Sex Differences in Billing Patterns Among Surgeons in a Single-Payer System
Sex Differences in Billing Patterns Among Surgeons in a Single-Payer System
Importance: Even in fee-for-service systems, female physicians consistently earn less than their male colleagues, with the largest disparities in surgery. This earnings gap exists even for hourly surgical billing in a fee-for-service system. Prior research has attributed this gap to differences in procedure mix and referral patterns, but billing behaviour itself remains underexplored.
Objective: To examine whether billing practices differ between male and female surgeons.
Design, Setting, and Participants: This cross-sectional, population-based observational study used administrative data from the Ontario Health Insurance Plan (OHIP) between 2008 and 2018. The sample included over 3 million procedures performed by general surgeons and urologists, focusing on 18 curated fee code combinations that are clinically comparable but remunerated differently.
Exposures: Surgeon sex.
Main Outcomes and Measures: The primary outcome was the likelihood of selecting the more remunerative option within a pair of fee code combinations, reflecting differences in surgical or billing behaviour. Multivariable logistic regression was used, adjusting for characteristics of the patient, surgeon, and surgical context.
Results: Among 988 male and 241 female surgeons, female surgeons had significantly lower odds of performing the higher-remunerated option. For instance, female surgeons had 35% lower odds of billing for nephroscopy while performing ureteroscopy (odds ratio [OR], 0.655; 95\% CI, 0.574–0.748). Differences in other pairs were smaller and not always statistically significant. For the subsample of these surgeries for which operative time could be estimated, female surgeons $25 less per operative hour (95\% CI, -25.691 to 23.560).
Conclusions and Relevance: Female surgeons were less likely than male colleagues to select higher-remuneration codes for comparable procedures, consistent with differences in intraoperative and billing decisions aside from referral patterns or patient mix. Such decision-making contributes to sex-based earnings disparities in surgery and highlight the need for interventions in coding education, compensation structures, and auditing practice to promote equity.