Productivity-Based Payment Model for Primary Care Generates 21% Physician Gender Pay Gap

For primary care physicians, a capitation model risk adjusted for age and sex generates the smallest physician gender pay gap, researchers found.

For primary care physicians, the gender pay gap among clinicians varies by compensation model, a new research article found.

Earlier research has shown that male physicians receive higher compensation than female physicians, with one study estimating that male physicians earn an average adjusted gross income that is about $2 million higher than female physicians over a simulated 40-year career. Another study found that in productivity-based compensation models female physicians earn less compensation than male physicians because they spend more time with patients and conduct fewer patient visits.

The new research article, which was published by Annals of Internal Medicine, features data collected from 1,435 matched primary care physicians (PCPs)—881 male clinicians and 554 female clinicians. The study has several key data points.

• Female PCPs conducted fewer patient visits than their male counterparts on an annual basis (1,210.3 versus 1,477.7)
   
• Under a productivity-based fee-for-service compensation model, median estimated annual compensation was $285,397 for male physicians and $225,276 for female physicians, for a difference of $58,829
   
• The gender pay gap was similar under a capitation model that was not risk adjusted, with a difference of $58,723
   
• The gender pay gap was larger under a capitation model risk adjusted for age alone, with a difference of $74,695
   
• The gender pay gap was largest under a capitation model risk adjusted for diagnosis-based scores alone, with a difference of $89,974
   
• The gender pay gap was smallest under a capitation model risk adjusted for age and sex, with a difference of $36,631

"We observe a 21% gender wage gap between matched male and female PCPs in the same practices under productivity-based primary care payment that is similar under unadjusted capitation, larger under capitation risk-adjusted for age alone and for diagnosis-based risk scores, and smaller when accounting for patient age and sex," the study's co-authors wrote.

Interpreting the data

Female PCPs conducting fewer patient visits contributed to the gender pay gap under the productivity-based compensation model, the study's co-authors wrote. "We found that despite female PCPs likely working similar hours to or even more hours than their male counterparts, female PCPs received less compensation under productivity-based payment due to conducting fewer visits. These lower visit rates may be explained by female PCPs spending more time per visit, or being less likely to work with nurse practitioners or physician assistants billing under their [National Provider Identifiers], for example, when performing female preventive visits involving pelvic examinations."

This gender pay gap under unadjusted capitated payment was likely due to female physicians having smaller attributed patient panels, the study's co-authors wrote.

Capitation with diagnosis-based risk adjustment may exacerbate the gender pay gap, the study's co-authors wrote. "We found that male physicians' patients had higher mean diagnosis-based risk scores than those of female physicians (and although male patients of female PCPs had the highest [Hierarchical Condition Category] scores of any group, this was offset by female PCPs having majority female patients with lower HCC scores)."

Adoption of a capitation model risk adjusted for age and sex may be well-suited to primary care, the study's co-authors wrote. "Going forward, an alternative payment model such as age- and sex-adjusted capitation that minimizes the gender wage gap, or future models that more directly capture primary care effort, may be beneficial not only from an equity standpoint but also for retention of the increasingly female primary care workforce that is already disproportionately subject to burnout. Sustaining these workforce members may mitigate primary care capacity constraints and, in turn, support better health outcomes at lower cost."

Related: 5 Reasons Women Doctors Earn Less Than Men