To the Editor:

In this Graham Center Policy One-Pager, Walter and colleagues state that evidence does not show that gender pay disparity is because female physicians “elect to work fewer hours or…are less productive than their male peers.”¹ Yet, they reference the Ganguli and colleagues study, which shows exactly those findings.² This study of more than 24 million office visits, by far the most rigorous and objective look at gender pay differences, found that women work fewer hours than men, see fewer patients per hour, take longer to see the same number of patients, and bill at lower levels for comparable patients.

Most physicians are paid based on relative value units or another productivity measure; thus, there is no structural pay bias by definition. Has anyone ever seen a productivity-based contract that differs between men and women?

The authors perpetuate the myth that gender bias explains salary disparities between male and female family physicians but miss an opportunity to pose an important question. Should physicians be reimbursed based on time rather than volume of patients seen? Several studies show longer visits with female physicians utilizing preventive care metrics result in better outcomes.^3–5

Gender bias in medicine likely exists as a cultural and communication reality and a leadership impediment, but there is little, if any, structural reimbursement bias in medicine, which relies almost exclusively on productivity measures. It is time to retire this tired trope.

In Reply:

Thank you for reaching out. To clarify, female physicians generate less annual revenue under volume-based payment models. The Ganguli and colleagues study¹ directly challenges the previously held belief that the gender pay disparity is due to “[working] fewer hours or…[being] less productive.” They found that female primary care physicians “spent more time with patients per visit, per day, and per year” than their male counterparts, which “translated into more time in direct patient care per day and per year.”¹ We cited several examples of how the gender wage gap persists, even after controlling for productivity and billing differences, among other variables.² We assert that the metrics for productivity are biased, not that the productivity-based contract differs by gender.

Research supports that alternative payment models can help address the wage gap. A study suggested a “capitation risk-adjusted for patient age and sex [resulted] in a smaller gap.”³ Productivity is a complex concept to measure. The broadest definitions of productivity output are “throughput-focused (eg, number of patients seen), procedure-focused (eg, number of individual health care services delivered), and revenue-focused (eg, financial earning)” approaches.⁴ Extensive research shows that male and female physicians practice differently. Female physicians spend more time with patients than do male physicians, which, as the authors mention, leads to better care. Rather than redefine productivity to encompass this nuance, our health care payment system continues to support only how male physicians practice. This ultimately penalizes female physicians, especially as more women are entering primary care.

We reject the assertion that the underlying root of the gender wage gap is not bias. A fee-for-service payment system benefits the practice patterns of male physicians over female physicians, highlighting the structural bias in our reimbursement system.¹ A 2017 comparison of relative value units for gender-specific procedures matched groups such that “the procedures were anatomically similar” and found that “male-based procedures were compensated at a higher rate than the paired female procedures.”⁵ Women are penalized for being too assertive in salary negotiations⁶ and the gender wage gap persists, despite controlling for factors such as hours worked, region, practice environment, and principal practice activity, indicating bias in the system as a critical element contributing to salary disparities.