Assessment of Gender Differences in Clinical Productivity and Medicare Payments Among Otolaryngologists in 2017 | Otolaryngology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Figure.  Total Medicare Payment to Otolaryngologists in 2017
Total Medicare Payment to Otolaryngologists in 2017

In each graph, the x-axis represents total payment in dollars ($) for individual otolaryngologists (panel C is adjusted for scale). The y-axis represents the percentage of otolaryngologists practicing in that setting.

Table 1.  Unique Billing Codes, Number of Services, and Medicare Payment to Otolaryngologists in Non–Facility-Based Settings in 2017
Unique Billing Codes, Number of Services, and Medicare Payment to Otolaryngologists in Non–Facility-Based Settings in 2017
Table 2.  Unique Billing Codes, Number of Services, and Medicare Payment to Otolaryngologists in Facility-Based Settings in 2017
Unique Billing Codes, Number of Services, and Medicare Payment to Otolaryngologists in Facility-Based Settings in 2017
Table 3.  Otolaryngologist Gender and Level of Productivity (Number of Charges) Provided in Non–Facility-Based Settings in 2017
Otolaryngologist Gender and Level of Productivity (Number of Charges) Provided in Non–Facility-Based Settings in 2017
Table 4.  Otolaryngologist Gender and Level of Productivity (Number of Charges) Provided in Facility-Based Settings in 2017
Otolaryngologist Gender and Level of Productivity (Number of Charges) Provided in Facility-Based Settings in 2017
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    Original Investigation
    July 30, 2020

    Assessment of Gender Differences in Clinical Productivity and Medicare Payments Among Otolaryngologists in 2017

    Author Affiliations
    • 1Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston
    • 2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
    • 3Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
    • 4Harvard Business School, Boston, Massachusetts
    • 5Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
    • 6Patient-Reported Outcomes, Value and Experience (PROVE) Center, Brigham and Women’s Hospital, Boston, Massachusetts
    JAMA Otolaryngol Head Neck Surg. 2020;146(9):1-10. doi:10.1001/jamaoto.2020.1928
    Key Points

    Question  Do physician productivity, diversity of practice, and Medicare payments differ between male and female otolaryngologists?

    Findings  In this cross-sectional study of publicly available Medicare data for 8456 otolaryngologists who received Medicare payments in 2017, female otolaryngologists billed for fewer unique codes (ie, had decreased diversity of practice), provided a lower number of services (ie, had lower productivity), and received less payment from Medicare than male otolaryngologists. When stratified by levels of clinical productivity, highly productive women collected less Medicare payment than highly productive men; gender-based disparities were more pronounced in the non–facility-based setting (eg, physician office) compared with the facility-based (ie, hospital) setting.

    Meaning  Female sex is associated with decreased diversity of practice, lower clinical productivity, and decreased Medicare payment in the field of otolaryngology; further efforts are necessary to identify and address potential causes of disparity within the specialty.

    Abstract

    Importance  Women comprise an increasing proportion of the otolaryngology workforce. Prior studies have demonstrated gender-based disparity in physician practice and income in other clinical specialties; however, research has not comprehensively examined whether gender-based income disparities exist within the field of otolaryngology.

    Objective  To determine whether diversity of practice, clinical productivity, and Medicare payment differ between male and female otolaryngologists and whether any identified variation is associated with practice setting.

    Design, Setting, and Participants  Retrospective cross-sectional analysis of publicly available Medicare data summarizing payments to otolaryngologists from January 1 through December 31, 2017. Male and female otolaryngologists participating in Medicare in facility-based (FB; hospital-based) and non–facility-based settings (NFB; eg, physician office) for outpatient otolaryngologic care were included.

    Main Outcomes and Measures  Number of unique billing codes (diversity of practice) per physician, number of services provided per physician (physician productivity), and Medicare payment per physician. Outcomes were stratified by practice setting (FB vs NFB).

