The Art of the Qualified Plan Audit

Posted by Maria T. Hurd, CPA

Much like people who make a wish to be fit with the turkey wishbone after a Thanksgiving feast, many plan sponsors think that their INTENT to be a safe harbor plan is a sufficient defense when they have not met the requirements to be a safe harbor plan. Although Keeping it Simple and Straightforward, as discussed in our previous blog, is one of the goals of a safe harbor plan, achieving safe harbor plan status requires:

1. Adopting a Safe Harbor Plan Document,

2. Contributing one of the pre-approved safe-harbor employer contributions, AND

3.  Sending Annual Safe Harbor Notices to all eligible employees

Each of the above three steps is required, such that compliance with one or two out of the three does not make a plan a safe harbor plan, but many plan sponsors try to use the “best two out of three” argument in their own defense.

For example, let’s say Company A submits incomplete census information to the third-party administrator (TPA) that computes the plan’s discrimination testing. Even if the employer contribution is consistent with a safe harbor formula, if the document is not a safe harbor document and a safe harbor notice has never been distributed, the plan is not a safe harbor plan and is not exempt from discrimination testing.

In certain cases, a plan sponsor can comply with all three of the rules enumerated above and still be subject to compliance testing. For instance, Company B has a safe harbor plan document, distributes a safe harbor notice, and makes a safe harbor employer contribution. Thinking that their plan is covered by the safe harbor protection, Company B makes an additional, class-based, discretionary profit sharing contribution which triggers the requirement for discriminiation testing and the top-heavy minimum contribution rules. Although it is possible to provide additional contributions and still be exempt from the ADP/ACP tests, it is crucial to engage a plan document provider that knows the common pitfalls. For example, safe harbor plans cannot have a two-year eligibility period or a last day of employment requirement.  Highly Compensated Employees cannot receive a rate of match at any level of deferral that is greater than the rate of match received by any Non-Highly Compensated Individual at the same level of deferral. Many of these rules are often overlooked by plan sponsors when their plans offer the opportunity to contribute additional discretionary amounts. If the additional contributions fail to comply with the safe harbor rules, the plan becomes subject to discrimination testing.

Last but not least, safe harbor plans must distribute a timely notice to all eligible employees at least 30 days, but not more than 90 days before the beginning of each plan year. That means the deadline for calendar year plans is Friday, November 29, 2013. If the day after Thanksgiving is a holiday for your company or organization, then the Notice must be distributed by Wednesday, November 27! (Clarification: The deadline is 30 days before January 1 (i.e., December 2) but it would be even better to beat the Holiday vacation and do it before Thanksgiving.) Generally, third-party administrators provide templates to their clients of a compliant safe harbor notice containing all the required disclosures to participants. In certain cases, “Maybe” Notices for Safe Harbor Plans may be more appropriate, as discussed in our previous blog. Although the IRS provides guidance for “Fixing Common Plan Mistakes – Failure to Provide a Safe Harbor 401(k) Plan Notice,” the suggested corrections generally involve making corrective contributions on behalf of employees that were negatively affected by the employer’s failure to distribute the safe harbor notice. Rather than going through the inconvenient and potentially costly process of executing a correction, employers should make sure that they take the steps necessary to BE a safe harbor plan, rather than wishing themselves safe.

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Posted by Maria T. Hurd, CPA

CPA firms that perform employee benefit audits can voluntarily join the American Institute of Certified Public Accountants’ EBPAQC (the Center). By joining the Center, member firms show their commitment to providing quality audit services to their clients. Membership indicates that the firm has complied with three important requirements:

a)     Minimum industry-specific training

b)     Documented industry-specific quality control procedures

c)     Self-monitoring through peer review and internal inspection

The EBPAQC requires the individual signing the audit opinion to have a minimum of 8 hours of Continuing Professional Education (CPE) that is specific to employee benefit plans every three years. For example, at BLS the designated audit shareholder who has firm-wide responsibility for the quality of the firm’s ERISA employee benefit plan audit practice completes all of the AICPA CPE requirements in topics related to retirement plans. She often exceeds the minimum tax and audit CPE hour requirements by attending both the American Society of Pension Professionals and Actuaries National conference and MidAtlantic Conference, and the AICPA National Conference. Additionally, a supervisor who specializes in retirement plan audits also exceeds the EBPAQC industry-specific training requirements by attending the AICPA National EBP conferences and nearly all of the webcasts offered by the Center and the firm’s PrimeGlobal Employee Benefit Plan Audit Group. The other 6 members of the audit department involved with retirement plan audits also exceed the Center’s minimum training requirement through attendance at the Center’s webcasts, self-study, and attendance at the various industry-specific conferences in the MidAtlantic region.

