Towards gender equity in procedure compensation: how far have we come in 20 years?

Abstract

<h3>Objectives:</h3> Discrepancies in the reimbursement of gender-specific procedures have been reported since the beginning of the fee-for-service model. Procedure-based reimbursement is mediated by both work relative value unit (wRVU) and a specialty-specific compensation rate. Whether gender-based discrepancies in reimbursement have improved over time and which of these factors, wRVUs assigned per procedure or dollars per RVU, are the driver of these discrepancies in unknown. We aim to describe how wRVUs for gender-specific procedures have changed over time and to compare time-based compensation for gender-specific procedures. <h3>Methods:</h3> Using the National Surgical Quality Improvement Program (NSQIP) 2015-2018 we compared operative time and wRVUs for twelve pairs of gender-specific procedures. Only cases with a primary current procedural terminology (CPT) code and without any other procedure or concurrent procedure CPT codes were included in the analysis. Procedures were matched to be anatomically and technically similar. We further compared procedure assigned RVUs in 2015 to those assigned in 1997. We also evaluated procedure-based compensation. Procedure compensation was determined using median dollars per RVU for Urology and Gynecology provided in SullivanCotter's 2018 Physician Compensation and Productivity Survey. This was compared with specialty-specific McGraw-Hill per RVU data from 1994. Wilcoxon rank sum test was used to examine associations. <h3>Results:</h3> A total of 12,120 patients underwent 6,217 male-specific procedures and 5,903 female-specific procedures between 2015-2018. Male-specific procedures had a median wRVU of 25.2 (IQR 21.4-25.2), significantly higher than the median wRVU of 7.5 (IQR 7.5-23.4) for female-specific procedures (p<0.001). Evaluation of wRVUs for paired procedures matched by technical complexity (e.g. exenteration for prostate versus cervix cancer) revealed that in 6 cases (50%), male versus female procedures had higher wRVUs. This is a change from 1997 when the majority (75%) of male-specific procedures had higher assigned wRVUs. Male-specific procedures were longer, lasting a median of 79 minutes more than female-specific procedures (male 136 mins [IQR 98-186] versus female 57 mins [IQR 25-125], p<0.001). Comparing gender-specific procedures by wRVU/hr female-specific procedures were reimbursed at a higher rate (10.6 RVU/hr [IQR 7.2-16.2] versus 9.7 RVU/hr [IQR 7.4-12.8], p<0.001) than male-specific procedures. However, when compensation was accounted for, male-specific procedures were better reimbursed ($599/hr [IQR $457-790] versus $555/hr [IQR $377-843], p<0.001). Overall, per procedure wRVUs for male-specific surgeries have increased 13% over the past two decades while per procedure wRVUs for female-specific surgeries have increased 26%. Reimbursement for male-specific procedures has decreased 8% ($67.30 to $61.65 per RVU) while reimbursement for female-specific procedures has increased 14% ($44.50 to $52.02 per RVU) over the past 20 years. <h3>Conclusions:</h3> Over the past two decades increases in wRVUs for female-specific procedures and specialty-specific per RVU reimbursement have resulted in more equitable reimbursement for female-specific procedures compared with male-specific procedures. However, even with these changes, our findings support an overall lower relative value of work and reimbursement for procedures performed for women-only when compared with equivalent procedures performed for men-only.