    Results  A total of 8456 otolaryngologists (1289 [15.2%] women; 7167 [84.8%] men) received Medicare payments in 2017. Per physician, women billed fewer unique codes (mean difference, −2.10; 95% CI, −2.46 to −1.75; P < .001), provided fewer services (mean difference, −640; 95% CI, −784 to −496; P < .001), and received less Medicare payment than men (mean difference, −$30 246 (95% CI, −$35 738 to −$24 756; P < .001). When stratified by practice setting, women in NFB settings billed 1.65 fewer unique codes (95% CI, −2.01 to −1.29; P < .001) and provided 633 fewer services (95% CI, −791 to −475; P < .001). In contrast, there was no significant gender-based difference in number of unique codes billed (mean difference, 0.04; 95% CI, −0.217 to 0.347; P = .81) or number of services provided (mean difference, 5.1; 95% CI, −55.8 to 45.6; P = .85) in the FB setting. Women received less Medicare payment in both settings compared with men (NFB: mean difference, −$27 746; 95% CI, −$33 502 to −$21 989; P < .001; vs FB: mean difference, −$4002; 95% CI, −$7393 to −$612; P = .02), although the absolute difference was lower in the FB setting.

    Conclusions and Relevance  Female sex is associated with decreased diversity of practice, lower clinical productivity, and decreased Medicare payment among otolaryngologists. Gender-based inequity is more pronounced in NFB settings compared with FB settings. Further efforts are necessary to better evaluate and address gender disparities within otolaryngology.

    Introduction

    Income disparity between male and female physicians across specialties is well documented within the medical literature.1 This compensation gap often begins with a physician’s starting salary and continues years into practice, despite controlling for factors such as age, hours worked, and academic productivity.1-3 Persistent salary differences are often attributed to unmeasured, and thus difficult to control, factors (eg, implicit managerial bias).1-4 Within the field of otolaryngology, survey data suggest that female otolaryngologists earn less than their male peers.5,6 However, the strength of this evidence is limited owing to small sample sizes and dated compensation data.

    In recent years, the Centers for Medicare & Medicaid Services (CMS) has begun releasing physician-level payment data under the 2010 Patient Protection and Affordable Care Act.7 These data have permitted further empirical investigation of the extent and drivers of gender-based income inequality. Recent analyses leveraging these data have demonstrated that women receive less Medicare payment compared with men within the fields of radiation oncology and ophthalmology.8,9 These differences stem in part from decreased breadth of practice and lower clinical productivity among female physicians in both specialties.8,9

    Prior research has not comprehensively examined whether gender-based income disparities exist within the field of otolaryngology. We therefore sought to compare diversity of practice, clinical productivity, and resulting payment among male and female otolaryngologists providing care to Medicare beneficiaries.

    Methods
    Data Source

    We used the CMS Physician and Other Supplier Public Use File to obtain physician-level payment information for services provided by otolaryngologists (specialty code 04) from January 1 through December 31, 2017.10 This database links Healthcare Common Procedure Coding System (HCPCS) codes submitted to Medicare to individual physicians identifiable via unique National Provider Identifier (NPI) numbers. To maintain privacy, any aggregated records comprising 10 or fewer Medicare beneficiaries are excluded from the data set.11 This study analyzed publicly available Medicare data and did not involve human participants and therefore did not require institutional board review by the Massachusetts Eye and Ear Human Research Protections Program or informed consent.

    Study Cohort

    We excluded nonphysicians (eg, physician assistants) from analysis on the basis of information provided within the “Credentials” fields. We then identified all unique physicians by NPI number and categorized their gender (male/female). This binary classification was provided by CMS. There were no ambiguous or missing data.

    Study Variables

    For each physician, we extracted HCPCS code-level information on the number of services provided, mean charges allowed (ie, average payment amount), practice setting (facility-based [FB] vs non–facility-based [NFB]), and total payment amount (calculated as number of services multiplied by mean payment amount). Facilities include settings such as hospital-based outpatient departments. Non–facility-based settings include settings such as physician offices and ambulatory surgical centers.11 These practice settings are not mutually exclusive, as otolaryngologists may routinely practice in both (eg, perform clinic visits in a physician office and perform surgeries within a hospital outpatient department). Payment for physician services varies by practice setting under the Medicare Physician Fee Schedule.12

    Study Outcomes

    For each physician, we aggregated HCPCS code-level results and evaluated 3 primary outcome measures: (1) physician diversity of clinical practice, (2) physician clinical productivity, and (3) physician Medicare payment. These outcome measures were defined in accordance with previously established methods.8,9

    We defined the diversity of physician practice as the total number of unique HCPCS codes billed by each physician. We defined physician clinical productivity as the total number of services provided. We calculated total Medicare payment as the sum of payments for all billed HCPCS codes.

    We performed a subset analysis to explore potential differences in the level of complexity of outpatient evaluation and management (ie, clinic) visits by gender. We determined the number and complexity (ie, CMS level 1-5) of all new (99201-99205) and established (99211-99215) clinic visits performed by otolaryngologists using HCPCS codes. We aggregated visits by otolaryngologist gender and stratified the results by practice setting.