The Quality Control Partner, who is in charge of the firm’s annual internal inspection, ensures that his review includes audits of ERISA employee benefit plans representative of the firm’s practice by considering the number and types of plan audits. In our case, the engagements inspected include 401(k), 403(b), other DC plans, DB plans, health and welfare, multiemployer plans, multiple employer plans, state government plans, limited scope and full scope audits. The internal inspection reports specific to the ERISA engagements are made available to the firm’s peer reviewer. The BLS peer review is conducted by individuals employed by a Center member firm and the peer review report is publicly available on the AICPA’s website.

The selection of a retirement plan auditor is an important fiduciary responsibility. In determining whether a potential auditor’s engagements are consistently performed in accordance with professional standards, as well as regulatory and legal requirements, and that the audit team is appropriately trained, it behooves a plan sponsor to ask not just whether the prospective firm meets the requirements for membership in the EBPAQC, but also how much they exceed those requirements. After all, an auditor that exceeds expectations is the most likely to ensure a positive outcome in the case of an IRS or DOL audit.

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Posted by Maria T. Hurd, CPA

The 2014 plan limits were just released. Below is a chart that outlines the recently announced cost-of-living adjustments affecting retirement plans:

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Posted by Stacey Snyder

Inheriting a retirement account, whether in a qualified plan or an IRA, can lead to complicated decisions regarding the treatment of the account.  There are many different considerations that affect the beneficiary’s options. A spousal beneficiary has two options when it comes to an inherited retirement account: the spouse can either (1) keep the IRA under the deceased spouse’s name with the surviving spouse remaining as the beneficiary, or (2) make an affirmative election to treat the inherited account as his/her own.   The benefits of each option vary, so the beneficiary must choose the option which best fits his/her particular circumstances. A non-spousal beneficiary, however, does not have the option to treat the Inherited IRA as his or hers, but can treat it only as an Inherited IRA.

Spousal Beneficiary Option 1:

The first option a spouse has when inheriting a retirement account is to keep the account under the deceased spouse’s name and remain as the beneficiary. If the inherited account is an employer-sponsored plan account, the spousal beneficiary may choose to roll over the account into a separate IRA.  The terms of the plan may allow the spousal beneficiary to keep the funds in the plan and take lifetime distributions, but many plans require that the funds be distributed from the plan within 5 years following the year of the deceased spouse’s death.  Since the account is still considered to be the deceased spouse’s, contributions may not be made into the retirement account and required minimum distributions (RMD) will be required as they would if the spouse were alive. The RMD will begin when the deceased spouse would have reached the age of 70½ or will continue if they had already started, and may be received in two forms: either under the life expectancy rule or the five-year rule. The life expectancy rule results in an amount received monthly which is calculated using a single life expectancy figure for the surviving spouse’s age, which can be found on a life expectancy chart. The five-year rule requires that all funds in the account must be distributed before December 31 of the fifth year following death, and can be withdrawn at any time and in any amount. The five-year method is only applicable if the RMD has not already started, or in the case of an employer-sponsored plan, the option must be available as a plan feature. Neither form of distribution will be subject to the 10% penalty tax.

Spousal Beneficiary Option 2:

The second option available to spousal beneficiaries is to elect to treat the account as his/her own. The spousal beneficiary can do this by rolling over the account into an existing IRA, qualified plan, annuity plan, tax-sheltered annuity plan, or a governmental plan, or by creating a new IRA account.  Using this option, contributions can be made to increase the balance of the new account that has been set up, and the RMD will be delayed until the spousal beneficiary reaches the age of 70½. In this case, any withdrawals which are made prior to the age of 59½ will be subject to the 10% penalty tax unless they are rolled into another qualified plan within 60 days (or are made pursuant to one of the exceptions to the 10% excise tax). Under this option, the spousal beneficiary can designate a beneficiary and the RMD made under this option will be calculated based on the joint life expectancies of the spousal beneficiary and his or her beneficiary figure which creates a larger disbursement than with the single life expectancy figure.

