Taiwanese National Health Insurance Card

Taiwanese National Health Insurance Card

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Taiwanese National Health Insurance Card



Taiwanese government has been providing health insurance coverage to all its citizens since 1997. Initially, the National Health Insurance Agency managed and tracked citizen's medical usage via four versions of paper national health insurance card. The health insurance card, the newly born handbook, the pregnancy handbook, and major disease/handicap certificate. Whenever a citizen visits health clinic, the visit is recorded on the back of the appropriate ID. When the card is full, the citizen exchange the used card for a new one at the local NHI office. The NHI also receive medical records from medical establishments when they file for claims.

Starting July 2003, the health insurance agency began its modernization process. It started consolidating four paper versions with the digital version-- a smart card containing IC chip. By Jan. 1, 2004, the entire country was upgraded to the digital NHI card. The goal of the modernization process is to reduce the NHI's operational overhead so that more resources may be directed toward medical care. It is expected to save over 42 billion NTD or roughly 1.2 USD over the period of seven years.5 In addition, visits to the health care provider will be more convenient, as patients no longer need to bring multiple ID/handbooks with them to medical facilities. And there will be no need to visit local NHI office for new ID cards. For health care providers, the digital card provides a electronic infrastructure that allows them to streamline the claim filing process avoiding mistakes. It also allow NHI to provide a more efficient collection mechanism to gather accurate information regarding overall citizen's health and disease statistics.

Despite its well intention and the ambitious plan, the modernization plan has serious ethical consequences. When the modernization process is completed, the NHI will has the most extensive online database of Taiwanese citizens. The database will contain nearly every citizen's medical record for his or her entire life. It will also contain the most up to date personal information such as home and work addresses. Because of the extensive nature of the database, if the database is misused, the consequence will be severe. Furthermore, Several human rights advocacy group has pointed out the infrastructure is insufficient to protect citizens' privacy rights as well as the lack of will on government's side to protect individual's personal information. And there is fear that there is risk that the leaked medical information can be used to persecute a specific segment of the population.

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This paper will explore the privacy issues relating to the NHI IC card. It will then debate whether the Taiwanese government's transition to the digital NHI card is an ethical one using the utilitarian and rights perspective.

Technical Details of NHI Card

The actual NHI IC card contains 32kilobytes of memory is designed to store the following information6:

Basic personal information: name, national ID number, birth date, gender, issuance date, photo.

NHI specific information: NHI ID number, expiration date, medical quota, last medical visit serial number, cumulative medical visit count, cumulative medical expenses, insurance fee, major disease or handicap, additional information regarding newly born, Information regarding pregnant women: prenatal examination, last menstruation cycle start date, expectant date.

Medical information: medicine person is allergic to, major medical entries, chronic prescription, regular prescription.

Administrative section: immunization record, organ donation information.

The personal information is expected to be updated every year before one's birthday.
This can be done at any public kiosk or any NHI certified clinics. Each ID card is protected by a pin number chosen by the card owner. Only authorized card readers with valid physician and patient passwords can be allowed to read or write to NHI IC card. Each authorized card reader is connected to the central database by the virtual private network. When the medical visit is registered, it is immediately sent to the central database. The patient's basic personal information is sent along with the following medical information: diagnosed illness, type of medication prescribed, and number of visits. The diagnosed disease and medication type (oral, injection, etc...) is transmitted as numbers instead of text. The information is further encrypted.

The physician may search the NHI database for all records submitted by him via the VPN.

The central database is protected by three layers of firewall, with intrusion detection monitoring. All medical facilities are connected to the central database by the VPN managed by Chunghua Telecom.

Benefits of NHI IC Card

In the past, the National Health Insurance Agency issued four different paper national health insurance card/handbooks: The health insurance card, the newly born handbook, the pregnancy handbook, and major disease/handicap certificate. Whenever a citizen visits health clinic, the visit is recorded on the back of the appropriate ID. When the card is full, the citizen exchange the used card for a new one at the local NHI office. The NHI also receive records from medical establishments when they file for claims on a monthly basis. This gap between report time, allows some hospitals or clinics to file for fraudulent claims since it is difficult for the NHI to verify each claim without patient's used NHI card.

