Assessment of Medical Industry Compensation to US Physicians by Gender

This cross-sectional study assesses payments from medical industry companies to US physicians by gender from 2013 to 2019.

Key Points

Question

Is there inequity in industry engagement of female physicians in the US?

Findings

In this population-based cross-sectional study that included 1050 payments made by medical industry from 2013 to 2019, 3.1% of highest earners were women; men received a significantly higher median total payment than did woman.

Meaning

This study found that male physicians received significantly higher payments from highest-grossing medical supply companies compared with female physicians from 2013 to 2019.

Abstract

Importance

It has been well established that female physicians earn less than their male counterparts in all specialties and ranks despite controlling for confounding variables.

Objective

To investigate payments made from highest-grossing medical industry companies to female and male physicians and to assess compensation and engagement disparities based on gender.

Design, Setting, and Participants

This retrospective, population-based cross-sectional study used data from the Open Payments database for the 5 female and 5 male physicians who received the most financial compensation from each of the 15 highest-grossing medical supply companies in the US from January 2013 to January 2019.

Main Outcomes and Measures

The primary outcome was total general payments received by female and male physicians from medical industry over time and across industries. The secondary outcome was trends in industry payment to female and male physicians from 2013 to 2019.

Results

Among the 1050 payments sampled, 1017 (96.9%) of the 5 highest earners were men and 33 (3.1%) were women. Female physicians were paid a mean (SD) of $41 320 ($88 695), and male physicians were paid a mean (SD) of $1 226 377 ($3 377 957) (P < .001). On multivariate analysis, male gender was significantly associated with higher payment after adjusting for rank, h-index, and specialty (mean [SD], $1 025 413 [$162 578]; P < .001). From 2013 to 2019, the payment gap between female and male physicians increased from $54 343 to $166 778 (P < .001).

Conclusions and Relevance

This study found that male physicians received significantly higher payments from the highest-grossing medical industry companies compared with female physicians. This disparity persisted across all medical specialties and academic ranks. The health care industry gender payment gap continued to increase from 2013 to 2019, with a wider compensation gap in 2019.

Introduction

The physician-industry relationship is prevalent in medicine and involves 80% of physicians.¹ Medical industry spends more than $30 billion per year on the advertising and promotion of medical devices and drugs, of which approximately 90% is directed toward physicians.² Since 2010, industry payments have been publicly accessible and have revealed larger payments to male physicians compared with female physicians not only in male-dominated fields such as urology, radiology, and orthopedic surgery,^3,4,5 but across all specialties.^6,7 The industry-physician relationship provides not only monetary gain but also networking opportunities and connections that could lead to opportunities for mentorship, access to research, and career advancement.⁸

The gender inequity of payments from and engagement of physicians by medical companies aligns with and contributes to the current state of gender inequity in medicine. In 2020, 52.4% of matriculating medical students were female,⁹ and women comprised one-third of the physician workforce. Despite this, gender pay gaps continue to exist, and women continue to be underrepresented in leadership positions across fields.^10,11,12 The gender salary pay gap between female and male physicians ranges from 16% to 37%,¹⁰ and this disparity persists even when controlling for variables such as age, specialty, and hours worked.

Therefore, we designed a study to examine the trends of payments to highest earners in medical industry with regard to gender. We hypothesized that physician-industry payment inequities would continue to be prevalent among the highest-earning physicians. We also aimed to examine the trends of industry payment to female and male physicians over our study period.

