Medicaid Managed Care - U.S. Senate Special Committee on Aging

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162 Tlbb. 5-Plso91 A& MerohJ H89t0 ODoe h f"p VWd F"4 1S-M.1 SysWs. Pawl F ,0 N lV G ns A-P5g 500.C-gl. Chiiqg. %t A91990 .. 199.S-9 0Ch., %I H.. 9.9.1.. (M!A 8- 5CY 95% C0) Won4 E.. 90 9.5 (SE) 47 ,4 90% 09 Won 5 95t Ps9100110H) 295 3.3(0.9) -4.0 -9250-1.0 32 50 9 472(1.0) -0.4 -3.0903.1 4 71 14 F.-4-M 194 45.1(00) -3.3 -5.710-0. 38 40 le 470(0.) 1.3 -12W39 *7 57 20 NlpeI PopW (HMO) 1740 079 45.3(0.5) -2.2 -3.05-0.0 24 x52,34 82 13 47.9(0.5) 14 02b2.0 51 X-4. 70 la F.-901.0950900 007 45.1 (0.4) -3.4 -4050 -2.2 30 57 12 495.(0.5) *.0 -0.81D2J I *8 s0 la -br b11 - p.W ana hfh.- 5050019 p00ty 915 lso-otsy 941(500) F.se . -Z7 e44 2 41 F~. gnIS 05%" 0910dm c 50.1, (CS) 40905 515o0 0.919199099 btftttt~ e t c tt m... o s.> 5.19.10190.10.5090 by~~r 419097500) 9 .03. 09,~~~~~~~~~~~~~~~~ Tostdo 0.-Phss ltoo 004 M05'55'1 5149)010500095 Prto0 904d F99-(INS-OotVI0 5005950 h0 1/1SONy P05t0tt5 01 tb PC/15 0100(5 ph"Ir. H-Rh- Msl H. nh A.P S.~t C.Wq. Ch- 7 A..p S-t c-W - Ch.-ss N. 6t4tttt(SE) -a. a7 qsscis Wc- S- Bttttt 6tat(SE) S.i "7 a sCSq Wczz sS.- B Pr.W (HMO) F-40.-A 90 120 35.21(0.0) 321)10 -2.09 50 -5. c 1.1 5 255007 33 5 S.19 q.95 45 22I 30 57 37. (0.9) 37=5)0A 4.5 59 54.. -. 4 M 105.0 2.2W006 56 i0 s5 34 20 45 -S- o .11ows 1. dWeg M_~tt di._tz, tt4_t c~- q Th. 4-r dtW ngt f.etu ptt yt-r h.Wth t(ttt re -cttt h-4tt) hWfxt d-f .5 0 SI 4.799 1090l-1 tSgW-- tc mjl - p scw - idm.t ~htth M. agebte W~a e h-Mn m~ OsN.On (HMO) N;CP dfct.tt ftbC tttt t ttttt tt . ttt-tttW- .t.Wte tTb. ?s MM. te. Wgi cl d.p W.t Ws fett -Masta n bd .tnc kifhttepwtt W hW "pt Ps d qW t n Sif th. 95% c.Ad- W-Wttt (0) cc Mt kkd. 0b M. ,.. vp c-V. W"'tets 11- hs_ W.Md. by d-tttt (F'.05). 0P0010 Vni.014. i..3 POt edo 975.040 compared to those in FFS (37% vs 63%, respectively, stayed the same; ?'=192, P
creased since MOS data collection ended in the early 1990s, high-risk patient groups may be at an even greater risk today. If information systems for monitoring and improving the quality of care ae better now and if health promotion and disease prevention initiatives are more successful in HMOs, MOS results may not apply to current health care. The MOS was not a randomized trial; such trials are rare in health care policy research." Although quasi-experimental methods' achieved equivalent average baseline health status scores for nearly all pairwise comparisons between FFS and HMO systems of care, unmeasured risk factors could have bhised estimates of differences mn outcomes. Further, differences in outcomes that occurred 'on the watch" of the FFS and HMO systems are not necessarily their csponsibility. Structural and process differences in care beyond their control, such as arrangements for home health and long-term care, may account in part for MOS findings. The MOS monitored outcomes in only 3 large urban cities; results should not be generalized to HMO or FFS plans in other cities or rural areas. Although the MOS reprsented 5 chronic conditions and many patients had comorbid conditions such as angina, back pain/sciatica, lung disease, and osteoarthritis, these patients do not necessarily represent other conditions or results of care provided by other medical specialties. Al patients had a regular source of care. All patients were being actively treated when the MOS began, and only three fourths who agreed to participate were followed up longitudinally. Two potential sources of bias in estimates of health outcomes-plan switching and loss to follow-up-were systematically studied. Patient loss to followup is an unlikely source of bias in comparisons of outcomes between systems because adjusted physical health scores at baseline did not differ between FFS and HMO cohorts followed within the total sample or for elderly or poverty subgroups (Tables 3 through 5). Further, all study participants were followed up through 1993 to determine their survival.' Seven years after baseline, those included and not included in this 4-year analysis were equally likely to have survived (MOS unpublished data). Two of 10 HMO patients switched to an FFS plan by the end of the 4-year follow-up. Comparisons between systems could have been biased had these rates differed within elderly or poverty subgroups or had switchers experienced different outcomes than nonswitchers. However, rates of switching did not differ for elderly or poverty subgroups, JAMA. October 2. 190-Vol 276, NO. 13 163 and system differences in physical and mental health outcomes were indistinguishable for those who stayed in the same system, in comparison with those who switched (MOS unpublished data). Thus, it is unlikely that conclusions about system differences in outcomes were biased by switching. Because more than two thirds of patients who switched systems during the follow-up period had been in their system at least 6 years before switching, we adhered to the logic of intent to treat and analyzed patients according to the systems from which they were sampled. The finding that MOS patients were significantly more likely to switch from an HMO than to an HMO (20% vs i5%; 2 =72, P
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S. HRG. 105-262 MEDICAID MANAGED CA
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CONTENTS PEOPLE WITH SPECIAL NEEDS,
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V Bazelon Center for Mental Health
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2 also apparent that structuring a
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4 through the doors when somebody o
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6 delay the onset of secondary disa
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8 BRIEFING FOR CONGRESSIONAL STAFF
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10 obstetric and gynecological serv
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JlSAes CRi. E CalD5Vilb J~iiiLi uls
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14 people with disabilities and spe
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16 and prospective enrollees the pl
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18 by the disorder. In fact, schizo
