OBJECTIVES: In the last twenty years there has been an intense debate on how to value lost productivity in economic evaluations. According to the Washington panel, lost productivity influences health-related quality of life (HRQoL) and should thus be considered a health effect instead of a cost to avoid double counting. Until now empirical evidence on the inclusion of income loss when valuing health states is not decisive. We examine the relationship between three aspects of lost productivity (work-status, absenteeism and presenteeism) and patient or social valuation of health-related quality of life. METHODS: Cross-sectional survey data from a total of 830 respondents with a rheumatic disorder from four Western-European countries. Health-related quality of life was expressed in either the European societal utility using EQ-5D-3L or the patient valuation using EQ-VAS. Linear regression analyses were performed to examine the impact of work-status (four categories), absenteeism (absent from paid work during the past three months), and presenteeism (QQ method) on EQ-5D utilities and VAS scores taking demographic characteristics and disease severity (duration, pain and restriction) into account. RESULTS: The relationship between work-status, absenteeism or presenteeism and HRQoL is stronger for patient valuation than societal valuation. Compared to work-status and presenteeism is the relationship between absenteeism and HRQoL even less explicit. However, results for all measures of work are only marginal significant and negligible compared to the influence of restriction due to disease we studied.  CONCLUSIONS: In four European countries, analyses among patients with a rheumatic disorder do not fully support the claim of the Washington panel that lost productivity has a significant relationship with HRQoL, and this is even more apparent for absenteeism than for work-status and presenteeism. Therefore absenteeism should continue to be included in the costs and not in the QALY. Findings need to be confirmed in other disease areas.