Economic woes may ratchet up penalties for obesity, smoking

'Those who do not lose weight/stop smoking will be held accountable.'

Will employers facing soaring health care costs begin penalizing smokers or obese employees with higher premiums or surcharges?

"Employers are continuously looking at ways to cut costs, and this will continue to be the case," says Barbara Klinner, RN, BSN, CCM, LNC, CWC, director of business services at Marshfield (WI). "Costs of employer insurance premiums are impacted by employee health. Higher risk equals higher costs."

Smokers, for instance, have higher absenteeism rates and medical expenditures. "In recognizing these facts attributed to smoking, it's only natural that employers would seek similar correlation to other preventable health conditions," she says.

The downward trend of the economy makes the penalty approach more likely.

"As early as 2005, public and private sector employers were imposing additional fees for health insurance premiums for smokers," says Susan Kennerly, RN, PhD, associate professor and deputy director of the occupational health nursing program at the College of Nursing at University of Cincinnati (OH). "In some cases, policies were put in place requiring that workers be fired if they continued to smoke in violation of the company's policy."

According to the 2010 Hewitt Associates Incorporated survey of over 500 companies, risk factors such as body mass index are the focus of penalties for 17% of the companies. "The implication of obesity as a risk factor that impacts health and productivity has emerged more recently," she says.

Success is limited

However, "success of penalty-based programs is limited due to a variety of factors," says Kennerly. For instance, employee self-reports are usually used to determine whether someone is assessed a fee for smoking, and workers may be dishonest.

"In contrast, more successful incentive-based programs have been operated in which biometric tests were administered," she says. When this data is available on tobacco use, cholesterol, body mass index (BMI), blood pressure, and blood glucose, employers see increases in the number of employees with acceptable results.

"Over a five-year period, as much as a 25% savings in health costs has been reported," says Kennerly. "Consumer-based health plans are encouraging employers to get their employees more involved in the improvement of their own health."

While some workplaces currently implement penalties for their employees that smoke, primarily through higher insurance premiums, very few employers penalize obese workers for being overweight. "However, some states are leading the way — North Carolina, Alabama, and Arizona, for example — in charging obese state employees higher rates for health insurance," Klinner notes.

Incentives more appealing

Generally, incentives are viewed in a more favorable light by employees than penalties. "There is a tendency for people to measure what they are getting against what they are giving up," says Klinner. "Getting something is more palatable and well-received than being punished."

However, penalties can be represented as incentives. Klinner gives the example of an employer stating, "We wish to help you lead a healthy life and will be offering assistance in that regard. Those who do not lose weight/stop smoking will be held accountable for a specific surcharge on their insurance premiums."

It can be argued that in the case of an overweight employee who is penalized, BMI may not be an accurate measurement of true body fat.

"It does not account for a muscular body habitus," she explains. "Being overweight can also be the result of, albeit more rarely, a true medical condition. At what point do we limit the medical conditions on which differentiating premiums are based?"

For her part, Kennerly recommends these approaches:

• Use biometric measurements to objectively determine an employee's progress.

• Offer alternative incentives for employees who unsuccessfully attempt health behavior change.

• Set policies that prevent intrusion into the employee's personal life.

"There is a shift toward more programs with discounts for positive health behaviors, rather than surcharges for unhealthy habits or the presence of risk factors," she says.


For more information contact:

Susan Kennerly, RN, PhD, Associate Professor, Deputy Director of Occupational Health Nursing Program, College of Nursing, University of Cincinnati. E-mail:

Barbara Klinner, RN, BSN, CCM, LNC, CWC, Director of Business Services, Marshfield (WI) Clinic. Phone: (715) 847-3195. Fax: (715) 847-3868. E-mail: