A Health Ombudsman for D.C.?

Troubled three years ago by a decline in his physical energy, which he blamed on his Parkinson's disease, Perry Cohen wanted a referral to a neurologist. But his health insurer, Kaiser Permanente, said no, ruling that the 56-year-old Friendship Heights resident needed treatment for depression instead.

Kathy Joyce, who also lives in the District, spent this summer pleading her case for a month's supply -- five pills -- of the fertility drug Clomid. But her insurer, CareFirst Blue Cross Blue Shield, denied the 42-year-old's request.

Both Cohen and Joyce eventually got the treatment they wanted, but only by paying for it themselves -- $250 for Cohen and $69 for Joyce. Both could have used a health care ombudsman to help make their case. They may soon get one. A bill introduced in the D.C. Council last week would create an ombudsman in the city's Health Department to advocate for District residents with or without insurance.

Maryland, Virginia and 18 other states have health insurance ombudsmen -- government-paid intermediaries to help consumers navigate the heath care system. In the District, though, consumers have had to fend largely for themselves. A recent survey by the nonprofit health advocacy group Families USA showed one in four District residents don't know where to turn for help in resolving a health insurance problem.

With government awash in red ink, though, adoption of the proposal budgeted for $500,000 a year is not assured, observers say. The legislation is now before the Council's Committee on Human Services, which may hold a public hearing by year's end.

Cohen, for one, would like access to such a resource. "I had to learn the right language to use within the system," he says. "If you know how to advocate for yourself, you can do it, but it's not easy. And if you're sick it makes it harder. An advocate would have helped."

Grading Insurance Plans

It's report card time again. Check out the Web site of the Maryland Health Care Commission, www.mhcc.state.md.us, or call 877-245-1762 for a free copy of the 2002 Consumer Guide to Maryland HMOs and Point of Service Plans or the 2002 Guide to Maryland HMOs and POS Plans for State Employees.

On member-satisfaction surveys contained in these reports, small plans Delmarva and Coventry outscored big carriers such as Aetna, CareFirst's Bluechoice, Cigna and Preferred Health Network. For additional sleuthing, check out ratings of Washington area health plans by the National Committee for Quality Assurance, a nonprofit health care accreditation group. To see the report, go to www.ncqa.org.

-- Melody Simmons

The System welcomes reports from patients, providers, insurers and others about the delivery of health care. WE CANNOT ADVOCATE ON BEHALF OF INDIVIDUALS PURSUING CLAIMS OR COMPLAINTS. But we are looking for patterns of problems and excellence that may direct our reporting. By e-mail: thesystem@washpost.com. By U.S. Mail: The System, Washington Post Health Section, 1150 15th Street NW, Washington, DC 20071. Include name and phone number; no phone calls, please. We can't guarantee a response or return of submissions; do not send original documents.