    Statistical Analyses

    We used descriptive statistics to characterize physician diversity of practice, clinical productivity, and Medicare payment. We evaluated for differences in these outcomes by gender and practice setting. In accordance with established methods,8,9 we additionally categorized all physicians into 8 quantiles of productivity (cutoffs of 12.5%, 25%, 37.5%, 50%, 62.5%, 75%, and 87.5% for number of provided services) and compared Medicare payment between genders within each quantile. Values that were exactly at the cutoff (eg, 25%) were categorized within the lower quantile.

    We performed sensitivity analyses to explore whether childbearing could explain gender-based differences in productivity. We linked our data set to 2017 Medicare Physician Compare13—which includes physician demographic information—using NPI numbers, which are unique to each physician. Based on publicly available estimates from the Association of American Medical Colleges14 and Centers for Disease Control and Prevention,15 we determined a mean age of medical school matriculation of 24 years and childbearing age of younger than 38 years. Accordingly, we then excluded any female physicians with medical school graduation year (column K, “grd_year”) of 2007 or later (age <38 years) to eliminate potential confounding owing to decreased female productivity during childbearing years.

    Mean values were compared using 2-tailed t tests. Medians were compared using the nonparametric Wilcoxon rank sum test. Median differences and 95% CIs were estimated using quantile regression models. P values < .05 were considered significant. Statistical analyses were performed using both Stata, version 13 (StataCorp LP) and Microsoft Excel 2016 (Microsoft Corporation). Data analysis was performed from March 10 to April 1, 2020.

    Results
    Physician Demographics

    In 2017, a total of 8456 otolaryngologists (of 9520 total active otolaryngologists16; 88.8%) provided care to Medicare beneficiaries. Women accounted for 15.2% (1289 of 8456) of otolaryngologists participating in Medicare and men accounted for 84.8% (7167 of 8456) (eTable 1 in the Supplement). Women represented 14.7% ( 1131 of 7711) and 13.6% (482 of 3542) of otolaryngologists billing in the NFB and FB settings, respectively.

    Diversity of Practice

    Otolaryngologists received payment for 834 unique billing codes in 2017. Women billed a total of 387 (46.4%) unique codes while men billed 804 (96.4%) unique codes. Nearly three-quarters (620 of 834; 74.3%) of codes were billed in the NFB setting and approximately one-half (433 of 834; 51.9%) were billed in the FB setting.

    Across both practice settings, otolaryngologists billed a mean (SD; range) of 11.1 (6.0; 1-52) and median (interquartile range) of 10 (7-14) unique billing codes per physician (eTable 2 in the Supplement). Female otolaryngologists overall billed fewer mean (mean difference, −2.10; 95% CI, −2.46 to −1.75; P < .001) and median (median difference, −1.0; 95% CI, −1.31 to −0.689; P < .001) unique codes per physician than male otolaryngologists (eTable 2 in the Supplement). This difference was driven by practice patterns in the NFB setting (Table 1), where female otolaryngologists billed fewer mean (mean difference, −1.7; 95% CI, −2.0 to −1.3; P < .001) and median (median difference, 1.0, 95% CI, −1.59 to −0.405; P < .001) unique codes per physician. There was no difference in number of unique codes billed between female and male otolaryngologists in the FB setting (Table 2).

    Number of Services

    Across both practice settings, otolaryngologists provided a total of 13 747 540 services to Medicare beneficiaries in 2017. Women provided 1 396 422 services (10.2% of total), and men provided 12 351 118 services (89.8%) (eTable 2 in the Supplement). The vast majority (13 092 123; 95.2%) of services were provided in the NFB setting; the remainder (655 417; 4.8%) were provided in the FB setting.

    Female otolaryngologists overall billed fewer mean (mean difference, −640; 95% CI, −784 to −496; P < .001) and median (median difference, −341, 95% CI, −409 to −273; P < .001) services per physician than male otolaryngologists. This difference was driven by practice patterns in the NFB setting (Table 1), where female otolaryngologists billed fewer mean (mean difference per physician, −633; 95% CI, −791 to −475; P < .001) and median (median difference, −375; 95% CI, −453 to −297; P < .001) services per physician. There was no difference in number of services per physician between female and male otolaryngologists in the FB setting (Table 2).