Inherited IRA:

The inherited IRA is the only option for non-spousal beneficiaries, and is required for a spousal beneficiary if the retirement account passes through a third party before being distributed to the spouse. With an inherited IRA, only a “Trustee-to-Trustee” transfer (Direct Rollover) may be made from an employer-based plan to an IRA created under the name of the deceased with the designated beneficiary (although President Obama has proposed treating nonspousal inherited retirement accounts the same as spousal inherited retirement accounts for rollover purposes). The inherited IRA assets cannot be mixed with non-inherited assets and contributions may not be made. RMDs must be made using the life expectancy rule or the five-year rule, and are not subject to the 10% penalty tax. The life expectancy rule for an inherited IRA uses the single life expectancy figure based on the age of the beneficiary and must begin the year after the death of the original owner, otherwise, the five-year rule will be required. Qualified plans may permit non-spousal beneficiaries to take lifetime distributions from the plan but many require that the funds be distributed under the five year rule.  Qualified plans are required to permit non-spousal beneficiaries to roll over benefits to an inherited IRA.

Comparison Chart:

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Posted by Saaib Uppal, CPA

When entering into a relationship such as marriage, there are immediate changes in one’s life. One of those is, of course, the requirement to consent. Those activities or decisions you pursued in the past while single are no longer exclusively in your hands. A second vote has been added (and depending on the spouse – perhaps a couple of votes!) into each process before it becomes final. Perhaps as a genuine public policy (or maybe to avoid the wrath of angry spouses) the IRS has required spousal consent for some distributions that a participant takes out of an employer-sponsored retirement plan account with a Qualified Joint & Survivor Annuity (QJSA) form of distribution. Generally, this includes defined benefit pension plans and defined contribution plans that have balances that were merged into the plan from an old money purchase pension plan. Some plans that offer annuity products as an investment option also require spousal consent for distributions.

But what if you take a distribution without receiving the required consent? Well, the IRS in Revenue Procedure 2013-12 has provided a couple of options to correct the failure and to “make the other half whole.”

1. The first is a simple “get out of jail free” card in which the spouse gives his or her consent retroactively for the distribution.
2. The second is slightly more complicated. A spouse is provided a benefit that is equal “to the portion of the qualified joint and survivor annuity that would have been payable to the spouse upon the death of the participant had a qualified joint and survivor annuity been provided to the participant under the plan at the annuity starting date for the prior distribution.”
3. Alternatively, the spouse making the claim may elect to receive a single-sum payment equal to the actuarial present value of that survivor annuity benefit described in option #2. Note that if the plan is subject to a restriction on single-sum payments, the plan sponsor must make a contribution to the plan to ensure the plan’s adjusted funding target attainment is not compromised.

It goes without saying (or does it?) that the spouse referred to above is the spouse at the time of the distribution. A participant whose retirement benefit is subject to the QJSA rules must obtain consent for a lump-sum payment, or making their other half whole may end up costing much more than flowers and chocolate.

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Posted by Stacey Snyder

As mentioned in my previous blog, EPCRS: How to Correct Improper Exclusions of Employees from a 401(k) Plan, the IRS implemented and recently revised the Employer Plan Compliance Resolution System (EPCRS), which offers three correction options for plans that incur disqualification failures. An example of a disqualification failure, which will be discussed below, is participant loan failures. Plan failures related to participant loans can be corrected using either Voluntary Correction Program (VCP) or Correction on Audit. Since plan loan failures are not operational failures, they cannot be corrected using the self-correction method. When filing for VCP, Form 8950 Application for Voluntary Correction Program and Form 8951 Compliance Fee for Application for Voluntary Correction Program must be submitted to the IRS. Appendix C, Part II, Schedule 5 must also be submitted to the IRS, on which the plan will disclose information about identified plan loan failures and the applicable correction method they will use.

