Two doctors spot a pattern

In Chicago in 2021, gynecologic surgeon Dr. Louise King and bioethics professor Katie L. Watson discussed a frustration: female surgeons earn less than male surgeons, even after accounting for specialty, rank and age.

The problem compounds in gynecology

Surgeons performing gynecological procedures earn less than those doing comparable surgeries on men. Gynecologic surgeons are predominantly women, serving primarily female patients. Watson called this double discrimination.

The gap has persisted for decades

In nineteen ninety-seven, gynecologic surgeons published a paper titled Is Adam worth more than Eve? They found doctors are paid around forty-four percent more for male-specific procedures than analogous female-specific ones.

“Is Adam worth more than Eve?”

The problem is now institutionalized

Three decades later, the disparity remains. Gynecologic procedures are reimbursed at lower rates than male-specific procedures even when they require similar time and skill, built into billing systems and codes.

Lower pay means fewer resources

When gynecological procedures generate less revenue, hospitals allocate fewer resources to women's health services. This leads to worse care for women and fewer training opportunities for gynecologic surgeons.

How procedures get their value

The Centers for Medicare and Medicaid Services sets reimbursement rates using relative value units, or RVUs, which account for procedure time, skill required and work intensity. Higher RVUs mean higher payment.

Female procedures are systematically undervalued

A Mount Sinai study of fifty-five pairs of sex-specific procedures found seventy-five percent had lower RVUs for female patients. Male-specific procedures averaged thirty percent higher RVUs and paid surgeons around twenty-six percent more.

A concrete example of the gap

Medicare's standard national rate for a penile biopsy is one hundred twenty-one dollars thirty-two cents. For a vaginal biopsy, it is sixty-five dollars seventy-four cents, despite similar procedures.

Gynecology was ignored from the start

Dr. Louise King believes gynecological services were largely ignored when the RVU system was created in the nineteen nineties, leaving the specialty undervalued from the beginning. That undervaluation has persisted.

Who decides procedure values

The American Medical Association convenes a committee of doctors to set RVUs. The committee surveys doctors on time and skill required for procedures. The federal government has historically accepted nearly ninety percent of recommendations.

The survey process is flawed

Surveys have low response rates from some specialties and reach only a small subset of doctors. Dr. Louise King has never received a committee survey in seventeen years of practice. Data quality remains poor.

The wrong doctors answer the surveys

The American College of Obstetricians and Gynecologists has a seat on the RVU committee, but most members are general OB-GYNs who operate rarely. Subspecialists who perform most gynecologic surgeries lack representation.

Self-reported times are inflated

A study comparing self-reported operating times to actual data found urologists overestimated time by a median of twenty minutes. Gynecologists overestimated by only five minutes, yet urologists earn much more.

The gap barely improved in twenty years

Between two thousand three and two thousand twenty-three, there were no statistically significant improvements to pay disparities. Comparing procedures across nineteen ninety-seven, two thousand fifteen and two thousand twenty-three, the gap narrowed only minimally.

Patients wait a year for surgery

Lower reimbursements reduce hospital resources for gynecologic surgery. Dr. Louise King said, I have patients who are waiting for surgery with me for a year at a time. I mean, that's crazy.

“I have patients who are waiting for surgery with me for a year at a time. I mean, that's crazy.”

Low volume surgeons have worse outcomes

Fewer operating opportunities mean less-trained surgeons. Low-volume gynecologic surgeons performing a procedure less than twelve times yearly have significantly higher rates of bowel and urinary tract injuries in patients.

Solutions exist but require action

Experts suggest reevaluating gynecology-related procedure codes, eliminating sex-specific billing codes, creating gynecology-specific conversion factors, and reforming the budget neutrality rule that offsets increased payments elsewhere.

Training periods must increase

General OB-GYNs train for four years with only eighteen months devoted to surgical gynecology. Dr. King believes training periods should increase for gynecologic surgeons to improve reimbursement and patient outcomes.

Inaction sends a message

Watson and King argued that failing to implement parity solutions is tantamount to saying female patients deserve less well-trained surgeons than male patients. The disparity has been enshrined in medical policy for decades.