Should doctors be charging disadvantaged patients for sick notes?
Can’t you do something, Judge? This was the question I was asked in Drug Treatment Court last week. Unfortunately, my answer was “I tried. But I can’t seem to get these doctors to change!” The issue was doctors charging their patients for one line notes stating they had been ill and had been seen in their office.
I am the Judge who administers the Toronto Drug Treatment Court at Old City Hall. Clients – we call them clients rather than accused – are participating in a unique court specially designed to supervise cases of drug dependent offenders who have applied to receive treatment for their substance abuse as an alternative to repeatedly cycling through the justice system. The Drug Treatment Court (DTC) is premised on the belief that drug dependency is not simply a law enforcement/criminal justice problem but an overriding public health and societal concern. DTC’s shift the emphasis from legal to therapeutic. Treatment and judicial stakeholders work collaboratively to facilitate change in the lives of those whose conflicts with the law are influenced by their addictions. Using a holistic approach to rehabilitation and social development, stakeholders also work together to provide clients with the relevant supports, structure and access to resources.
Participants in the DTC programme are required to meet expectations that include attendance at individual and group therapy sessions and regular attendance at DTC to report their progress to the presiding Judge. The DTC requires that if the participants have not met their treatment or court attendance expectations due to illness or medical appointments that they provide a note from their health professional. The note must state that the participant attended at their office due to an illness or a scheduled appointment. The note need not be detailed – simply that he/she attended at the office on a particular date and can be signed by the receptionist if that is more convenient for the physician.
Almost all of our DTC participants have extremely limited financial resources. Most are supported through Ontario Works or the Ontario Disability Support Programme and as such have difficulty finding sufficient financial resources to house and feed themselves. There is nothing left over at the end of the month.
I wrote to the College of Physicians and Surgeons over a year ago and asked them what steps they were prepared to take to prohibit their member physicians from charging their patients who are in receipt of OW or ODSP, fees for these one line notes. I submitted that the College’s Policy #3-10 entitled “Block Fees and Uninsured Services” covered this situation. I noted that this policy states that the fees charged for uninsured services are to be reasonable and that I had difficulty believing that the College would consider a fee of $20 or more for a simple one line note to be reasonable, particularly when it is required from a patient of extremely limited or essentially no financial resources. My second submission was that according to the policy “patient decisions about payment for uninsured services must not negatively affect the physician-patient relationship or pose a barrier to accessing health care services”. I noted that participants in our programme who miss treatment appointments or court appearances and are unable to provide the necessary documentation risk sanctions or being asked to leave the programme. Since our DTC programme combines both the criminal justice and health care systems, the imposition of these fees acts as a barrier for our DTC participants in accessing health care services. I stated that in my opinion those physicians who were requiring a fee from indigent patients in these circumstances were contravening the College’s Policy #3-10. I asked for a response from the College as to their position on this situation and what action they might take to ensure that physicians comply with their policy.
I received a rather unsatisfactory response from Dr. Gerace, Registrar of the College of Physicians and Surgeons of Ontario thanking me for expressing my concerns and stating that the College responds to individual patient complaints or concerns. Our DTC clients are particularly vulnerable and are most unlikely to file individual complaints with the College. They are afraid to take any action that might affect the relationship with their physician. A number of them have had difficulty even finding physicians willing to take them on as patients.
Dr. Gerace did indicate that he was going to ask the editors of Dialogue to “work this issue up for an article in the publication”. I have yet to see any such article, but it is possible that one was published and they simply neglected to send me a copy. Surely, an article is not the answer. We have had to modify our practices in DTC, and now only ask for a doctor’s note if we feel in the circumstances it is absolutely necessary. I am certain we are not the only programme serving the poor and vulnerable in our society that requires a doctor’s note from time to time. The College’s Policy #3-10 may look good on paper; but, unless it is enforced by the College, it is of little benefit to those who need it most and who will be the last to complain.
In the words of our DTC client – “Can’t you do something about this, doctors?”
Mary Hogan is a Judge who administers the Toronto Drug Treatment Court.