I'm Anusha Subramanian, a Future Perfect fellow at Vox. My most recent piece looks at why doctors are paid less to treat women or anyone with female anatomy. AMA!
Hi Reddit, I’m Anusha Subramanian, a Future Perfect fellow at Vox! You may have read my piece about the lifesaving case for CPR dummies with breasts and the transplant surgery that could save countless lives. But my latest reporting looks at why doctors get paid less for procedures on women and those with female anatomy compared to men and why it hasn’t been fixed even though experts have been sounding the alarm for decades.
Gynecological procedures and gynecologic surgeons are reimbursed by Medicare for their services at rates that are often lower than comparable surgical procedures on men. For example, the Medicare national rates for a genital biopsy — when doctors take a tissue or cell sample from an area to diagnose diseases — was $121.32 for a penile biopsy but only $65.74 for a vaginal biopsy in 2023. Both procedures are medically similar.
These national rates not only affect Medicare reimbursement, but they are also used by private payers to determine the value of the service being offered.
While it may be tempting to write this off as a boring billing problem, it has many downstream consequences for the quality of healthcare available to women in their non-childbearing years. Lower pay means hospitals put fewer resources into gynecologic surgery, fewer doctors choose to specialize in it, and women end up waiting longer for care. And because most of those surgeons are women themselves, the gap hits them twice, something the bioethicist Katie Watson calls "double discrimination." But this gap is not inevitable — researchers have pointed to many solutions over the years.
Medical misogyny often hits when you least expect it, and it is especially significant in healthcare policy and financing because those fields already tend to seem so convoluted to those of us on the outside. It is a frustrating gap, even if it is unintentional, and is born from gynecologic services generally being historically undervalued. It reinforced the message that the system may not care as much about a woman's health when she is not engaged in reproduction.
What do you think? What questions do you have about this systemic pay gap?
Proof:
https://x.com/ASubramanian99/status/2105742213808296090?s=20
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u/DrOkemon 12d ago
How did we get to a state where women’s procedures are reimbursed less? What are the market forces and players that caused this state? Specifically the imbalance between male and female procedures.
Also second question… there is so much complaints about medical costs in this country. How do we hold the general desire for medicine to cost less with this argument that seems to say “specifically women’s healthcare is too cheap! It should cost more”
I feel I could have also read an article that explained women’s healthcare is cheaper and gave it a positive spin.
So how to distinguish between women’s healthcare being underpriced and men’s being overpriced?
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u/DrOkemon 12d ago
> “One unintended possible result of that advocacy is that pushing for a smaller pay gap for services related to pregnancy, has in turn sent the message that women’s bodies are literally worth less, and are less deserving of care when they’re not engaged in the god-given duty of reproduction”
Taking this framing from the article, it is confusing to me as a healthcare consumer. So if my healthcare for my body js expensive, it is a message to me that my body is deserving of care? It seems like the opposite message… that I’m not deserving of care because the cost is so high!
And if it’s higher during pregnancy, I’d interpret that as women being basically punished for being pregnant instead of like… being treated as special.It’s really confusing to think about this on both sides of the incentives
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u/HotBunnz 12d ago
I’d argue that these questions are all addressed in the article and mentioned ‘Adam and Eve’ paper.
The AMA in this situation is essentially a price-setter and not subject to market forces due to monopoly control. The article claims (and presents supporting information) that the set price is lower for female procedures than equivalent male procedures.
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u/DrOkemon 12d ago
Yeah first question is definitely answered in article, but doesn’t answer how to think about whether male procedures are overpriced or female underprice
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u/vox 12d ago
Thank you for your question! There are a few things to separate out here.
My story mainly addresses the pay gap faced by surgeons in a predominantly female specialty who operate on female anatomy, which Katie Watson termed "double discrimination." It's also important to note that gynecologic services weren't reimbursed less for the sake of reducing women's health costs, and it's certainly not a given that those "savings" pass on to female patients so directly.
I can't speak to whether patients actually pay less from an insurance standpoint, since that depends entirely on your plan, copay, deductible and so on. But what I know from my reporting is that underpaying gynecologic surgeons costs women access to important health care they need for most of their lives. When gynecologic surgeries are reimbursed less than similar procedures on male anatomy, they contribute less to hospital revenue. Hospitals are less likely to invest in services that bring in less money, and may not allocate surgical staff, operating rooms or operating time to gynecologic care. Patients with conditions that severely affect their quality of life end up waiting longer for treatment, and there are fewer real-world opportunities to train gynecologic residents.
Doctors offering gynecologic surgery, such as for endometriosis, may also stop accepting insurance and move to cash-based practices, which pass the cost on to patients, as the authors of the Price and Prejudice study note.
The budget neutrality rule I write about also matters here. It means that if payments for some procedures go up, payments for others have to come down, so underpaying gynecology doesn't make the overall system cheaper. That money is effectively spread across other procedures. This is, of course, an abstraction of the concept - in theory there is more to it.
