2015 Na(onal Medicaid and CHIP Oral Health Symposium. Renée W. Joskow DDS, MPH

Transcription

1 MSDA Medicaid CHIP State Dental Association 2015 Na(onal Medicaid and CHIP Oral Health Symposium Session 2 Opportuni(es for Special Popula(ons: Pregnant Women; CSHCN; Aged, Blind, and Disabled Adults Renée W. Joskow DDS, MPH Washington Marrio9 Wardman Park Monday, June 1 st,

2 Learning Objec.ves Par.cipants will gain knowledge about: Ø Efforts to promote oral health and primary care prac.ce integra.on Ø Opportuni.es to leverage programs for special popula.ons 2

3 Disclosure and Conflict of Interest Declara.on ü I declare that neither I nor any member of my family have a financial arrangement or affilia.on with any corporate organiza.on offering financial support or grant monies for this con.nuing dental educa.on program, nor do I have a financial interest in any commercial product(s) or service(s) I will discuss in the presenta.on. q I declare that I have a financial interest/arrangement or affilia.on with the corporate organiza.on offering financial support or grant monies for this con.nuing dental educa.on program, or I do have a financial interest in any commercial product(s) or service(s) I will discuss in the presenta.on. 3

4 Disclaimer The views expressed are solely the opinions of the author and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services, or the Health Resources and Services Administra.on, nor does men.on of the department or agency names imply endorsement by the U.S. Government. 4

5 Integra.on of Oral Health and Primary Care Ø Oral Health is an integral part of overall health and therefore, oral health care is an essen.al component of comprehensive health care. Ø Oral health promo.on and disease preven.on are essen.al to any strategies aimed at improving access to care. IOM (Ins.tute of Medicine) and NRC (Na.onal Research Council) Improving access to oral health care for vulnerable and underserved popula6ons. Washington, DC: The Na.onal Academies Press. 5

6 Why Integrated Approach? Ø Importance of oral- systemic connec.on Ø Reduce dispari.es for certain groups Ø Promote quality pa.ent- centered care Ø Benefits of training and educa.ng interprofessional teams 6

7 Advisory Committee Reports

8 Ini.a.ves and Special Popula.ons Ø Integra.ng Oral Health and Primary Care Prac.ce Ini.a.ve Ø Pregnant Women and Infants (MCHB) Ø Children with Special Healthcare Needs Ø Persons living with HIV/AIDS Ø Older Americans 8

9 Integra.ng Oral Health and Primary Care Prac.ce Ini.a.ve 9

10 HRSA Report 10

11 Recommenda.ons 1. Apply oral health core clinical competencies within primary care prac.ces to increase oral health care access for safety net popula.ons in the United States. 2. Develop infrastructure that is interoperable, accessible across clinical seengs, and enhances adop.on of the oral health core clinical competencies. The defined, essen.al elements of the oral health core clinical competencies should be used to inform decision- making and measure health outcomes. 11

12 Recommenda.ons 3. Modify payment policies to efficiently address costs of implemen.ng oral health competencies and provide incen.ves to health care systems and prac..oners. 4. Execute programs to develop and evaluate implementa.on strategies of the oral health core clinical competencies into primary care prac.ce. 12

13 Integra.on Implementa.on 13

14 Improving Maternal and Child Health 14

15 BRIGHT FUTURES 15

16 Perinatal and Infant Oral Health Quality Improvement Ini.a.ve Ø Reduce the prevalence of oral disease in pregnant women and infants through improved access to quality oral health care (i.e., preven.ve services, restora.ve treatment, educa.on). Ø Target pregnant women and infants at high risk for oral disease, resul.ng in improved oral health and increased u.liza.on of oral health services. hhp:// 16

17 Perinatal and Infant Oral Health Quality Improvement Ini.a.ve (I) Ø Pilot program- 3 grantees Ø To integrate a successful community- based approach for integra.ng quality oral health care into a health care system with statewide reach to improve the oral health status of pregnant women and infants at high risk for oral disease. hhp:// 17