With the advent of digital NHI card, the operational overhead is reduced by eliminating the periodic re-issuing of the paper NHI card. Second, it is more convenient for the individuals visiting medical facility because they only need one card instead of four. In addition, the medical visits are immediately reported to the central repository, making it more difficult for doctors to make fraudulent claims and abuse the medical resources. The financial benefit is estimated at 42 billion NTD or 1.7 billion USD over the period of seven years.

This instantaneous tracking provides an additional benefits to the health officials. They can identify the spread of an epidemic in realtime and create a better containment against the spread of the disease. For example, in the NHI press release, in December, the government uses the IC card to determine which hospitals were visited by the SARS patient. This instantaneous tracking will prove useful in constructing the path of infection.7

The digital IC card also provides paramedics with vital information when the victim is unconscious. Medication that may causes allergic reactions, current prescriptions, these are information that can help a medical personal make sound judgments in what medication to administer. And the digital IC card provide these information with minimum burden on the carrier.

Another benefit provided indirectly by the digital NHI card. Since the central database is now networked, the NHI has opened the database to researches by selected academic and commercial entities. The following data is available upon request8:

basic information that includes clinic statistics, medical staff information, records of major illnesses, yearly clinic visit expense, and yearly in-hospital care expense.
randomly sampled data that includes
itemized in-hospital expenses.

prescription records.

anonymized individual's life-long medical record.

Customized data-- if researchers has a specific needs, it can submit a request for information which will be subject to board review.

These type of information may lead to better study of the Taiwanese health throughout their lifetime. It may also help establish government health policy. For example, in year 2000, the NHI released the following figure: 74.2% of male adult did not utilize any of the medical services in the past two years9. These type of information may help government health department to create programs advocating for preventive care. These types of analysis will be even faster and more accurate with the modernized NHI. The commercial entity may even design medical products that better fullfill the needs of Taiwanese.

Issues Concerning NHI IC Card

While digital IC card provides enormous benefits to the NHI, health care provider, and ultimately the public. It also has some privacy issues.

Some advocacy groups argue prior to NHI IC card, the major illness/handicap certificate is only presented when required. However, with NHI IC card, any health care provider may examine the certificate. It may lead to discrimination against certain segment of the society. For example, AIDS and chronic mental diseases are listed among the 32 types of illness classified by the NHI as major illness/handicape11, It is well known that Taiwanese hospital discriminates against AIDS patients. If the major illness/handicap certificate is examined without actual needs, AIDS patient may be subject to unnecessary discrimination4.

Another private personal information which may also be viewed without needs are last menstruation date. These type information is considered private and may only be viewed by gynecologists yet it is viewable by all physicians.

The most controversial aspects of the digital NHI card lies in the management of the central database, and the agency's plan to expand the use of the digital NHI card and store patient's entire medical history on the NHI card. The storage of patient's entire medical history on the NHI card poses a lot of risk since everyone with a card reader will be able to obtain that information.

Another privacy issue that concerns the digital NHI card opponents is not the card itself, but the database that is used to verify and track the card user. The database contains detailed information of every citizens who has a medical history. It contains their name, photo, birth date, home and work address, phone number, and entire medical diagnosis submitted by the physician. Since the card owner is required by law to update their personal information once a year. The information is considered to be the most up to date among all government database. In addition to information being fresh, the database is also very complete. It contains 21.4 million people's records or 96.2% of the population10. Because of the database is fresh and complete, there is so complete that there is enormous amount of commercial interest to link up to the database. News outlet has reported that the corporation that architects the medical network and digital NHI card have a draft business plan connecting the database to 3rd party medical insurers. The estimated revenue was 8 billion NTD or 260 million USD. There was also another business plan by the same corporation to use the digital NHI card as digital wallet. Given the Taiwanese culture of close association between the business and government, it will be difficult to defend the database against commercial interest. Already, commercial entity may be granted access to the database for researching purposes. It places heavy on the government to monitor that the commercial entity does not mis-use such privilege.

