Nearly three decades after researchers first documented that surgeons are paid more for male-specific procedures than comparable female-specific ones, the gap has barely narrowed, and experts say it is now shaping how hospitals allocate operating room time, Vox reported Oct. 7.
A 1997 paper in Gynecologic Oncology, titled “Is Adam worth more than Eve?”, found physicians were paid about 44% more for male-specific procedures than for analogous female-specific ones.
A more recent study from New York City-based Mount Sinai Health System, “Price and Prejudice,” found that among 55 pairs of sex-specific procedures evaluated in 2023, 75% carried lower relative value units for the female procedure. RVUs for male-specific procedures averaged 30% higher, and surgeons were paid about 26% more when those procedures were performed in a hospital or surgical center. Between 2003 and 2023, the researchers found no statistically significant improvement in the disparity.
The study’s examples are stark. In 2023, Medicare’s national rate paid surgeons $121.32 for a penile biopsy and $65.74 for a vaginal biopsy.
Louise King, MD, a minimally invasive gynecologic surgeon and director of reproductive bioethics at Harvard Medical School Center for Bioethics who contributed to the study, has described the problem with bioethics professor Katie Watson as “double discrimination.” Gynecologic surgery is a predominantly female specialty that also serves a primarily female patient population, so lower reimbursement penalizes both the surgeons and their patients.
Dr. King said gynecology was largely overlooked when the RVU system was created in the 1990s, and that undervaluation has persisted. Part of the issue is how values are set. RVUs are recommended by a committee of physicians convened by the American Medical Association, which relies on surveys in which physicians self-report the time and skill their procedures require. CMS has historically accepted nearly 90% of the committee’s recommendations.
Miriam Laugesen, PhD, an associate professor of health policy and management at Columbia University Mailman School of Public Health, said the committee’s process lacks transparency, making it unclear what evidence its valuations rest on.
“It’s just a committee that was put together by the [AMA]. It’s pretty unusual in terms of how policy is made,” Dr. Laugesen told Vox.
The American College of Obstetricians and Gynecologists holds a core seat on the committee, but most of its members are general OB-GYNs who operate relatively rarely. The subspecialists who perform the bulk of gynecologic surgery, including gynecologic oncologists, urogynecologists and minimally invasive gynecologic surgeons, largely belong to their own societies, which do not have a seat. Dr. King, who operates two to three times a week, said she has never received a committee survey in 17 years of practice.
“So they’re not the right people to be answering these surveys. They [the survey committee and ACOG] don’t target the surveys to people who operate a lot,” she said.
Self-reported data also skews the results. A study led by Shitanshu Uppal, MD, a gynecologic oncologist at Ann Arbor-based Michigan Medicine, compared survey estimates with actual operating times from the American College of Surgeons’ National Surgical Quality Improvement Program across 901,917 surgeries. Gynecology had the third-lowest median RVUs per hour of any specialty studied. Urologists overestimated their operating times by a median of 20 minutes, compared with five minutes for gynecologists, and specialties that reported longer times tended to receive higher RVUs.
“The system that they have now developed over time,” Dr. King said, “now creates discrimination because of its complexity.”
The effects reach well beyond surgeon pay. Because hospitals allocate resources based on revenue, lower-paying gynecologic procedures can receive less operating room access, staffing and block time. That also limits training opportunities for residents, contributing to a workforce of low-volume gynecologic surgeons. Research shows that surgeons who perform a given gynecologic procedure fewer than 12 times a year have significantly higher rates of bowel and urinary tract injuries.
“I have patients who are waiting for surgery with me for a year at a time. I mean, that’s crazy,” Dr. King said.
Experts point to several possible fixes: submitting gynecologic procedure codes to the committee for reevaluation, expanding the single billing code for endometriosis surgery that pays the same regardless of complexity, reforming Medicare’s budget neutrality rule, creating gynecology-specific conversion factors and eliminating sex-specific codes where procedures are essentially the same, such as genital biopsies. Dr. King has also called for longer surgical training for gynecologic surgeons. General OB-GYNs spend about 18 months of a four-year residency on gynecologic surgical training.
The push comes as maternity care billing undergoes a major overhaul, with new CPT codes separating prenatal, delivery and postpartum services set to take effect in 2027. Gynecologic surgery, which covers most of a woman’s life outside her childbearing years, has largely been left out of that conversation.