18 Perinatal and Infant Oral Health Quality Improvement ini.a.ve (II) Ø Na.onal Learning Network Ø Coordinate development and tes.ng of na.onal strategic framework to inform and transform health care systems with statewide reach. Ø The Children s Dental Health Project, collabora.ng with the Associa.on of Maternal and Child Health Programs, the Associa.on of State and Territorial Dental Directors, and the Na.onal Academy for State Health Policy, serve as the management team for the PIOHQI Na.onal Learning Network 18

19 Perinatal and Infant Oral Health Quality Improvement ini.a.ve (III) Ø Expansion Grant Program Ø Expand targeted demonstra.ons to integrate quality oral health care into perinatal and infant primary care delivery systems with statewide reach Ø An.cipate August 1, 2015 start date Ø Four year project period 19

20 Division of Services for Children with Special Healthcare Needs Ø State implementa.on grants to improve the system of services for CYSHCN Ø 12 Grants Ø Approximately $3,600,000 FY14 20

21 Ryan White HIV/AIDS programs Ø Include oral health, recognizing the importance of the oral- systemic connec.on Ø Ryan White HIV/AIDS Dental Programs Ø Dental Reimbursement Program Ø Community Based Dental Partnership 21

22 Older Americans 22

23 Geriatrics Workforce Enhancement Program Ø Funds health professions schools and training programs to provide interprofessional geriatrics educa.on and training responsive to specific needs of their communi.es Ø Title VII, Sec6ons 750 and 753(a), and PHS Act Title VIII, Sec6on 865 b Ø 3 Years; es.mate $38.6 M total Ø An.cipate 40 awards, start date 07/01/

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25 Oral Health and the OAA OAA Title IIIB (Suppor.ve Services) webpage: hhp:// Highlighted below in yellow are the parts of Sec.on 321 (Title IIIB) of the OAA that allow Title IIIB funds to be used for oral health. PART B SUPPORTIVE SERVICES AND SENIOR CENTERS PROGRAM AUTHORIZED Sec.on (a) The Assistant Secretary shall carry out a program for making grants to States under State plans approved under sec.on 307 for any of the following suppor.ve services: (8) services designed to provide health screening (including mental health screening) to detect or prevent illnesses, or both, that occur most frequently in older individuals; (17) health and nutri.on educa.on services, including informa.on concerning preven.on, diagnosis, treatment, and rehabilita.on of age- related diseases and chronic disabling condi.ons; (25) any other services necessary for the general welfare of older individuals; if such services meet standards prescribed by the Assistant Secretary and are necessary for the general welfare of older individuals. For purposes of paragraph (5), the term client assessment through case management includes providing informa.on rela.ng to assis.ve technology.

26 Resources Ø hhp:// oralhealth/primarycare/index.html Ø hhp:// oralhealth/primarycare/oralhealthprimarycare.pdf Ø hhp:// Ø hhp://hab.hrsa.gov/abouthab/parrdental.html 26

27 Contact Informa.on Renée W. Joskow DDS, MPH Health Resources and Services Administration Senior Advisor for Oral Health

28 MSDA Medicaid CHIP State Dental Association 2015 Na(onal Medicaid and CHIP Oral Health Symposium Session 2 Perinatal & Infant Oral Health A New Approach Marty Milkovic Washington Marrio9 Wardman Park Monday, June 1 st, 2015

29 Learning Objec.ve(s) Par.cipants will gain knowledge in: Factors that influence perinatal dental u.liza.on Methodology to increase perinatal dental u.liza.on Methodology that does not increase perinatal dental u.liza.on How collabora.on can successfully increase perinatal dental u.liza.on 29

