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Unique Health Identifier for Individuals

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Any unique identifier must be practical and cost-effective:

• In order for a unique individual identifier to be effective, every individual should have an identifier that applies only to that individual and that does not change over time.
• An identifier or identifier system that is not practical to implement or that does not meet the requirements of administrative simplification must be deemed unacceptable.
• The costs of implementation and use of the identifier must be within an acceptable range. To determine whether costs are acceptable, we must consider costs for all the participants in the health care setting - patients, health care providers, health plans, state and local governments and the federal government. (from government White Paper on Unique Health Care Identifier published 7/2/98).

Privacy issues are key in choosing an identifier. Several criteria might be used to determine if a particular identifier satisfies privacy concerns:

• Privacy protection governing use and disclosure of the underlying data attached to the identifier, in the form of legal, technical and administrative controls, is essential.
• The identifier should not contain substantive information about the individual.
• The identifier must not be used to establish a single national data base of all health records.
• The identifier must not be used as a basis for a national identity card system.
• There must be prohibitions on use of the identifier for purposes outside of health.

In summary, the criteria used to evaluate candidate identifiers relate to practicality, cost effectiveness and privacy.

Social Security Number as a Personal Identifier - historical background:

The Social Security law was passed in 1935 - the SSN was called the Social Security Account Number- meant to identify the account, not the person. The SSN has since been adopted for many identification purposes outside of the Social Security system. In 1943, President Franklin Roosevelt signed an executive order mandating Federal agencies to use the SSN as an identifier for any new records system. In 1967 the Department of Defense officially adopted the SSN as an Armed Services personnel identifier. In 1961 the Civil Service Commission adopted the SSN as an official Federal employee identifier and in 1962 the IRS adopted it as the taxpayer identification number. In the 1960's the Treasurty Department required buyers of series H savings bonds to provide their SSN's and again in the 1970's required it for purchase of Series E bonds. The SSN was selected as the Medicare health insurance number in the 1960's. The Tax Reform Act of 1976 authorized states to use the SSN for state and local tax authorities, welfare systems, driver's license systems, DMVs and for tracking parents delinquent in child support. Uses of the SSN were expanded to unclude participation in school lunch and food stamp programs as well. By the year 2000 the SSN will be required on drivers licenses under a 1996 immigration reform provision.

There are few restrictions on use of the SSN in the private sector. The SSN is used as a student identifier in many educational systems, the National Student Loan System has required the SSN since 1989 and many health care providers use the SSN to identify patients. The SSN already serves as a personal identifier. Use of the SSN would make it easier to link medical records and administrative databases for public health and clinical research purposes. The Social Security Act would have to be modified to specifically authorize the SSN for this kind of mandatory use.

Over the past 20 years the SSA has taken steps to improve its verification process prior to issuance of an SSN. The verification process currently is based on a combination of personal data (name, date and place of birth, sex, mother's maiden name, father's name). These are used to screen the SSA's database for previous SSN issuance to another individual.

Tax returns filed after 1/1/98 must include the SSNs of all claimed dependents - thus a child could need an SSN during the first year of life. SSA's "Enumeration at Birth" process allows a parent to apply for an SSN for a newborn as part of the birth registration process. All 50 states , Washington D.C. and Puerto Rico participate in this process.

All of the proposals for a health care identifier that depend on the SSN or the SSA would benefit from improvements in the process for issuing and maintaining SSNs and birth certificates. A newborn could be assigned an SSN, birth certificate number and health care identifier in the birth hospital allowing a longitudinal patient record to begin at the initial health care encounter (birth). Delivery in the non-hospital setting would need access to the systerm as well.

The cost of building upon an existing system (such as the SSA) should be relatively less than to create an entirely new system. SSA reported recently that, based on 1996 data, verifying the identities of all SSN holders and issuing new cards would have a basic minimum cost of $3.9 billion. Estimates approached $10 billion if new security features were added to the cards. A revalidation and reissuance project would benefit other activities that use the SSN (immigration and welfare reform, e.g.) - the cost could be apportioned to all agencies that could potentially benefit from the improvements. Efforts to incorporate a health identifier could be incorporated in the process from the beginning resulting in lower costs as compared to starting a new system.

Unique health identifier proposals based on the SSN have positive and negative aspects. The positive aspects relate to accessibility, cost effectiveness and being content-free. The negative aspects relate to areas of not being focused for health care, not being unique and for being able to merge or split identifiers when necessary. (The reader is referred to the government White Paper on Unique Health Care Identifiers published 7/2/98 ffor more details).

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