What's the big difference between a twisted ovary and a twisted testicle? (Hint: Look at your fee schedule)

Women are often charged higher prices than men for services such as haircuts and dry cleaning, but when it comes to healthcare, the services provided to female patients tend to be priced lower by provincial health insurers than those provided to men—further widening the gender-based pay gap among physicians, according to a study published in the July issue of the Canadian Journal of Surgery. “Our study revealed a trend toward devaluation of the healthcare provided to female patients across Canada,” wrote the study authors—a mix of Canadian clinicians trained in obstetrics, gynecology and urology. “The lower reimbursement of the surgical care of female patients than for similar care provided to male patients represents double discrimination against both female physicians and their female patients, as female providers predominate in obstetrics and gynecology.” The researchers used a modified Delphi process to generate a list of common gynecological procedures performed on female reproductive anatomy, which would correspond to a patient population of predominantly cisgender women as well as nonbinary people, transgender men and transgender women with ovaries, a uterus, vagina and/or a vulva. These procedures were then analyzed to identify comparable procedures performed exclusively on male patients, resulting in a finalized list of 23 procedural pairs. Using data from provincial fee schedules, the researchers compared the fees paid for the two sets of procedures and found that in eight out of 11 provinces and territories, surgeons were reimbursed at “significantly lower” rates for procedures performed on female patients than for similar procedures performed on male patients. “For 70% of the procedural pairs . . . the average billing fee for procedures for female patients was 28.1% lower than the fee for the corresponding procedure for male patients,” wrote the study authors. “This corresponds to a mean difference of $43.91 for procedures for female versus male patients.” Read: Timing of menopausal hormone therapy important in terms of CVD risks When the researchers compared reimbursements from one province to another, they found the largest fee discrepancies in Saskatchewan—which had a mean percentage difference in fees of 67.3%—British Columbia with 61.2% and the Yukon with a 41.8% fee discrepancy. “Smaller but still significant differences were seen in Alberta, Manitoba, Ontario, New Brunswick and Prince Edward Island,” wrote the authors. “Notably, there were no statistically significant differences in the average fees in Nova Scotia, Newfoundland and Labrador or Quebec.” In an interview with CBC’s Radio Canada International, Joanne Sivertson—the provincial department head for obstetrics and gynecology in Saskatchewan—described the fee discrepancies as “demeaning to women” and blamed discriminatory historical policies. Care for women has been undervalued for decades and policymakers continue to perpetuate that under evaluation, she explained. It will take a large correction to close this gender-based fee gap. As an example of the unfairness of the fee discrepancies, Sivertson cited a procedure where a physician needs to untwist an ovary or testicle. When this procedure involves an ovary, the physician must go into the abdominal cavity, adding risk and complexity to the operation. Yet this procedure is reimbursed at 50% less compared to a similar case involving a twisted testicle. Read: Gender pay gap in Canadian medicine—yes, it’s real! The study authors noted that obstetrician-gynecologists, who make up 3.2% of Canadian physicians, account for 3.2% of total service fees paid to doctors in the country. By comparison, urologists make up only 1% of the total physician population but earn 1.3% of total service fees. This discrepancy may be attributed to a “structural gender bias” reflected in provincial and territorial remuneration schedules, rather than evidence that physicians operating on the male reproductive tract work harder or work longer hours. “Ob-gyns are surgical specialists who undergo the same length of training and have the certification requirements per the Royal College of Physicians and Surgeons of Canada as urologists,” wrote the study authors. “Moreover, gynecologists who also practise obstetrics pay the Canadian Medical Protective Agency nearly 400% higher premiums for malpractice insurance than urologists or most other surgical specialists.The high premiums reflect in part the high-risk nature of the conditions and care of ob-gyns’ patients, but this is not at all reflected in the remuneration ob-gyns receive for the high-risk procedures they perform.” While female physicians are, in general, devalued by provincial fee schedules, those who care for female patients are even further devalued. “As female providers predominate in obstetrics and gynecology, this may reflect one form of structural sexism leading to decreased compensation for female surgeons,” wrote the study authors. This “systematic oppression” that disadvantages female physicians also threatens the quality of care for women. The study authors pointed to a recent commentary in the publication Obstetrics & Gynecology, which highlighted how poor reimbursement of gynecologic surgeons disproportionately affects female surgeons and also leads to a higher prevalence of low-volume surgeons and higher complication rates for their patients “We hope our analysis will catalyze recognition and meaningful change to address this systematic inequity, which both disadvantages female physicians and threatens the quality of care for Canadian women,” concluded the study authors. Read: Male doctors disproportionately refer patients to male surgeons: study

What's the big difference between a twisted ovary and a twisted testicle? (Hint: Look at your fee schedule)

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