That’s especially true for managing the health of employees’ adolescent children. Most of the attention goes to pre-natal and early childhood care. But a host of serious medical issues typically emerge during teenage years.

Physical issues

It’s every bit as important for employees’ adolescent dependents to undergo complete health assessments as it is for employees’ themselves. This is especially true for weight management issues.

There has been an epidemic rise in overweight and obese adolescents, which can contribute to (or worsen) a variety of physical and/or behavioral health problems.

Remember: These issues can create large-scale direct costs (treatments for the teenager) and indirect costs (absenteeism and/or presenteeism by the parent(s) who work for you). Other crucial factors:

• immunizations (shots or vaccines) to reduce the risk of getting diseases such as hepatitis, meningitis, tetanus and mumps
• preventive health counseling and age-appropriate health information (e.g., drug and alcohol abuse, sexually transmitted diseases)
• vision and hearing tests, and
• blood-pressure screening (especially if there’s a family history of high blood pressure).

Psychological issues

Regular physician visits provide an opportunity to discuss emotional changes and other challenges that most adolescents experience. In some cases, it’s also a front-line means of referring teenagers-in-need to behavioral counseling.

Remember: Proactive care greatly reduces the risk of a host of chronic and debilitating conditions. It can even be a life-safer in extreme cases.

Even if it’s not in the budget, you can adopt some of the newer employee education techniques used in successful plans.

What’s out: Harping on the message that smoking causes lung cancer, emphysema, etc.  Virtually every smoker knows the risks by now. That doesn’t mean you should ignore the issues of smoking and serious health conditions, but it shouldn’t be the only focus.  

What’s in: The employee education trend has moved toward teaching people strategies to overcome the barriers that keep them from quitting.

Common barriers

The Agency for Healthcare Research and Quality recommends that before smokers try another cessation attempt, they look at past quit attempts – what helped and what led to relapse. Three common relapse triggers:

• social drinking. Many smokers get their strongest cigarette cravings when they’re in social situations that involve drinking alcohol.
• smokers at home. Having other people in the household who smoke in the employee’s presence greatly reduces the chance of a successful quit attempt, and
•  the weaning approach. While some people can quit gradually, those who go cold turkey are usually better off once they get through the first few weeks of discomfort.

Identify non-health benefits

Your employees’ doctors likely already review the health benefits of quitting with their patients.
While it’s good to provide info that supports this message, you may want to make your focus the non-health rewards of quitting.

Example: Show smokers how much money they can save by quitting. Multiply the cost of a pack of cigarettes by the days or weeks of the year. Then add the cost difference between your health plan’s premiums for smokers and non-smokers.

One final step: Encourage people to set a personal “quit date,” preferably within two weeks. Many people respond best to deadlines – even when the deadlines are self-imposed.

But a Duke University shows that the group you might think would be the least likely to quit – people over the age of 50 –  may actually have the best odds for quitting through a smoking cessation program.

Researchers tracked 573 older patients over 10 years. They found that just 16% of those who joined the smoking cessation program later returned to smoking.  Meanwhile, previous research has found young smokers who try to quit have a 35% to 45% relapse rate within two years.

Bottom line:  Given the aging employee population and the cost of retiree health care, you may want to keep trying with smoking cessation education for your older employees.

For the most part, however, wellness programs have remained an outsourced service. Three reasons:

• Experience. The outsourced vendors are the ones who have the expertise, know how to administer the plan, and know how to communicate it to your employees. 
• Employee trust. Many times an employee will be much more candid with a wellness coach about his or her health and wellness problems and fears than they’d be with someone who’s a representative of the company, and
• Legal protection. Outsourcing wellness helps insulate you from later claims that the company disciplined an employee due to health risk factors. When you outsource, your company can prove it wasn’t privy to the details of employees’ confidential medical information.

Are there any employers for whom it makes sense to keep the wellness program in-house? Yes. Hospital systems are the most common candidates for in-house administration.

In this work setting, there may already be internal wellness people and they might be very, very good at what they do. In addition, there’s already a well-defined system in place for protecting people’s private health information, and employees are familiar with HIPAA’s disclosure rules.