There are three possible failures related to participant loans, which include:

1. Plan loans in excess of the maximum limit

If a participant loan exceeds the limit set forth by the IRS (currently the lesser of (1) $50,000, reduced by the highest balance of that participant’s outstanding plan loans during the preceding 12 months; or (2) 50% of the participant’s nonforfeitable benefit) a corrective repayment must be made in the amount of the loan that exceeds the maximum allowed limit. If the participant had already begun making repayments on the loan, there are three methods available to make the required correction for the participant loan failure. The first option is to apply the repayments received to the original loan amount that was not in excess of the limit. This would create a corrective repayment equal to original loan excess as well as interest accrued. The second available option would be to apply the payments first to the interest that has accrued on the portion of the loan in excess of the limit and then, used to reduce the principal of the loan amount which was not in excess of the limit. Therefore, the corrective repayment would consist only of the original loan excess, not the interest as in the first option, since it was already reduced by the loan repayment. Lastly, the third option would be to pro rata the repayments against the loan excess and maximum allowable amount of the loan. This creates a corrective repayment of the amount of the loan excess at the date of the correction. After one of the three correction payments has been made, the loan may be re-amortized over the remaining period.

2. Loan terms do not satisfy repayment requirements

The IRS requires that loans must be paid off within 5 years of issuance and payments cannot be any less frequent than on a quarterly basis. If a participant’s loan does not comply with the repayment requirements, the loan must be re-amortized starting from the loan issuance date.

3. Loan defaults due to repayments that are not in accordance with the loan term

The third type of loan failure is created when the participant defaults on loan repayments.  Normally, a defaulted loan is considered a deemed distribution and reported on Form 1099-R. This can be avoided if the plan corrects the defaulted loan and requests relief through the VCP method. In order for the plan to correct the defaulted loan, the participant must either make a lump sum payment equal to the outstanding balance of the loan plus interest accrued, or the loan may be re-amortized over the remaining period of the loan.  This type of plan loan failure cannot be corrected through Audit CAP.

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Posted by Stacey Snyder

You may have asked yourself the title question after hearing ‘QNEC’ or ‘QMAC’ in a discussion related to ADP/ACP testing.

I’ll first start by defining the acronyms mentioned above:

QNECs and QMACs are available corrections when a 401(k) plan fails the required ADP/ACP testing. The ADP/ACP tests limit the disparity in deposits between highly compensated employees (HCE) and non-highly compensated employees (NHCE) within a plan, by comparing the average deferral/contribution percentage of HCEs to the average deferral/contribution percentage of NHCEs. The difference between the two tests is that ADP considers the employee’s deferrals, while ACP focuses on the employer matching contributions. If the plan is deemed to have failed either of these tests, a correction must be made by:

• returning excess deposits to the HCEs, or
• making either a QNEC or a QMAC (sometimes both) to all eligible NHCEs, in order to increase their average percentage deferrals or match in comparison to the HCEs.

QNECs are immediately vested contributions made by the plan sponsor to a participant’s account. QNECs are calculated based on a percentage of the participant’s compensation, which is limited to 5%. An exception, however, is if the plan has implemented a representative contribution rate, which is the lowest percentage of compensation the NHCE can receive from a QNEC. In this case, the maximum percentage of compensation the NHCE can receive cannot exceed two times the representative contribution rate.

QMACs are immediately vested matching contributions made by the plan sponsor, calculated based on a percentage of the employee’s elective deferral. Similar to QNECs, the total amount the NHCE receives from the QMAC cannot exceed: 5% of their compensation, two times the plans’ representative matching rate, or the total amount of the NHCE’s elective deferrals.

Both of these corrective contributions are always 100% vested and follow the same distribution requirements as employee deferrals. The contributions must be made by the last day of the plan year following the ADP/ACP testing failure, and cannot be paid with forfeitures. Generally, QNECs are treated as employee deferrals and are used to satisfy the ADP testing requirements, while QMACs are used to satisfy ACP requirements. However, QNECs may be used to also satisfy the ACP test and QMACs may be used to satisfy the ADP test, as long as the same contributions are not used in both tests.

Still confused? There’s a solution! By implementing a safe harbor plan feature into a 401(k) plan, as explained in K.I.S.S.: Keep It Simple and Straightforward with Safe Harbor Plan Designs | The Art of the Qualified Plan Audit, the plan can avoid ADP/ACP testing altogether, and you will never have to wonder what the heck a QNEC is, ever again!

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Posted by Stacey Snyder

Failing to allow eligible employees to defer in an employee benefit plan can be very costly and result in plan disqualification. However, the IRS issued updates to the Employer Plan Compliance Resolution System (EPCRS) which provides plan sponsors three options for correcting the four types of qualification failures.

