AT A GLANCE
- In 2020, female retina specialists received only 65 cents on the dollar in total annual payment through Medicare compared with male retina specialists.
- Both married female physicians and female physicians with children work, on average, fewer hours than the respective male physician population.
- The extra time female physicians spend with patients can lead to increased rates of preventive care, lower patient volume, and higher patient-reported experiences of empathy from their care provider.
- We must always be careful when examining multifactorial issues such as gender inequity because an oversimplification of the causes and outcomes can be misleading.
The most recent Nobel Prize in economics was given to Claudia Goldin, PhD, the Henry Lee Professor of Economics at Harvard University, for her work identifying key drivers for gender differences within the labor market. She showed that the average woman in the United States earns only 80 cents on the dollar compared with the average man.1 The field of health care is not immune to this disparity, considering that the Association of American Medical Colleges found that White male physicians earned more than women or men of color.2 In the field of retina, significant disparities remain for female retina specialists.
THE STATE OF THE FIELD
We recently examined physicians’ total annual payment through Medicare in 2020 and found that female retina specialists received only 65 cents on the dollar compared with their male counterparts (Figure 1).3 This represents the conflation of many underlying factors that affect pay, such as patient volume, prevalence of female leadership and mentorship, funding opportunities, career advancement, and rates of female authorship. However, equally important are larger societal pressures for working women to sacrifice their careers for tasks related to childcare and other domestic responsibilities.4
Figure 1. In 2020, female retina specialists received only 65 cents on the dollar in total annual payment through Medicare compared with their male counterparts.3
Although Medicare reimbursement is not equivalent to take-home physician compensation, it offers a unique benefit when examining the wage gap, in that it is a nationally standardized system. Apart from some geographic variations, any physician who bills for CPT 67028, an intravitreal injection, will receive the same standardized reimbursement in the same geographic area. This affords researchers a unique opportunity to examine disparities with minimal confounding factors, such as salaries that are negotiated on a case-by-case basis.
Our study found that the greatest identifiable contributor to the inequity in Medicare reimbursement is the difference in the average number of patients seen by male and female retina specialists.3 When controlling for the number of patients seen by female retina specialists, the disparity lessens to 89 cents on the dollar (Figure 2). Although this finding provides a path for intervention, it also makes us question why there is such a significant gap in the first place.
Figure 2. When controlling for the number of patients seen, the Medicare reimbursement increased to 89 cents on the dollar for female versus male physicians.3
One of Dr. Goldin’s points in her work was that the pay gap would increase after a woman has her first child, which could lead to a decrease in hours worked and patients seen. This assumption could extend to physicians, because unmarried physicians work the same amount regardless of their gender, but both married female physicians and female physicians with children work, on average, fewer hours than the respective male physician population.5,6 However, this reduction would be expected to occur only in a smaller window when children are younger. Unfortunately, there is limited evidence that the reimbursement disparity decreases at specific timepoints of life. The inequity between attending physicians in their first years after fellowship continues through 25 years of experience, and all stages in between.
Although family responsibilities (traditionally—albeit unduly—placed on women) affect the hours worked, they do not completely explain the wage gap.
Factors that affect how many patients a physician sees are not unique to ophthalmology. Female physicians, regardless of specialty, spend more time, on average, with each patient than male physicians.7 Some research suggests this may be related to differing patient expectations, with the assumption that female providers should spend more time with patients compared with male providers.8,9 As physician compensation is often directly linked to the throughput of services provided, spending more time with each patient can have negative effects on a female provider’s total compensation.
However, research shows that the extra time that female physicians spend with patients can lead to increased rates of preventive care, lower patient volume, and higher patient-reported experiences of empathy from their care provider—all of which contribute to lower rates of litigation for female versus male physicians.10,11 Thus, female retina specialists are compensated at a lower rate, despite providing exceptional patient care.
Many other factors can lead to decreased patient volume, including different referral rates between male and female retina specialists. For each patient, female ophthalmologists may perform fewer procedures, perform procedures that are compensated less, or code clinic visits differently, leading to reduced reimbursement for equivalent work. For example, a level 2 visit is often reimbursed the same by the same insurance; however, if a female ophthalmologist elects to code a 21-minute visit as an 18-minute one, she will receive lower reimbursement.