30 Disclosure and Conflict of Interest Declara.on q I declare that neither I nor any member of my family have a financial arrangement or affilia.on with any corporate organiza.on offering financial support or grant monies for this con.nuing dental educa.on program, nor do I have a financial interest in any commercial product(s) or service(s) I will discuss in the presenta.on. q I am an employee of Dental Benefit Management, Inc., a dental benefit management company, doing business as BeneCare, which contracts with the State of Connec.cut to operate the Connec.cut Dental Health Partnership. 30

31 Connec.cut Dental Health Partnership CTDHP is the dental plan for everyone enrolled in HUSKY Health, the Medicaid and Children s Health Insurance (CHIP) Plans for Connec.cut. More than 700,000 people are on the plan. CTDHP was created on August 1, 2008 by the State of Connec.cut Department of Social Services. 31

32 Connec.cut Dental Health Partnership CTDHP provides a comprehensive adult dental benefit More than 2,000 den.sts are enrolled in CTDHP About half see adults and nearly all of those will treat pregnant women With about 14,000 HUSKY Health births per year and about 1,000 den.sts seeing pregnant pa.ents - the ra.o is excellent Geographic access is also excellent Robust call center, website & support services 32

33 Connec.cut Dental Health Partnership Our IniKal Approach CTDHP began prenatal outreach in 2009 Clients iden.fied by medical MCO s Tradi.onal direct telephone and mail outreach Some community outreach Limited success: 30% already in care addi.onal 11% respond to direct outreach and u.lize dental services 50% have bad phone numbers, most reached don t follow through 33

34 Connec.cut Dental Health Partnership New Approach (Intensive Community Outreach) Focus on the client s Trusted Persons in the community who see perinatal women Iden.fy and visit Community Partners Convince them of the importance of oral health They promote it with their clients/pa.ents They give us beher phone numbers Pilot in Norwich CT Instead of 11%, reached 44% u.liza.on Replicated, reached 40% 34

35 Connec.cut Dental Health Partnership Community Partners Determined for Each Community May Include: Community Ac.on Agency - best phone numbers, Federally Qualified Health Center (FQHC) - many clients, local WIC office many clients, Other Community Agencies OB/GYN Offices Pediatric PCP Offices Outreach visits, training, materials Identified through medical claims attribution 35

36 Connec.cut Dental Health Partnership Opportunity As we expanded ICO, HRSA MCHB Perinatal and Infant Oral Health Quality Improvement (PIOHQI) grant announced Connec.cut one of three states awarded Four year ini.a.ve to develop and disseminate best prac.ces and create a comprehensive state- na.onal plan Seven states to be added in second round 36

37 Connec.cut Dental Health Partnership ImplementaKon Focus on Towns with 80% Medicaid Births by Mother s Residence Expanded from Pilot Community into Seven More Results so far: Visited 206 pediatric PCP offices, successful in geeng 182 to promote oral health and distribute materials Visited all 153 OB/GYN HUSKY Health offices in the state, nearly all successful Distributed more than 200,000 oral health kits, posters, First Tooth bibs, flyers, Rx referral pads, referral pads and other materials under the grant 37

38 Connec.cut Dental Health Partnership First Tooth First Dental Visit Bib Oral Health Kit OH Rx Referral Pad 38

39 Connec.cut Dental Health Partnership In developing our baseline 60.0% 57.7% data we learned that 50.0% between 2005 and % we nearly doubled the 30.0% 29.8% dental u.liza.on rate of 20.0% pregnant women from 10.0% 0.0% 29.8% to 57.7%, using many of the same techniques that are part of Intensive Community Outreach (ICO). 70.0% 39

40 Connec.cut Dental Health Partnership Statewide Collabora.on Perinatal and Infant Oral Health Work Group Part of the Connec.cut Coali.on for Oral Health All stakeholders Na.onal Collabora.on NaKonal Learning Network Children s Dental Health Partnership (CDHP), Associa.on of Maternal and Child Health Programs (AMCHP), Associa.on of State and Territorial Dental Directors (ASTDD) and Na.onal Academy for State Health Policy (NASHP) 40

