Fee-for-service medicine, referrals, and the gender pay gap.

A recent quote in the Dallas Medical Journal made by a male physician stated that the well studied difference in pay between male and female physicians was due to an simple gap in hours worked, or a personal choice by female physicians to work slower and see fewer patients, or both.  Sadly it is a view likely held by the majority of male physicians, and although it provoked social media outrage, it was largely only from female physicians, with a very muted response from our male colleagues.  It was also somewhat misdirected rage at only the individual who made the unsurprising (to me anyway) statement and not at the wider patriarchal system which has allowed this pay gap to be perpetuated. Perhaps the only mildly surprising thing about the doctor’s attitude was that he allowed the quote to be published.  The data on the gender pay gap (the fact that female physicians earn less than male for the same work) in medicine is clear.  The gap is NOT explained by differences in work hours, speciality choice, seniority, or other factors.  It mirrors gender pay gaps in other areas of the workforce as well.

The argument has been put forth that this medical gender pay gap does not exist in Canada due to our largely fee-for-service model of billing (hereafter referred to as FFS and not meaning the other acronym it sometimes stands for).  70 % of physician remuneration paid in Ontario is FFS.  A doctor of either gender sees a patient, bills a code, (usually irrespective of the time taken to actually do the work the code represents), and the total dollar value of your codes is your monthly income (minus expenses).  There are time based billing exceptions like psychiatry and anesthesia, and capitation billing methods for family medicine but I’m not going to discuss those. Therefore, the reasoning goes, FFS is an entirely gender neutral, equitable way of paying physicians, which is completely blind to the gender of a physician. Do the work, get paid, and therefore no gender pay gap!  It’s completely fair!  Except that it’s not. This blog is my opinion and will not be referenced- the studies mentioned you can look up yourselves.  I think it is extremely likely as more data is generated on the gender pay gap (not that any more data should be needed at this point for our medical organisations to go ahead and address it), it will confirm what most female physicians already know (and the data confirms)- the system is rigged unfairly to pay female physicians less than men for equal work.  Yet another reason (among the many) that we need to be exploring better ways of paying physicians than straight FFS.

Reasons fee-for-service is not a gender neutral payment system.