Methods

The primary outcome of this retrospective, population-based cross-sectional study was total general payments from medical industry received by the highest-earning female and female physicians. The secondary outcome was trends of industry payment to female and male physicians from January 2013 to January 2019. To accomplish this, we investigated the 15 highest-grossing medical supply companies and, using the Open Payments Database (OPD), determined the 5 men and 5 women who received the most from each of the selected companies from 2013 to 2019. This study was deemed exempt by the institutional review board at the University of California, Irvine, and individual informed consent was waived because the study was retrospective and used public data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Company Selection

We selected the 15 highest-grossing medical supply companies from 2018. These companies were selected based off earnings reported in the company filings and S&P Capital. The 15 companies selected include Medtronic PLC; Edwards Life Sciences Corporation; Fresenius Medical Care AG & Company KGaA; Terumo Corporation; Abbott Laboratories; Becton, Dickinson and Company; Siemens Healthineers AG; Cardinal Health, Inc; Stryker Corporation; Olympus Corporation; Smith & Nephew PLC; Baxter International, Inc; Boston Scientific Corporation; Zimmer Biomet Holdings, incorporated; and Novartis International AG.

Physician Selection

The OPD¹³ releases payment information each year regarding physician compensation from medical industry. The OPD began reporting financial information for physician compensation in 2013 after approval of the Physician Payments Sunshine Act in 2010, which mandates the reporting of all financial relationships between medical industry and clinicians.¹⁴ The OPD was used to determine the 5 men and 5 women most highly compensated by each of the selected companies. Each company was tracked back to 2013, when the OPD began reporting payment information. For each year from 2013 to 2017, the 5 men and 5 women who earned the most from each company were selected. To identify the highest-earning women, we had to look beyond the 10 overall highest-paid physicians for each company. Following initial data collection of highest earners from 2013 through 2017, the OPD web interface was updated and reported only the 10 highest earners from each company. To identify the 5 highest-earning men and 5 highest-earning women from 2018 to 2020, OPD data sets were processed in R, version 4.2.0 (R Project for Statistical Computing) and subset in the same fashion as the 2013 to 2017 data. Owing to the COVID 19 pandemic, the 2020 payments were significantly lower, and therefore, these data were excluded from final analysis.

The OPD releases payment information based on general payments, research payments, and ownership and investment interest. To assess the highest-earning physicians, we included only general payments. General payments include consulting fees, non–publicly traded ownership, honoraria, gifts, travel and lodging expenses, entertainment, royalties or licensing agreements, compensation for serving as speaker or faculty, and compensation for services other than consulting. For physicians earning more than $1 000 000 in any given year, further investigation was performed to ensure that those physicians did not receive substantial payment from an ownership interest in the company. If an ownership interest existed that resulted in a substantial proportion of their total general payment, those physicians were excluded from the study.

Data Extraction

For each of the highest-earning physicians, OPD was used to determine compensation, number of payments, specialty, institutional affiliation, and academic rank (if applicable). If this information could not be found on OPD, Scopus and PubMed were queried for further investigation using the author’s first and last names. We defined a payment position for each physician because we had to search past the 5 overall highest-earning physicians to find the highest-earning women. Each physician was given a payment position based on their compensation relative to the other physicians compensated by the same company each year. For example, the overall highest-paid physician (male or female) from any selected company from any year would be given the position of 1, and the 10th overall highest-paid physician would be assigned the payment position of 10 until the 5 highest-earning men and women were identified. To find the fifth highest-paid female physician, the farthest down the list of overall highest-paid physicians from a company in a certain year was the 473rd payment position. Using this system, we analyzed the payment position of each of the 5 highest-earning men and 5 highest-earning women for each of the 15 selected companies for each year from 2013 to 2019. Scopus was used to identify the h-index for each physician identified. The h-index, defined as an author-level metric that measures the productivity (number of articles published) and citation impact of publications from an individual, was used as a marker for scholarly productivity. The h-index values were grouped into 3 quartiles (≤19, 20-39, and ≥40) and compared. The gender compensation gap was also analyzed by controlling for academic rank. The physicians were categorized into 4 groups: full professor, associate professor, assistant professor, and community physician.

Statistical Analysis

Total amount of compensation, total number of payments, and payment position were compared for the 5 highest-earning men and 5 highest-earning women from 2013 to 2019. t Test was used to assess for statistically significant differences between groups. The association between general payments and gender, academic specialty, h-index, and academic rank was analyzed using a multivariate regression model, as reported by the F test and corresponding P value. The F test was used to assess the overall association of the independent variables with payments in the multivariate regression model.