Types of Qualification Failures:

1. Plan document failures,
2. Operational failures,
3. Demographic failures, and
4. Employer eligibility failures.

The failure to allow eligible employees to defer in a retirement  plan is considered to be an operational failure since it likely results from a failure to follow plan provisions.

Correction options provided through EPCRS:

1. Self-Correction,
2. Voluntary Correction with Service Approval, and
3. Correction on Audit.

Any of the three options are available for corrections related to operational failures, but self-correction is the only option in which the plan sponsor will not incur a fee. Self-correction can only be used if the failure is corrected by the last day of the second plan year following the year in which the failure occurred.

The correction under EPCRS for a missed deferral opportunity requires a Qualified Non-Elective Contribution (QNEC) be made equaling 50% of the participant’s missed deferral, determined by multiplying the actual deferral percentage (ADP) for the employee’s group in the plan (highly compensated or non-highly compensated) by the employee’s compensation for that year. In the case of a safe harbor plan, the missed deferral is the greater of 3% of compensation or the maximum deferral percentage for which the employer provides a matching contribution rate of 100% or greater. For safe harbor plans with a 3% nonelective contribution, rather than a match, the missed deferral is deemed to be 3% of compensation. In every case, the QNEC, or missed deferral opportunity, equals 50% of the missed deferral.

Also, if the participant would have been eligible to receive an employer matching contribution based on the missed deferral or a safe harbor matching contribution, the employer must make a corrective employer nonelective contribution equal to the entire amount the participant would have received if they had been properly included. In this case, the amount would be 100% of the match attributable to the missed deferral.

If an employee is not provided an opportunity to contribute elective deferrals to a safe harbor § 401(k) plan that uses an automatic contribution arrangement to satisfy the safe harbor requirements of § 401(k)(13), the missed deferral is generally deemed to equal 3% of the employee’s compensation under the plan. If the failure occurs for a plan year or plan years subsequent to the first eligibility year, then the missed deferral for each subsequent plan year is equal to the percentage specified in the plan document.  The computation of the missed deferral in this case replaces the estimate based on the ADP test in a traditional § 401(k) plan, as explained above. The required corrective employer contribution on behalf of the excluded employee is equal to the missed deferral opportunity, 50% of the missed deferral, plus an amount equal to either the matching contribution that would apply to the missed deferral or the nonelective contribution that would have been made on behalf of the employee, whichever applies under the plan.

All corrections mentioned above need to be adjusted for earnings to the date that the correction has been made.

The EPCRS program document includes 10 examples of how to compute a correction for an improperly excluded employee from a plan providing benefits subject to 401(k) and 401(m).

Although self-correction sounds very complicated, it is not difficult once you work through the examples. However, it is costly since QNECs must be funded from the employer’s money, not the employee’s. In every case, identifying eligible employees on a timely basis is the best alternative.

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Posted by Maria T. Hurd, CPA

Many of our retirement plan clients who receive a letter from the IRS indicating their plan is the lucky winner of the “You’ve Been Selected” contest, scratch their heads in disbelief when they see the dates on the first item in the information request letter, which requests:

• Good Faith Amendments for the automatic rollover provisions for distributions after March 28, 2005. These involuntary cash-out, or IRC 401(a)(31)(B) amendments, had to be executed by December 31, 2005.
• The Final 401(k) Regulations adopted by the end of the first plan year beginning after December 31, 2005.
• The Final Section 415 Regulations adopted by the due date of the employer’s income tax return for the year beginning after June 30, 2007.
• Any other amendments applicable to the plan needed to make the plan qualified as of January 1, 2013.

In almost every case, clients ask why the Statute of Limitations doesn’t seem to apply to their plan.

Although it is true that plan disqualification and the IRS’s ability to impose a tax is effective only for taxable years for which the statute of limitations has not expired, the IRS uses the “tainted assets” theory to validate the expectation for plans to maintain their old documents for an eternity.

In a nutshell, the sponsor’s failure to amend the plan document for a new law in a timely fashion is a document failure that may have taken place in a closed year based on the statute of limitations, but it caused the assets in the disqualified plan to be tainted in the current year. As such, the IRS can impose a tax on the current year for a document failure that took place a long time ago, in many cases as a result of actions a plan official who is no longer employed by the plan sponsor or bad advice from a service provider that has since been replaced.

