Reimbursement for Female-Specific Compared With Male-Specific Procedures Over Time

Abstract

Objective:

To evaluate whether per-procedure work relative value units (RVUs) have changed over time and compare time-based compensation for female-specific compared with male-specific procedures.

Methods:

Using the National Surgical Quality Improvement Program files for 2015–2018 we compared operative time and RVUs for 12 pairs of sex-specific procedures. Procedures were matched to be anatomically and technically similar. Procedure-assigned RVUs in 2015 were compared to 1997. Procedure compensation was determined using median dollars per RVU provided in SullivanCotter’s 2018 Physician Compensation and Productivity Survey. This was compared with specialty-specific McGraw-Hill per RVU data from 1994. Statistical analysis was performed with chi-square and Kruskal-Wallis tests.

Results:

A total of 12,120 patients underwent 6,217 male-specific procedures and 5,903 female-specific procedures. Male-specific procedures had a median RVU of 25.2 (IQR 21.4–25.2), compared to a median RVU of 7.5 (IQR 7.5–23.4) for female-specific procedures (p<0.001). Male-specific procedures were 79 minutes longer (136 mins [IQR 98–186] versus 57 mins [IQR 25–125], p<0.001). Female-specific procedures were reimbursed at a higher hourly rate (10.6 RVU/hour [IQR 7.2–16.2] versus 9.7 RVU/hour [IQR 7.4–12.8], p<0.001). However, male-specific procedures were better reimbursed ($599/hour [IQR $457–790] versus $555/hour [IQR $377–843], p<0.001). Overall, per-procedure RVUs for male-specific surgeries have increased 13% while for female-specific surgeries per-procedure RVUs have increased 26%. Reimbursement per RVU for male-specific procedures has decreased 8% ($67.30 to $61.65) while for female-specific procedures it has increased 14% ($44.50 to $52.02).

Conclusion:

Increases in RVUs and specialty-specific compensation have resulted in more equitable reimbursement for female-specific procedures. However, even with these changes, there is a lower relative value of work, driven by specialty-specific compensation rates, for procedures performed for women-only than equivalent men-only procedures.

PRECIS

Reimbursement for female-specific procedures has become more comparable to male-specific procedures; however, disparities in specialty-specific reimbursement rates remain.

INTRODUCTION

Effective January 1st, 2021, the Centers for Medicare and Medicaid Services increased the relative value of evaluation and management billing codes. Because of mandated budget neutrality, meaning Medicare expenditures cannot significantly increase or decrease from year to year, this change necessitated a reduction in the reimbursement of surgical procedures. The work relative value units (RVUs) assigned for procedures did not change; however, the dollars per RVU decreased. As a result, Obstetrics and Gynecology was projected to have an 8% increase in payments¹. This is because Obstetric care is paid for using global codes, meaning labor and delivery, prenatal, and postpartum office visits are paid for using a single code, valued at evaluation and management billing rates. However, if an obstetrician-gynecologist derives most of their income from gynecologic surgical procedures, they are likely to experience a 7% decrease in reimbursement,¹ as these changes in evaluation and management billing rates do not apply to global surgery codes.

The Medicare Resource-Based Relative Value Scale was implemented in 1992 and most public and private payers follow this scale to determine reimbursement. Physician compensation plans can range from salaried to productivity-driven, based on RVUs billed or collected. To establish RVUs for most current procedural terminology (CPT) codes, each specialty developed estimates of the work involved to perform procedures, based on time and skill². Two RVU-based analyses, from 1997 and 2015, show sex-specific procedures for women are undervalued and poorly reimbursed, without any surgically justifiable reason for this disparity^2–4. Despite similar operative times for paired gynecologic and urologic procedures, male-specific procedures were consistently assigned higher RVUs. We aimed to evaluate whether sex-based discrepancies in reimbursement have improved over time and which of these factors, RVUs assigned per procedure or dollars reimbursed per RVU, is the primary driver of unequal pay.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent sex-specific procedures between 2015 and 2018. The National Surgical Quality Improvement Program is a hospital-based surgical quality database that collects preoperative, intraoperative and 30-day postoperative data. Hospitals voluntarily participate in the database, and in exchange for participation, are given access to data regarding their own procedures to drive quality improvement.⁵ Data are abstracted by trained clinical reviewers and audited regularly. For an institution’s data to be used in the nationally available file, interobserver agreement during an audit must be greater than 95% and averages 98% for included sites.⁶ This study was reviewed by the Institutional Review Board of Northwestern University and deemed exempt from formal review as the data is deidentified.

