Jul 20, 2022 - Health

Health reform may be making gender wage gaps worse for female docs

Illustration of a doctor carrying the red cross symbol on her back.
Illustration: Shoshana Gordon/Axios

It's no secret that gender pay disparities are a problem in medicine, but it turns out reforms to how we pay doctors — specifically in primary care — could make the problem worse.

Why it matters: The shift to value-based care aims to incentivize better care delivery by paying doctors for what matters most — patient outcomes — rather than by how many services they perform.

  • But a new study in the Annals of Internal Medicine found these reforms could wind up favoring practice patterns more closely associated with male doctors while also missing the mark on the very goal they've set out to address: Providing better care to patients.

State of play: Previous studies have shown female doctors generally tend to spend more time with patients (and in some scenarios, produce better outcomes) than male doctors.

  • But that extra time adds up, meaning those female doctors are generally reimbursed for fewer patient visits, contributing to the gender pay gap.
  • The study, led by Harvard Medical School and Brigham and Women's Hospital researchers, found female primary care physicians made 21% less than their male counterparts under the traditional fee-for-service model.

"We wondered: There are other ways of paying doctors that policymakers are experimenting with. How does the wage gap fare under those alternative models?'" Ishani Ganguli, lead author and assistant professor of medicine at Brigham and Women's Hospital, told Axios.

Be smart: The news wasn't great, as it turns out.

  • The researchers compared data for more than 1,400 male and female doctors from more than 1,200 primary care practices across the country.
  • They created a simulation of doctor pay under what are known as "capitated" payment models that limit how much practices can be paid for caring for a population of patients.
  • Such models are increasingly being tested in federal health programs but for the most part haven't been expanded nationally.
  • In most of those scenarios, the pay gap persisted or even worsened.

What's happening: The disparity comes down something called "risk adjustment" that tweaks physician payments above or below a baseline according to age, sex and complexity of diagnoses of their patients, Ganguli said.

  • When comparing doctors who are otherwise similar, male doctors tended to see older patients and patients with diagnoses like liver disease that led to a higher risk scores.
  • Meanwhile, female doctors tended to see somewhat fewer patients who skewed younger, female and were more often uninsured or on Medicaid.
  • Their patients' conditions, which were more likely to come with diagnoses such as anxiety or the consequences of social determinants of health, are still complex and time-consuming, but more often rated with lower risk scores, she said.
  • So when capitated payments were adjusted based on diagnoses or on the sex of their patient panel, the gender pay gap worsened. That disparity was only "fixed" when researchers risk-adjusted payments to factor both the age and sex of patients.

The big picture: But differences in what male and female doctors get paid can't just be attributed to female doctors having more female patients, Ganguli cautioned.

  • "It's not that women patients took more time. It's that women doctors spend more time with all of their patients than male doctors with all of their patients," Ganguli said. "It's really about the different ways men and women doctors work."

The bottom line: The study raises the question of whether we are considering the right factors in how we reward doctors as we overhaul decades-old payment models to contain health spending.

  • "We're moving toward this value-based payment," Ganguli said. "But are we really measuring and accounting for the right things?"
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