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20 r_ 06/23/1997 16: 03 7836845968
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22 Kathy. STATEMENT OF KATHLEEN H.
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24 even lead to an improvement-but
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26 MANAGED CARE AND LONG TERM T h e
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Consortium for C. 20249&Oid Citizen
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30 11 Managed care
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Strong Oualitv Assurance Measures 3
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NATIONAL ASSOCIATION 34 DEVELOPMENT
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36 Mrs. M.'s care plan is quite com
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38 nurses and social workers be ava
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40 EXPENDITURES FOR NURSING HOMES S
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REQUIRES THE SKILL OF A HIGHLY TRAI
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44 ALZHEIMER'S DISEASE AND RELATED
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46 WITHOUT ADEQUATE RESPITE CARE, I
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48 PROBLEM FOR PEOPLE SUFFERING FRO
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50 Ms. CHRISTENSEN. Thank you. Don.
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52 it will eradicate the virus. Man
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I 54 Today I participate in a state
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56 Ms. CHRISTENSEN. Thank you. [Ina
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58 rather than to community-based s
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60 now has to start looking at thin
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62 plan for that matter, can measur
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64 ual is getting state-of-the-art
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66 a larger population of people wi
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68 of recovery or rehabilitation th
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70 are entitled to renew their pres
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72 point and say that Patsy comes f
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74 .The WASHNTND MEDICAL CENTER CEN
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76 exceptions - have largely based
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78 Plans have not shown a willingne
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eligible people and for the program
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Table l.b Selected Provisions Relat
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VariiaIioils in rownlr-c1t language
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Variations in cbonIlrlcl Is1sgu;age
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Executive Summary 1. Setting the Co
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age, which pays for those M
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This consensus building exercise is
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95 Ms. CHRISTENSEN. I'm going to in
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97 abled population will all need s
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5601 Smetua- Drive PO. r,. 9310 Mmn
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101 Our experience with the AFDC po
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103 I have tried to list both the o
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105 BACKGROUND INFORMATION PATRICIA
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164 Communicating the Quality Messa
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166 Communicating the Quality Messa
Page 116 and 117: 168 Communicating the Quality Messa
Page 124 and 125: 119 Dr. SCANLON. In this series of
Page 126 and 127: 121 lation in managed care in Minne
Page 128 and 129: 123 thing, because you will have va
Page 130 and 131: 125 If we develop them now around e
Page 132 and 133: 127 I think those are the things yo
Page 134 and 135: 130 to use, and they will be collec
Page 138 and 139: 134 unlikely though that these futu
Page 140 and 141: 136 While we are in the midst of th
Page 142 and 143: 138 Center for Health Program Devel
Page 144 and 145: 140 ('enter for Hearlth Proeram Dev
Page 150 and 151: 146 If More is Better, Cost Contain
Page 152 and 153: 148 ANALYSIS OF OUTCOMES SF-36 phys
Page 154 and 155: 150 4-Year Physical Health Outcomes
Page 156 and 157: 152 MAJOR FINDINGS -1 PHYSICAL DECL
Page 158 and 159: 154 INTERPRETATION OF RESULTS * Equ
Page 160 and 161: 156 Additional Information is on th
Page 162 and 163: order) were followed. Samplingpatie
Page 164 and 165: AP Ag. 0065(0 og. qP e8 y. d-ftd 04
Page 168 and 169: and chest pain sufficient to requir
Page 170 and 171: 166 Quality Special</strong
Page 172 and 173: THE STATE OF THE STATES TUESDAY, JU
Page 174 and 175: 171 a little bit about some of the
Page 176 and 177: 173 gatekeeper, and we also wondere
Page 178 and 179: 175 Maryland ought to submit that w
Page 180 and 181: 177 fined by us in our regulations,
Page 182 and 183: 179 To get to that kind of situatio
Page 184 and 185: 181 Outline of Presentation for Dep
Page 186 and 187: 183 B. Approaches to Ensure Quality
Page 188 and 189: 185 * Holds MCOs accountable for qu
Page 190 and 191: 187 HealthChoice and People with <s
Page 192 and 193: 189 HealthChoice and People with <s
Page 194 and 195: 191 Take these three steps to choos
Page 196 and 197: 193 Call 1-800-888-1965 if you are
Page 198 and 199: IF YOU HAVE HIV/AIDS 195 MCO staff
Page 200 and 201: 197 * Refer you to a medical specia
Page 202 and 203: *pV 199 SERVICES FOR CHILDREN IN ST
Page 204 and 205: 201 Ms. CHRISTENSEN. Thank you. Go
Page 206 and 207: 203 We implement these QI goals thr
Page 208 and 209: 205 Medicaid recip
Page 210 and 211: 207 My name is Peggy Bartels. I am
Page 212 and 213: 209 At the forefront of Wisconsin's
Page 214 and 215: 211 Finally, we believe that high q
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213 WISCONSIN DEPARTMENT OF HEALTH