A subanalysis was performed to examine the gender distribution of the CEO and board members for each of the studied companies. The 15 official company websites were queried for the list of CEO and board members. The CEO and board members’ gender identification was determined by pronouns used on company websites. A multivariate analysis was performed to evaluate the association of the gender distribution of the CEO and board members of each company with physician compensation.

All statistical analysis were performed using SAS/STAT, version 9.4 (SAS Institute Inc); SPSS, version 26 (IBM Corp); and Microsoft Excel, version 16.47. Two-sided P < .05 was considered statistically significant.

Results

Of the 1050 payments sampled, 1017 (96.9%) of the 5 highest earners were men and 33 (3.1%) were women. The variable of payment position was used to rank the overall highest to lowest compensated physicians, with 1 being the highest overall compensation and 473 being the lowest. Women held a lower mean payment position compared with men (79.7 [10.0] per year vs 3.2 [0.11] per year; P < .001).

The median and mean general payments by the 15 highest-grossing medical device companies from 2013 to 2019 were stratified by gender (Figure 1). Women were compensated less than men (mean [SD], $41 320 [$88 695] vs $1 226 377 [$3 377 957]; P < .001), with a difference of $1 185 057. The median total payment for men was $129 387 (IQR, 2771-37 182 318) compared with $20 622 (IQR, 61-1 664 244) for women (P < .001), with a difference between payments of $108 765 (Table). The mean (SD) number of payments to men was 57 (69) compared with 36 (42) for women (P < .001).

Figure 1. Median General Payments Stratified by Gender per Year From 2013 to 2019.

Table. Mean and Median General Payments Stratified by Gender^a.

Gender	General payment, median (IQR), $	Difference, $	General payment, mean (SD), $	Difference, $
Women	20 622 (61-1 664 244)	108 765	41 320 (88 695)	1 185 057
Men	129 387 (2771-37 182 318)		1 226 377 (3 377 957)

^a P < .05 for all comparisons.

The median and mean payments by the 15 companies stratified by gender were analyzed per year from 2013 to 2019. Each year, there was a significantly higher median and mean general payment to male physicians compared with female physicians (Figure 1). The difference in median compensation between female and male physicians in 2013 was $54 343, whereas the difference in 2019 increased 3-fold to $166 778.

On multivariate analysis, payments made to physicians by medical companies were significantly different for men and women after adjusting for medical specialty, h-index, academic rank, company, and year when data were collected (mean [SD], $1 025 413 [$162 578]; P < .001). The median h-index for men was 23 (range, 0-160) compared with 9 (range, 0-150) for women (P < .001) Men were paid significantly more than women when controlling for each h-index quartile group.

Our study identified 307 physicians with the academic rank of professor, including 111 female professors (36.2%) and 196 male professors (63.8%). Women were more likely than men to be associate professors (75 of 140 [53.5%] vs 65 of 140 [46.4%]; P < .001) and assistant professors (72 of 86 [83.7%] vs 14 of 86 [16.3%]; P < .001). On subgroup analysis, men were more likely to hold a full professor position (196 of 307 [63.8%]) compared with women (111 of 307 [36.2%]) (P < .001). Male physicians had higher median compensation compared with female physicians in all academic rank groups: professor ($129 499 [range, $2772-$37 182 318] vs $19 559 [range, $344-$348 148]; P < .001), associate professor ($86 616 [range, $4901-$16 721 999] vs $17 000 [range, $373-$10 000]; P < .001), assistant professor ($47 224 [range, $11349-$1 180 060] vs $16 845 [range, $66-$105 249]; P < .001), and community physician ($176 509 [range, $3032-$15 822 423] vs $24 103 [range, $61-$1 664 244]; P < .001) (Figure 2).

Figure 2. Median General Payment Stratified by Academic Rank.

