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JAMA Surg. 2019 Oct 2. doi: 10.1001/jamasurg.2019.3769. [Epub ahead of print]

Sex-Based Disparities in the Hourly Earnings of Surgeons in the Fee-for-Service System in Ontario, Canada.

Dossa F1,2,3, Simpson AN3,4,5, Sutradhar R3,6, Urbach DR1,3,6,7, Tomlinson G8,9, Detsky AS3,9,10, Baxter NN1,2,3,6.

Author information

1
Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
2
Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada.
3
Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
4
Division of Minimally Invasive Gynecologic Surgery, University of Toronto, Toronto, Ontario, Canada.
5
Department of Obstetrics and Gynecology, St Michael's Hospital, Toronto, Ontario, Canada.
6
ICES, Toronto, Ontario, Canada.
7
Department of Surgery, University Health Network, Toronto, Ontario, Canada.
8
Department of Epidemiology and Biostatistics, University Health Network, University of Toronto, Toronto, Ontario, Canada.
9
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
10
Department of Medicine, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada.

Abstract

Importance:

Sex-based income disparities are well documented in medicine and most pronounced in surgery. These disparities are commonly attributed to differences in hours worked. One proposed solution to close the earnings gap is a fee-for-service payment system, which is theoretically free of bias. However, it is unclear whether a sex-based earnings gap persists in a fee-for-service system when earnings are measured on the basis of hours worked.

Objective:

To determine whether male and female surgeons have similar earnings for each hour spent operating in a fee-for-service system.

Design, Setting, and Participants:

This cross-sectional, population-based study used administrative databases from a fee-for-service, single-payer health system in Ontario, Canada. Surgeons who submitted claims for surgical procedures performed between January 1, 2014, and December 31, 2016, were included. Data analysis took place from February 2018 to December 2018.

Exposures:

Surgeon sex.

Main Outcomes and Measures:

This study compared earnings per hour spent operating between male and female surgeons and earnings stratified by surgical specialty in a matched analysis. We explored factors potentially associated with earnings disparities, including differences in procedure duration and type between male and female surgeons and hourly earnings for procedures performed primarily on male vs female patients.

Results:

We identified 1 508 471 surgical procedures claimed by 3275 surgeons. Female surgeons had practiced fewer years than male surgeons (median [interquartile range], 8.4 [2.9-16.6] vs 14.7 [5.9-25.7] years; P < .001), and the largest proportion of female surgeons practiced gynecology (400 of 819 female surgeons [48.8%]). Hourly earnings for female surgeons were 24% lower than for male surgeons (relative rate, 0.76 [95% CI, 0.74-0.79]; P < .001). This disparity persisted after adjusting for specialty and in matched analysis stratified by specialty, with the largest mean differences in cardiothoracic surgery (in US dollars: $59.64/hour) and orthopedic surgery ($55.45/hour). There were no differences in time taken by male and female surgeons to perform common procedures; however, female surgeons more commonly performed procedures with the lowest hourly earnings.

Conclusions and Relevance:

Even within a fee-for-service system, male and female surgeons do not have equal earnings for equal hours spent working, suggesting that the opportunity to perform the most lucrative surgical procedures is greater for men than women. These findings call for a comprehensive analysis of drivers of sex-based earning disparities, including referral patterns, and highlight the need for systems-level solutions.

PMID:
31577348
DOI:
10.1001/jamasurg.2019.3769

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