty care and co-

design condition specific population health care paths.

-6%

Em

ergency Department Visits

-8%

Hospitalizations

-6%

Medicare Spend


Decentralized Model: A large Integrated Delivery System (IDS) with primarily an employed physician base has developed a care

management model that uses an interdisciplinary team of nurse practitioners (NPs) and nurses working closely

with the physician to manage complex chronic patients. This system has also invested heavily in virtual health and

is leveraging this technology, that started as an eICU/telestroke system, to interact with patients in their home on

a weekly basis. The patients under management in this program represent the top 1 percent of spend, with 5-10

hospitalizations per year and high ED utilization.

ResultsThrough this program, inpatient utilization for this population cohort has declined by 50 percent, resulting in

savings of 30 percent, net of investments. In addition to these more financially-oriented outcomes, patients

report improvements in quality of life. This model is being expanded to manage congestive heart failure (CHF) and

pneumonia patients at home for the last couple days of the historical hospital stay.

Centralized Model: A community health system with a mixed model of independent and employed physicians created a centralized care

management model where a team of nurses, social workers, care guides and pharmacists engage with chronic patients.

Roles and responsibilities of each of the care team members are very clearly defined along with the clinical pathways.

ResultsThis team is working with the highest risk Medicare and Commercial patients under management and has realized

a 2 percent reduction in total cost of care through this program. This system has designed their care management

program as a “catch and release” model where patients are in the program for 90 days.

Hybrid Model: A large physician group has implemented a hybrid model with a central call center coupled with bedside discharge

planning to assist with scheduling follow up appointments, coordinating home health and other durable medical

equipment (DME) needs and assisting with medication fulfillment. These care managers work collaboratively with

the hospital-based care managers or assume full responsibility for the assigned members. Given the complex needs

of this subset of patients, these care managers have a more longitudinal perspective for the patient’s care needs

and better connectivity to the primary care office. In addition, care managers in a central call center are assigned to

pods by physician office and conduct outreach to the patient as a member of the physician’s office.

ResultsAlthough telephonic, they have achieved a high patient engagement rate. These care managers have access to the

patient’s medical record and document directly in the EMR to reinforce a seamless care experience for the patient.


Foundational Elements Supporting Value-Based Innovation Leaders also shared their focus on continuous innovation to their care models, with iteration on their program design to

more efficiently drive results. Many organizations noted that the following five dimensions are foundational elements to

value-based care, even if the direct cause-effect link to quality/cost is not fully demonstrable.

Post-Acute CareMore and more, health systems are viewing PAC providers as an extension of themselves

and their brand, and are developing preferred relationships with select PAC providers

based on criteria such as average length of stay in the given PAC setting, clinical outcomes,

patient experience and ability to report select data elements. Some health systems have

taken this a step further to create even tighter integration with select PAC providers

by extending their EMRs and care paths into the PAC providers’ workflows, and at

times assigning physicians or NPs to serve as medical directors or rotate through these

settings. In a handful of instances, health systems have also formed joint ventures with

rehabilitation facilities and home health agencies. Improvements in the PAC setting also

have the added benefit of improving the total cost of care while not hurting the health

system’s financials.

Virtual HealthMost providers interviewed have invested in some form of virtual health, although the

uses and breadth of offerings varies widely. Most are using virtual health, at a minimum,

to handle a series of very low acuity, urgent care needs. Others have expanded this

capability to include telehealth functionality to connect with other providers for remote

monitoring of eICUs, distant care for screenings and post-op follow up care and e-consults.

Some providers are beginning to expand virtual health to engage with patients for care

management needs while others have been reluctant to invest in virtual health due to the

payment rules in their state that do not allow for reimbursement of these visits.

Claims and Financial AnalyticsAccess to claims data has enabled providers to gain insights in two areas – 1) a longitudinal

understanding of an individual’s clinical experience including utilization patterns across

all providers and care settings; and 2) a more comprehensive picture of each individual’s

risk. Both elements are critical to not only designing the most appropriate care plan

and interventions for each beneficiary, but also understanding common themes across

larger data sets to refine predictive algorithms. In addition, these data enable providers

to understand the potential financial exposure that they are assuming under risk-based

contracts. To fully process, understand and leverage these data, providers have invested in

specialized resources – e.g., data scientists, actuaries, claims analysts – by building these

capabilities and/or through vendor relationships.

