Telephone Sick Note: A Small Figure with Great Attention

The rate of sick leave in Germany has increasingly come into focus for politics, business, and healthcare in recent years. In particular, the sharp increase in issued sick notes (Arbeitsunfähigkeitsbescheinigung, AU) since 2022, coinciding with the launch of the electronic sick note, has triggered a broad discussion about possible causes. In this context, telephone-based sick notes, which were introduced during the Corona crisis and later integrated into regular care, are also being discussed more intensely.

There are different perspectives on this. The Federal Ministry of Health (BMG) refers to the official statistics of statutory health insurance, which are based on electronically transmitted sick leave notifications, when discussing the sick leave rate. Federal Minister of Health Nina Warken (CDU) told the Tagesspiegel that the high sick leave rate in international comparison is a "factual description." At the same time, she pointed out that the low-threshold possibility of telephone-based sick notes could be misused. Against this backdrop, Warken announced that the existing regulations for telephone-based sick notes would be reviewed. The goal is to find practical solutions and prevent misuse. This announcement was already enshrined in the coalition agreement.

The telephone sick note (Telefon-AU) is not being named as a factor for a high sick leave rate for the first time in these debates. For example, in September 2024, then Federal Minister of Finance Christian Lindner called for the abolition of telephone-based sick notes and announced that the regulation would be reviewed as part of the federal government's growth initiative. Most recently, the Chairman of the National Association of Statutory Health Insurance Physicians (Kassenärztlicher Bundesverband, KBV), Andreas Gassen, also weighed in. He already advocated for an end to telephone-based sick notes and for a waiting period of three days without a doctor's certificate.

"Trust is Required"

In response to an inquiry from heise online, Gassen reiterated, "In the spirit of social partnership, trust is required. We therefore recommend a waiting period of 3 days, which is the responsibility of the employees themselves. A resulting future sick note from the fourth day would again have the significance of a genuine medical certificate and not a 'form' without the necessity of medical treatment." For illnesses lasting more than 3 days, "a potentially serious illness is more likely to be assumed, and a doctor's visit with appropriate diagnostics is indicated." This would significantly relieve practices, according to Gassen. "Partially dubious business models like the Click-AU would thus be eliminated. The role of the telephone AU would also have to be rethought." After Corona, it has hardly any necessity anymore.

The head of the Association of General Practitioners, Dr. Markus Beier, also calls for stricter regulation of commercial online services that offer sick notes for payment, which is the case with AU Schein GmbH, for example. However, Beier does not fundamentally question medically responsible telephone-based sick notes. The board of the Bavarian Association of Statutory Health Insurance Physicians (KVB), on the other hand, advocates for the retention of telephone-based sick notes. They are a sensible addition to outpatient care for minor illnesses and relieve practices without any indication of significant misuse.

Data-based assessments come from the Central Institute for the National Association of Statutory Health Insurance Physicians (Zi). Its analyses (PDF) have already shown in the past that the increase in AU figures is primarily related to reporting effects due to the introduction of electronic AU and an increase in infections. According to the analyses, telephone-based sick notes account for only a small proportion of the total AU cases. We asked Daniel Wosnitzka, Head of the Communications Staff Unit at the Zi, about this topic.

According to your analyses so far, the massive increase in AU cases cannot be explained by telephone sick notes. Does the Zi stand by this assessment?

Yes. We do not expect significantly different results for the years 2024 or 2025, because: The G-BA has severely restricted the possibility of telephone-based sick notes in its guidelines. Only patients who are personally known to a practice can be issued sick notes by telephone, and only for a short period of up to 5 days. Therefore, it is not to be expected that the proportion of telephone-based sick notes has increased significantly in 2024 and 2025 compared to 2023.

The possibility of telephone-based sick notes has existed since 2020. Over time, the largest increase in AU cases was observed not between 2020 and 2021, but between 2021 and 2022, after the reporting procedure was switched from paper to electronic AU. Although AU figures continued to rise in the following years up to 2024, they did not do so to the same extent as in 2022.

What is not being considered at all in the general discussion, by the way, is that the number of AU notifications was again declining in 2025 (by -9 percent compared to the previous year) according to the Gematik dashboard.

Your analyses indicate that the importance of telephone-based sick notes is very low, with a small proportion (0.8 to 1.2 percent annually) of all AU cases. In your view, is the political attention given to telephone sick notes proportionate to their actual significance in sick leave?

The discussion starts with the comparatively high sick leave rate in Germany. International comparisons suggest that the introduction of waiting days would have a significant effect. If the introduction of waiting days were to be considered, telephone-based sick notes would also be largely obsolete. Of the approximately 124 million electronic AUs in 2024, about 37 percent are short-term AUs (up to 3 days) according to the AOK absence report. This equates to approximately 46 million short-term AUs. Practices would also be relieved if the issuance of AUs that merely serve as a submission to the employer but are not medically relevant for treatment were to cease.

In the conclusion of the 2025 analysis, it states that the abolition of telephone sick notes is "neither empirically justifiable nor sensible for healthcare practice." What specific negative consequences for patient care and the burden on doctor's practices do you fear if Mr. Merz's demand were to be politically implemented?

Unless waiting days are also introduced, thereby reducing the overall number of formally required sick notes, the relief effects that have been observed, particularly in general practices, would be lost again.

(mack)