 
January 15, 2002
Director Re: Notice of a new system of records, Federal Register 12/6/01. To the Director: The Association of American Physicians and Surgeons (AAPS), a nationwide organization of physicians founded in 1943 to preserve private medicine, objects to this proposed collection of private information on individuals under one system for the following reasons: 1. Data will be entered without individual consent. In contrast to the situation involving information collected by private organizations, individuals have no meaningful way of avoiding participation in the system by declining to enroll. All persons eligible for Medicare must enroll in Medicare Part A as a condition for receiving the Social Security benefits to which they have been required to contribute throughout their working lives. Moreover, the federal government has totally preempted the field of medical insurance. There is no alternative form of insurance available. 2. It is quite likely that individuals would refuse consent, if they were fully informed and had that opportunity. The database will make their private information readily available for activities to which they might object or which might be contrary to their own best interest. Such uses include: nonconsented research; collection of IRS penalties; determining an individual's competence to manage his own affairs; supporting litigation (on the side of the government); supporting capitation (a payment methodology that many find to be unethical because of the inevitable conflict of interest between patients and "providers"); nonconsented disclosures to other insurers or to employers; and the facilitation of third-party intrusion into medical decision-making in the name of quality control or for outright rationing. Note that the list of potential uses is not exhaustive; it "includes, but is not limited to" the itemized purposes. 3. Affected individuals - all current and future Medicare beneficiaries-have not had the opportunity for reasonable notice and comment. The short period permitted for comment spanned the Christmas/New Year's season. The comment period should be extended for 90 days. 4. While various requirements are given in order to prevent unauthorized use of data, there are no penalties for violations. Thus, while there are tremendous financial incentives to gain access to personal medical data, these rules provide no significant measures to deter such access. Yet, government databases have frequently been unlawfully penetrated and misused in the past. 5. Prominently absent from the list of laws to which the database is supposed to conform is mention of the Health Insurance Portability and Accountability Act. Why should not the highly touted advantages of this Act be extended to Medicare beneficiaries? Surely CMS should set an example of compliance and demonstrate for all the purported benefits of administrative simplification. 6. No method is cited for determining who will be authorized to have access to this data set; for challenging such determinations; or for guarding against conflicts of interest. 7. No audit trail is provided for citizens to see who has accessed their data and for what purpose, although CMS intends to force such a tracking requirement even on very small offices with far less resources (and far fewer inducements to abuse the data) than CMS. For these reasons, we strongly object to the centralized data collection on individuals who do not give their fully informed consent. Thank you for your consideration.
Jane M. Orient, M.D.
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