1

2

3


“Population Health” Analytics/InformaticsAlthough the perspective regarding the breadth and depth of analytics and informatics

capabilities required to support value-based care is still evolving, most providers

interviewed agreed that an enterprise data warehouse or similar mechanism is required

to collect and analyze disparate data sources. In addition, they generally noted that

registries, algorithms to predict risk, care management workflow tools and automated

reporting capabilities are all critically important. Some have chosen to build these

capabilities in house, whereas others have decided to outsource these solutions through

various vendor relationships. Many admit that there is some trial-and-error with finding

the right vendor even when the best selection process and interdisciplinary team is

assembled upfront given the immaturity in this space. Regardless of the approach, most

leaders agreed that this is likely the largest area of investment to date as well as to come

in future years.

Physician EngagementEvery organization interviewed stressed that broad physician engagement is critical in

governance/oversight roles as well as direct leadership roles. Many organizations said

physicians should be engaged in the program design across both clinical and business

dimensions to instill a greater sense of ownership. Furthermore, most cited the critical

role of primary care providers to actively managing the patient’s care and maintaining

care in network as much as possible to enable more seamless and real-time exchange

of clinical data across the continuum. In addition, organizations cited the importance of

sharing data and reports in a transparent manner to drive results, with some sharing data

unmasked so that physicians know everyone’s relative performance within their group.

Beyond these five key dimensions, leaders also identified several additional areas for exploration, including:

• Incorporating environmental/social factors such as availability of transport, medications and support at home,

as well as behavioral health elements into predictive algorithms.

• Developing palliative care clinical models including those specific to end of life care.

• Further engaging specialists in developing population health oriented care paths.

• Incorporating behavioral health interventions into the care delivery model.

• Continuing to refine the financial models for measuring the effectiveness of these care management models.

4

5


Structuring and Developing Value-Based Organizations and Capabilities Most organizations began their foray into value-based care as a side business, with related investments viewed as start-

up funds, distinct from their core fee-for-service (FFS)-based enterprise. As upfront funding to support infrastructure

development is declining, such as per member per month (PMPM) care management fees, some are questioning how they

will continue to fund this infrastructure. Meanwhile, most providers continue to operate in a mixed economic model with

uncertainty on when or how much they ultimately will shift to value – bringing to the fore the question of how and when to

incorporate this ‘start up’ into the ‘core business.’

Many of those interviewed noted that a particularly challenging function

to collapse into one structure is care management. Most comprehensively

defi ned, care management encompasses myriad roles: care coordinators,

care managers, social workers, pharmacists, community health workers,

clinical aides and patient educators; and spans all care settings. Even before

the advent of value-based care models, these functions typically resided

under different reporting structures either by function or care setting or

clinical service line, or a combination of these variables – and many continue with a decentralized model. Yet, a handful of

organizations are pulling all of these functions under one umbrella to enable a single line of sight across the organization

and care continuum to improve hand offs and effi ciencies. Some organizations have also pulled related patient-facing

technologies such as patient engagement solutions and virtual health under this same structure, given the implications to the

care processes and the care model of deploying these technologies.

Other new functions such as claims/fi nancial analytics, management of predictive algorithms and physician performance

monitoring, and value-based contracting, have not been incorporated into the population health organizational structure

for most entities. Given the highly technical capabilities that are required to perform these functions, most organizations

feel it is better to develop and maintain these resources within the technology/informatics and contracting departments

respectively, with matrixed reporting into the population health leaders.

Several organizations noted challenges with how to structure and develop fi nancial management capabilities and approaches

specifi c to value-based care – whether housed within the core fi nance function or not. Many are challenged by budgeting

around value-based models and still drive value-based payment models through a fee-for-service revenue model, with

reconciliations at year end that are paid in the form of incentives, creating some dissonance day-to-day and creating a lack of

awareness of the distinct differences in value-based care relative to a fee-for-service model. Only a handful of organizations

have incorporated quality and utilization measures into base compensation models rather than as separate payments.

... a particularly challenging

function to collapse into

one structure is care

management.

Several organizations noted challenges with how to structure and develop fi nancial management capabilities and approaches


Page 8


around value-based models and still drive value-based payment models through a fee-for-service revenue model, with

reconciliations at year end that are paid in the form of incentives, creating some dissonance day-to-day and creating a lack of

awareness of the distinct differences in value-based care relative to a fee-for-service model. Only a handful of organizations

have incorporated quality and utilization measures into base compensation models rather than as separate payments.


Page 9

There was a fair amount of diversity in how each organization had chosen to structure and organize its physicians.

