Examining the Million Dollar Question: Why is There Still a Gender Wage Gap in Family Medicine?

• Family Medicine
• Gender Equity
• Income
• Women Physicians

In their policy brief “Lifetime Impact of the Gender Wage Gap in Family Medicine,” Sanders et al. report that female^§ family physicians in their early careers experience an annual wage gap of nearly $32,000 relative to their male colleagues with similar subspecialties and hours worked.¹ While this disparity is alarming in itself, the authors find through modeling that this wage gap could lead female physicians to earn approximately $1 million less than their male colleagues over the course of a 30-year career or to accumulate $3 million less if the difference in these earnings were invested.¹

This report is an important contribution to our growing understanding of gender-based wage disparities in medicine. Sanders et al.’s wage gap estimates are similar to that of a 2023 Health Affairs study estimating that female physicians across specialties earned $2 million less over a 40 year career; for primary care physicians (PCPs), this difference was nearly $1 million.² Related findings summarized in a recent Commonwealth Fund report include that the gender-based wage gap is larger in medicine than in most professions, and across specialties, salaries tend to be lower in fields dominated by female physicians, including pediatrics, primary care, and obstetrics/gynecology.³ While the gender wage gap in primary care is enormous, it is even larger in other specialties ($57,000 vs $95,000).³ Although we might hope that the gender wage gap is narrowing as a result of more awareness and increasing numbers of women entering medicine, the wage disparity between female and male PCPs grew from $32,000 in 2017 to $57,000 in 2022.³ Furthermore, data suggest that wage disparities are even greater for female Family Medicine physicians who identify as Black/African American or Asian.⁴ Wage disparities for physicians who identify with nonbinary genders and/or as transgender likely exist as well but have been harder to study due to data limitations.^5–7

For many women in medicine, these results are not surprising. If we haven’t experienced the wage gap ourselves, we likely know a colleague who thought she had successfully negotiated her compensation, only to learn that a man with similar experience and skills was being paid a higher base salary or signing bonus. Some women in this situation choose to advocate for a correction, but most probably do not, wanting to avoid being seen as demanding or difficult. Worse, some physicians may internalize that they did something to deserve lower pay.

There is some evidence that certain types of physician compensation models are worse for the wage gap than others. In the United States, these models vary from fixed salaries to revenue-based models based on fee-for-service (FFS), capitated, or “value-based” insurance payments to a combination of base compensation with supplementary earnings from fee-for-service, capitated, or value-based revenue. Ganguli et al. found that fee-for-service payment – which remains the most prevalent compensation model for US physicians - is a structural contributor to the wage gap, in that female PCPs earn 11% less FFS revenue annually due to conducting 11% fewer visits despite them spending more time with patients per visit and per year.⁸ On average, female PCPs earn less fee-for-service revenue per minute than their male counterparts by spending more time not only in face-to-face patient care but also more time in the electronic health record (EHR) and more time providing counseling and other services that have lower or no reimbursement.^3,8–10

One concrete example of how fee-for-service-based compensation might result in lower earnings for women physicians is the Pap or Papanicolaou smear, a standard office-based procedure that is more often completed for patients cared for by female primary care physicians.⁹ Although Papanicolaou smears can take significant time and skill, these services are reimbursed at low rates and are often unbilled. So, despite their importance, Papanicolaou smears often present an opportunity cost, in effect displacing a patient visit or a different billable service.

What can we do? Notably, Sanders et al. point out that the gender wage gap is unlikely to be fixed by better negotiating on the part of female physicians, and on the contrary, females are sometimes penalized for negotiation efforts.¹ Instead, they suggest systemic interventions and policy changes to correct the gap, including equal pay legislation, transparent salary structures, career support, and ongoing monitoring and evaluation.¹

Ideally, health systems would develop standard compensation packages that reward physicians equitably for their experience, unique skill sets, and clinical responsibilities. Such equity is especially important for systems with fixed salaries, and physicians of all genders can support this goal by openly discussing compensation packages with our peers and advocating for corrections when we identify gender or other types of wage disparities. We can also contribute our compensation information to online databases, which allow women to assess trends in their fields and geographic areas without engaging in potentially uncomfortable conversations with colleagues.

To the extent that fee-for-service payments are a modifiable mechanism of the wage gap, there is some evidence that adjustments to the physician fee schedule may help: Li et al. found that in one health system, a 2021 Evaluation and Management billing adjustment that relaxed documentation requirements for time-based billing was associated with a greater increase in work relative value units for women vs men internal medicine physicians (18 vs 10% increase, respectively).¹⁰ This finding suggests that other interventions to improve the billable productivity of women physicians, such as improved compensation for services that they provide, may meaningfully narrow the gender wage gap.¹⁰

Another key solution is to use payment models that better capture the work that is disproportionately done by women physicians (and, incidentally, concentrated among primary care specialties). For example, value-based payment models involve paying physicians bundled or prospective payments alongside quality bonuses to reward time well spent and may align better with women physicians’ typical practice patterns.³ Two studies have found that such models may narrow or even reverse the compensation gap.¹¹ Value-based payment models could also help in light of evidence that female physicians may provide higher quality care in certain scenarios.^3,8,11,12

We note one additional consideration that has gained importance as more and more physicians are employed by practices and health systems: For any changes in physician reimbursement models to narrow the gender wage gap, health system and other physician employers must distribute the financial rewards of these models to their physicians equitably, for example, by allocating more to primary care clinicians or practices when their efforts result in quality savings or payments to the institution. Even when this happens, it may be difficult for quality incentive bonuses to close the wage gap if there is a large difference in any salary-based compensation for men and women.³

As researchers continue to identify evidence-based approaches to close the physician gender wage gap, enacting these solutions will require dedicated efforts from policy makers and health systems leaders. Sanders et al.’s report is an important contribution to the argument for why it is urgent for them to act.