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2 SELECTED INDICATORS Access to <st
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Mental Health 217 * HMOs reported f
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'Nisconsin Medicaid</strong
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Program for Program Chareolorletice
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Primary Program AFDC/H8 Provlqar Ch
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225 Children Come First of Dane Cou
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227 Wraparound Milwaukee saving dol
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229 Another positive outcome of the
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231 AltDoughl Nkvie' iniCil costs i
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233 CCE's staff consist of a variet
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235 Al the cturent time, there is n
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237 PACE/Partnership programs guide
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239 necessarily relevant to the AFD
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241 about including these specialty
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EXECUTIVE COMMITTEE Ct-u B.1r- M.mb
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Considerations: 245 Enrolling <stro
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247 Medicaid <stro
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a. some counties 249 b. mandatory e
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251 counties as well-of managed car
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253 In other States devolution is m
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255 /-LCenter for Health Ca
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257 Forums on Managed</stro
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259 Medicaid Carve
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261 So I view Medicaid</str
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264 Medicaid: Spen
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266 a 50 percent match. 2 Since 198
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268 If enrollment of eligible indiv
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270 drugs, ICF services, and optome
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272 Table 20-1. Medicaid</s
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274 The slowdown in spending after
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276 Section 1115 Demonstration Waiv
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278 primary care case management ar
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280 Table 20-2. Enrollment in <stro
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282 / Figure 20-6. Enrollment Growt
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284 Marnaged-care growth at the sta
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286 Figure 20-9. Enrollment in Risk
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288 The extent of problems in repor
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290 plans (PPRC 1996). In other are
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292 There appears to be a clear tre
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Enrollment and Disenrollment Polici
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296 individually with plans over ra
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298 Health Care Fi
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Medicaid M
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Support & Services Office 120 W. Tw
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INTRODUCTION 304 Presently, nearly
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306 more mandatory services. Full-r
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308 the ability of beneficiaries to
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310 managed care also requires the
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312 condition period. Such requirem
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314 If a state contracts with or in
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Appendix A State Activity* 316 Many
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GA { I ~United States (3 Mu General
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Results in Brief E.. - 320
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Significant Efforts Needed to Ensur
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Recommendations Agency Comments E-d
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cow 326 Chapter 4 Traditional Rate-
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Chapter I Background 328 Me
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ovapt I 330 the option of extending
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Federal Requirements Govern State U
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Table 1.2: Comparison of Ma
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Objectives, Scope, and Methodology
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338 Chapter 2 States Are Moving Tow
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Table 21 nEnollmen of Disabled Bene
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342 chona Se. As To~ed Id C"fn, Dai
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Table a& Eabent to Which 17 State I
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346 So A- hbydf TSo -d Cam fo DIbbi
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Table 2.5: Extent to Which 17 State
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350 8t" Age Bowi T-Mar 11 Cue fRa D
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352 C".Pt a Q...itA- Efl~t. . - C f
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Addressing Concerns Through Enrollm
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Assignment Active Management of a D
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358 fo.V D Axd B ref .Ak,.d - CC-e
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Targeted Quality-of-Care</s