41 References Perinatal and Infant Oral Health Quality Improvement Ini.a.ve website: hhp:// Connec.cut Dental Health Partnership website: Connec.cut Voices for Children website (Publica.ons/ Health): 41

42 Contact Informa.on Marty Milkovic MSW Marty is Co- Director of the Connec.cut Dental Health Partnership (CTDHP), the dental plan for HUSKY Health (Medicaid/CHIP). It serves nearly one third of Connec.cut s children and is the largest dental plan in the state. The program has had great success, doubling child and adult dental u.liza.on while reducing costs. Previously he was Execu.ve Director of the Connec.cut Oral Health Ini.a.ve where he led the effort to sehle Connec.cut s dental Medicaid lawsuit. He is a graduate of the University of Connec.cut and a twenty- year veteran of the United Way system in Connec.cut including serving as President of United Way of Connec.cut, operator of the na.on s largest 211 program. marty.milkovic@ctdhp.com 42

43 MSDA Medicaid CHIP State Dental Association 2015 Na(onal Medicaid and CHIP Oral Health Symposium Session 2 Steve Perlman, DDS, MScD Washington Marrio9 Wardman Park Monday, June 1 st, 2015

44 People With Special Needs 56.7 Million people in the United States with disabili.es (Census 2010). 1 Million children under age 6 with disabili.es. 4.5 Million children 6-16 with disabili.es. 7.5 Million with intellectual disabili.es. 4.5 Million with seizure disorders. 700,000 with cerebral palsy. The World Health Organiza.on reports over 300 million people with intellectual disabili.es globally. Nearly 3% of the world s popula.on.

45 People with DisabiliKes Experience: Greater unmet health care needs than people without disabili.es Unequal access to health care services Have less educa.on Worse socioeconomic outcomes Higher rates of poverty Lower employment rates

46 People with DisabiliKes Have: A higher risk of developing secondary condi.ons Higher risk of co- morbid condi.ons Greater vulnerability to age related condi.ons Increased rates of health risk behaviors, ie: obesity, smoking, physical inac.vity Greater risk of being exposed to violence Higher risk of uninten.onal injury (burns, falls, car crashes, bicycles Higher risk of premature death, ie: schizophrenia and depression (2.6 and 1.7.mes greater)

47 Co- Morbid CondiKons Commonly Associated with Intellectual Disability: Seizure disorders Dysphagia Aspira.on pneumonia Osteoporosis Cons.pa.on Poor oral health Sensory processing disorders Behavioral (challenging, self abusive, limited impulse control) Obesity Mental health issues Spas.city Polypharmacy (increase in side effects, drug interac.ons, etc.) Gait problems Accidents Demen.a

48 People with Special Needs Must Depend on a Community Based Health Care System for Medical and Dental Care 48

49 Barriers To Care Degree of Dependence on Others Finances Aetudes of Care Provider Availability of Professional Care Handicap Access

50 Dental Care for Individuals With Special Needs A new Barrier to Access: Fear of Accusation. Editorial. Special Care in Dentistry v. 14 N5 1994: O Donnell, JP. The growing trend by well intentioned but misguided bureaucrats to micromanage the delivery of health care under the guise of defending the human rights of the disabled.

51 S.gma: Described by Goffman as "spoiled iden.fy" s.gma impacts on health care by having providers not see this popula.on as benefi.ng from preven.ve protocols, receiving adequate pain medica.on, surveillance for "risk factors," associated by many healthcare professionals as a low reward popula.on, limited respect afforded to those clinicians with an allegiance to this popula.on. Communica.on: Difficult for clinicians to understand pa.ents with limited expressive communica.on, limited.me by physicians increases the frustra.on and they (clinicians) do not take thorough histories leading to premature ill thought thru treatment plans. Difficult for clinicians to know who is "in charge" (who has the legal authority to represent the pa.ent). Direct Support Professionals (DSPs or front line staff): at best the DSP's are dedicated, commihed supporters - unfortunately (based on sta.s.cs) there is a high turnover (70%+) which contributes to lack of con.nuity of care, indifference, low health literacy, limited experience, limited "person specific" care skills, no career ladder, low pay and limited societal apprecia.on of their role.

