Doctor: This Positive Trait May Hurt You Financially

Physicians who spend more time with patients generate less revenue—a finding that may, in part, explain the gender wage gap between male and female physicians.

According to a new study led by researchers from Brigham and Women’s Hospital and the University of Minnesota, female primary care physicians spend more time in direct patient care per visit, per day, and per year. Consequently, they have a lower volume of visits than their male counterparts, resulting in less revenue.

“All doctors, especially in primary care, want more time with their patients,” said first author Ishani Ganguli, MD, MPH, a health policy researcher and assistant professor at Harvard Medical School and Brigham & Women’s Hospital Division of General Internal Medicine and Primary Care, Boston, MA. “What we’re seeing is that female doctors seem to spend more time but at a personal cost.”

Volume-based pay has gone astray

In results published in The New England Journal of Medicine, Dr. Ganguli and coauthors found that female primary care physicians spent about 1,200 more minutes with patients per year—or 2.4 more minutes per visit on average—than their male counterparts.

“Observational studies suggest that more time per visit is associated with higher rates of screening and counseling, better patient outcomes, greater patient satisfaction, and decreased physician burnout,” the researchers wrote in the article.

Indeed, nearly 79% of physicians reported that patient relationships are one of the most satisfying aspects of medical practice, according to the 2018 Survey of America’s Physicians conducted by Merritt Hawkins for the Physicians Foundation. Likewise, more than 12% of physicians said that the short amount of time they can spend with patients factors into their dissatisfaction with medicine.

Dr. Ganguli and coauthors wrote: “Although longer visits are associated with better care, such differences may disadvantage female physicians within the still-predominant volume-based physician payment model that values visit number over quality.”

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An explanation for the gender wage gap?

For this study, the researchers analyzed detailed time data from 24.4 million primary care office visits across the US in 2017, which were culled from electronic health records (EHR) from primary care physicians in all 50 states.

“The observed visit time measure relied on time stamps, which capture clinicians’ actions in the EHR across sequential stages of an encounter with a patient,” the authors noted.

Researchers compared female and male physician visits within the same practices and controlled for physicians’ age, degree level, specialty, number of sessions worked per week, and patient and visit characteristics.

On average, female physicians had the same number of visits per week as male physicians. However, female physicians were generally younger than their male counterparts and were more likely to specialize in family practice. They also had more visits with patients who were under age 65, female, non-White, and covered by Medicaid or commercial insurance.

But after adjusting for physicians’ age, academic degree, specialty, and number of sessions worked per week, the researchers found that female primary care doctors worked only 2.6% fewer days per year than their male colleagues. Also, female physicians provided 10.8% fewer patient visits and generated 10.9% less visit revenue than male physicians.

Dr. Ganguli said, “When talking about the gender wage gap, researchers have long assumed that women are working fewer hours, or that they’re working part time. Yet when we compared just the time doctors spent face to face with patients alone, women physicians, in fact, spent more time than their male counterparts despite making 87 cents to the dollar for that work.”

The researchers also found that female physicians were more likely to underbill visits than male physicians. While female physicians documented more diagnoses and placed more orders, they more often missed opportunities to bill higher-paying visit codes for the time they had spent with patients. The researchers didn’t explain or speculate about why this was so.

“Our findings provide more evidence that our current system of paying doctors based on the volume of services they provide is a flawed measure of work effort,” said senior author Hannah Neprash, PhD, a health economist and assistant professor at the University of Minnesota’s School of Public Health, Minneapolis, MN.

Highest risk of burnout, at what cost?

Overall, female physicians spent more time with both male and female patients than male physicians did. Female physicians spent even more time (16%) with patients who had two or more chronic conditions.

The researchers acknowledged that their study had some limitations. For one, they weren’t able to investigate whether extra time spent per patient improved patient care or outcomes. Also, the data came from a single EHR company, which may not be generalizable to all primary care doctors nationwide. Also, the analysis focused on visit-related revenue, but that may not directly reflect physicians’ compensation. Lastly, even though the data provided a detailed timeline of the patient visit, the researchers couldn’t be sure exactly how this time was used beyond what was noted in billing codes, or whether more time equaled better patient outcomes.

Nevertheless, the incongruity between the time that female doctors spend per patient visit and the revenue they generate may indicate why they face a greater risk of burnout than their male counterparts, the researchers suggested.

“Female physicians report the highest rates of burnout and our findings may help explain why,” said Dr. Neprash. “If longer visits contribute to feelings of time pressure and a chaotic work environment—for lower pay—it’s understandable that job satisfaction might be lower.”

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