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Encounter Data Analysis Shows Poten
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364 Chapter 4 Risk-Adjusted Rates a
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366 Cu.pd 4 Rk-A4tAjLd Row Ad RIASW
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States Could Experience Adverse Sel
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370 Ckspt. 4 JUek-Mtod Rate Wd HIa
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372 Ch.piWr 4 JU-i.k.d Row md RJAk-
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374 Coob,, 4 RkikAdjned Rtr -d Rub-
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376 rued R.I. . 2".shBd c- provider
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378 c-5 Obh- .. I, Co.eWda, ad CHe
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380 Ob-e-eU-o, Co-ded, end C-ost pr
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382 United States General Accountin
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Results in Brief B-Z70335 384 manag
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B-2Kn0 386 assess service utilizati
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Table 1: Characteristics of <strong
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B-27035 390 numbers of patients. In
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B-270335 392 number of primary care
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B-Z7Oa33 394 developed on the premi
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States Challenged to Develop Effect
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B-270335 398 that beneficiary use o
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B.270335 400 of the care provided a
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States Could Learn More From Improv
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Targeted Analyses of Grievance Data
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Observations Agency Comments and Ou
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B-270335 408 Finally, the experts w
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410 Appendix I Scope and Methodolog
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- I 412 App-edU I Sw Wd Methodology
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414 AppeAdt U Fedo.I aod Stt. Ove0s
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416 Appendix III Major Contributors
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GAO July 1996 GAO/HEHS-96-120 418 U
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B-26632 420 family home, rather tha
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Background 1-206320 422 traditional
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States Use Waivers to Expand and Ch
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84=20 426 Figure 1: Staftes Use of
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B-266320 428 began the 1990s with s
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B26320 430 variety of other service
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Enrollment Caps and Management Prac
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Change in Federal Rule Could Result
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States Are Introducing Innovations
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B-nato 438 offered and the means fo
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440 We are sending copies of this r
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C-m 442 Table 2: Changes in Number
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444 App-ar I So-p and Mraodsogo ent
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446 Appendix H Medicaid</st
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448 App-di. f M~I Wd., _. So 4 Of0
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450 App-.i. il _-.1 - Desd s UCFVA'
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452 Apeadls mn Stadad Seee - Defind
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454 Appedi. M St.d.ed Se&ee s Dneoe
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Chore 456 Am..& IV LAO n.Gd .Mt. ,
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Occupational Therapy and Assessment
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Psychological Services Provider Typ
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462 AWppdi IV U-e, Cotfi-, E d Othe
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Licensure/Registration Other Standa
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466 United States General Accountin
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Results in Brief B-276078 468 care
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B-270078 470 Medi-Cal was implement
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_.27_7 Tab 1: Mad-C Eiglbli and Enr
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~~- - o~~BZ760?S 474 I J I the enro
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B.276078 476 delaying the contracti
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State's Education Process Has Not R
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B.276078 480 and thereby supplement
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Weaknesses in State Management of t
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B-276078 484 standards can provide
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Insufficient Communication and Invo
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Some Safety-Net Providers Are Encou
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Conclusions B-276D78 490 Safety-net
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B-270078 492 current enrollment bro
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Contents Letter 494 Appendix 30 Sco
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(1115) oPP. -.M.taoy 496 oversight
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498 ACKNOWLEDGEMENTS This Volume of
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500 Is Lock-in to a Managed
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502 Plan and Provider Issues ......