  1. Not all payment and other benefits received by physicians are FFS. Women often negotiate poorly or not at all when they start jobs, leaving them behind at the starting line financially in terms of accessing perks like clinic and OR time, assistance of ancillary providers like medical scribes, physician assistants, and nurse practioners, and other hospital based resources.  Transparency and protocols for payment at the hospital and other administrative levels would of course help to even this out, but this is hard to come by in hospitals in Ontario.  As an aside, while the fee schedule in Ontario is completely transparent, the total billings are not and in fact nobody in Ontario, least of all other physicians, largely has any idea what anyone else makes aside from specialty averages available. This lack of transparency has the role of keeping those making less (females) uninformed, and therefore less likely to raise a protest.  It has also been my observation that female physicians seem to be asked to do jobs such as committee work which are not associated with stipends or any payment, while male physicians are more likely to apply for, and be awarded, roles associated with extra income. I gave CME talks for no payment, only to find out another male specialist was in fact paid to do the exact same thing I had done for free. In academic centres female physicians are often asked to do tasks which are less associated with being promoted up the professorship ladder, therefore decreasing their income. Data shows female physicians are less likely to be approached to consult for or to accept industry payments from pharmaceutical and other medical device companies, a sometimes not insignificant source of income which is currently not transparent.
  2. Time spent with patients. It’s a well studied fact that female physicians, on average, spend more time with patients than male.  It’s been studied comprehensively- I invite you to go look up the data.  There are some female physicians who spend very little time with patients, and some male docs spend a lot of time explaining things, but on the whole, FFS will lead to women earning less as they spend more time talking with patients.  FFS  financially rewards volume over anything else including quality.  This is a big problem with increasingly complex patients, the era of googling medical information, and shared decision making, where more time should be taken to ensure the patient fully understands their options.  I would note that getting rid of FFS would be more fair for all physicians who spend more time with patients, regardless of gender.
  3. Maternity leave.  It shouldn’t be a surprise to anyone that female physicians sometimes must take maternity leave, and that if you are billing straight fee-for-service and running an office this is going to leave you in the hole financially. Maternity leave for physicians is often for very limited lengths of time, due in part to the fact is a lot of physician work arrangements have little to no maternity leave allowed for- a problem in itself.  Again the old fashioned system of physicians running private offices with expenses paid for out of billings leaves female docs financially behind here. Medical organisations should have policies on the books around office expenses, locum coverage, and parental leave which support female physicians during maternity leave. And while we are at it, breast feeding support including dedicated space for feeding and pumping in the hospital and workplaces would be nice. There should also be the option for male physicians to take time off as well.  In Iceland there is mandated “use it or lose it” parental leave for both parents.  It means employers can expect that both male and female employees will take time off after kids are born, therefore lessening discrimination against female employees who are often assumed to be the only ones who will take parental leave. Female physicians also spend more time doing child care and housework than male physicians, even when working similar hours thus decreasing the time available to work. There are mechanisms to save for maternity leave with incorporation (a poor substitute for proper maternity leave policies in my opinion) and also a modest parental leave payment available for up to 17 weeks in Ontario for female physicians.  Employers need to plan for some flexibility for both genders to take parental leave without requiring those taking the leave to make up call before or after.  The fact is though, females bear the physical brunt of bearing and then breast feeding children, so poor parental leave policies will continue to disproportionately affect women for the forseeable future. A spinoff of this is that offices expenses tend to be somewhat fixed, not generally increasing that much based on volume.  So if you are earning less because you as a female parent are the one doing the majority of the childcare, a larger proportion of your income goes to office expenses than your male counterpart who can work longer hours.
  4. Referral bias- specialists depend on referrals for their practice income.  A lower number of referrals equals less income, but also the mix of referrals is important.  Physician remuneration generally rewards procedures over cognitive work, and this occurs within specialties as well as between them.  A recent study showed after a poor surgical outcome, referrals to female surgeons dropped, the authors postulating that the GPs drew the conclusion that it was due to a surgeon factor such as lack of clinical judgement or skill. Whereas in the same study, referrals (from both male and female GPs) went UP to male surgeons after a bad outcome, with the assumption being that the bad outcome was a related to something that made the patient a higher surgical risk, as opposed to a lack of clinical or technical skill on the part of the male surgeon.  This sort of gender bias affects referrals in other ways and it’s naive to think that it doesn’t.  Female surgeons often receive a disproportionate amount of non operative referrals.  The fee schedule tends to reward procedures much more than consults, and so if you do more clinic hours seeing fewer patients than your male colleagues, and also fewer patients who require surgery, that results in being unable to fill your OR lists (or unable to fill them with the quicker, lucrative cases) and you make less money.  As an example-breast surgery is an area of general surgery which deals largely with female patients and often with breast cancer especially, making the consultations take quite a bit longer than other issues. This results in decreased income if you are seeing a lot of these patients. It is one of the few areas of surgery where there are more women than men choosing to subspecialise in this area. It is not known as being particularly lucrative with respect to the fee codes.  In other areas of the workforce, as women migrate to a job the amount being paid for that job has tended to decline and I suspect that is what we will see with breast surgery. In addition, female surgeons will tell you (as will I) that there are referring doctors who routinely send them non operative but complex or extremely anxious (or both) time consuming patients as referrals while they can’t seem to find their number when it comes to an easy slam dunk surgical case.  While these patients all need to be seen, it certainly could be a source of increased burnout in female physicians when they  see a disproportionate number of patients with complex challenging problems for which there are no quick or easy answers like an operation. Female surgeons operating lists sit unfilled, while waiting lists for those operations rise.  This would of course be a problem with gender bias at least partially solved by centralised referrals, which are already in routine use in many settings, including DAPs (diagnostic assessment programs) and oncology centres.  The excuse used by referring doctors protesting the idea of centralised referrals is “I need to select the best consultant for my patient” can in fact often be a thinly veiled excuse for- consciously or subconsciously “I want to continue to discriminate against female doctors by sending them fewer or less lucrative referrals.”  (I will need to save a more complete takedown about the other meretricious arguments used against centralised referrals for another time.) There are some community based specialists who refuse to see referrals for conditions for their specialty which are known to be less lucrative- cherry picking is the name of this practice. This of course is unfair to those specialists who then have to see increased numbers of patients with a given time-consuming clinical condition.  As well it is unfair to the patients referred who have to wait longer to see the fewer number of specialists seeing that condition and also as an FYI contravenes CPSO policy on accepting referrals.  While this practice is not exclusively seen in male physicians, it certainly predominates there- in my opinion and recent experience. The old boys club sometimes lends a hand here as well with established referral patterns hard for a new physician to overcome.  I feel the need to say here that no physician in Ontario should be accepting payment or gifts in exchange for referrals, regardless of gender. Please see my blog on referral etiquette for more guidance.

In addition to the above, no approach to eliminating the medical gender pay gap can be successful without addressing relativity, which is the term for the fact that doctors in Ontario earn widely varying incomes depending on what it is they actually do for a living.  5 fold differences are seen and the higher paying procedure based specialties like surgery tend to be male dominated, whereas the low paying specialities are female dominated (paediatrics).  A lot of this reflects the hidden curriculum, where female medical students are discouraged from pursuing high paying specialties in medical school, being warned of tough working hours, difficulty negotiating work life balance, and of course a dose of good old sexism.   Until more women are represented in medical leadership and at negotiating tables, and more attention is paid to gender bias and its negative effects on society, both male and female physicians, and our patients, we will continue to have problems with this issue. I’m going to postulate here that if women had been present in leadership and negotiating tables proportionate to their numbers we would have had a lot more progress on the corrosive issue of relativity pervading our profession and also that we might have moved farther away from straight FFS billing, a move that would likely benefit both genders of physicians and our patients.

I can think of other issues related to the gender pay gap (lack of mentoring of females with regard to billing, hiring practices, lack of success securing research funding, getting published, receiving awards etc).  This has given you an inkling that when you say to a female physician that we don’t have an issue with a gender pay gap in Canada due to fee-for-service billing, that is an incorrect assumption.  While getting really mad at Gary (or any other male physician who publicaly disputes the gender pay gap) may be therapeutic, it isn’t going to change anything until a critical mass of physicians, both male and female, get up, get mad, and say our payment system needs a massive overhaul.  We need to start voting people into medical leadership positions in the PTMA (provincial territorial medical association who negotiate pay for physicians in Canada) who firstly acknowledge the problem of gender pay gap in medicine, and secondly are prepared to do something about it.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s