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?”

The comments section is closed.

  • Chris Houston says:

    A month has passed since the author posted onto Healthy Debate telling the medical community what she thinks they should do. And yet, the author appears to have not replied to a single comment or entered into the debate. What’s the point of posting an article to a site called Healthy Debate if you don’t want to debate it.

  • Mat Rose says:

    Trying to get an organization to change is rarely a speedy process. Focus on practical solutions. I’m sure your clients, just like the DTC clients in Alberta, are generally connected with physicians–usually those working with inner city or marginalised populations. Establish a relationship with those physicians who are willing to work with you, and who are happy to provide a simple service that contributes significantly to an individual’s wellbeing, the smooth function of an institution that is trying to contribute positively to social change (the DTC, if anyone’s not clear on that), and that costs them nothing. Any physician who makes the claim that not charging DTC clients for sick notes—or anyone for sick notes–will affect their income in any significant way needs to provide a legitimate, supportable argument. I have yet to hear one.
    As a primary care physician, it is my responsibility to provide what people need to be well, or at least better, or at least not as harmed. I try to keep my head out of my wallet most of the time.
    And I do agree that the DTC needs to change its policy about who determines legitimate illness and how that is verified. I agree that it’s not necessary, at least not in general.

  • scott wooder says:

    Dear Judge Hogan

    Why don’t you pay? I don’t mean personally, but why isn’t this a line item in your budget?

    There are 2 possibilities. The note may have value to you, in which case $10 or $20 dollars is a bargain for a professional assessment and documentation. Or the note has no value in which case one wonders why it’s needed.

    Doctors don’t want people with minor viral infections in their offices. It exposes high risk patients to needless risk and it clogs up the booking system. For every patient I see who is in my office just to get a note it means I see one less person with a medical need.

    I understand that you deal with a vulnerable population. In my office such a person would not be charged for a note. But for other physicians I understand why they bill for a professional service. It’s what they for a living. Every time they give it away for free, it devalues them and makes it harder for them to make the point that our “free” health isn’t free.

    Hire a Nurse Practitioner or a Physician Assistant to police illness in your program or attach a fee for a doctor’s note but please don’t blame doctors for a poorly thought out program.

  • stopmakingsense says:

    Scott and Rob, there’s a whole field of medicine devoted to addictions. Docs in that field would not consider such assessments “medically unnecessary” – rather they’d point out that they introduce accountability for patients who badly need it. These are patients whose disease has led them to commit crime – taking them at their word would be pretty naive. The medicine here goes beyond the virus – see the bigger picture.

    • Atul Kapur says:

      The situation the Judge is referring to is not the medical visit to assess the addiction. It is a “sick note”. %featured%The bigger picture is that sick notes are a way of policing absenteeism but the third-party that is using it that way (whether it’s an employer or, as in this case, the DTC) is downloading the costs onto the healthcare system and onto the doctor. This shouldn’t be paid for by the patient, but by the third-party.%featured%

      I am pleased to hear in the penultimate paragraph that the DTC has modified its policy somewhat, but not that they had to be dragged, whining all the way, to do so; that they still think it’s someone else’s problem to solve; and that they still haven’t stepped up to their responsibility to pay for what they’ve requested.

      • KM says:

        wow this responsibility assigngment and avoidance game is so entrenched in the culture of legal liability and “risk management” that every time I see arguments like this it is a **head slapper** for those truly in the trenches of community development work and ground level, local infrastructure and prosperity development advocates. We need more aknowledgement for people driving ownership, community and personal accountability for civic engagement and pride in a communitarian approach toward *all* citizens.
        “Never doubt that a small group of thoughtful, committed citizens can change the [their] world; indeed it’s the only thing that has.” M. Mead
        The inherent desire for a disembodied institution to maintain status quo by not examining its disfunction is rampant with its increasing layers of protection generates quagmire. Oppose quagmire; try engaging problem solving by seriously respecting and integrating the lived experience insights that come from that. Compare the successes of personal empowerment and leadership to such lipservice as “writing an article” to their own about their own disengagment.

    • KW says:

      Well said stopmaking cents

  • Chris Houston says:

    Hi Mary, if you are the one demanding that people produce notes, why don’t you pay for them? Maybe an easy solution?

  • Rob Sargeant says:

    The solution to this is pretty obvious – change the policy of the Drug Treatment Court to allow clients to be taken at their word – and leave the doctors out of it.

  • Scott Wooder says:

    Her’s a solution Judge.

    The Drug Treatment Court should pay for the note and for any medically unnecessary assessments.

    As a third party who is in effect downloading costs for the Ministry of the Attorney General to the Ministry of Health, you should be prepared for something you see as having value.

    We can talk another time about the dangers of you forcing your clients with viral illnesses to sit in my waiting room with vulnerable children, pregnant women an immun-compromised patients.


Mary Hogan


Mary Hogan is a Judge who administers the Toronto Drug Treatment Court.

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