That’s all changed, with the rules established last year by the DOL and U.S. Treasury Department. The rules themselves haven’t changed, but they’ve been clarified. Here’s what you need to know:

‘Participation incentives’ are fine

As long as you structure incentives as rewards for wellness participation, the new rules provide a lot of freedom. All of these are fine under HIPAA:

• reimbursing all or a portion of the cost of fitness club membership
• financial rewards for undergoing health risk assessments so long as the reward is based on participation rather than test results
• encouraging preventive care by waiving co-pays or deductibles for these services (i.e., well-baby visits or prenatal care)
• reimbursing employees for the cost of smoking-cessation programs without regard to the result, and
• offering rewards tied to employees attending a monthly health education seminar or working with a health coach.

Conditional rewards OK if…

But what if you want to make the reward conditional on participants meeting specific health goals? Example: Employees who achieve a cholesterol count under 200 get a 20% reduction in the cost of their health plan contributions pending results of an annual cholesterol test.

The feds say it’s OK under HIPAA to do this, too, but your plan must meet five additional requirements:

• The reward can’t exceed 20% of the cost of employee-only (or, if you allow dependents to participate, employee-plus-dependent) coverage under your health plan.
• The standards must be reasonable (e.g., you can’t limit rewards to folks who can run a marathon). The rewards also can’t be used as a backhanded way to negatively single out certain employees (e.g., rewards for all non-diabetics).
• Participants must have the opportunity to qualify for the reward at least once per year (e.g., a smoker who fails to quit this year gets another chance next year).
• Rewards must be available to all “similarly situated individuals.” In other words, you can’t make a company-paid weight management program available to certain employees but not others.

If, for medical reasons, it’s unreasonably difficult for an individual to satisfy conditions that are otherwise reasonable, you must offer an alternative. Example: A pregnant employee may not be able to meet certain standards, so you must offer her an alternative.

Negative incentives violate HIPAA

So what’s not allowed under HIPAA’s non-discrimination rules? Anything that punishes people for their health conditions or health risks.

The rules prohibit employers from charging different premiums, contributions, co-pays or deductibles based on personal health factors such as obesity or smoking. However, it’s OK to reimburse these expenses based on someone’s participation in your wellness program, without regard to success.

In addition, the feds have added an important new non-discrimination rule: Employers’ health plans can’t deny benefits for treatment of injuries resulting from a medical condition, even if the condition wasn’t diagnosed before the injury.

For instance, some health plans have a “suicide exclusion” that denies payment for treating self-inflicted wounds from a suicide attempt.

Now let’s suppose the employee suffers from clinical depression. Even if the depression was undiagnosed prior to the suicide attempt, it’s illegal for your plan to deny benefits to this employee.

Walking programs are the most effective way, according to a presentation at the American College of Sports Medicine. The reason: Programs with small, achievable exercise goals are more effective in helping sedentary adults start (and stay with) fitness programs than those with more challenging fitness goals.

Researchers conducted an eight-week study of adults who said they hated to exercise. One randomly chosen group of men and women were given relatively tough-to-reach fitness goals. The other was put on a less-strenuous walking program.

Across the board, the latter group demonstrated better fitness levels at the end of the program, because they stuck with their programs.

Pedometers boost interest

Walking programs work even better when participants use pedometers. Reason: Pedometers are a simple, non-invasive (and low-cost) way for people to increase their awareness of their daily activity and improve their overall fitness level.

In fact, the majority of folks who participated in the research project said they planned to continue wearing the device after the study was over.

There are a variety of pedometers on the market. Some tips from your colleagues on choosing the right device for employees:

• the simpler and cheaper the item, the easier it is to use and replace
• if you want to go more upscale but are worried about the price, consider asking participants to pay a portion of the cost, and
• consider practicality. For instance, pedometers with straps often work better than “pocket pedometers.”

Many employers overlook community-based health resources available to employers for free or at minimal cost. In some cases,  it’s a great way to supplement services that aren’t offered in your wellness vendor’s plan.

Examples: Some local branches of the American Heart Association offer free or nominal cost blood-pressure testing. The American Cancer Society can provide referrals to dermatologists who offer onsite skin cancer screenings at little or no cost to an employer. Some nonprofit men’s health groups can direct employees to low-cost prostate cancer screenings.