CPT codes, maintained by the American Medical Association, represent discrete physician services and are used to determine reimbursement. CPT codes were used to identify patients who underwent one of the following sex-specific procedures. Male-specific procedures: 54015; 55041; 55175; 55180; 54125; 55150; 54130; 54135; 55821; 55842; 55845; 55810; 51597. Female-specific procedures: 56405; 58925; 56810; 57110; 56620; 56637; 56640; 57530; 58200; 58210; 58285; 58240. Only cases with one of the aforementioned primary CPT codes and without any other procedure or concurrent procedure CPT codes were included in the analysis. Procedures were matched to be anatomically and technically similar based on previous research on this topic^2,4. Twelve of the original 24 pairs of sex-specific procedures examined in 1997 were analyzed including: exenteration for prostate versus cervical cancer; resection of scrotum versus vulva; radical prostatectomy versus hysterectomy. The other 12 sets of procedures were not recorded in the National Surgical Quality Improvement Program due to being minor procedures such as scrotal and vulvar biopsy. We compared median operative time and RVUs for these 12 pairs of sex-specific procedures. Of note, scrotoplasty data for simple and complex procedures were averaged and compared with perineoplasty as no subcategorization exists for this female-specific procedure. We further compared procedure assigned RVUs in 2015 to those assigned in 1997⁴.

We also evaluated procedure-based compensation, which was estimated using median dollars per RVU for Urology and Obstetrics and Gynecology provided in SullivanCotter’s 2018 Physician Compensation and Productivity Survey⁷. The median operative time for a given procedure was assessed; the RVUs assigned for the procedure were divided by this time; that number was then multiplied by 60 minutes to generate an RVU per hour value for each procedure. A procedure-specific per hour compensation value in dollars was then determined by multiplying this RVU per hour value by a Urology or Obstetrics and Gynecology specialty-specific per RVU reimbursement rate, as appropriate. Median dollars per RVU for Urology and Obstetrics and Gynecology provided in SullivanCotter’s 2018 Physician Compensation and Productivity Survey and specialty-specific McGraw-Hill per RVU compensation data from 1994 for Urology and Obstetrics and Gynecology were used to compare the dollars reimbursed per procedure for matched sex-specific procedures over time.⁸

Median operative times, procedure-specific RVU per hour rate and procedure-specific dollars per hour rate were calculated. Because the number (n) of CPT codes varied widely (n = 2 to 3,184), these were weighted by the case volume of each procedure in the overall calculation for male versus female-specific comparisons. The operative time utilized was the median intraoperative time per CPT code, not including perioperative or anesthesia time. Operative time is directly measured and recorded in the National Surgical Quality Improvement Program. These values were then compared for matched sex-specific procedures. Chi-square and Kruskal-Wallis tests were used to examine associations. All analyses were done using Stata, version 15.1 (StataCorp), with statistical significance determined using an α of 0.05.

RESULTS

A total of 12,120 patients underwent 6,217 male-specific procedures and 5,903 female-specific procedures between 2015 and 2018 (Table 1).