52 Follow- up: Follow up (return to clinic or specialty referrals) is o{en derailed by staff changes, inability to transport to office because of strict staff- client ra.os (and inability free up a staff to escort pa.ent to office), lack of proper record keeping (bowel movement logs, seizure logs, temperature logs, behavioral records, medica.on compliance) negates value of follow- up. O{en staff do not comply with instruc.ons (no food a{er midnight, bring all current medica.ons, food lists) thus nega.ng the yield of the appointment. Community con.nuity of care: See Direct Support Professionals (above), reimbursement changes o{en change the scheduling, frequency and intervals of needed therapies (OT, SLP, PT, sensory support, behavioral interven.ons); staff changes, regulatory mandates, lack of care transi.on plans. Social role valoriza.on: coined by Wolf Wolfensberger; described the low view that society holds for people with intellectual and developmental disabili.es; describes how society views them as burdens, menaces, uneducable, non- contributory, pi.ful, holy innocents...values that provide lihle incen.ve to support their development including their healthcare status.

53 Health belief systems: What exactly is the "value" of health and wellness to individuals that require constant and intense care regardless of their health status. Inappropriate belief that all presen.ng problems relate to the individual's primary disabling condi.on. Culture: Every agency, medical office, clinic and healthcare community has their own dis.nct and unique "culture." The "culture" o{en determines the core values of the group and dictates the level of care from sub- op.mal to stellar. Cultural values dictates the level of care, depth of follow- up, insistence of collabora.on and referral and need to "go the distance." Erroneous mythology about the health, nature and characteris.cs of individuals with intellectual and developmental disabili.es. Regula.ons: Local, state and federal regula.ons o{en impede best healthcare prac.ces, for example in some states there is a policy that restricts the applica.on of sun block to licensed nurses; direct support professionals are not permihed to use this to prevent sunburn and sun poisoning. Many regula.ons are dinosaur al, archaic and no longer make sense in community support infrastructure.

54 Accountability: Many layers of management community support agencies, mul. disciplinary staff, silo mentality, fear of scope of prac.ce viola.ons, echo of "not my responsibility" Ownership: who actually is the responsible party; problems with balancing competency, self determina.on, assignment of legal custodians and guardians, informed consent, medical legal issues. Changing face of healthcare: increase of new physicians op.ng out of private prac.ce to become employees of HMOs, hospitals, clinics, large consolidated groups and have limited input as to pa.ent popula.ons, formulary choices, protocols, and advocacy. Use of hospitalists dilute the con.nuity of care.

55 Unmet Dental Care Needs Among Children With Special Health Care Needs: Implications for the Medical Home Charlotte Lewis, Andrea S. Robertson and Suzanne Phelps Pediatrics 2005;116;e426-e431 DOI: /peds This information is current as of September 19, 2005 The online version of this article, along with updated information and services is located on the World Wide Web at:

56 Interviewed 38,866 Families CSHCN Results: Dental care is the most prevalent unmet health care need for CSHCN. Over 78% of CSHCN needed dental care in the past 12 months. Second only to prescrip.on medica.ons in frequency of need. Poorer children, uninsured children, children with lapses in insurance, and children with greater disabili.es had greater odds of unmet dental needs. Children with a personal doctor or nurse were significantly less likely to have unmet dental needs.

