Presentation (CTI)

OBJECTIVES: The introduction of formularies at the regional level or by insurers is attracting attention as a means of achieving three goals: improving the quality of healthcare through standardization, reducing drug costs, and ensuring a stable supply of drugs. This study focuses on reducing drug costs. The objective of this study is to estimate the reduction of drug costs by introducing formularies.
METHODS: Using “Wellness-Star☆”, a database consisting of claims from multiple employment-based health insurance plans, we conducted a simulation to estimate the reduction of drug costs if the 30 formularies developed by the Japanese Society of Formularies were to be applied as a standardized employment-based health insurance plans. Nippon Life owns the database. The amount of cost reduction was estimated as the sum of the differences between actual and hypothetical costs for all claims that included not-recommended drugs in the 30 formularies. The hypothetical cost was calculated as the number of days prescribed multiplied by the average cost per day of the recommended drugs in the same formulary.
RESULTS: The database consisted of health insurance claims for 4,881,403 insureds from April 2014 to March 2023. The medical cost Per Member Per Year (PMPY) was 129,469 JPY, the drug cost PMPY was 30,390 JPY (23.5% of the medical cost), the drug cost PMPY for drugs covered by the formulary was 5,366 JPY (4.1%). Thus, the drug cost reduction achieved PMPY was 2,318 JPY (1.8%).
CONCLUSIONS: The potential reduction in medical cost for a standardized health insurance society by introducing the formularies was 1.8% of total medical cost. As those insureds by employment-based health insurance plans are younger than the population, the reduction would be greater if expanded to all the population.