Table 1 –

Relative value unit based compensation and operative time for patients recorded in the National Surgical Quality Improvement Program 2015–2018

Description	CPT (n)	RVU 2015	RVU 1997	%Δ	Operative time (mins)	Difference (mins)	RVU per/hr	$ per/hr
Incision & Drainage
Penis	54015 (55)	5.36	5.16	+4%	37 (18–56)	+21	8.69	$536
Vulva	56405 (830)	1.49	1.39	+7%	16 (11–23)		5.59	$291
Excision of bilateral Hydroceles	55041 (409)	8.54	7.38	+16%	49 (34–68)		10.46	$645
Excision of bilateral ovarian cysts	58925 (1,001)	12.43	6.40	+94%	74 (52–100)	+25	10.08	$520
Scrotoplasty
Simple	55175 (77)	5.87	4.93	+19%	72 (39–90)	+44	4.89	$301
Complex	55180 (18)	11.78	10.07	+17%	65.5 (43–137)	+37.5	10.79	$665
Perineoplasty	56810 (229)	4.29	3.97	+8%	28 (17–47)		9.19	$478
Resection Penis	54125 (28)	14.56	12.80	+14%	124.5 (94.5–156)		7.02	$433
Vaginectomy	57110 (23)	15.48	13.48	+15%	83 (68–120)	−41.5	11.19	$582
Resection Scrotum	55150 (111)	8.14	6.62	+23%	38 (24–61)	+8	12.85	$792
Vulva	56620 (1,842)	7.53	6.67	+13%	30 (20–45)		15.06	$783
Radical amputation Penis with GND	54130 (6)	21.84	18.92	+15%	200 (163–247)	+61	6.55	$404
Radical vulvectomy with GND	56637 (41)	24.75	20.34	+22%	139 (109–223)		10.68	$556
Radical amputation Penis with GND & PND	54135 (2)	28.17	25.01	+13%	244.5 (208–281)		6.91	$453
Radical vulvectomy with GND & PND	56640 (5)	24.78	20.09	+23%	58 (42–75)	−186.5	25.63	$1,333
Prostatectomy
Subtotal	55821 (340)	17.19	13.00	+32%	99 (79–129)	+45	10.42	$642
Trachelectomy	57530 (65)	5.27	6.63	−21%	54 (32–80)		5.86	$305
Prostatectomy with limited nodes	55842 (1,730)	21.36	22.70	−6%	133 (105–173)	−7.5	9.64	$594
TAH BSO with limited nodes	58200 (430)	23.10	20.34	+14%	140.5 (104–195)		9.86	$513
Radical Prostatectomy	55845 (3,184)	25.18	26.73	−6%	155 (116–202)		9.75	$601
Hysterectomy	58210 (1,312)	30.91	23.97	+29%	168 (115–220)	+13	11.04	$574
Radical prostatectomy Perineal approach	55810 (177)	24.29	21.21	+15%	152 (120–193)	+64	9.59	$591
Radical hysterectomy Vaginal approach	58285 (29)	23.38	17.45	+34%	88 (69–131)		15.94	$829
Exenteration for prostate Cancer	51597 (80)	42.86	35.27	+22%	319.5 (262.5–386)	+4	8.05	$496
Exenteration for cervical Cancer	58240 (96)	49.33	28.79	+71%	314.5 (230–448.5)		9.41	$489

Abbreviations: CPT = current procedural terminology; RVU = relative value unit; %Δ = percent change; IQR = interquartile range; mins = minutes; hr = hour; GND = groin node dissection; PND = pelvic node dissection; TAH BSO = Total abdominal hysterectomy and bilateral salpingo-oophorectomy

Overall, male-specific procedures had a median RVU of 25.2 (IQR 21.4–25.2), significantly higher than the median RVU of 7.5 (IQR 7.5–23.4) for female-specific procedures (p<0.001). In 1997, the majority of male-specific procedures had higher assigned RVUs than their female specific counterparts. The three exceptions to this were vaginectomy, radical vulvectomy with groin lymphadenectomy, and vulvar resection. All female-specific procedures that were assigned more RVUs in 1997, remained with higher RVUs in 2015 with the exception of vulvar resection. Five paired procedures had higher RVUs assigned to the male specific procedures in 1997 and these remained higher in 2015. There were four paired procedures where the RVUs assigned to the male procedure were higher in 1997, but by 2015, the female-specific procedure was valued more highly. The female-specific procedure in these pairings were excision of bilateral ovarian cysts, total abdominal hysterectomy and bilateral salpingo-oophorectomy with limited nodes, radical hysterectomy and pelvic exenteration for cervical cancer (Table 1).

