CHICAGO, IL — A conversation in a Chicago lobby bar helped sharpen a problem that doctors and health policy experts have documented for years: procedures centered on women are often reimbursed at lower rates than comparable procedures on men. That difference affects more than paychecks. It can influence which services hospitals prioritize, how much operating time they devote to them, and how many surgeons are trained to do the work well.
Dr. Louise King, a gynecologic surgeon, and Katie L. Watson, a bioethics professor, have described the pattern as “double discrimination.” In their view, female surgeons are paid less while also working in a specialty that serves a mostly female patient population and receives lower payment for many of its procedures. The result, they say, is a system that can leave women waiting longer for care and can weaken the pipeline of surgeons who treat them.
How Medicare decides what a procedure is worth
At the center of the issue is the way Medicare assigns value to procedures. The Centers for Medicare and Medicaid Services uses relative value units, or RVUs, to help set reimbursement levels. Those units are meant to reflect time, skill, and intensity. Medicare and private insurers both rely on them when deciding how much a service should pay.
The values are shaped in large part by a committee of physicians connected to the American Medical Association. The committee surveys doctors about how long procedures take and how difficult they are, then recommends values to the federal government. Those recommendations have historically been accepted at a high rate. Critics say the process can be opaque and too dependent on self-reported estimates instead of direct operating data.
That structure matters because a small difference in RVU assignments can translate into a large difference in what hospitals and surgeons are paid. When procedures on women are assigned lower values than similar procedures on men, the gap can echo through the rest of the system.
Studies show the gap has lasted for decades
The disparity is not new. In 1997, gynecologic surgeons published a paper asking, “Is Adam worth more than Eve?” Their research found doctors were paid about 44 percent more for male-specific procedures than comparable female-specific ones. More recent analysis suggests the pattern remains stubbornly in place.
In a 2025 study titled “Price and Prejudice,” researchers examined 55 matched pairs of sex-specific procedures. They found that 75 percent of the pairs had lower RVUs for procedures on female patients. On average, male-specific procedures carried RVUs that were 30 percent higher. When procedures were performed in a hospital or surgical center, the payment difference averaged about 26 percent.
The numbers were striking in specific examples as well. Medicare’s national rate for a penile biopsy was $121.32, while a vaginal biopsy paid $65.74. Researchers also found a large spread in other closely matched procedures involving lesions, surgeries on reproductive organs, and urinary tract operations.
Why self-reported operating times can skew pay
One reason the system can tilt is the way doctors estimate procedure time. The committee that helps shape RVUs relies on surveys filled out by physicians, but those responses are self-reported. Experts say that can distort the picture, especially when some specialties have low response rates or when the wrong doctors are answering for procedures they do not perform often.
King said she has never received one of those surveys in 17 years of practice. She argues that many of the physicians answering them are general OB-GYNs who do not operate frequently, while the specialists who spend much of their careers on gynecologic surgery often are not the ones consulted. Those subspecialists include gynecologic oncologists, urogynecologists, and minimally invasive gynecologic surgeons.
Dr. Shitanshu Uppal and colleagues compared self-reported survey data with records from the American College of Surgeons’ National Surgical Quality Improvement Program. They analyzed 901,917 surgeries and found that gynecology had the third-lowest median RVUs per hour among the specialties studied. They also found that specialties reporting longer operating times tended to receive higher RVUs.
Lower payment can ripple into hospital access and training
The consequences do not stop with reimbursement rates. Hospitals operate on revenue, and when gynecologic surgery brings in less money, institutions may devote fewer resources to those services. That can affect access to operating rooms, staff time, and available surgical slots.
King said some of her patients wait a year for surgery, even when they have conditions such as endometriosis, fibroids, or cysts. She and other advocates say that low reimbursement also reduces training opportunities. If surgeons have fewer cases and fewer resources, residents and fellows get less hands-on experience.
That can feed a cycle of lower volume and weaker outcomes. Research cited by the doctors shows that surgeons who operate less often tend to have more complications. Low-volume gynecologic surgeons have been linked to higher rates of bowel and urinary tract injuries, while higher-volume surgeons are more likely to use minimally invasive techniques associated with better results.
Reforms could start with billing codes and reevaluation
Advocates do not see the problem as impossible to fix. Medicare billing changes over time as procedures are reviewed and new services are added. One possible starting point is to send gynecology-related codes back for reevaluation, or to ask Congress for a closer look at how the payments are set.
Some experts want gynecology-specific conversion factors that would better reflect the work involved in female-specific surgery. Others argue for removing sex-specific billing codes whenever possible. For example, genital biopsies are billed differently depending on anatomy, even though the procedures are essentially similar. A single sex-neutral code could help reduce that gap.
The AMA and other reform advocates have also pointed to Medicare’s budget neutrality rule, which requires higher payments in one area to be offset elsewhere. They say that rule can make equity changes harder. In the meantime, the payment structure still sends a clear signal about what kinds of care the system values most.
Training time and specialty status remain part of the debate
Supporters of higher reimbursement for gynecologic surgery say training is another reason the specialty has been undervalued. King said gynecologists traditionally train for fewer years in surgery than urologists or some other higher-paid specialists. General OB-GYNs spend four years in residency, and about 18 months of that is devoted to gynecologic surgery.
She argues that longer and more specialized training would support better pay and better care. In some cases, she said, experience gained during a two-year gynecologic surgery fellowship can equal years of practice. That kind of training, advocates say, would better prepare surgeons for minimally invasive advances and complex cases.
For Watson and King, the larger point is simple: if the system continues to pay less for work that primarily serves women, it effectively accepts worse staffing, weaker training, and slower care for female patients. They say the billing rules may look neutral on paper, but their impact is not.