Yet given the importance of physician alignment, defi ning how to functionally stay connected to physicians required

organizations to take a purposeful approach to physician alignment, including a deliberate resourcing to this realm.

Advancing Physician Relationship Management:A large integrated delivery system with a large aligned physician base created a new department of physician

relationship managers called a “fi eld operations advisory team.” The team is comprised of young, early career,

business-minded individuals that meet with primary care providers monthly to review reports, provide feedback

on performance and create a playbook for success. These advisors also communicate any feedback that these

physicians may have related to the hospitals or the overall operations of the clinically integrated network. This

team meets as a group for a full day retreat one day per month to share common learnings and plan for the

following month, and for the rest of the month are in the fi eld.

ResultsThis is the third year of this program and the program made a signifi cant

impact to overall performance, driving nearly 100% compliance. The

program has also helped physicians feel more empowered in using data

to affect their cost and quality and feel they have a personal connection

to the network and IDS through these advisors.

... the program made

a signifi cant impact to

overall performance,

driving nearly 100%

compliance.


Key Insights to Guide Value-Based PursuitsOur conversations reaffi rmed that there is not a clear, singular path for succeeding under value-based payment models. Yet

across these interviews, some key advice and lessons learned emerged that can serve as guidance for other providers in their

pursuit of value-based care and payment models.

Exercise Disruptive InnovationHealthcare providers must be willing to disrupt themselves in meaningful ways to forge a new path forward. Innovating new

models of care will require investments in infrastructure (e.g., analytics, virtual care, ambulatory network) and a different

framework for considering profi tability by service that seeks to provide care in the lower cost care setting. While providers

should carefully evaluate these investments, they need to look beyond tying the fi nancial equation solely to value-based

lives, to how this change will position them for the future across all business lines.

Engage a Multitude of StakeholdersMost organizations have chosen a physician-administrative dyad or single physician leader to drive their value-based agenda

while also encouraging broad participation in solution development across different physician cohorts as well as across

various verticals within the organization. Cross-functional collaboration across fi nance, IT and clinical functions will yield the

best results and garner buy in and ownership from the outset.

Don’t Underestimate the Importance of Attaining ScaleNot only is attaining scale in the number of lives managed important from an actuarial risk perspective, but also to warrant

suffi cient organizational and individual attention to drive change. The transition to value is hard and requires a lot of time;

practice and experience appear to be the only consistent keys to success. If the lives under management only represent

a tiny fraction of the current business, garnering the requisite attention of physicians, advanced practice providers and

administrators will be even harder given the number of competing priorities. In addition, to understand which innovations

are truly working versus “luck” will require economies of scale in experience and knowledge. And fi nally, the infrastructure

investment (i.e., analytics, technology, care models, personnel) required to support the transition to value is material; being

able to scale these costs across a broad population will help support the investment.

Be Willing to Admit Mistakes and Try AgainCreating a new business model that focuses on disease management and disease prevention, and is able to accurately predict

and appropriately deliver care within a fi xed budget, is materially different from how healthcare is delivered today. Executive

leadership in particular must understand that some trial and error will be required before landing on an effective model.

The most important contribution executive leadership can make is committing to iteration. Instead of punishing individuals

for efforts that do not yield desired results, leadership should welcome and reward experimentation as part of a continuous

development cycle.


Advocate Health CareLee Sacks, MD, Executive Vice President and Chief Medical Offi cer, Advocate Health Care

Chief Executive Offi cer, Advocate Physician Partners

Allina Health Rodney Christensen, MD, Vice President Medical Operations, Allina Integrated Medical Network

Brian Rice, Vice President Medical Operations, Allina Integrated Medical Network

Robert Wieland, MD, Chief Strategy Offi cer

Beacon Health System Diane Maas, Chief Planning & Business Development Offi cer

Carilion Clinic Michael Jeremiah, MD, FAAFP, Senior Medical Director of Population Health

Donna Littlepage, Senior Vice President, Accountable Care Strategies

CentraCare David Tilstra, MD, CPE, President, CentraCare Clinic

Cleveland Clinic Michael Modic, MD, Chief Clinical Transformation Offi cer

Kevin Sears, Executive Director, Market and Network Services

Detroit Medical Center William Restum, PhD, Chief Executive Offi cer, Rehabilitation Institute of Michigan

Senior Vice President, Detroit Medical Center

Dignity HealthKeith Frey, MD, MBA, Chief Physician Executive, Dignity Health Arizona

President, Dignity Health Medical Group in Arizona

Duke Health Devdutta Sangvai, MD, MBA, Executive Director for Duke Connected Care