Male-specific procedures were longer, lasting 79 minutes more than female-specific procedures (136 mins [IQR 98–186] versus 57 mins [IQR 25–125], p<0.001). Generally, when comparing male and female-specific procedures, the longer procedure had higher assigned RVUs. This was not the case for the following paired procedures: resection of penis and vaginectomy, radical vulvectomy with groin node dissection and radical amputation of the penis with groin node dissection, and exenteration for cervical cancer and exenteration for prostate cancer (Table 1).

Comparing sex-specific procedures by RVUs per hour, female-specific procedures were valued at a higher rate than male-specific procedures (10.6 RVU/hour [IQR 7.2–16.2] versus 9.7 RVU/hour [IQR 7.4–12.8], p<0.001). However, when compensation was accounted for, male-specific procedures were better reimbursed ($599/hour [IQR $457–790] versus $555/hour [IQR $377–843], p<0.001). Despite having a similar RVU per hour rate, excision of bilateral ovarian cysts is poorly reimbursed relative to excision of bilateral hydroceles (10.08 RVU/hour versus 10.46 RVU/hour; $520 versus $645). By contrast, resection of the scrotum is better reimbursed than resection of the vulva despite a lower RVU per hour rate (15.06 RVU/hour versus 12.85 RVU/hour; $783 versus $792). This is also the case comparing prostatectomy with limited nodes and total abdominal hysterectomy and bilateral salpingo-oophorectomy with limited nodes (9.86 RVU/hour versus 9.64 RVU/hour; $513 versus $594) and radical hysterectomy relative to radical prostatectomy (11.04 RVU/hour versus 9.75 RVU/hour; $574 versus $601).

Overall, per-procedure RVUs for male-specific surgeries have increased 13% over the past two decades while per-procedure RVUs 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), driven by changes in specialty-specific per RVU compensation rates.

DISCUSSION

We examined 12 pairs of major sex-specific procedures recorded as the primary procedure CPT code in the National Surgical Quality Improvement Program between 2015 and 2018. Evaluation of RVUs for procedures matched by technical complexity (e.g. exenteration for prostate versus cervix cancer) revealed that in 6 cases (50%), male-specific procedures had higher assigned RVUs. This represents a significant change since 1997, when Goff et al compared RVUs and operative time for paired sex-specific procedures, and among the same 12 sets of procedures 75% had higher assigned RVUs for the male-specific procedure⁴. Similarly, per procedure RVUs for male-specific surgeries have increased 13% over the past two decades while per procedure RVUs for female-specific surgeries have increased 26%. Based simply on RVUs assigned per procedure, our analysis found improvements in compensation equity between male and female-specific procedures over the last 20 years.

In 2015, 72% of reviewed procedures had higher assigned RVUs for male-specific procedures as compared with female-specific procedures and 84% of male-specific procedures were reimbursed at higher rates². In our study 58% of male-specific surgeries were reimbursed at higher rates, albeit with a smaller set of paired procedures. It, therefore, appears that persistent pay inequality for sex-specific procedures is largely driven by differences in the per RVU compensation of the specialists who typically perform either male-specific or female-specific procedures, namely the difference in per RVU compensation for Urology compared with Obstetrics and Gynecology.