I do think that where we choose to invest our money usually points to what our priorities are. If gynecologic surgeries are systematically assigned fewer RVUs, and are therefore reimbursed less, than analogous surgeries on men, it's worth asking why the system values them less.
The point of my story isn't that male procedures should be reimbursed less or that they're necessarily overpriced. It's that the system we built to value surgical procedures has devalued gynecologic care and should be reevaluated. Dr. Uppal's study is a good example. The AMA committee that recommends RVUs relies on self-reported surveys about the skill and time different procedures take, a process many health policy experts have criticized, not only for the bias it creates in gynecology. Why rely on doctors' own estimates when, as Uppal and his colleagues argue, more objective measures of surgical time are available?
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u/DrOkemon 12d ago
Thank you. The system is extremely complicated. Makes me think we’d be better off paying surgeons an hourly rate or salary and sidestepping some of these incentives.
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u/r-monteiro4792 12d ago
That’s the key distinction: a gap alone can’t tell us which rate is right. You’d need an independent benchmark for time, complexity and resources. The matched-code comparisons show a disparity; the access consequences explain why low gynecologic reimbursement matters.
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u/214b 12d ago
So, does this mean that these surgeries cost less too? Would be an example of this benefitting women, at least those who self-pay.
However, just like those “studies” that allege that women earn only 81 cents for every dollar a man earns, there seems to be a lot of selective reporting here. For starters, just because the body parts are analogous to each other, doesn’t make the surgeries on them of equal difficulty. And some are actually cheaper on men. For example, I’m almost certain that a bilateral orchiectomy (castration) is cheaper than an oophorectomy on a woman. The male surgery is simply easier for anatomical reasons .
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u/vox 12d ago
Thank you for your question. For starters, it is well established that the wage gap is a real, persistent problem, and many well-cited papers in high-impact journals show that female surgeons earn less than their male counterparts overall, even after controlling for factors like age, rank and specialty.
On the billing comparisons, the studies I relied on compare pairs of billing codes, one for a procedure on female anatomy and one for an analogous procedure on male anatomy. In the 2025 Price and Prejudice study, the pairs were matched anatomically and then reviewed by both gynecologic and urologic surgeons to check that the comparisons made technical sense.
Notably, many of my sources pointed out that surgery on the female reproductive anatomy is often more difficult, because it takes place in the abdomen, whereas the testicles are contained in their own sac. Back in the day, gynecologic surgeons were essentially pelvic surgeons.
You're right that it doesn't always skew one way. The graphic in my story shows Medicare's 2023 rates for every pair in the study, and in some of them the procedure on women pays more. The study didn't include a simple or bilateral orchiectomy, which is what you're describing, but its orchiectomy pairs show both sides. A radical orchiectomy for cancer paid $511.02, while an oophorectomy paid $567.27. But when both were done with cancer staging, the orchiectomy paid $1,320.25 and the oophorectomy $1,169.79. The study's finding is about the overall pattern, where the procedure on women was valued lower in 75 percent of pairs.
On cost to a self-paying patient:
These are Medicare's payments to the surgeon, not necessarily what a self-paying patient would be charged. And in some cases, low reimbursement has had the opposite effect. The Price and Prejudice paper notes that some gynecologic surgeons, such as those who treat endometriosis, have stopped taking insurance because of low pay and instead charge patients directly, passing the cost on to them.-9
12d ago
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u/sissytendencie 10d ago
I agree with you, these people are insane. They just misconstrued cheaper services for women's healthcare versus men's health Care meaning people pay more for men's health Care, construed to, because it's cheaper to afford women's healthcare it means that it's actually misogynist because people aren't paid as much for the cheaper services.
These people are the definition of I want my cake and need to eat it too and I want your cake because you're not eating it but you're not eating it because you didn't like the cake because your are racist.
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u/214b 12d ago
Thanks. I was going to point this all out to him…but clearly he sees only the “data” he wants to. Not worth arguing over what has been debunked so many times.
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u/tehflambo 12d ago
You pointed out that some surgeries are more expensive on women. Doesn't that make it worse that doctors are paid less for doing them?
Should doctors be paid less for doing more expensive surgeries?
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12d ago
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u/returnofheracleum 12d ago
Your kleenex, sir, to wipe away your baby tears because a woman rejected you or some shit
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u/EvenStevenKeel 11d ago
My background doesn’t change the evidence we are discussing. Let’s stick to the topic and hand, shall we?
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u/returnofheracleum 11d ago
Okay. Topic: the vast majority of women that I've dated have experienced rape or some form of sexual assault. Not exaggerating. This does not happen nearly at the same rate to men I know.
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u/EvenStevenKeel 11d ago
Hmmm. The vast majority of women I know have not experienced that. Why do you suppose that is?
