Budget impact analysis of osteoporosis medications for primary prevention of fractures in Taiwan

  • Kun-Ling Wu
  • Chih-Hsing Wu
  • Yin-Fan Chang
  • Yun-Ting Lin
  • Jason C. HsuEmail author
Original Article



Taiwan's national health insurance currently only covers the use of osteoporosis drugs for the secondary prevention of fractures and does not provide coverage for primary prevention. The purpose of this study is to develop a model for analyzing the budgetary impact of the use of osteoporosis medications of primary prevention.


The budget impact model in this study is the “actual medication cost” minus the “medical expenses for all types of fractures that can be avoided by taking osteoporosis medications.” We developed six possible insurance payment plans for primary prevention based on the age of the patients and T-scores and performed eleven steps to estimate the budget impact of each payment plan.


The results of this study indicated that there may be 71,220 (T-score ≤ − 3.0, 75 + y/o) to 157,515 (T-score ≤ − 2.5, 65 + y/o) people using the drugs, and the budget impact may be US$26.28–58.98 million in 2019. However, the payment plans may avoid 492–766 fracture events and save medical expenditures for fracture treatment by US$1.30–2.02 million. The average costs for primary prevention within a year will be US$53,386–77,006.


The budget impact of using osteoporosis medications to primary prevention of fractures is significant, but it can be compensated due to savings in fracture treatment costs.


Budget impact analysis Osteoporosis medication Primary prevention Taiwan 



Budget impact analysis


International Society for Pharmacoeconomics and Outcomes Research Health Sciences Policy Council


Fracture Risk Assessment Tool


International Osteoporosis Foundation


World Health Organization


National Health Insurance


International Classification of Diseases, 9th edition


National Health Insurance Research Database


Dual-energy X-ray absorptiometry


Author contributions

KLW, CHW, YFC, and JCH conceptualized and designed the study. KLW, CHW, and YTL collected data and conducted the analyses. JCH and YTL drafted the manuscript. All authors reviewed all data, revised the manuscript critically for intellectual content, and approved the final version for submission.


This work was supported by National Cheng Kung University Hospital-the Show Chwan Health Care System R&D Project grant (Grant number: NCKUSCMH10710), National Cheng Kung University Hospital (Grant numbers: NCKUH-106-9007, NCKUH-10709012), and Taiwan Ministry of Science and Technology (Grant number: 106-2314-B-006-064-MY2). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors have no competing interests.

Ethics approval and consent to participate

Use of the publicly published data and NHIRD for research purpose is exempt from IRB review in Taiwan.