Men had significantly higher median compensation across all specialties, including in female-predominant specialties such as pediatrics and obstetrics and gynecology (Figure 3 and Figure 4). The largest discrepancy was in orthopedic surgery, with the median general payment for men being $1 752 573 (range, $10 965-$31 235 464) compared with $24 387 (range, $373-$205 972) for women, a difference of $1 728 186 (P < .001).

Figure 3. Median General Payment Stratified by Medical Specialty and Gender.

OBGYN indicates obstetrics gynecology.

Figure 4. Median General Payment Stratified by Surgical Specialty and Gender.

Of the 15 highest-grossing medical supply companies, only 1 company (6.7%), Terumo Corporation, had a female CEO and 14 (93.3%) had a male CEO. Terumo Corporation had a median payment of $5367 (range, $344-$26 679) to female physicians compared with $31 490 (range, $9928-$87 491) to male physicians, a difference of $26 123 (P < .001). This payment difference was the third overall lowest between female and male physicians among the 15 companies. All 15 companies had more men than women on the board of directors, with a mean (SD) of 60% (5.8%) of members identifying as men and 40% (5.9%) of members identifying as women. Terumo Corporation had the highest percentage of members identifying as women (5 of 11 [45%]). On multivariate analysis, companies with predominantly male (>50%) board member composition were associated with lower payments to female physicians. A total of 52 (21 men [40.4%], 31 women [59.6%]) of the physicians receiving industry payments were from obstetrics and gynecology. Despite a higher female-to-male ratio, male obstetricians and gynecologists received 3 times the amount of payment compensation from industry (men: median, $87 596 [range, $35 672-$14 751 093); women: median, $31 166 [range, $1161-$663 240]; P < .001). A total of 81 general surgeons were among the highest-earning female (44 [54.3%]) and male physicians (37 [45.7%]). Despite the higher female-to-male general surgeon ratio, male general surgeons received 12.5 times higher median general payment compared with female general surgeons (men: $82 678 [range, $5291-$26 843 392]; women: $6504 [range, $110-$144 598]; P < .001)

Discussion

To our knowledge, this is the only study to examine industry payments to the highest-earning physicians across all specialties and to report industry payment trends and gender inequities over a 7-year period. We found that in the 15 highest-grossing medical industry companies from 2013 to 2019, there was a median 3-fold increase in the compensation of highest-earning men compared with the highest-earning women. Only 3.1% of women were within the 5 overall highest compensated physicians. The OPD ranks the overall highest-paid physicians per company per year from 1 to 500, which this study labeled as payment position, with payment position 1 being the highest-paid physician for that company that year. Across all companies, the mean payment position for men was 3 compared with 79 for women. Men received higher compensation compared with women regardless of academic rank (professor, assistant professor, associate professor, or community physician), specialty, and h-index.

Gender disparity in physician payments has been shown to be prevalent in industry payments to physicians. Velez et al⁵ used the OPD to study industry payments to urologists and found that male urologists earned twice as much as female urologists for research and general payments. Male gender was also found to be associated with higher payment amount for industry payments to orthopedic surgeons.⁴ Of 3418 orthopedic physicians receiving royalties and consulting fees, 99.6% of the payments were to men.⁴ Similarly, Deipolyi et al³ showed that female interventional radiologists earned 1% of total industry payments despite comprising 13% of all interventional radiologists who received payments. Despite more women having entered the fields of urology, orthopedic surgery, and interventional radiology in recent years, these fields continue to be male dominated. We looked at all medical fields, including but not limited to surgery, radiology, pathology, dermatology, internal medicine, and obstetrics and gynecology and found that men earned significantly more than women regardless of their medical specialty. Obstetrics and gynecology is a female-dominated specialty of which women compromise more than 60% of all physicians.¹⁵ Our study showed that 52 of the physicians receiving industry payments were from obstetrics and gynecology: 31 women and 21 men. Despite a higher female-to-male ratio, male obstetricians and gynecologists received 3 times the amount of payment compensation from industry. Men received higher compensation than women even in female-predominant fields, including family medicine and pediatrics. This finding is concordant with those from a study showing gender bias not just in male-dominated fields but also in gender-balanced and female-dominated fields.¹⁶