A recent National Surgical Quality Improvement Program RVU-based analysis that examined the correlation between observed operative time and surgeon-reported operative time demonstrated an RVU per hour rate of 10.2 for Obstetrics and Gynecology⁹, which is consistent with our reported RVU per hour rate of 10.6. Among nine surgical specialties analyzed, Obstetrics and Gynecology had the lowest median overreported operative time (+5 mins). Urology had a median overreported operative time of +20 mins and overreporting of operative time by specialty was strongly correlated with higher RVUs per hour, highlighting the complex factors which interact to create the discrepancies we observed.

In medicine as a whole, the gender wage gap persists: female surgeons earn 65% of the salary of male surgeons, unchanged over the past 5 years, with self-reported RVUs only 27% different¹⁰. Narrowing of this gap has been largely driven by a decrease in men’s earnings, offset by a minor increase in women’s wages¹¹. This is born out in our data, which shows an 8% decrease in specialty-specific per RVU reimbursement for Urology and a concomitant increase of 14% for obstetrics and gynecology in the last two decades. Overall, obstetrician–gynecologist salaries, a workforce that is currently 59% female, are the lowest among surgical specialties. Salaries in obstetrics and gynecology were 20%−25% higher than the mean physician salary in the 1970s and 1980s when the female workforce share was 8% and 18%, respectively. By 2017, with a female workforce share of 57%, an obstetrician gynecologist became an average physician earner. In contrast, Urology earned 123% of the average physician salary in the 1980s when it was 1% female and 125% of the average salary in 2017 when it was 9% female¹². The issue is compounded for gynecologic sub-specialty surgeons; due to the substantially higher conversion factor for obstetric procedures, most gynecologic surgeries are reimbursed less than vaginal deliveries³.

Gynecologic surgical subspecialties have designated Centers for Medicare and Medicaid Services specialty number assignments, but do not have subspecialty-specific per RVU reimbursement rates¹³. In 2017, Benoit et al proposed “adding value” back to gynecologic CPT codes, not detracting from Urology,² and it appears that for some sex-specific procedures this has been achieved through better parity in RVU assignment. To address persistent disparities in dollars reimbursed per procedure, a gynecology sub-specialty adjustment factor could be considered. This might allow for parity between reimbursement in urogynecology and urology as well as gynecologic oncology and surgical or medical oncology². The value of high-volume gynecologic surgeons, specifically those with fellowship training in minimally invasive gynecology, is not realized in the current model of health care compensation. Perhaps as we move towards outcomes-based payment models this can be improved.

A limitation of this analysis is that procedures coded with concurrent and other CPTs were excluded to allow for comparison of procedure-specific median operative time, resulting in the exclusion of cases that are often routinely performed with concurrent CPTs. Additionally, the National Surgical Quality Improvement Program collects data on a representative sample of patients undergoing major surgery from member hospitals and therefore may not be generalizable to the entire US population. In this analysis, we included 12 of the original 24 pairs of sex-specific procedures examined in 1997; the other 12 sets of procedures were not recorded in the National Surgical Quality Improvement Program due to being minor procedures such as scrotal and vulvar biopsy. Several of the examined procedures are specific to urologic or gynecologic oncology and were selected to facilitate direct comparison to the 1997 and 2015 analyses. However, other sex-specific procedures such as oophorectomy versus orchiectomy could have been investigated. Additionally, this analysis does not account for global fees, which are structured into the reimbursement of certain procedures as RVUs are a representation of not just operating room time and technical skill, but also the perioperative care of the patient which this study cannot account for.

With the aforementioned 2021 Centers for Medicare and Medicaid Services changes in reimbursement of surgical procedures the income disparity for gynecologic sub-specialty surgeons is likely to increase. The origins of the gender wage gap in medicine are multifactorial, but our study suggests that an undervaluing of procedures performed on female patients relative to male patients does play a role. Efforts to increase specialty-specific per RVU reimbursement rates would help achieve equitable reimbursement for sex-specific procedures. Correcting the global devaluation of the work of female-predominant specialties is challenging, but systematically raising reimbursement for procedures performed on women-only could decrease compensation inequities.