The IRS recently has won a court case successfully disqualifying a plan retroactively to its inception in the 1980s. In this case, the plan sponsor thought they had rectified their problem when they amended the plan in 2008 for the final 401(k) and 401(m) regulations that had to be adopted by December 31, 2006. The plan sponsor thought that the IRS would be precluded from disqualifying the pre-2008 years because the statute of limitations had expired. The IRS conceded that it could not impose any sanctions for closed years because of the statute of limitations, but asserted that the plan was nevertheless disqualified in 2006 and 2007, and that as long as the tainted pre-2008 assets remained in the plan, the plan remained disqualified. Accordingly, the IRS can disqualify the plan and impose sanctions for the past three years if it can establish that the plan still holds tainted assets.

The IRS does not want to make decisions that would impact the participants negatively. If the IRS discovers a plan document failure on examination, the plan generally avoids disqualification by negotiating a settlement under the Audit Closing Agreement Program (Audit CAP). The sanctions for document failures are significant because the IRS computes the sanction based on a Maximum Payment Amount that the IRS could impose if it disqualified the plan.

Unfortunately, plan officials cannot ignore plan qualification issues during years preceding their involvement in the plan. Old qualification errors do not just stay in the past. Like a bad dream, they will come back to haunt us and our clients during an IRS audit.

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Posted by Michael E. Mast, CPA

As part of the Patient Protection Affordable Health Care Act (PPACA), the Patient Centered Outcome Research Institute (PCORI) was created and tasked with assessing a fee on the insurance company for fully insured welfare plans, and on the employer for self-insured welfare plans, including Health Reimbursement Arrangements (HRA) and Flexible Spending Accounts (FSA). If your company offers a self-insured health and welfare plan, a HRA, or a FSA, your company must pay a fee per covered person by July 31, 2013 on Form 720.

While the actual fee can be easily calculated (rate x average number of covered lives), determining what plans are subject to the fee and the average number of covered lives can be quite complicated. In some cases, a single individual may count as more than one covered life. For example, if a fully insured medical plan is paired with an HRA, the insurance company would pay for that participant’s eligibility to the fully-insured part of the plan, and the employer would pay because he/she is eligible to the HRA.  However, if the plan sponsor offers a self-insured welfare plan and an HRA, then the participant would only be counted once.

The PCORI fee does not apply to Health Savings Arrangements (HSAs), stand-alone dental plans, vision plans, accident plans, stop-loss policies, or individuals residing outside of the United States. To verify whether your plan is subject to the PCORI fee, click here.

The fee is assessed as follows:

After you determine whether your company owes the PCORI fee, there are four optional methods (Actual Count, Snapshot, Snapshot Factor, Form 5500) that you can use to calculate the number of covered lives.

Methods available for sponsors of self-insured plans

• Actual Count Method: The total count of all lives covered by the plan each day of the plan year divided by the number of days in the plan year.
• Snapshot Method: The sponsor may select a day (or days) from each quarter to calculate the average number of covered lives. The days selected each quarter must be within 3 days of each other. For example, if a calendar year policy uses January 3rd for the first quarter, April 3rd, July 3rd and October 3rd are used for the second, third and fourth quarters, respectively. The total number of lives covered on these days is then divided by 4 to calculate the average covered lives. If more than one day per quarter is selected, the principle is applied consistently. For purposes of this method the 30th and 31st are treated as the last day of the month.
• Snapshot Factor Method: This method is the same as above, but self-insured plans have the option of counting participants with self-only coverage as one life and participants with other than self-only coverage as 2.35 lives. For example, if on January 1st a plan has 500 participants with self only coverage and 300 participants with other than self-only coverage the number of covered lives is 1,205 (=500 + 300 X 2.35).
• Form 5500 Method: A self-insured plan may take the average of the total number of participants covered at the beginning and end of the plan year, if the Form 5500 is filed timely to facilitate the filing of Form 720 by July 31st, and the plan only offers self-only coverage. IF the plan offers other than self only coverage, the average number of covered lives is computed using the total of the number of participants at the beginning and end of the plan year.

With the additional funding provided by this fee, the PCORI hopes to fulfill its mission of helping people make informed health care decisions and improve health care delivery and outcomes by producing and promoting high integrity and evidence-based information that comes from research guided by patients, caregivers and the broader health care community.

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