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Study debunks ‘women choose to work less’ myth behind health-care pay gap

Experts have known about the gender pay gap in health care for years, but a recent Ontario Medical Association (OMA) study highlights where the issue is most acute: in semi-urban areas; in privately run offices; in some specialties like neurosurgery; and in fee-for-service, the supposedly gender-blind system that pays most doctors.

The September study reaffirmed that male doctors in Ontario are paid 13.5 per cent more per day than women, higher than the 11 per cent gap cited for male and female Canadian workers in general.

Sharada Weir, health economist and co-author of the study, says the “daily gap” is the closest the researchers could get to an apples-to-apples comparison between male and female physician pay. She says previous studies looked at annual pay gaps, which led gap skeptics to interpret the results as, “women just choosing to work less.” However, the number of days worked per year only accounted for one-third of the total gap. Hourly data is not tracked for most specialties.

Weir says another strength of the study is its breakdown of different payment models that found the largest gap occurs when physicians are paid by fee-for-service (FFS) – a payment system generally considered to be immune to gender bias. Under FFS, doctors bill per service or procedure, which some say results in care that is volume-driven rather than value-driven.

The OMA called the FFS gap “perplexing.” National data from 2016 showed that 97 per cent of all physicians received at least some payments by FFS, and FFS accounted for 70 per cent of all payments. “If we’re finding (the gap) in fee-for-service, it’s likely that it’s the same issue in other provinces as well,” Weir says.

But not all accept the study’s findings. In an October Twitter poll, physician and evidence expert Ken Milne presented the OMA’s latest findings to emergency physicians and asked them to estimate the size of the gap in their own workplaces. Of 471 doctors, 35 per cent denied a gap.

This followed a 2020 OMA member survey showing that only 34 per cent of male respondents agreed that a gender pay gap exists, compared to 84 per cent of female respondents.

The recent OMA study examined Ontario Health Insurance Plan billings of more than 31,000 Ontario doctors from April 2017 to March 2018. Researchers accounted for specialty, years of experience, days per year worked, weekends and holidays worked, payment model and distance from an urban centre. Apart from finding a 13.5 per cent daily pay gap, they found the gap varied in certain settings:

  • The gap was wider when physicians were paid by fee-for-service (23 per cent), compared to other payment models such as capitation (13 per cent).
  • The gap doubled in private offices (17 per cent) compared to hospitals (8 per cent).
  • The gap was wider in urban (12 per cent) and semi-urban areas (16 per cent) than in rural areas (8 per cent).
  • The gap was significant in 20 out of 36 specialties and varied greatly by specialty.
  • Family doctors were in the middle of the pack at 17 per cent, and neurosurgery had the largest gap at 38 per cent.

“In Canada, we’re still at the stage of debating whether or not (a physician gender pay gap) exists,” says doctor and gender equity researcher Michelle Cohen, who began her research on the topic in 2019 and was shocked at how little research had been done on the issue in Canada.

Much of the literature comes from work done outside Canada, including in the U.S. and U.K. In Canada, there are comparatively fewer studies looking directly at the gap:

  • 2016 Ontario Ministry of Health data showed that women made up only eight per cent of the province’s highest-paid physicians.
  • A 2017 study of family doctors in B.C. showed that women made 36 per cent less than men despite similar workloads.
  • A 2019 study of more than 3200 Ontario surgeons found that women earned 24 per cent less per hour than men.
  • An Oct. 18 study showed that Ontario fee-for-service payments to female doctors were 74 per cent of men’s payments.

Cohen is not surprised at the OMA’s findings. She says that women in medicine experience gender imbalances early in their training through the “hidden curriculum,” which is “subtle, sometimes overt messaging that medical students receive about which specialties are better for them.”

Cohen recalls her own experience as a medical student learning from a male surgeon. “He didn’t teach me anything about the (surgical) procedure. He didn’t give me any advice about anything, except that I needed to get married and have babies right away – and if I waited too long, I’d be making a terrible mistake.”

When it comes to addressing the gap, part of the future lies in studying the inequity of referral patterns. Weir says many tell her, “There cannot be a gender pay gap in fee-for-service because the fee schedule does not discriminate between men and women … But the question is, am I going to get the referral for that lucrative procedure, or is that more likely to go to a male physician?”

Says Cohen: “Women are still doing different work than men, even within the same specialty.”

The other major area of interest is studying the fairness of the FFS schedule itself. A 2020 American study of family doctors found that women earned less than men because they spent more time with each patient. “Women in general are expected to provide more empathy, more time and understanding … that may have implications for quality that are also not reimbursed,” says Weir.

Cohen says, “We need to critically examine this assumption we have – that there is no gender bias at all in the Schedule of Benefits.”

In a 2020 analysis, Cohen and co-author Tara Kiran outlined several actions we could take to close the gender pay gap in Canadian medicine. I asked Cohen where we are at with implementing them. Her response was emphatic.

“At the very beginning.”

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Anthony Fong

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Anthony Fong is an emergency physician in Vancouver and clinical assistant professor at the University of British Columbia Faculty of Medicine. He is currently a fellow in global journalism at the Dalla Lana School of Public Health, University of Toronto.

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