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u/returnofheracleum 11d ago
All kinds of reasons. They might not understand some of their bad sexual encounters as assault; many don't until seen in a certain light, which was the case with mine. More likely, they don't talk about it with you. Most likely, you don't want to know about it.
This is an exchange I had a little while back where I wrote in more detail about this sort of thing. I'm not going to demand that you read the dozens of reply chains, but the top 2-3 address that specifically. https://reddit.com/r/self/comments/1d7i5pe/i_29m_had_a_very_bad_experience_on_bumble_bff/l70mjg5/?context=3
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u/Jeckari 12d ago
Thank you for your reporting. On the topic of anatomy, do you also find similar disparities in providers of gender affirming care / surgery?
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u/vox 12d ago
Thank you for the question! My research and reporting for this story did not go into any possible billing disparities in gender affirming care or surgery, so that’s not something I want to speculate on without more information or data. But it is something I am interested in covering in the future.
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u/lurkity_mclurkington 12d ago
Is it because of the inherent misogyny baked into the systems like the inherent racism, e.g. mortality rate deltas for black women vs white women and white men?
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u/vox 12d ago
Yes, I think this is another case of gynecologic care being historically undervalued. What makes it tricky is that the billing gap, the mortality differences you mentioned and other structural inequalities are each baked into the system through different mechanisms, so they often need different solutions.
A big part of my story explains how medical billing rates are set using relative value units, or RVUs. An RVU is essentially a number that reflects how much skill and time a procedure takes, so that different services can be paid out on a comparable scale. Like most things, it started out well-intentioned. But when the system was created, gynecologic surgery was undervalued from the start, and in the decades since, very little has been done to close that gap.
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u/irrelevantusername24 12d ago
Is it because of the inherent misogyny baked into the systems like the inherent racism, e.g. mortality rate deltas for black women vs white women and white men?
Like most things, it started out well-intentioned.
I know that looking at these kinds of discrimination are well intentioned, but they are inherently harmful. Because when you look at superficial differences that in the terms of the system do not matter, that causes negative effects for those not specified. I am not saying racism doesn't exist. I am not saying sexism doesn't exist. I am not saying that any other kinds of discrimination doesn't exist. I am saying when it comes to any kind of discrimination, it needs to be dealt with in the terms of the system not in the terms of "objective" reality.
What I mean is it has to be dealt with within our human designed systems. A simple way to understand that is, can literally anything besides a human (or computer) even perceive the thing? If only humans can perceive the thing, that is because it is part of our shared cognitively built world. Which is, most simply, laws, money, and communication. An animal can see that some people have dark skin and others have light skin. An animal can see that you are a woman and I am a man. An animal can not understand the reason your pet is well taken care of is because you have money while my pet is also dealing with the same problems I am. Everything stems from money, law, and communication.
So when it comes to discriminatory practices, though they may be correlated with things like race, country of origin, or whatever... some people who have those traits do not suffer from the discrimination, and therefore using the superficial traits rather than looking at the actual problem gives more advantages to people who don't need it, which by definition means some people who need that assistance are not receiving it... and, to look at the reasons why in terms of the system, that would be most simply because the communication channels are oversaturated by people who don't need the assistance.
Getting back into the terms of your specific topic, if we paid doctors the same way we pay everything else, it starts to make a lot more sense. Look at it in terms of either hourly work or salary or some combination of the two. Problem solved.
By separating things into ever smaller categories more problems are created that wouldn't otherwise exist. Humans have identity, that is how we are known. Not through our groups based on superficial traits. It starts at the individual and expands outward, not the reverse. Which truthfully, yes, that is a two way street. And only by relating and looking from one direction can the other direction be known. But if we don't start at the individual level, then suddenly humans are no longer ends in themselves.
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u/l_maruyama-9493 9d ago
Who can trigger a review of an undervalued RVU, and how often are rates revisited? I’m curious whether the bottleneck is the evidence, the review process, or getting anyone to prioritize gynecologic procedures.
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u/vox 8d ago
Great question! The RUC (the AMA committee that recommends RVUs) meets three times a year to review codes that are new, revised or flagged as potentially misvalued by CMS or the RUC's own workgroup.
Anyone can request a review in two ways. You can nominate a code as potentially misvalued to CMS. Or you can submit an application to the CPT Editorial Panel, which maintains the billing codes, to create or revise a code. The Panel has to approve each application for it to move forward.
From my reporting, evidence does exist in medical literature. AMA, RUC and ACOG have, on occasion, addressed the existence of this disparity and made some efforts to reevaluate the codes through the years (hence the minimal improvement in RVUs and reimbursement rates). My sources believe that the system itself might need to change how it bills and assigns value to medical procedures - for instance, adopting sex-neutral billing codes.
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u/mnemonic-glitch 8d ago
What about market issues? Is there data on the amount of providers driving up or down costs?
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u/Tess47 12d ago
What is a Future Perfect fellow at Vox?