Differences in how women and men get paid in the U.S. abound across sectors. While certain economists have suggested that the wage gap is attributable to women working fewer hours than men, recent studies have found more nuances in the differences between the way men and women work that may lead to a discrepancy in pay. A new study out of Harvard shows that in the world of medicine, female doctors are sacrificing pay to spend more time with patients.
The study, titled “Physician Work Hours and the Gender Pay Gap,” found that male primary care doctors generated nearly 11% more revenue from office visits in 2017 than their female counterparts. The reason for the discrepancy seems to be that women in primary care took on fewer patient visits and spent more time with their patients—a style of working that the medical industry agrees is better for both patients and doctors. Unfortunately, that way of working comes at a price.
Primary care physicians who are employed by a health system often have a base salary along with performance bonuses and profit-sharing options. Those who work in private practice make their earnings from their office’s revenue. In both cases, doctors have an opportunity to earn more if they have a higher volume of appointments and either conduct or recommend higher-priced medical services.
For the study, researchers analyzed electronic health records for 24.4 million primary care office visits that took place in 2017. It found that male and female doctors generated the same amount of revenue for each patient they saw, though female doctors logged more total hours. However, they differed in how they spent that time. Women spent 2.4 minutes on average more with patients than their male colleagues—a 16% difference. Longer visits mean that women can take on fewer patient visits, and that can translate into less pay. Notably, the study found that though women were taking on a lower number of patient visits, they were not less productive than their male colleagues. Women reported more diagnoses and placed more orders for follow-up examinations and treatments, but tended to bill insurers at a lower reimbursement rate despite spending extra time with the patient, which led to lower revenue for the practice.
“If a patient sends me a message through the patient portal and asks for advice on something, I will do a whole exchange through email to sort out their problem or I’ll give them a call—but I don’t get paid for this,” says Ishani Ganguli, the lead author on the study. “Doctors have every incentive to say, I’m not going to talk to you now over email—I’m going to have you come in for a visit.”
Female doctors who take greater care with their patients may be less likely to partake in profit-sharing opportunities at their practice. Medical news site Medscape’s 2020 compensation report found incentive bonuses—additional pay that doctors can get for generating profits—on average contributed an extra $26,000 to primary care doctor pay. About 34% of primary care physicians say that they’ve increased the number of hours they work to capture incentive bonuses. The report also found that women in primary care made 25% less than men in the field.
“Paying doctors by visit seems to be contributing to the wage gap,” says Ganguli. “If you pay doctors a different way, that might help.”
Unfortunately, doctors may not be keen to buy into new forms of pay. According to Medscape’s data, doctors who participated in programs that reward better quality care with financial incentives were “extremely disappointed” with their earnings. To receive additional money, doctors have to fill out reports showing that the work they do with patients is leading to better health outcomes. Many said that the extra cash was not worth doing this work. Furthermore, a decreasing number of primary care physicians said they would sign up for this kind of incentive program in the future.
The gender wage gap among doctors is compounded by a bigger problem that has to do with the way healthcare systems make money. Health systems rely on insurance to pay for medical services, not medical care. Even when doctors are paid with a salary, they are often encouraged to be more productive in order to meet revenue targets, Ganguli says.
Still, quality primary care has been linked to better health outcomes for patients and lower burnout among doctors. Ganguli says that health systems need to reevaluate the value of primary care and charge accordingly, therefore making way for doctor compensation that is more focused on quality outcomes. She says big health systems that can rely on revenues from specialists such as surgeons are starting to readjust the way they pay doctors, and this may help lower the gender pay gap.
“There’s moves to pay doctors in different ways, like by salary or by paying doctors by the number of patients they take care of, with that rate adjusted for how sick those patients are,” she says. “We don’t know what that will do, but it’s at least worth exploring.”
CORRECTION: This article has been updated to clarify how female primary care doctors billed insurers for their work.