In addition, Taiwan has a strained relationship with China. China may wish to obtain private informations of the political activists who are viewed as trouble makers. The protection of individual privacy is now directly related to national security and personal safety. While the NHI has repeated stated that the NHI medical network is safe (whatever they meant by "triple firewalls"), it is not inconceivable to break into the database. With so many points of penetration, every hospital that is connected to both VPN and internet is a vulnerable target, it is likely that there is a weakness that maybe exploited with grave consequences.

Prevalent Societal Attitude on Privacy

Taiwan was run under a near-totalitarian regime for 40 years. The government closely monitored its citizens and use the information to capture/intimidate political dissidents. However, with persistent work of the political activists, Taiwan has emerged from the totalitarian rule as a democratic country. President Chen was one of the jailed political dissident in the former era.

Because of this past, Taiwanese population are divided in their opinions about their privacy. They value their privacy because they understand how privacy abuse may endanger their life. For example, digital national ID card initiative was canceled because citizen's protest. And NHI IC card received intense scrutiny from the community as well as the academic. Yet at the same time, they accept the government's surveillance of its citizens. For example, each city section has many surveillance camera installed monitoring the street. In one section, the community used government fund to install 48 surveillance camera to their neighborhood. It was enough camera to monitor a person walking down the street in multiple angles. In Taiwan, all cellphone conversations are recorded and stored away, yet people do not seem to object at such intrusion.

Also, while Taiwan has emerged from its totalitarian past, some government agencies still have not shaken off their big-brother attitude. There is a general lack of respect on citizens' privacy by the government official. Coupled by the rampant corruption, there was 6 major abuse of citizen's private information by the government agencies where they sold off information to the commercial firms from 9/01/2003 to 12/31/20031,4. On Jan. 15, 2004, fifteen days after the complete transition to the new IC card, police has uncovered a mafia run debt collection agency that purchased database entries from NHI employee2. Clearly the government agencies only paid lips services to their privacy pledge and very little enforcement.

A case for NHI IC card from the utilitarian perspective:

According to the utilitarian perspective, the ethical action is the one that provides the greatest goods for the greatest number, or produces the greatest good while minimizes the harm. Applying such standard, the government's decision to modernize the NHI system is an ethical action. Medical resource is finite. Any abuse or fraud will take away valuable resources from actually helping people. Any operation overhead is using up this valuable resource. NHI IC card is designed to detect and prevent fraudulent claims and abuses to minimize the waste on medical resource. And the technology used in the digital NHI card help improve the efficiency of the data tracking, thus minimize the operation overhead. Not only does the NHI IC card minimizes the waste on medical resources, it also increases the quality of the health care. With the extensive medical database that is available to the researches, the public health policy makers can easily find out about the current health trend and devise policies accordingly. It can also track the efficiency of certain medical procedures and make recommendation on the appropriate treatment for a particular diseases. These benefits are derived from analyzing the central medical database and will provide vast benefits to every Taiwanese citizens. Thus, NHI IC card maximizes the benefits citizen gets from the national medical resources by reducing misuses and overhead, and by increase effectiveness of the medical treatment.

The negative consequence of using NHI IC card is the risk of losing one's privacy. However, one should be careful when examining the potential for privacy abuse. Some of the privacy abuse is the result of current NHI IC card implementation while others are risks inherent to using a digital NHI card. An example of privacy abuse caused by current implementation is the viewing of embarrassing information, such as the last menstruation date, by the physicians. These type of privacy abuses can be stopped with changes in the implmentation-- e.g. using access control to prevent dentists from viewing patient's prenatal care information. Therefore, such complaints should be discarded. The attention of the debate should be focused on the risks that are inherent in using the digital NHI card: illegal access to the medical database.

When the database misused, the person's home and work address as well as the medical history are revealed. This can lead to physical harassment by the person who have access to the database. Or the medical history may be used against the person. In the US, the primary concern about revealing the medical history is that the victim will be denied proper medical insurance if he or she has known chronic diseases. In Taiwan, this will not be a problem because government provides the health care coverage to all eligible citizens regardless of his or her medical history. However, the medical history may be used by the employer to disqualify a candidates with poor medical conditions. In addition, the medical history may be publicized to embarrass the victim.

