The 'Double Discrimination' Leading to Undervalued Women's Healthcare

Gynecologic surgeons are consistently underpaid compared to their male counterparts, a disparity that is exacerbated by the fact that procedures specifically for female anatomy are often reimbursed at lower rates than comparable procedures on male anatomy. This phenomenon, termed "double discrimination" by bioethics professor Katie L. Watson and gynecologic surgeon Dr. Louise King, has been documented for decades and is deeply embedded in the U.S. healthcare billing system.

In 1997, research indicated that male-specific procedures were reimbursed about 44 percent more than analogous female-specific ones. While some progress has been made, the core issue persists, impacting not only surgeon compensation but also the allocation of resources within hospitals and the training opportunities for future gynecologic surgeons.

How Surgical Procedures Are Valued

The valuation of medical procedures in the U.S. is largely determined by relative value units (RVUs), a metric used by the Centers for Medicare and Medicaid Services to establish reimbursement rates. RVUs are intended to reflect the time, skill, and work intensity of a procedure. However, studies have shown that procedures on female patients often receive lower RVUs than those on male patients, even when similar time and skill are required. For instance, a 2023 study found that 75 percent of sex-specific procedure pairs had lower RVUs for female patients, with male-specific procedures averaging 30 percent higher RVUs.

This undervaluation can be traced back to the committee responsible for recommending RVU values to the government. This committee, convened by the American Medical Association (AMA), relies on self-reported surveys from doctors about the time and skill their procedures require. Critics argue that the process lacks transparency and that surveys are not adequately distributed to specialists who perform the bulk of complex gynecologic surgeries. Consequently, the data informing these crucial valuations may not accurately reflect the realities of these procedures.

Furthermore, a significant portion of gynecologic surgeons are women, and the specialty itself is overwhelmingly female. This demographic reality intersects with the payment disparities, creating a cycle where procedures primarily serving women are systematically undervalued. The American College of Obstetricians and Gynecologists (ACOG), while having a seat on the RVU committee, primarily represents general OB-GYNs whose practices may not heavily involve complex surgeries, leaving subspecialists with less direct influence.

Consequences of Low Reimbursement Rates

The financial implications of lower reimbursement rates for gynecologic procedures extend beyond individual physician salaries. Hospitals and healthcare facilities, operating on revenue models, may be disincentivized from investing in women's health services if they are not financially lucrative. This can lead to reduced access to operating rooms, surgical staff, and crucial operating time, directly impacting patient care.

Dr. King has reported patients waiting as long as a year for necessary surgeries. This delay can exacerbate conditions and worsen patient outcomes. Additionally, the scarcity of resources can limit training opportunities for residents, potentially leading to a workforce of lower-volume surgeons who may have less experience and potentially worse outcomes compared to those who operate more frequently.

The Path to Payment Reform

While the process of updating RVUs is complex and time-consuming, experts and advocates argue that reform is possible. Potential steps include re-evaluating gynecology-related procedure codes submitted to the AMA committee, prompting congressional reports on the matter, and reconsidering the AMA's budget neutrality rule, which can offset increased payments for one procedure with cuts elsewhere.

Some propose creating gynecology-specific conversion factors or eliminating sex-specific billing codes where possible to promote parity. For example, using a single, sex-neutral code for genital biopsies, regardless of patient sex, could help narrow the billing gap.

Another area for reform involves enhancing the training for gynecologic surgeons. While historical training structures may have contributed to lower RVUs, increasing the surgical training duration could justify higher reimbursement and produce more skilled surgeons, ultimately benefiting female patients. Addressing these systemic issues is seen as crucial to ensuring equitable care and outcomes for women.