A surprising new study has found the gender gap between male and female gastroenterologists extends to Medicare reimbursements.

Based on coding, it is reasonable to expect Centers for Medicare & Medicaid Services (CMS) billing to be gender-neutral, but female gastroenterologists were found to receive approximately 15% less in Medicare reimbursements than their male counterparts, according to Shaina Hasan, MD, an internal medicine resident at the University of Virginia, in Charlottesville.

Although “much of the discussion regarding gender pay gaps can be subjective,” Dr. Hasan said the difference in Medicare reimbursement found in her study “was substantial even after multiple adjustments.”

CMS payments only represent a slice of the revenue sources for gastroenterologists, but it is not insignificant, according to Dr. Hasan. She cited data indicating that this income represents more than 20% of average GI compensation nationally.

While the gender pay gap has been documented repeatedly over decades, this study and other data suggest there has been little if any progress. In the recently issued 2023 Physician Compensation Report, issued by the digital platform Doximity, female physicians made about $110,000 less than men across specialties.

Some previous reports of gender pay differences have been criticized for incomplete control of confounding factors, such as differences in experience or types of care performed. However, the analysis presented by Dr. Hasan at Digestive Disease Week 2023 (abstract 927), was designed to circumvent many of these variables by looking only at CMS compensation. In principle, this should be the same for any given type of procedure independent of skill or experience.

In the multivariate model she presented, the comparison of CMS payments by gender was performed “after adjusting for region, practice setting, number of services performed, average complexity of the case, age of the Medicare beneficiary and physician experience,” explained Dr. Hasan, who performed this study with Aditya Khurana, MD, now a resident in radiology at Mayo Clinic in Rochester, Minn.

Prior to the adjustments, the gap in Medicare compensation was 42%. After adjustments, the reason for the remaining 15% difference remained unclear. To Dr. Hasan, the persistent pay gap suggests that the problem is more complex than previously thought. The difference in compensation, she said, might explain why the gender pay gap has been so difficult to resolve.

The next goal “will be to identify the factors that account for these differences” by looking at the CMS payment data at a much more granular level.

Although gender disparities are not necessarily greater in gastroenterology than other specialties, the underrepresentation of women in gastroenterology is a potentially related issue. In 2019, the same year that women represented the majority of medical students for the first time, only 33.9% of GI fellowships were filled by women, according to the Accreditation Council for Graduate Medical Education. This was a less than 4% increase over the number of fellowships filled by women in 2009.

According to the 2023 Doximity compensation report, the gender pay gap is narrowing in some subspecialties, particularly those that involve care of children. In fact, one of narrowest gender pay gaps is in pediatric gastroenterology. The 10% difference—$293,771 for men versus $264,135 for women—sounds promising, but these numbers are tempered by the fact that the average GI income among those not specialized in children was $496,677.

Noting the high relative representation of women with many GI disorders, Richard McCallum, MD, the chief of internal medicine at Texas Tech University School of Medicine, in El Paso, expressed dismay at the persistently low number of women entering the field of gastroenterology.

It is possible that efforts to eliminate the gender pay gap in gastroenterology might draw more women to the specialty, but it is not completely clear how this is best achieved, particularly when the exact causes are unknown.

One of those who have looked at this issue, Aparajita Singh, MD, the medical director of quality and safety in the Division of Gastroenterology at University of California, San Francisco, agreed that the data raise more questions than answers.

“Given that Medicare payments are based on coding, one might assume gender neutrality in compensation,” said Dr. Singh, who published a study on gender disparity in income and academic seniority more than 15 years ago (Am J Gastroenterol 2008;103[7]:1589-1595). In that study, disparities were evaluated between men and women 10 years after starting practice. Women made significantly less than men even after adjusting for practice type, work hours, vacation time and call days.

Calling these most recent data “interesting,” she said they “highlight the need for in-depth analysis to understand the underlying causes.”

Aasma Shaukat, MD, the moderator of the session at DDW where the data were presented, also underscored the need for more data. Calling the new analysis incomplete, Dr. Shaukat, the director of outcomes research in the Division of Gastroenterology and Hepatology at NYU Langone Medical Center, in New York City, noted that “many questions were raised about the study.” Reiterating that Medicare payments should be blind to physician gender, she said she believes the differences are likely due to “confounding by the types of patients and billing codes submitted by male and female doctors.” According to Dr. Shaukat, it is too soon to speculate on pay disparities until “these factors are accounted for.”

—Ted Bosworth

Drs. Hasan and Singh reported no relevant financial disclosures. Dr. McCallum reported a financial relationship with Evoke. Dr. Shaukat reported financial relationships with Freenome, Medtronic and Motus.