While it is impossible to avoid the potential for abuse, the risk for privacy loss can be significantly reduced by taking proper network security precautions, government vigilance and community watchdog groups. Therefore, it is possible to use the digital NHI card to produce concrete benefits to all citizens while the potential for abuse can be greatly minimize. Thus, Taiwanese government's decision to use digital NHI card is an ethical action only if it has a reasonable policy and security mechanism for preventing abuses. The recent scandal of NHI employee selling database to mafia indicates that Taiwanese government do not enough security mechanism in place to protect citizens' private personal data. However, the proponent of the NHI card should not be discouraged. It should be a viewed as an opportunity for the community and Taiwanese government to adapt their privacy policy and approach to better suit the future that will certainly be more reliant on the high tech solutions.

A case for NHI IC card from the rights perspective:

According to Rights approach, an action is considered ethical if it protects and respects the moral rights of those affected. Using this framework, the deployment of NHI digital card protects and strengths the right to medical care for majority of people because medical resource can be accurately and fairly distributed among the populous. It also protects the health care providers' right to conduct its business in a manner that is efficient and profitable. However, the right to privacy is been weakened. Some will argue that for small number of people their rights to medical care has been weakened as well due to the loss of privacy. For example, an AIDS patients' NHI card will indicate he or she is HIV positive. This information can be viewed by any health care provider. Since Taiwanese hospitals are known to discriminate against HIV patients, AIDS patients are guaranteed to be denied of quality health care. However, the discrimination is the result of Taiwanese culture and not because of the data revealed by the NHI card. Any major illness or handicap must be recorded on the NHI IC card for the benefit of not only the card holder, but the health care provider as well. A health care provider has right to a safe working environment. It is selfish for AIDS patients to advocate hiding his or her HIV infection. In an effort to get medical care, they are putting other people's life at risk.

Therefore the only major conflict is between the right to health care and right to privacy. Again using the same argument from the utilitarian analysis, there exists only a potential for right to privacy to be weakened. If the government and the community can devise a sufficiently secure mechanism to safeguard the data, the NHI IC card upgrade will be considered ethical.

Conclusion

Even though the NHI IC card has potential for abuse, a digital health insurance card is an inevitable future. It is too useful a tool in managing limited national medical resources to completely disregard it. However, the privacy issues raised by the community and academia should not be ignored either. And these privacy issues are not specific to the NHI IC card. The same privacy issues can be applied to every use of networked computer database. The NHI IC card merely thrust the privacy issues to the public lime light. It presents an excellent opportunity for Taiwan to examine its current policy on privacy and adapt it to a future that is increasing reliant on information technology.

Reference

"Mistake at National Health Insurance Agency-- 30,000 asthma patients record leaked", United News, Dec 25, 2003, A13.

"Another Mistake, medical information leaked from NHI to Mafia" , United News, Jan. 15, 2004, A1

National Health Insurance IC Card Information Page, http://www.nhi.gov.tw/IC_Card/english/main.htm

Citizen Personal Information Privacy Advocacy and Protection Group, http://www.tahr.org.tw/PDPA/index.htm

National Health Insurance Press Release, April 20, 2001, http://www.nhi.gov.tw/07information/News_detail.asp?News_ID=215

Understanding National Health Insurance IC Card, http://www.nhi.gov.tw/IC_Card/knowIC/knowIC1.htm

National Health Insurance Press Release, Dec. 18, 2003, http://www.nhi.gov.tw/07information/News_detail.asp?News_ID=391

National Health Insurance Research Database Content, http://www.nhri.org.tw/nhird/date_01.htm

Bureau of National Health Insurance Press Release, http://www.nhi.gov.tw/07information/News_detail.asp?News_ID=178

National Statistics Report No. 063, Executive Branch Accounting Office, April 9, 2001

National Health Insurance Major Illness and Handicap list, http://www.nhi.gov.tw/02hospital/hospital_5_01-1.htm
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