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504 Chapter 1 Program Design Issues
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506 Other studies attest to improve
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508 Will the Program Be Voluntary o
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510 additional option for people wi
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512 contractor collect spenddown pa
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514 Option A is still quite rare. P
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516 experience with special populat
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518 particularly on a full risk bas
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520 Dual eligibility raises a disti
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522 special populations, and states
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524 Chapter 2 Care
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526 settings. Finally, plans that s
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5281 needs. For example, women who
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530 Oregon's rules require that pla
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532 beneficiaries on July 1, 1997.
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534 facility's delivery, dosage, an
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536 * Strategies for measuring netw
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538. arrangements with traditional
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540 community based or well elders.
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542 Finally, coordination for vulne
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544 Care Coordinat
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546 home health agency developed a
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548 develop a case management syste
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550 Coordinating services is compli
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Highlights 552 Effective care coord
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554 beneficiaries that belong to th
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556 services when needed. This is t
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558 federal government and not at s
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560 cannot enroll a person in a Med
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562 Medicare members are not typica
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564 Regence HMO Oregon staff noted
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566 community based organizations t
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568 Although technical advice for c
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570 Risk pools are usually used to
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572 Internal Quality Program Standa
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574 enrollee utilization patterns,
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576 that the overall prevalence of
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578 HMOs with risk contracts must h
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580 Summary As Medicaid</st
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582 Chapter 3 Medicaid</str
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584 carve-out approach: - improves
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586 Coordinating Medical and Non-Me
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588 Oregon,8 program planners origi
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590 Medicaid syste
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592 Oversight/Monitoring Quality De
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594 with family and friends, contac
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596 * The type(s) of data necessary
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598 * Specificity of desired result
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600 Initiatives under way may prove
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602 a estring the services authoriz
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604 Development of appropriate plan
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606 OFFICE OF INSPECTOR GENERAL The
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Establishing core developmental tea
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610 taken into account considerable
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PURPOSE 612 INTRODUCTION Our purpos
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614 MANAGED CARE PENETRATION The de
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616 CHALLENGES AND RESPONSES Our re
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618 > In building up and maintainin
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620 * For the most part, the agenci
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622 beginning to look for associate
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624 challenge will be to ensure tha
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626 RETOOLING AS AN ISSUE Retooling
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628 finding effective ways of deali
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630 COMMENTS ON THE DRAFT REPORT We
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Defining Managed <
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DATE: JU 27 1997 TO: June Gibbs Bro
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636 protocols will be enhanced thro
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638 Broad and explicit state health
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640 APPENDIX C ENDNOTES 1. See, for
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642 The First Biannual Report of th
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644 30. In Massachusetts, for examp
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646 CHILDREN WITH SPECIAL HEALTH CA
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Prface 648 The U.S. Maternal and Ch
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650 L DEFINING AND IDENTIFYING CHIL
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2. Child Health Questionnaire (CHQ)
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654 Limits * This approach identifi
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656 To what extent does the definit
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658 II. FAMILY PARTICIPATION IN MAN
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660 Description This is an integrat
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12. American Academy of Pediatries