The fields with the largest payment gaps, however, were male-dominated surgical fields: orthopedic surgery, urology, and neurosurgery. Orthopedic surgery had the overall largest payment gap of $1 752 573, which is consistent with previous studies looking at the industry relationship with female and male orthopedic surgeons.^17,18 The study by Marshall et al¹⁹ showed that the trend of industry payments was to direct larger payments to a reduced number of physicians, especially within medical and surgical subspecialties. This finding may explain the discrepancy in the male-dominated surgical specialties in our study because there were few women among the highest-earning recipients of industry payment in these fields.

Although general surgery is currently a male-dominated field, our study showed high industry engagement with female physicians. Our study showed that 81 general surgeons were among the highest-earning female and male physicians (44 female and 37 male). Despite the higher female-to-male general surgeon ratio, male general surgeons received 12.5 times higher median general payment compared with female general surgeons, showing that even though women had more engagement with industry, they were still compensated at a lower rate compared with men. A study²⁰ showed that even though more women were present in a particular field, the gender bias continued to persist in association with biased workplace structures, current gender norms, and practices engrained within the system.

Gender inequity in medicine transcends salary and compensation because it is also prevalent in academic and leadership positions. Studies^10,21,22,23 showed that women were less likely to achieve high academic rank, senior leadership positions, or remain in academic fields compared with men, even when adjusting for total years of work, department, and academic productivity, and were compensated significantly less by industry regardless of academic rank. Our findings are concordant with these data because we demonstrated that female physicians who were professors earned 6.6 times less than male physicians who were professors.

In the past 2 decades, gender disparities in medicine have been a prevalent issue and programs for change have been implemented. In 2018, The American College of Physicians released a position statement highlighting the inequities that female physicians face as well as recommendations.¹⁰ Similar calls for action and programs have been started by many large medical organizations within the past 10 years; however, the national gender wage gap for physicians has continued to widen.²⁴ Our study showed that the industry payment gap widened from 2013 to 2019, with the median payment gap between male and female physicians increasing from $54 343 to $166 778, a continued 3-fold increase.

Of the 15 companies sampled, 14 were led by a CEO who identified as male. Furthermore, all 15 companies had a board of directors composed of mostly men. A study by Bell²⁵ showed that gender pay disparity correlated with the gender of the CEO and leadership of a company. Higher pay disparities were seen in companies with male-predominant leadership compared with female leadership. However, that study showed that even in companies with female leadership, gender pay disparity, though smaller, still existed. At Terumo Corporation, the company with a female CEO and a board of directors that was almost half female, the compensation gap was in the third lowest of the 15 companies, with a median difference of $26 123.

Limitations

Limitations to this study include those inherent to a database analysis, including missing or inaccurate data and reliance on the accuracy of the input data. The database lacked pertinent demographic and physician information, including race, age, and years in practice. Although years in practice were not available, a study²⁶ showed that gender inequity in both payment and leadership positions persisted even when controlling for this variable. Furthermore, certain academic institutions have organizational restrictions on industry interactions, which may have skewed the results of this study. However, the effect of these organizational restrictions would be equal for both female and male physicians.

Conclusions

In this cross-sectional study, we found a large gender pay gap in industry payments among the highest earners from 2013 to 2019. Men earned significantly more than women during the study period, and significantly fewer women than men were among the 5 overall highest-compensated physicians per year for each company. This inequity was also prevalent in female-dominated specialties. Despite increased scrutiny over the past decade with regard to equity, we demonstrated that the industry payment gap increased over time. Future studies are needed to elucidate why the gender gap in medical industry payments continues to widen despite national recognition and more women in medicine.