Employers should have to foot the bill for mandatory sick notes

Doctors send invoices to insurance companies or lawyers all the time for things not covered by provincial health care plans. This would be no different.

There are social and financial costs to mandatory sick notes. Employers should have to pay them

A doctor writes a note on an Rx pad.
Doctors send invoices to insurance companies or lawyers all the time for things not covered by provincial health care plans. This would be no different. (Getty Images)

The issue of employers requiring doctors' notes for minor illnesses has been hotly debated for years. Medical associations are strongly opposed to the practice, and according to a recent Ipsos poll, 70 per cent of Canadians agree.

While doctors' notes can be important when there is a major medical condition requiring workplace accommodation, a significant number of notes are written to excuse absences for minor illnesses. This is widely acknowledged to be an employee management strategy, a way to reduce absenteeism by forcing the worker to "prove" his or her illness.

As any physician who's written a note for a minor illness can tell you, we don't perform sophisticated medical tests to verify a cold.

Going to the doctor for a note is used as disincentive to calling in sick — but not because medical expertise is needed for colds or minor stomach bugs. Simply reporting a few of the typical symptoms of one of these infections will invariably result in a note as requested. Doctors are not applying clinical skills to benefit patients in these cases (our medical advice would be to simply stay home); rather, we are unwilling participants in the workforce management strategy of employers.

Bureaucratic costs  

These types of sick notes are problematic for multiple reasons. The requirement to see a physician takes up an appointment spot that could otherwise be used for a real medical need, not something for which the best health advice is to spend a day or two in bed. In addition, the cost of the medical assessment is paid by our increasingly overstretched public health care system. 

The cost for the paperwork itself is not covered by provincial medicare plans, so that is either billed to the patient or else absorbed by the doctor. But most importantly, acute infections like colds and stomach bugs are highly contagious, so it's a significant public health risk to force employees to sit in clinic and hospital waiting rooms, places that contain some of the most medically fragile people in our society.

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'Sick leave abuse'

Employers and supporters of mandatory doctors' note policies point to the problem of "sick leave abuse," which is reported to cost billions per year in Ontario in productivity loss. Yet nowhere in our health care legislation is there a requirement for public health care resources to be used as cost-cutting tools for private employers. That's why we should consider putting the financial onus back on the employer — in other words: billing employers when their employees go to the doctor for sick notes. 

What typically happens when you go to the doctor for a sick note is that the physician will bill medicare for the visit, and the patient will get billed for the sick note itself (or the doctor waives the fee for the note). Really, what should  happen is the doctor sends an invoice to the employer for both the visit and the note. We send invoices to insurance companies or lawyers all the time for non-medicare-covered services (usually to write a medical opinion or complete insurance forms), so this would follow the same idea.

Certainly there are situations in which communication between the workplace and the employee's physician is important for the health of the employee. Those are truly the only times when public health care funding can justifiably be used for doctors' notes.

And, if anything, we should see private employers as accountable for the societal costs of increasing the spread of infectious disease and taking up appointment and waiting room space in our already overburdened system.

Mandatory doctors' notes are just one management tool available to reduce the cost of absenteeism. Other strategies include workplace changes that improve morale, providing paid sick leave and allowing work-from-home flexibility. Large employers could also hire private health care staff, like a company nurse. 

Another option would be for employers to pay into a fund similar to the provincial workers' compensation boards, which reimburse health care providers directly for services rendered to injured workers. 

We don't have a comprehensive picture of the public health costs stemming from mandatory doctors' note policies and the resulting infectious disease spread. But we do know they are having an impact — an unnecessary one, especially considering much better options are available. As long as employers can get away with demanding sick notes without carrying any of the logistical or financial burdens, they will continue to do so. That's why it's time to change that.

This column is part of CBC's Opinion section. For more information about this section, please read our FAQ.


Dr. Michelle Cohen is a family physician in Brighton, Ont., and an assistant professor in the Department of Family Medicine at Queen's University. She typically blogs about health care and medical politics at Huffington Post.