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AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Topic Description

Medicare Prescription Drug, Improvement and Modernization Act of 2003, Section 1013: Priority Topics for Effective Health Care Research (1 of 2)
(1 of 2 pages)

The American Association of Clinical Endocrinologists (AACE) appreciates the opportunity to submit recommendations for topics of research to be conducted under Section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Section 1013 of the MMA authorizes research, demonstrations, and evaluations to improve the quality, effectiveness, and efficiency of the Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) entitlement programs. The Federal Register announcement of January 5, 2006 specifically seeks recommendations relevant to the Medicaid and SCHIP programs. Founded in 1991, AACE is a professional medical organization of over 5,200 practicing endocrinologists in the United States and 84 other countries. AACE is dedicated to the enhancement of the practice of endocrinology and to providing the highest quality of care to patients with endocrine problems such as diabetes, thyroid disorders, growth hormone deficiency, osteoporosis, lipid disorders, hypertension and obesity. Our research recommendations focus on morbid obesity in children. Below, we provide background information on Section 1013 of the MMA, discuss the importance of obesity in terms of the health status of children and tax-payer funded programs including Medicaid, and provide our specific research recommendations. As indicated in the MMA, research and other activities undertaken and authorized by Section 1013 may address: (1) The outcomes, comparative clinical effectiveness, and appropriateness of health care items and services (including prescription drugs); and (2) Strategies for improving the efficiency and effectiveness of Medicare, Medicaid, and SCHIP programs, including the ways in which health care items and services are organized, managed, and delivered under such programs. For its role in implementing Section 1013, AHRQ has requested public input for suggestions regarding which technologies and conditions should be included in their research priorities for FY 2006. AACE applauds AHRQ’s efforts in requesting public input for research topics.

Morbid Obesity and the Medicaid/SCHIP Programs

Obesity is a complex, multi-factorial condition characterized by excess body fat. Approximately 30.3 percent of children (ages 6 to 11) are overweight and 15.3 percent are obese. For adolescents (ages 12 to 19), 30.4 percent are overweight and 15.5 percent are obese. Overweight children and adolescents are more likely to become overweight or obese adults; and one study has shown that children who become overweight by age 8 were more severely obese as adults.

Morbid obesity, also referred to as clinically severe obesity or extreme obesity, is a chronic disease that afflicts approximately 9 million adult Americans. Morbid obesity is defined as having a Body Mass Index (BMI) of 40 or more. This equates to approximately 100 pounds more than ideal weight.

orbid obese children have BMI’s exceeding the 95 th percentile for age and gender (BMI >35). Morbid obese children exhibit abnormalities of growth and maturation - including taller than predicted stature, early pubertal development and early onset of menstruation in females. Morbid obese children often show many conditions that limit their physicalmobility, school performance and short-term and long-term health. Specifically, respiratory conditions related to obesity in children include obstructive sleep apnea, severe asthma often necessitating repeated hospitalization, as well as Pickwickian syndrome and orthopedic conditions including Blount’s disease and slipped capital femoral epiphyses, limiting mobility and necessitating surgery. Additionally, these children are often at greater risk for hypertension, type 2 diabetes, gall bladder disease and non-alcoholic steatohepatitis, the latter sometimes resulting in cirrhosis of the liver and subsequent liver failure. (See Table Below)

Conditions Related to Morbid Obesity (BMI > 95 th%ile) Among Children


Sleep Apnea
Sleep Disorders
Pickwickian Syndrome

Cardiovascular Risk Factors

Syndrome X


Type 2 Diabetes (NIDDM)
Insulin Resistance
Menstrual Abnormalities
Gall Bladder Disease
Liver Steatosis/Steatohepatitis
Liver Fibrosis/Cirrhosis
Neurocognitive Deficits

Orthopedic Complications

Blount's Disease
Slipped Capital epiphyses


The economic costs of obesity are huge, but the overall impact of this disease cannot be measured simply in economic terms. Obesity is responsible for at least 300,000 deaths per year. and the direct health cost of obesity in 2003 alone was $75 billion dollars, representing 6 percent of total health expenditures for the year. It has also been estimated that if you are an American age 18 to 36 and obese, you will, on average, incur 36 percent more medical expenses per year than if you were not obese.

Among the poor and disabled Medicaid population, 30 percent were obese. The health costs related to obesity were $21 billion, approximately 11 percent of total Medicaid health spending. Twenty-one percent of Medicare patients – most of whom are elderly – were obese. They were responsible for $18 billion in cost, or 7 percent of the Medicare budget. Taken together, obese patients in Medicaid and Medicare accounted for 49 percent of total obesity-related health expenditures in America.

Moreover, as obesity rates increase, obese patients in these programs will consume a larger share of tax-payer funded health care. The costs associated with treating these patients and their obesity-related complications are significant.

hile the incidence of overweight and obesity has been increasing in the US since the 1970’s, the actual number of children with symptomatic morbid obesity is not well established. Thus the question of how to apply measures to identify children with morbid obesity needs to be determined. This in turn will spur the implementation of appropriate prevention and treatment strategies, providing opportunity for improved quality and cost savings in the Medicaid and SCHIP programs, which will also translate to future cost savings in the Medicare program. Because Medicaid and SCHIP provides health benefits to the neediest patients, state Medicaid and SCHIP programs play an important role in terms of patient access to the diagnosis and treatment of morbid obesity.