Remember the company doctor and the company nurse?

They're back, but they've been outsourced -- not to India, but to outside firms that set up clinics in an office or factory.

What could be more convenient than dropping by the clinic to check on a sore throat, for antismoking counseling, or for a routine physical examination?

If employees become healthier and the staggering cost of health insurance declines, everyone wins, or so the theory goes.

But as companies do what they can to lower health-insurance premiums, they threaten to overstep traditional work-life boundaries, dictating how employees must behave even when they are off the clock.

"This is the crossroads of where we are now," said Frank "Bud" Martin, chairman of I-trax Inc., a Chadds Ford firm that sets up medical clinics and pharmacies for companies around the nation.

"Most people want to feel better, if you give them the tools, whether it's a nurse that's available on the phone" or nutritional advice, he said. "But what can you do to a person who doesn't follow your [medical] advice? Can you deny employment to someone who is overweight?"

Last year, a Michigan company did something just like that, firing smokers to reduce health-care costs. Locally, Montgomery County considered a similar move for its employees, but has since backed down, offering a smoking-cessation plan instead.

"It almost seems like a no-brainer to go down that road" of firing employees who engage in unhealthy behaviors, given that "health-care costs follow health risks," said Frank Alvarez, an employment-law partner at the national workplace law firm Jackson Lewis L.L.P.

"But there are significant legal obstacles. Equally important is that it goes to the heart of the employer-employee relationship," he said.

Alvarez spoke last month about the potential clash between employer and employees over workers' health behaviors at the Society of Human Resource Management's annual conference.

The title of his speech? "Eat Your Veggies, or Else!"

Companies have already done about as much as they can, said Sharon "Sherry" Tomlinson, outgoing executive director of the Penjerdel Employee Benefits and Compensation Association, a Philadelphia nonprofit group of area benefits professionals.

They have fiddled with plan details, shifted costs to employees, and crafted alternative ways to help workers fund their own health care, she said.

Now, more are examining wellness and disease-management programs.

Wellness programs promote exercise and healthy living. Disease-management programs lower costs by helping workers with chronic conditions such as diabetes or asthma stick to treatment plans and avoid expensive crises.

Common sense would dictate that healthy employees spend less time in hospitals, are absent less, and are more productive. But when companies fund these programs, they want to rely on more than common sense.

At Pitney Bowes Inc., the Connecticut-based provider of document-management services, medical director Brent Pawlecki has done the research.

"For every dollar we spend in wellness, we are able to get back $2 or $3 in health savings and productivity," he said.

But some executives "are not excited about spending more money on benefits that they aren't sure will generate the savings," said Arnold Katz, president of Brokerage Concepts Inc., of King of Prussia, a national health-insurance brokerage.

"Suppose we have an employee turnover of 22 percent," Katz said. "Let's assume we teach them how to give up smoking. Nine years from now, when they work for a different company, they are healthier. I spent all the money, but what did it save me?"

Still, more companies are adopting the programs. Mercer Human Resource Consulting found that, nationally, 67 percent of large employers used disease-management programs last year, up from 58 percent in 2004.

Some companies run the programs themselves through a medical department, some rely on their insurance companies, and others outsource programs to companies such as I-trax and WellNow, a new venture of Model Consulting Inc., an employee-benefits consulting firm in Trevose.

I-trax typically sets up doctor's or nurse's offices in larger facilities, such as L-3 Communications Holdings Inc. in Camden, which employs 1,200. WellNow provides less-expensive nurse practitioners for smaller firms.

WellNow and I-trax both market data-crunching software that analyzes employee health questionnaires compared with benchmarks to give the employer an overview of the health and productivity of its workforce.

"There are provisions out the wazoo to safeguard privacy," WellNow president Michael Rosenfeld said. The data "never gets to the company in individual form."

Companies can use the information to gauge the effectiveness of their wellness programs or even to select which programs would be most beneficial to employees.

Both I-trax and WellNow recommend using incentives to persuade employees to undergo health assessments, including blood tests, family histories, and questions about lifestyle such as seat-belt use.

Once an employee is found to have a health risk such as smoking or high cholesterol, a nurse or health coach may call to encourage him to begin a treatment program. Companies can request to be told whether a specific employee is in compliance with a program, though not which particular program.

The way employers use carrots or sticks in pushing participation in wellness programs is a developing area of law, said Alvarez, the employment lawyer.

The federal Equal Employment Opportunities Act, the Americans With Disabilities Act, and the Health Insurance Portability and Accounting Act offer guidance, but have conflicting provisions.

These days, benefits managers think hard about how to motivate employees to use benefits as varied as asthma advice and discounts at the local gym.

Some firms offer discounts in co-pays, contributions toward medical deductibles, or gift certificates to ball games. At Pitney Bowes' company cafeteria, salmon patties cost less than cheeseburgers.

At Paylocity, an Elk Grove Village, Ill.-based payroll-processing company, employees can lower their health-insurance contributions if they take steps to keep themselves healthy, such as undergoing routine testing and meeting goals for conditions such as high cholesterol and high blood pressure.

So far, most employers are not willing to punish employees for nonparticipation.

"It's messy," Rosenfeld said.

But given the strain of health-care costs, chief executives might begin to see more punitive measures as their "right and responsibility" as they "drive returns for shareholders" and work to keep their businesses financially healthy so jobs are secure, Martin said.

Companies may start telling employees, "You can't continue to work here unless you change," Martin said.