    Payment

    Otolaryngologists received a total of $687 028 998 in Medicare payment in 2017. Women accounted for $71 683 065 (10.4%) and men received $615 345 933 (89.6%) in payment (eTable 2 in the Supplement). The vast majority ($626 537 510; 91.2%) of payment was for services provided in the NFB setting; the remainder ($60 491 491; 8.8%) was for services provided in the FB setting.

    Female otolaryngologists overall received less mean (mean difference, −$30 246; 95% CI, −$35 738 to −$24 756; P < .001) and median (median difference, −$21 632; 95% CI, −$25 575 to −$17 691; P < .001) payment per physician than male otolaryngologists (eFigure 1 and eFigure 2 in the Supplement). This difference existed in both the NFB (Table 1; Figure, A and B) and FB (Table 2; Figure, C and D) settings.

    Influence of Clinical Productivity on Payment

    Female otolaryngologists overall comprised a disproportionately high share (24.5%) of the lowest productivity group (259 of 1057) and a disproportionately low share (7.5%) of the highest productivity group (79 of 1057) (eTable 3 in the Supplement). This difference was primarily driven by the NFB setting, where female otolaryngologists comprised 22.9% (221 of 967) of the lowest productivity group and 7.5% (72 of 963) of the highest productivity group (Table 3). In the FB setting, women comprised 10.9% (52 of 479) of the lowest productivity group and 14.7% (65 of 441) of the highest productivity group (Table 4).

    There was no statistically significant difference in mean Medicare payment per physician (mean difference, −$30 628; 95% CI, −$67 647 to $6389; P = .10) between female and male otolaryngologists within the highest productivity group. However, female otolaryngologists in the highest (median difference, −$31 473; 95% CI, −$65 862 to $2916; P = .004) and second-highest (median difference, −$11 337; 95% CI, −$24 644 to $1969; P = .009) productivity groups both received lower median Medicare payment per physician than male otolaryngologists in these groups.

    This difference in median payment was primarily driven by the NFB setting, where female otolaryngologists in the highest productivity group earned lower median payment per physician (median difference, −$17 584; 95% CI, −$52 898 to $17 728; P = .01) than male otolaryngologists. There was no statistically significant difference in median Medicare payment per physician between female and male otolaryngologists practicing in the FB setting. Female otolaryngologists in multiple productivity groups received less mean and median Medicare payment per physician in both the NFB and FB setting (Table 3 and Table 4).

    Physician-Level Variables

    After adjusting for age (graduation year) as a covariate, gender remained a highly significant predictor for all outcomes of interest (unique codes: β = 2.36; P < .001; number of services: β = 678.5; P < .001; payment: β = 30006; P < .001) in the overall analysis. In subsequent sensitivity analyses excluding female physicians of childbearing age (younger than 38 years),15 gender disparities persisted in number of unique charges, number of services, and total Medicare payment (eTable 4 in the Supplement). There was no apparent difference in the distribution of visit complexity between genders in either practice setting (eTable 5 and eTable 6 in the Supplement).

    Discussion

    In this retrospective, cross-sectional analysis of compensation and productivity among otolaryngologists participating in Medicare in 2017, we found that female otolaryngologists overall submitted significantly fewer unique billing codes (ie, had a less diverse scope of practice), provided fewer services (ie, were less clinically productive), and received lower Medicare payment than male otolaryngologists. This disparity was more pronounced in NFB settings rather than FB (ie, hospital) practice settings. In the FB setting, female otolaryngologists had similar diversity of practice and clinical productivity as male otolaryngologists. Nonetheless, Medicare payment to female otolaryngologists was still significantly less than for men in both FB and NFB settings. The exclusion of women of childbearing age and adjustment for physician age did not influence observed gender disparities for any outcome measures.

    The influence of gender on professional opportunities and advancement within the field of otolaryngology is well described in the literature. Female otolaryngologists have less National Institutes of Health grant funding than male otolaryngologists at all time points in their career and have lower h-indices (index of scientific research impact) than male otolaryngologists.17,18 Female otolaryngologists additionally have fewer financial relationships with industry and receive less industry contributions than male otolaryngologists.19 Lower levels of federal research funding and industry collaborations may in part explain why women are less likely to advance to higher academic ranks (ie, associate and full professor) and positions of leadership (eg, department chairs and other senior leadership) within the field of otolaryngology.20-22 Despite these inequities, female otolaryngologists who achieve senior academic rank have increased productivity compared with men, indicating that female otolaryngologists are able to achieve high levels of performance in academic medicine despite potential barriers.18 In addition to senior-career productivity, female otolaryngologists are now beginning to achieve parity in several other key spheres of influence, including specialty society membership and leadership positions,23 publication of peer-reviewed literature,24,25 and authorship of opinion pieces.26