57 Tu{ s Study The oral health status of 4,732 adults with intellectual and developmental disabili.es Morgan, et al..jada v n. 8 p August 2012

58 Characteris.cs of I.D.D. contribu.ng to increased risk of oral disease Cogni.ve physical or behavioral limita.ons making it difficult to perform daily oral care and cooperate during dental visits. Medica.ons affec.ng oral health. Elevated rates of poverty. Older adults who lacked access to care along their lifespan. Type of residence. Role of family members or paid care givers. Medicaid issues. Scarcity of trained den.sts and hygienists. Issue of consent, guardianship.

59 Results 32.2% prevalence of untreated caries. 80.3% had periodon..s. 10.9% were edentulous. 87.8% had caries experience. DMF DT. Highest ages MT. Highest 60 and over. FT. Highest years. Ø DMFT higher in two oldest age groups, reflec.ng high burden of missing teeth. Ø 25% of par.cipants only a limited ability to accept any dental interven.on without u.lizing advanced behavioral guidance techniques. Ø 40% required some form of behavioral assistance to receive dental treatment. Ø One third of par.cipants were able to receive dental treatment without these modali.es.

60 Conclusions Even with access to a specialized dental program, this popula.on had a high burden of dental disease.

61 Special Olympics Special Smiles Milestones Yale Report The Health Status And Needs Of Individuals With Mental Retarda.on. Sept. 15, 2000 Hearing before a Subcommihee of the Commihee on Appropria.ons United States Senate One Hundred Seventh Congress First Session Special Hearing March 5, Anchorage, Alaska. Surgeon General s Conference on Health Dispari.es and Mental Retarda.on. Dec. 5 & 6, 2001 Tes.fy at Senator Bingaman s Children s Oral Health Hearing June 25, American Academy of Developmental Medicine and Den.stry. (AADMD) CODA Standard July, 2004 Collabora.ve agreement with the AGD Collabora.ve agreement with FDI Collabora.ve agreement with IADH Collabora.ve agreement with NCOHF Collabora.ve agreement with LMC

62 Public Policy Posi.on Papers Five Essen.al Concepts of Developmental Medicine Medically Underserved Popula.on (MUP) Status Consensus Statement The Curriculum Assessment of Needs (CAN) Project Na.onal Task Group on Intellectual Disabili.es and Demen.a Prac.ces (NTG) Vitamin D Task Force Recogni.on of the Role of the Direct Support Professional (in Healthcare Issues with pa.ents with ID/ND).

63 Public Policy Posi.on Papers Amelia Rivera CHOP case (organ transplants for pa.ents with ID/ND) End of Life Care Planning for Individuals with ID/ND Ashley X Treatment case ("pillow angels") Sarah Murnaghan case (age excludes placement on organ donor needs list) Groningen Protocol (euthanasia for children "suffering") Use of electric shock as a behavioral treatment in individuals with ID/ND. Discon.nua.on of ci.ng "mental retarda.on" as a primary cause of death on death cer.ficates

64 Public Policy Posi.on Papers Discon.nua.on of "mental retarda.on" by clinicians Support of the "community model" Deamonte Driver case (boy dies of brain infec.on due to inability to obtain dental care from lack of den.sts par.cipa.ng in Medicaid/Medicare reimbursement). Support of defiant nurses (being ordered to employ unethical prac.ces towards pa.ents with ID/ND) Support of the implausibility of pursuing perfec.on in humankind

65 CODA Standard 2-24 (Implemented January 1, 2006) Graduates must be competent in assessing the treatment needs of pa.ents with special needs. Intent: An appropriate pa6ent pool should be available to provide experiences that may include pa.ents whose medical, physical, psychological, or social situa.ons make it necessary to consider a wide range of assessment and care op.ons. The assessment should emphasize the importance of non- dental considera.ons. These individuals include, but are not limited to, people with developmental disabili6es, cogni6ve impairment, complex medical problems, significant physical limita6ons, and the vulnerable elderly. Clinical instruc.on and experience with the pa.ents with special needs should include instruc.on in proper communica.on techniques and assessing the treatment needs compa.ble with the special need.