Even if onsite screening services themselves aren’t available to your employees, the agencies are almost always be happy to provide educational literature for employees about why they should get screened for certain health risks.

Just for the asking, you can build up a library of wellness education materials.

A new study in the Journal of Occupational and Environmental Medicine (JOEM) finds that employers can save money by having overweight employees participate in a weight-management program over the phone.

How it works: Your firm contracts with a telephonic health provider.

The service will call enrolled employees as many as five or six times per year to offer counseling. The study found that most employees lost weight. And one firm participating in the study saved an estimated $311,755 between lower premiums and reduced health claims.

In order to be effective, the program must meet participants’ individual medical and psychological needs, not to mention your own organization’s need to control long-term health costs.

How wide-reaching should the program be? After all, it doesn’t make sense to pay for services your employees don’t want or can’t use.

Mary Beth Chalk of Resources for Living suggests that obesity programs can be broken down into four tiers of employee need, from which your organization’s return on investment (ROI) can also be measured.

Tier 1: Education

Tier I employees struggle with weight management problems but don’t need a health coach.  Instead, they may benefit from a self-directed program that provides weight-management related materials online, targeted mailing, and/or access to nurse call line.

How to measure ROI: utilization. Do employees click on the Web site? Do they return to the site regularly? Do people use the nurse line? Your program vendor should provide you detailed use stats.

Tier 2: Clinical supervision

If the employee has been diagnosed as obese — a body mass index (BMI) score over 30 is obese, over 35 is clinically obese — he or she would do better working with a health coach in a clinically supervised program.

Three keys to getting maximum results:

1. Periodically have participants rate their relationship with their health coaches. Not everyone clicks, so a change may be in order.
2. Coordinate your disease management care with your employee assistance program (EAP)services. Reason: Inability to control weight is often closely tied with mental health issues — and one can negatively affect the other. The more closely your EAP and obesity program managers work together, the higher the chance for success.
3. Beware of the fade-out effect. Many employees in weight-loss programs get off to a great start and then fall back into old habits. People should re-commit to the program after three sessions, four months and nine months.

To measure ROI, look at utlization, goal achievement and reduced presenteeism. Of course, presenteeism is notoriously difficult to measure with reliable dollar figures. So how can you overcome that problem?

• Start with employees’ salaries. Let’s suppose one participant earns $40,000 per year.
• Ask workers to self-report how energetic and productive they feel on the job, on a percentage scale. Then have supervisors estimate the employee’s productivity and split the difference. For this example, let’s assume it averaged to 50%.
• Collect scores again six months and one year into the program and then multiply the difference by salary. The result is your estimated productivity ROI.

In the example above, if the employee earning $40,000 improves from 50% to 75% after one year, the productivity related ROI is $10,000.  

Tier 3: Medical management

At this level, the obese employee needs a higher level of care than a health coach can offer. The employee has chronic health conditions related to obesity — such as diabetes, high blood pressure, and/or sleep apnea — and needs a physician case manager. Specifically, the employee needs to set up regular visits with the doctor and create a treatment plan.

To measure ROI, start with the lower-tier criteria, then track quarterly and year differences in FMLA or paid absences, and prescription drug costs. Then compare it to the per-participant cost of the obesity program.

Tier 4: Morbid obesity

At this level, the employee has been diagnosed as morbidly obese — BMI over 40 — and is considered a potential candidate for gastric bypass surgery.

ROI is measured through ongoing health claims as well as the previous criteria.

In Washington, lobbyists have spearheaded a push for Congress, the DOL and IRS to crack down on “punitive” wellness programs.

Specifically, the groups seek to limit programs in which employees’ share of their health costs are directly tied to their willingness to participate in a wellness program.

HIPAA’s non-discrimination rules prohibit employers from creating negative financial incentives for workers with health risks. 

For instance, you can’t raise someone’s premium share because he or she smokes. What you can do is offer a discount if someone completes a smoking cessation program.

Reason: The law does allow for financial incentives to workers who willingly participate in wellness programs.

The watchdog groups seek greater regulation to make sure incentives and discounts are used only as rewards for healthy behavior, not as a thinly veiled form of discrimination against high-risk employees.