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664 knowledge of a child's conditio
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666 though only the NACHRI approach
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668 Sources Ash A, Porell F, Gruenb
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C. Recommended Adivities 670 With t
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672 B. Examples of Current Research
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674 The Practice Parameters Project
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076 -Administrative Survey: Enrollm
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678 Description This guide provides
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680 APPENDIX 1: PARTICIPANT LIST MA
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682 MANAGED CARE EXPERT WORK GROUP
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684 APPENDIX H: BIBLIOGRAPHY MANAGE
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686 MANAGED CARE EXPERT WORK GROUP
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688 MAKING MEDICAID MANAGED CARE PR
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690 On Saturday, July 13, 1996 and
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INTRODUCTION Medicaid</stro
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694 INTRODUCTION People living with
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696 |CONSENSUS FOR ATO of many of o
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- 698 There is a huge need to educa
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700 People fiving with HIV, and the
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702 The HIV epidemic disproportiona
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NATIONAL ASSOCIATION OF PEOPLE WITH
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706 People living with HIV must be
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708 CONSENSUS FOR ACTION service Fo
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710 E . | CONSENSUS FORACTION Peopl
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712 CONSENSUS FOR ACTION _ Under Cr
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714 PNDX Aj MedIcaId -A health care
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Resources 716 NAPWAserves as the vo
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Medicaid Working G
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Background 720 FAMILY"7OICES A nati
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722 was included. A telephone numbe
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724 provider to ask questions. fami
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726 * Families were twice as likely
Page 730 and 731:
728 carefully to explain why they a
Page 732 and 733:
Table I Family Voices Survey on <st
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Table 2 (continued) Family Voices S
Page 736 and 737:
Table 4 Family Voices Survey on <st
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736 Table 7 Family Voices Survey on
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738 Table 8 Family Voices Survey on
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740 Table 10 Family Voices Survey o
Page 744 and 745:
al 742 Table II Family Voices Surve
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744 Tn Uvman 1usoUU - Ya..e. PeMh i
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746 Tihe b d. - Yc'.n-e-aPcopb bith
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748 UT1, W L= 1. - Y g o. ith ,Pb M
Page 752 and 753:
750 o As with the rest of the <stro
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752 Mlbe 1 Mediaid Benefici7 ibtas
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754 9: Office of the Assistant Secr
Page 758 and 759:
The research for this paper Was sup
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Definitions of "Medically Necessary
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Who Should Define What Is Necessary
Page 764 and 765:
762 contract. In that situation, th
Page 766 and 767:
764 sannes and for certain conditio
Page 768 and 769:
Defining Elements of a Definition o
Page 770 and 771:
768 (6J identify and evaluate a men
Page 772 and 773:
770 This paper highlights children'
Page 774 and 775:
772 din resulut in inadequate or in
Page 776 and 777:
774 dividual under public-sector ma
Page 778 and 779:
BAZELON CENTER RESOURCES ON MANAGED
Page 780 and 781:
ivn58ffR1eL_ 778 THF VARIAI LITY OF
Page 782 and 783:
_4 What are the essential benefits
Page 784 and 785:
WHAT PUBLIC PURCHASERS CAN DO - Oen
Page 786 and 787:
ASSESSMENT OF STANDARDS - Quality M
Page 788 and 789:
Accessibility, Availability, Referr
Page 790 and 791:
- Credentialing and Recredtentialin
Page 792 and 793:
Standards for Members' Rights and R
Page 794 and 795:
Preventive Behavioral Health Servic
Page 796 and 797:
9b4 etfJovrk9imut July 16, 1997 794
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hel,4Neipaork SEmi July 16, 1997 79
Page 800 and 801:
798 Principles for Accountable <str
Page 802 and 803:
800 The Coalition for Accountable <
Page 804 and 805:
802 Principles for Accountable <str
Page 806 and 807:
Im. Community 804 Health plans shou
Page 808 and 809:
806 4. participating in community p
Page 810 and 811:
808 5. give patients opportunities
Page 812 and 813:
810 aRve New Children With Disabili
Page 814 and 815:
Table of Contents 812 Executive Sum
Page 816 and 817:
814 combination of HealthPartners d
Page 818 and 819:
Introduction 816 F amilies whose ch
Page 820 and 821:
818 Of the 24 families asked, 13 pa
Page 822 and 823:
820 Shriner's Hospital, or claims s
Page 824 and 825:
822 Major Child and Family Concerns
Page 826 and 827:
Services and Funding Sources 824 Nu
Page 828 and 829:
Physician Survey 826 M ost physicia
Page 830 and 831:
828 Discussion and Recommendations
Page 832 and 833:
830 * Claims and billing informatio
Page 834 and 835:
832 El Advocate for a safety net of
Page 836 and 837:
834 :i:PTNG F'AITH SYMThMr -"r W, M
Page 838 and 839:
836 We recognize that managed care
Page 840 and 841:
due to a host of complex demographi
Page 842 and 843:
affect many different facets of an
Page 844 and 845:
state agencies, must be held accoun
Page 846 and 847:
In selecting managed care entities
Page 848 and 849:
Z, W 0 V==4 . k PQ- 0 V-- 9 Q) bo =
Page 850 and 851:
plans were virtually identical in b
Page 852 and 853:
to chronically i persons has been t
Page 854 and 855:
Managed Risk Medic
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the lead. Large purchasers might wo
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ISBN 0-16-055952-9 9 [ 10111111 155
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Medicaid Managed Care - U.S. Senate Special Committee on Aging

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