Associate Chief Medical Offi cer for Duke University Health System

Medical Director, DukeWELL

Hackensack Meridian HealthPatrick Young, President of Population Health

We’d like to thank…


Hill Physicians David Joyner, Chief Executive Offi cer

KentuckyOne Health Don Lovasz, President and Chief Executive Offi cer

Brian Christopher, Vice President, Administration

Amy O’Connell, NP, Vice President, Clinical Services

Mary Washington Healthcare Travis Turner, Senior Vice President, Clinical Integration

Meritus HealthKathy Lewis, DHSc, MS, RN, Director of Clinical and Service Excellence

Joseph Ross, President and Chief Executive Offi cer

MercyShannon Sock, Executive Vice President, Strategy, Chief Financial Offi cer

Northwestern MedicineHannah Alphs Jackson, MD, MHSA, Director, Value-Based Care, Northwestern Memorial

HealthCare

Gary Wainer, DO, Medical Director, Northwestern Medicine Physician Partners

Brian Walsh, Vice President, Managed Care, Northwestern Memorial HealthCare

Partners HealthCare Shelly Anderson, Senior Vice President, Strategy and Operations, Brigham Health

Jessica Dudley, Chief Medical Offi cer, Brigham and Women’s Physicians Organization

Vice President of Care Innovation, Brigham Health

Kelly Fanning, Executive Director for Care Innovation and Population Health, Brigham and

Women’s Physicians Organization

ProMedica Dee Ann Bialecki-Haase, MD, MBA, CPE, Vice President Medical Operations, ProMedica Physicians

President, ProMedica Health Network

Jered Wilson, Vice President, Managed Care

VirtuaAl Campanella, Executive Vice President and Chief Operating Offi cer

Steve Kolesk, MD, Senior Vice President, Clinical Integration

We’d like to thank…


About the Authors

Cindy Lee

Director and Value-Based

Care Practice Leader

415.254.7743

[email protected]

Cindy Lee is a Director with The Chartis Group and leader of the

Value-Based Care practice. Ms. Lee has advised some of the nation’s

preeminent academic medical centers, children’s hospitals and

integrated delivery systems for more than 18 years. She focuses

on developing organizational strategies to support value-based

payment models such as go-to-market strategies and population

health infrastructure development across multiparty ventures

and single system networks. Ms. Lee has authored and been

featured in numerous articles and webcasts including: “Leading the

Conversation: New Channels for Provider Contracting”; “Consortium

Model Networks: Evaluating the Potential of Collaboration”; “Points

to Consider: The Next Generation ACO”; and “Delivering Value

through Post-Acute Care.”

Greg Maddrey

Director and Senior

Vice President, Strategic

Growth

952.250.0529

[email protected]

Greg Maddrey is a Director with The Chartis Group who brings more

than 18 years of management consulting and healthcare executive

experience to the firm. Mr. Maddrey has advised some of the

nation’s pre-eminent academic medical centers, schools of medicine,

integrated delivery systems and hospitals. He has led consulting

engagements in the areas of: enterprise strategic planning, service

line planning, organizational alignment, economic alignment (funds

flow), practice plan governance, operations improvement and value-

based care. Mr. Maddrey also brings to the firm extensive payor

experience having managed several health plans.

Giselle D’Agostino

Strategy Practice Area

Specialist

617.216.6566

[email protected]

Giselle D’Agostino is a Strategy Practice Area Specialist with The

Chartis Group. Ms. D’Agostino has 15 years of healthcare consulting,

administration and project management experience, working with

academic medical centers, biotechnology and pharmaceutical

companies and health IT providers. At The Chartis Group, Ms.

D’Agostino’s consulting experience includes advising academic and

community health systems in the areas of strategic planning, service

line planning and economic alignment.

Boston | Chicago | Minneapolis | New York | San Francisco

© 2017 The Chartis Group, LLC. All rights reserved. This content draws on the research and experience of Chartis consultants

and other sources. It is for general information purposes only and should not be used as a substitute for consultation with

professional advisors.

About The Chartis Group

The Chartis Group® (Chartis) provides comprehensive advisory services and analytics to the healthcare industry. With

an unparalleled depth of expertise in strategic planning, performance excellence, informatics and technology, and health

analytics, Chartis helps leading academic medical centers, integrated delivery networks, children’s hospitals and healthcare

service organizations achieve transformative results. Chartis has offices in Boston, Chicago, New York, Minneapolis and

San Francisco. For more information, visit www.chartis.com.

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