66 Medically Underserved Popula.on According to HRSA (hhp://bhpr.hrsa.gov/shortage/ muaguide.htm), a popula.on can be considered a Medically Underserved- Popula.on (MUP) if it receives an Index of Medical Underservice (IMU) score of less than The IMU is calculated using the simple addi.on of four scores. In the case of ND/ID popula.on, it would be calculated by adding scores

67 Medically Underserved Popula.on V1, V2, V3 and V4 as follows: V1 = The percentage of the ND/ID popula.on living below the poverty line V2 = The percentage of the ND/ID popula.on over the age of 65 V3 = The infant mortality rate among people with ND/ID V4 = The ra.o of primary care physicians to pa.ents with ND/ID

68 MUP Designa.on Formula Do the math

69 Medically Underserved Popula.on V1 According to one ar.cle (Mental Retarda.on: Vol. 41, No. 6, pp ), roughly 33 percent of the popula.on of both children and adults with intellectual disabili.es live in poverty. Cross referencing this with the HRSA score table give a V1 score of 5.6. the maximum score for this criterion is 25.1.

70 Medically Underserved Popula.on V2 There are a number of sta.s.cs that can be used to calculate the percentage of people with ND/ID that are over the age of 65. Our ini.al es.mates show roughly 10 percent of the ND/ID popula.on are over the age of 65. this corresponds with a V2 score of The maximum score possible for this criterion is 20.2.

71 Medically Underserved Popula.on V3 According to the Na.onal Vital Sta.s.cs Reports, (Vol. 53, No. 5, October 12, ) the number one cause of infant mortality in the United States, accoun.ng for 5,623 infant deaths is classified as congenital malforma.ons, deforma.ons and chromosomal abnormali.es, essen.ally, the biomedical causes of neurodevelopmental disorders and/or intellectual disabili.es. Since roughly 60,000 to 120,000 people with ND/ID are born every year, the infant mortality for this popula.on is between 47/1000 and 94/1000. Both of these scores represent a V3 score of 0.0. The maximum score for this criterion is 26.0.

72 Medically Underserved Popula.on V4 This is perhaps the most difficult score to calculate, as it is extraordinarily difficult to es.mate the number of primary care physicians willing and capable of caring for this popula.on. We know this number to be fairly low. However, we shall use the maximum score, by default, for purposes of comple.ng the IMU calcula.on. The maximum score for this criterion is 28.7.

73 Medically Underserved Popula.on To summarize the IMU calcula.on, we have es.mated the following: V1 = 5.6 V2 = 19.8 V3 = 0.0 V4 = 28.7 The total IMU score for the ND/ID popula.on, then, is This falls well below the determina.on score of 62.0.

74 Benefits of MUP Designa.on Medical/Dental/Health Professional School Loan Forgiveness/ReducKon

75 Benefits of MUP Designa.on Physician and Allied Health Professional Training ImmigraKon for InternaKonal Medical Graduates

76 Benefits of MUP Designa.on Community Health Centers Screening and PrevenKon Medical/Dental Research

77 Designa.on of the Intellectually Disabled as a Medically Underserved Popula.on At the American Medical Associa.on s (AMA) 2010 Interim Mee.ng, the House of Delegates passed Resolu.on , which calls for the AMA to lobby Congress to work with the appropriate federal agencies, such as the Department of Health and Human Services, to classify intellectually disabled persons as a medically underserved popula.on.

78 American Dental Associa.on Resolu.on 96H H Resolved, that the American Dental Associa.on support a simplified process across appropriate governmental agencies to designate individuals with intellectual disabili.es as a medically underserved popula.on, and be it further Resolved, that the ADA seek to collaborate with the American Medical Associa.on and the American Academy of Developmental Medicine and Den.stry to promote this process to appropriate governmental agencies.