    Despite such progress, our study demonstrates that income inequality remains a barrier to true gender parity. Our findings are consistent with analogous studies in the fields of radiation oncology and ophthalmology, which suggest that gender-based payment disparities may in part be attributed to lower productivity and narrower scopes of practice among female physicians. Our results reveal that income inequity persists even among the most highly productive (as measured by service count) groups of otolaryngologists. This indicates that female otolaryngologists are typically performing less remunerative services. This difference was not driven by complexity of clinic visits but instead may be related to the number or relative value units of procedural aspects of care.

    Although our study did not examine the potential factors underlying this phenomenon, the literature describes a number of reasons for gender-based income inequality, such as an increased desire for part-time and flexible scheduling among female physicians,27,28 gender-based differences in procedure intensity and acuity,29 inequities in salary negotiation,27,30 and a disproportionate participation in noncompensated activities and committee membership for female physicians.30 In addition to these factors, many acknowledge that implicit gender biases continue to contribute to gender pay inequity.2,4,31,32 Strategies to address implicit biases include human capital investment (eg, contract negotiations training) in female physicians and awareness and bias reduction strategies targeted toward department leadership (ie, those with most control over salary and promotions).32

    Although women can be effective in raising awareness about these inequities, female otolaryngologists must partner with their male colleagues to meaningfully drive action to achieve gender parity. Recent research has demonstrated that women are disproportionately represented as authors of pieces advocating for gender equality in medicine, particularly related to compensation.33 However, in an era in which female medical students outnumber men34 and women account for more than one-third of otolaryngology residents,35 effort must be directed at both at the pipeline as well as the proverbial glass ceiling to meaningfully effect change. In a hospital-based organization, leadership may use multiple strategies, including recruitment targets, mentorship programs, and block time allocation, to promote gender parity. Organizational adoption of such strategies to date may help explain our findings of gender parity with respect to diversity of practice and clinical productivity in the FB setting. In contrast, there may be fewer institutional efforts focused on gender parity in NFB settings, such as independent physician practices. Senior-level physicians within such practices—who are most often male—should consider both formal means (eg, practice support, including physician extenders) and informal means (eg, referral patterns of patients likely to require procedures) to promote equitable practice growth among their female colleagues.

    Limitations

    Our study has limitations. First, our analysis was limited to outpatient Medicare data, which reflects a portion of physician practice and compensation within otolaryngology. However, based on existing salary-level data, we believe that our findings are likely representative of overall gender-based payment disparities in our field and that gender-based disparity would be increased with inclusion of higher-paying commercial payer and inpatient populations.5,6 Second, our retrospective analysis was restricted to a single year (2017) and may therefore fail to reflect current patterns of practice and compensation. Third, we did not adjust for physician subspecialty in our analysis, although such information is not consistently available for all physicians participating in Medicare. Additional research is necessary to delineate differences in patient and/or payer mix among male and female otolaryngologists and evaluate trends over time.

    Conclusions

    Female sex is associated with decreased diversity of practice, lower clinical productivity, and decreased Medicare payment among otolaryngologists. Gender-based inequity is more pronounced in NFB settings compared with FB settings. Further efforts are necessary to better evaluate and address gender disparities within otolaryngology. Such efforts will benefit from the engagement and support of male colleagues and organizational leadership.

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    Article Information

    Accepted for Publication: June 3, 2020.

    Corresponding Author: Ashley L. Miller, MD, Massachusetts Eye and Ear, 243 Charles St, Boston, MA 02114 (ashley_miller@meei.harvard.edu).

    Published Online: July 30, 2020. doi:10.1001/jamaoto.2020.1928

    Author Contributions: Dr Miller had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Miller, Rathi, Gray.

    Acquisition, analysis, or interpretation of data: Miller, Rathi, Burks, DeVore, Bergmark.

    Drafting of the manuscript: Miller, Rathi.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Miller.

    Study supervision: Bergmark, Gray.

    Conflict of Interest Disclosures: Dr Bergmark reported receiving grants from American Board of Medical Specialties outside the submitted work. No other disclosures were reported.

    Funding/Support: This work was conducted with support from Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UL 1TR002541) and financial contributions from Harvard University and its affiliated academic health care centers.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or the National Institutes of Health.

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