By Sharon Begley

NEW YORK (Reuters) - U.S. companies are increasingly penalizing workers who decline to join "wellness" programs, embracing an element of President Barack Obama's healthcare law that has raised questions about fairness in the workplace.

Beginning in 2014, the law known as Obamacare raised the financial incentives that employers are allowed to offer workers for participating in workplace wellness programs and achieving results. The incentives, which big business lobbied for, can be either rewards or penalties - up to 30 percent of health insurance premiums, deductibles, and other costs, and even more if the programs target smoking.

Among the two-thirds of large companies using such incentives to encourage participation, almost a quarter are imposing financial penalties on those who opt-out, according to a survey by the National Business Group on Health and benefits consultant Towers Watson (For graphic see http://link.reuters.com/byr73w)

For some companies, however, just signing up for a wellness program isn't enough. They're linking financial incentives to specific goals such as losing weight, reducing cholesterol, or keeping blood glucose under control. The number of businesses imposing such outcomes-based wellness plans is expected to double this year to 46 percent, the survey found.

"Wellness-or-else is the trend," said workplace consultant Jon Robison of Salveo Partners.

Incentives typically take the form of cash payments or reductions in employee deductibles. Penalties include higher premiums and lower company contributions for out-of-pocket health costs.

Financial incentives, many companies say, are critical to encouraging workers to participate in wellness programs, which executives believe will save money in the long run.

"Employers are carrying a major burden of healthcare in this country and are trying to do the right thing," said Stephanie Pronk, a vice president at benefits consultant Aon Hewitt. "They need to improve employees' health so they can lead productive lives at home and at work, but also to control their healthcare costs."

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But there is almost no evidence that workplace wellness programs significantly reduce those costs. That's why the financial penalties are so important to companies, critics and researchers say. They boost corporate profits by levying fines that outweigh any savings from wellness programs.

"There seems little question that you can make wellness programs save money with high enough penalties that essentially shift more healthcare costs to workers," said health policy expert Larry Levitt of the Kaiser Family Foundation.

FOUR-FIGURE PENALTIES

At Honeywell International, for instance, employees who decline company-specified medical screenings pay $500 more a year in premiums and lose out on a company contribution of $250 to $1,500 a year (depending on salary and spousal coverage) to defray out-of-pocket costs.

Kevin Covert, deputy general counsel for human resources, acknowledged it was too soon to tell if Honeywell's wellness and incentive programs reduce medical spending. But it is clear that the company is benefiting financially from the penalties. Slightly more than 10 percent of the company's U.S. employees, or roughly 5,000, did not participate, resulting in savings of hundreds of thousands of dollars.

Last year, Honeywell was sued over its wellness program by the Equal Employment Opportunity Commission. The EEOC argued that requiring workers to answer personal questions in the health questionnaire - including if they ever feel depressed and whether they've been diagnosed with a long list of illnesses - can violate federal law if they involve disabilities, as these examples do. And, if answering is not voluntary.

"Financial incentives and disincentives may make the programs involuntary" and thus illegal, said Chris Kuczynski, an assistant legal counsel at the EEOC.

Using the same argument, the EEOC also sued Wisconsin-based Orion Energy Systems, where an employee who declined to undergo screening by clinic workers the company hired was told she would have to pay the full $5,000 annual insurance premium.

SICK? PAY MORE.

Some vendors that run workplace wellness for large employers promote their programs by promising to shift costs to "higher utilizers" of health care services, according to a recent analysis by Joann Volk and Sabrina Corlette of Georgetown University Health Policy Institute - and by making workers "earn" contributions to their healthcare plans that were once automatic.

Consider Jill, who asked that her name not be used for fear of retaliation from the company. A few years ago, her employer, Lockheed Martin, provided hundreds of dollars per year to each worker to help defray insurance deductibles. Since it implemented its new wellness program, workers must now earn that contribution by, among other things, quitting smoking (something non-smokers can't do) and racking up steps on a company-supplied pedometer.

"Basically, if you don't participate in these programs, you have to pay something like $1,000 out of pocket for healthcare before insurance kicks in," said Jill.

Companies insist the penalties are not intended to be money-makers, but to encourage workers to improve their health and thereby avoid serious, and expensive, illness.

As evidence of that, said Honeywell's Covert, the company offers employees "easy ways to get out of" some of the wellness requirements, such as certifying that they do not smoke rather than submitting to a blood test.

BALANCING THE WELLNESS BOOKS

Why are companies so keen on such plans?

Most large employers are self-insured, meaning they pay medical claims out of revenue. As a result, wellness penalties also accrue to the bottom line.

About 95 percent of large U.S. employers offer workplace wellness programs. The programs cost around $100 to $300 per worker per year, but generally save far less than that in medical costs. A 2013 analysis by the RAND think tank commissioned by Congress found that annual healthcare spending for program participants was $25 to $40 lower than for non-participants over five years.

Yet at most large companies that impose penalties for not participating in workplace wellness, the amount is $500 or more, according to a 2014 survey by the Kaiser foundation.

"For economic reasons, most employers would prefer collecting the penalties," said Al Lewis, a wellness-outcomes consultant and co-author of the 2014 book "Surviving Workplace Wellness."

Lori, for instance, an employee at Pittsburgh-based health insurer Highmark, is paying $4,200 a year more for her family benefits because she declined to answer a health questionnaire or submit to company-run screenings for smoking, blood glucose, cholesterol, and blood pressure. She is concerned about the privacy of the online questionnaire, she said, and resents being told by her employer how to stay healthy.

Highmark vice president Anna Silberman, though, doesn't see it that way. She said the premium reductions that participants get "are a very powerful incentive for driving behavior," and that "people deserve to be rewarded for both effort and outcomes."

(This version of the story corrects name, Lorin Volk, in 16th paragraph, to Joann Volk)

(Reporting by Sharon Begley. Editor: Michele Gershberg and Hank Gilman)