The gender pay gap in primary care: Women paid 21% less

Female primary care physicians earn about 21% less than their male counterparts, although the gender wage gap differs based on compensation models, according to a study published in Annals of Internal Medicine.

Researchers said the findings emphasize the need for an alternate, more equitable payment model.

Ishani Ganguli, MD, MPH, an assistant professor of medicine at Harvard Medical School, and colleagues wrote that female PCPs “are a growing share of the workforce and may achieve better outcomes in some scenarios,” but they continue to be paid less than their male counterparts. This could be because current compensation models do not effectively value primary care efforts and “may favor traditionally male practice patterns,” the researchers wrote. Current payment models, they added, do not take into account that female PCPs often conduct fewer, longer visits involving shared decision-making and more counseling.

“Evidence suggests that these traditionally female practice patterns, which are valued by patients and may themselves be linked to better outcomes, are systematically undervalued in the still-predominant productivity-based payment model,” the researchers wrote.

As an example, the researchers cited a study that found female PCPs generate 11% less revenue each year because they conduct 11% fewer billed visits, even though female PCPs spend more time with their patients both per visit and per year.

Ganguli and colleagues conducted a microsimulation study to assess how compensation for PCPs varies by gender when alternate compensation and productivity-based models are applied. The microsimulation included 1,435 PCPs, of whom 554 were women. The researchers focused on four compensation models: productivity-based fee-for-service, panel size-based capitation, panel size-based capitation with risk adjustment, and hybrid productivity-based fee-for-service and risk-adjusted panel size-based capitation.

The researchers noted that they opted for microsimulation instead of a direct comparison of practices “to allow pragmatic comparison of these models within practices and to avoid selection bias in which practices choose to use different models and which physicians and patients affiliate with these practices.”

Ganguli and colleagues found that female PCPs’ panels often included patients who, on average, were also female (72% vs. 52%), younger (mean patient age, 57.4 years vs. 62.4 years), were more often uninsured (3% vs. 1%) or insured by Medicaid (9% vs. 7%) and had lower diagnosis-based risk scores. Additionally, female PCPs were more likely to specialize in family medicine (78.7% vs. 74.9%) rather than internal medicine (20.5% vs. 24.2%) and had less time, on average, since medical school than males (mean, 23.1 years vs. 25.3 years).

The researchers reported that productivity-based payment scales and capitation had similar disparities. When it came to the productivity-based payment scales, female PCPs earned a median of $58,829 (interquartile range [IQR], $39,553 to $120,353) less per year than male PCPs. Under capitation, the gap was $58,723 (IQR, $42,141-$140,192).

With capitation risk-adjusted for age and sex, “the gap was smaller and nonsignificant” at $36,631 (IQR, $12,743-$73,898), according to the researchers. With capitation risk-adjusted for age alone, the gap was wider at $74,695 (IQR, $42,884-$152,423).

The gap was also wide when the researchers analyzed capitation risk-adjusted for only diagnosis-based scores — $114,792 (IQR, $49,080-$215,326) with the Charlson Comorbidity Index (CCI) and $89,974 (IQR, $26,175-$173,760) with the Hierarchical Condition Category (HCC) — as well as for age-, sex- and diagnosis-based scores ($83,438 [IQR, $28,927-$129,414] for CCI and $66,195 [IQR, $11,899-$96,566] for HCC).”

Ganguli and colleagues wrote that their results “highlight the need for explicit conversations about the societal and professional values and intentions underlying a given compensation approach.”

“If the goal is to compensate clinicians for time well-spent and for improved patient outcomes, evidence suggests that productivity-based compensation falls short,” they wrote.

Moving forward, an alternative model such as age- and sex-adjusted capitation that helps narrow the gender wage gap, “or future models that more directly capture primary care effort, may be beneficial not only from an equity standpoint but also for retention of the increasingly female primary care workforce that is already disproportionately subject to burnout,” the researchers wrote.

“Sustaining these workforce members may mitigate primary care capacity constraints and, in turn, support better health outcomes at lower cost,” they added.