N.J. State Program Mandates Free Annual Checkups

A new state program that went into effect this month requires HMOs and health insurance plans to provide free, comprehensive annual physicals to millions of New Jersey adults.

The New Jersey Health Wellness Promotion Act, described as the first of its kind in the nation, requires many insurers to provide a 17-point “Healthful Life Program” aimed at encouraging more healthful living and catching problems early.

Already, creator Dr. Donald B. Louria of the University of Medicine and Dentistry of New Jersey is working to bring his program to New Jersey residents in plans exempt from the law--and to the rest of the country.

“If we can effectively implement it, it could be a model for the nation,” said Louria, chairman emeritus of the university’s department of preventive medicine and community health. “We’re going to start a push for this to be national policy immediately.”

The program, covering those 20 or older, includes periodic, standard tests to detect cancer, diabetes, heart disease, anemia and glaucoma.

A physician or nurse practitioner also must counsel patients on such topics as breast or testicular self-examination, smoking cessation, weight control, seat belt use and back-strengthening exercises. The most unusual feature is a consultation allowing patients to discuss any health concerns.

“For every dollar you spend, you save two dollars” in future health care costs, Louria predicted.

Dr. Mohammad Akhter, executive director of the American Public Health Assn., said the program is “really revolutionary.”

“This will be very good for patients and for doctors too,” because they can catch more illnesses early, when they can help patients more, Akhter said.

Louria, a Harvard Medical School-trained physician, spent two decades fine-tuning his program, determining which types of screening tests and health counseling have been proved to promote health. It took him an additional decade to persuade state government to mandate the program.

The first legislation, signed by then-Gov. James J. Florio in 1993, never took effect because health plans tried to make it a rider to policies--and charge extra. An amended version, sponsored by Republican state Assemblyman John Kelly, required the program to be part of basic coverage. That became law Nov. 6.

While health plans initially opposed the mandate, Louria said, they supported it when a later version set caps on what the physical could cost. This year, it will average $220. The state will adjust that in coming years, based on inflation, and an advisory board made up of Louria and two other experts will regularly review new scientific evidence for possible changes to the program.

Susan Pisaro, spokeswoman for the American Assn. of Health Plans, a managed care trade group, said members generally cover many tests and services in the program and may add more.

“The whole idea behind managed care is to prevent what is preventable and to screen, detect early and treat comprehensively what is not,” she said.

But Louria noted that the services are generally not provided as part of a routine physical examination. Studies have shown a low percentage of patients in some health plans actually get recommended screenings.

“What’s good about this is that it looks at prevention as a package and it recognizes the need for some counseling services,” said Dr. David Atkins, staff director of the U.S. Preventive Services Task Force. Doctors “don’t have the extra five minutes to talk about smoking or diet because they’re not getting paid for that time.”

Atkins said the task force recommends most of the same tests and counseling as the New Jersey program.

The task force, an advisory board of preventive medicine and primary care experts overseen by the federal Agency for Healthcare Research and Quality, issues preventive health guidelines endorsed by many health plans and medical groups.

The New Jersey law requires the annual “tuneup” for adults in a commercial HMO, preferred provider organization, or a traditional, fee-for-service insurance plan. Those plans cover about 3.7 million New Jerseyans, including children and adolescents not affected by the law.

For various reasons, other health plans covering more than 4 million New Jerseyans are exempt from the law, said Peter Hartt, spokesman for the state Department of Banking and Insurance. Those include such federally regulated plans as Medicare, Medicaid and “self-insured” plans funded directly by a company, and plans purchased by individuals or by businesses with 50 or fewer employees.

Medicare and Medicaid already provide many benefits in Louria’s program, and Medicare and Medicaid HMO plans may be subject to the law, Hartt said.

A Web site explaining the program, summarizing recent medical research and critiquing advertising claims for food and nutritional supplements will debut Jan. 1.