FUTURE EFFORTS
We must always be careful when examining multifactorial issues such as gender inequity because an oversimplification of the causes and outcomes can be misleading. Were the conversation to end at the explanation that reimbursement disparities are due to differences in patient volume, an incorrect conclusion may be that female physicians are receiving less compensation because they aren’t working as hard. This could not be further from the truth.
Decreased patient volumes for female retina specialists is a complex issue with multiple underlying factors. A disparity in Medicare reimbursement is just a symptom of an underlying inequity.
In 2020, only 17% of practicing retina specialists were women.12 Less than 30% of first or last authors in retina publications are women.13 Female ophthalmologists receive less national funding and are less likely to be represented in senior academic positions.14,15
The wage gap is just one piece of a very large puzzle. Hopefully, further research will reveal other factors so that we can adequately address these issues.
1. Goldin C. The Century-Long Fight to Close the Gender Pay Gap - Claudia Goldin. Harvard Mossavar-Rahmani Center for Business and Government. October 6, 2021. Accessed January 29, 2024. www.hks.harvard.edu/centers/mrcbg/programs/growthpolicy/century-long-fight-close-gender-pay-gap-claudia-goldin
2. Redford G. New report finds wide pay disparities for physicians by gender, race, and ethnicity. Association of American Medical Colleges. October 12, 2021. Accessed January 29, 2024. www.aamc.org/news/new-report-finds-wide-pay-disparities-physicians-gender-race-and-ethnicity
3. Gilson AS, Adelman RA. Disparity in medicare reimbursement between female and male vitreoretinal surgeons [published online ahead of print December 23, 2023]. J Vitreoretinal Dis.
4. Chesak SS, Yngve KC, Taylor JM, Voth ER, Bhagra A. Challenges and solutions for physician mothers: a critical review of the literature. Mayo Clinic Proceedings. 2021;96(6):1578-1591.
5. Wang C, Sweetman A. Gender, family status and physician labour supply. Soc Sci Med. 2013;94:17-25.
6. Buddeberg-Fischer B, Stamm M, Buddeberg C, et al. The impact of gender and parenthood on physicians’ careers—professional and personal situation seven years after graduation. BMC Health Serv Res. 2010;10:40.
7. Martinez KA, Rothberg MB. Physician gender and its association with patient satisfaction and visit length: an observational study in telemedicine. Cureus. 14(9):e29158.
8. Linzer M, Harwood E. Gendered expectations: do they contribute to high burnout among female physicians? J Gen Intern Med. 2018;33(6):963-965.
9. Mast MS, Hall JA, Köckner C, Choi E. Physician gender affects how physician nonverbal behavior is related to patient satisfaction. Med Care. 2008;46(12):1212-1218.
10. King RH. Why are female doctors sued far less often than male doctors? MedPage Today. May 28, 2023. Accessed January 29, 2024. www.medpagetoday.com/opinion/wiredpractice/104728
11. An analysis of malpractice claims by physician gender. Accessed January 16, 2024. www.thedoctors.com/the-doctors-advocate/second-quarter-2019/an-analysis-of-malpractice-claims-by-physician-gender
12. Nahar A, Mahmoudzadeh R, Rama M, et al. Authorship trends of women in retina: a 25-year analysis. Ophthalmol Retina. 2023;7(2):164-170.
13. Fathy CA, Cherkas E, Shields CN, et al. Female editorial authorship trends in high-impact ophthalmology journals. JAMA Ophthalmol. 2021;139(10):1071-1078.
14. Svider PF, D’Aguillo CM, White PE, et al. Gender differences in successful National Institutes of Health funding in ophthalmology. J Surg Educ. 2014;71(5):680-688.
15. Lopez S, Svider P, Misra P, Bhagat N, Langer PD, Eloy JA. Gender differences in promotion and scholarly impact: an analysis of 1460 academic ophthalmologists. J Surg Ed. 2014;71(6).
_1773249222.png?auto=compress,format&w=75)
