Thread by @louise_p_king

So proud of our publication in Green Journal today. For those who might not have easy access here's a run down of argument presented. Would love feedback. 1/?

@HMSbioethics @PetrieFlom @hastingscenter @aagl @acog @MigsRunner @temkins @pringlmillermd
journals.lww.com/greenjournal/F…

Article title: "Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care"

What is "double discrimination?" you ask .... let me tell ya 2/?

The gender wage gap is fairly well documented. Congress passed Equal Pay Act in 1963 but women in US are paid
82% of men’s wages. In medicine it's worse: female physicians/surgeons paid only
71% of what their male counterparts are paid. (cites in article or please request)

Wage gap in gyn surgery has disproportionate effect
because women are disproportionately represented
among gynecologic surgeons (in one study, 48% vs
range less than 1–19% in other surgical disciplines) 4/?jamanetwork.com/journals/jamas…

So what's the "double" part of "double discrimination" you ask?

Wage gap in gyn surgery is also driven by gendered discrimination in reimbursement. CMS set rates, and insurers then reimburse procedures for
women at a lower rate than similar procedures for
men. 5/?

In one study, 84% of the male procedures were compensated at a higher rate than the paired female procedures; on average, the male-specific surgeries were reimbursed at a 28% higher rate than the paired female-specific surgeries. 6/?
pubmed.ncbi.nlm.nih.gov/28024653/

Sex disparity in billing rates is not supported by reference to complexity - argument can be made that anatomically similar female surgeries may be more difficult given diseases such as endometriosis and higher rates of prior surgeries related in part to cesarean deliveries. 7/?

And - billing disparity is not news—a similar finding was
published in 1997. 8/?

So - is this just a simple request to be paid more? No, it's not.

What happens when you devalue women's surgery through disproportionate billing disparities and contribute to a large gender gap in wages? We believe the result is a parallel gap in quality in women's surgery. 9/?

Over time, lower reimbursement rates have played a part in developing and maintaining a workforce of low-volume gynecologic surgeons who likely do not perform as well as high-volume surgeons would. 10/?

Poor reimbursement for gynecologic surgery is one factor that pushes many obstetrics and gynecology surgeons to
preferentially perform obstetric services. 11/?

The history of this is complex and covered in detail in the article. You can read about it also in this sociology article onlinelibrary.wiley.com/doi/10.1111/j.…

Basics - gyn was originally part of general surgery. When OB and Gyn merged, surgical training was shortened for gyn surgeons from 5 years to 18 mos and obgyns would only devote about 15% of their practice to surgery. 13/?

That low surgical volume remains the standard today. Studies have shown that in gyn surgery - as in all surgery - lower volume is associated with more complications and worse outcomes. pubmed.ncbi.nlm.nih.gov/30243685/

So - to sum up. We have a system of low reimbursement that pushes many OBGYNs to have low volume surgical practices. Those who wish to have higher volume surgical practices will struggle to keep their doors open (based on ACOG workforce studies). 14/?

This leads to lesser care for our patients and contributes to a persistent wage gap. It also contributes to moral distress for many of my residents and colleagues who see this problem and how it manifests for many patients as lesser care but don't see an obvious solution. 15/?

So - in our paper we propose solutions. None are perfect but "Although change would be difficult to
implement, failing to implement it is tantamount to
saying that female patients deserve less well-trained
surgeons than male patients." 16/?

In terms of training many have done great work already and we cite to those who have called for tracking. pubmed.ncbi.nlm.nih.gov/32453127/

In terms of legal remedies - I'll copy this call to action from our paper. "Yet, implementation of
training and workforce changes without addressing
sex differences in reimbursement does not address
the unethical discrimination inherent in reimbursement patterns....

"Moreover, low-volume gynecologic
surgery likely will remain the norm because reimbursement will continue to incentivize a focus on
obstetric care. Women’s surgical care will continue
to be unjustifiably devalued, and double discrimination will continue...."

"Therefore, the American College
of Obstetricians and Gynecologists @acog should partner
with allies to advocate for sex parity in reimbursement rates for gynecologic surgery...."

"If this internal solution is not pursued, or if it is not successful, gynecologic surgeons, their patients, or state attorneys general should turn to legal remedies."

A legal challenge to sex-discriminatory billing codes would have to be framed as governmental action in setting CMS rates that violates Equal Protection, or as private
insurers’ violation of Section 1557, the nondiscrimination provision of the Affordable Care Act.

So - although the optimal solution is not readily apparent at the very least addressing the sex disparity in reimbursement in gyn surgery will reap benefits for patients and surgeons alike.

"It might be easy to deride surgeons’ calls for increases in billing as self-serving, but the devaluation of women’s surgical care results in a profound injustice to patients and
moral distress to surgeons....

"If surgical care for women were reimbursed at a level commensurate with similar care for men nationwide, it is likely that many disparities in the care of female patients, as well as in the pay and advancement of female physicians, could be reduced."