  1. 1.
    Mauskopf JA, Sullivan SD, Annemans L, Caro J, Mullins CD, Nuijten M, Orlewska E, Watkins J, Trueman P (2007) Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices—budget impact analysis. Value Health 10:336–347CrossRefGoogle Scholar
  2. 2.
    Marshall DA, Douglas PR, Drummond MF, Torrance GW, Macleod S, Manti O, Cheruvu L, Corvari R (2008) Guidelines for conducting pharmaceutical budget impact analyses for submission to public drug plans in Canada. Pharmacoeconomics 26:477–495CrossRefGoogle Scholar
  3. 3.
    Wu TY, Majeed A, Kuo KN (2010) An overview of the healthcare system in Taiwan. Lond J Prim Care (Abingdon) 3:115–119CrossRefGoogle Scholar
  4. 4.
    Lin YC, Pan WH (2011) Bone mineral density in adults in Taiwan: results of the Nutrition and Health Survey in Taiwan 2005–2008 (NAHSIT 2005–2008). Asia Pac J Clin Nutr 20:283–291PubMedGoogle Scholar
  5. 5.
    Hwang JS, Chan DC, Chen JF, Cheng TT, Wu CH, Soong YK, Tsai KS, Yang RS (2014) Clinical practice guidelines for the prevention and treatment of osteoporosis in Taiwan: summary. J Bone Miner Metab 32:10–16CrossRefGoogle Scholar
  6. 6.
    Kanis JA, Oden A, McCloskey EV, Johansson H, Wahl DA, Cooper C, Epidemiology IOFWGo, Quality of L (2012) A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 23:2239–2256CrossRefGoogle Scholar
  7. 7.
    Chan DC, Chang CH, Lim LC, Brnabic AJM, Tsauo JY, Burge R, Hsiao FY, Jin L, Gurbuz S, Yang RS (2016) Association between teriparatide treatment persistence and adherence, and fracture incidence in Taiwan: analysis using the National Health Insurance Research Database. Osteoporos Int 27:2855–2865CrossRefGoogle Scholar
  8. 8.
    Yi H, Ha YC, Lee YK, Lim YT (2013) National healthcare budget impact analysis of the treatment for osteoporosis and fractures in Korea. J Bone Metab 20:17–23CrossRefGoogle Scholar
  9. 9.
    Tosteson AN, Burge RT, Marshall DA, Lindsay R (2008) Therapies for treatment of osteoporosis in US women: cost-effectiveness and budget impact considerations. Am J Manag Care 14:605–615PubMedGoogle Scholar
  10. 10.
    Sullivan SD, Mauskopf JA, Augustovski F, Jaime Caro J, Lee KM, Minchin M, Orlewska E, Penna P, Rodriguez Barrios JM, Shau WY (2014) Budget impact analysis-principles of good practice: report of the ISPOR 2012 Budget Impact Analysis Good Practice II Task Force. Value Health 17:5–14CrossRefGoogle Scholar
  11. 11.
    NICE Pathway—Osteoporosis overview: 20 September 2016 update.
  12. 12.
    PBAC—Pharmaceutical Benefits Scheme.
  13. 13.
    Health Insurance Review & Assessment Service (HIRA).
  14. 14.
    Canadian Agency for Drugs and Technologies in Health (CADTH).
  15. 15.
    Nih Consensus Development Panel on Osteoporosis Prevention D, Therapy (2001) Osteoporosis prevention, diagnosis, and therapy. JAMA 285:785–795CrossRefGoogle Scholar
  16. 16.
    Wu C, Chang Y, Yao W, Wu D, Lin R (2009) Under-estimation and under-treatment of osteoporosis: the halves phenomenon. 14th Annual meeting of ISCD, Orlando, USA. J Clin Densitom 12(3):390. CrossRefGoogle Scholar
  17. 17.
    Black DM, Thompson DE, Bauer DC, Ensrud K, Musliner T, Hochberg MC, Nevitt MC, Suryawanshi S, Cummings SR, Fracture Intervention T (2000) Fracture risk reduction with alendronate in women with osteoporosis: the Fracture Intervention Trial. FIT Research Group. J Clin Endocrinol Metab 85:4118–4124CrossRefGoogle Scholar
  18. 18.
    Maricic M, Adachi JD, Sarkar S, Wu W, Wong M, Harper KD (2002) Early effects of raloxifene on clinical vertebral fractures at 12 months in postmenopausal women with osteoporosis. Arch Intern Med 162:1140–1143CrossRefGoogle Scholar
  19. 19.
    Cummings SR, San Martin J, McClung MR, Siris ES, Eastell R, Reid IR, Delmas P, Zoog HB, Austin M, Wang A, Kutilek S, Adami S, Zanchetta J, Libanati C, Siddhanti S, Christiansen C, Trial F (2009) Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med 361:756–765CrossRefGoogle Scholar
  20. 20.
    Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H, Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D, Eriksen EF, Cummings SR, HORIZON Pivotal Fracture Trial (2007) Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 356:1809–1822CrossRefGoogle Scholar
  21. 21.
    Wu CH, McCloskey EV, Lee JK, Itabashi A, Prince R, Yu W, Li-Yu J, Chionh SB, Zhao Y, Shin CS, Gunawan T, Tsai KS, Chieng PU, Changlai SP, Chan DC, Chen JF, Tanner SB, Hans DB, Kanis JA, Chang YF, Sun ZJ, Yang RS; Asia Pacific Panel of ISCD (2014) Consensus of official position of IOF/ISCD FRAX initiatives in Asia-Pacific region. J Clin Densitom 17:150–155CrossRefGoogle Scholar
  22. 22.
    Insurance BoNH (2004) National Health Insurance Annual Statistical Report. (accessed 8 June 2011)
  23. 23.
    Liu SZ, Romeis JC (2003) Assessing the effect of Taiwan’s outpatient prescription drug copayment policy in the elderly. Med Care 41:1331–1342CrossRefGoogle Scholar
  24. 24.
    Yang NP, Chan CL, Yu IL, Lee CY, Chou P (2010) Estimated prevalence of orthopaedic fractures in Taiwan—a cross-sectional study based on nationwide insurance data. Injury 41:1266–1272CrossRefGoogle Scholar
  25. 25.
    Chen FP, Shyu YC, Fu TS, Sun CC, Chao AS, Tsai TL, Huang TS (2017) Secular trends in incidence and recurrence rates of hip fracture: a nationwide population-based study. Osteoporos Int 28:811–818CrossRefGoogle Scholar
  26. 26.
    Department of Statistics, Ministry of Health and Welfare, 2017 medical payment statistics.
  27. 27.
    National Health Insurance Drug Payment Program and Payment Rules—Section 5.6 Hormones and Endocrine Machines.
  28. 28.
    Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, Baim S, Favus MJ, Khosla S, Lindsay RL, National Osteoporosis Foundation Guide C (2008) Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int 19:437–447CrossRefGoogle Scholar
  29. 29.
    Pueyo MJ, Larrosa M, Suris X, Garcia-Ruiz AJ (2012) Cost-utility and budget impact analysis of primary prevention with alendronate of osteoporotic hip fractures in Catalonia. Rheumatol Clin 8:128–134Google Scholar
  30. 30.
    Wu CH, Chang YF, Chen CH, Lewiecki EM, Wüster C, Reid I, Tsai KS, Matsumoto T, Mercado-Asis LB, Chan DC, Hwang JS, Cheung CL, Saag K, Lee JK, Tu ST, Xia W, Yu W, Chung YS, Ebeling P, Mithal A, Ferrari SL, Cooper C, Lin GT, Yang RS (2019) Consensus statement on the use of bone turnover markers for short-term monitoring of osteoporosis treatment in the Asia-Pacific region. J Clin Densitom. CrossRefPubMedGoogle Scholar

Copyright information

© The Japanese Society Bone and Mineral Research and Springer Japan KK, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Family MedicineTainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation)TainanTaiwan
  2. 2.Outpatient Clinic DepartmentTainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation)TainanTaiwan
  3. 3.Department of Family Medicine, National Cheng Kung University Hospital, College of MedicineNational Cheng Kung UniversityTainanTaiwan
  4. 4.Institute of Geriatrics, College of MedicineNational Cheng Kung UniversityTainanTaiwan
  5. 5.Department of Pharmacy, College of MedicineNational Cheng Kung UniversityTainanTaiwan
  6. 6.Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of MedicineNational Cheng Kung UniversityTainanTaiwan

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