Revenue reflects fewer visits, but are the visits higher quality?

In an average primary care practice, women physicians log fewer patient visits, thus generating less revenue for the practice. But that is only half of the story: these women physicians spend more time in direct patient care “per visit, per day, and per year.”

Those findings, which emerged from a cross-sectional analysis of data culled from electronic health records, were reported in The New England Journal of Medicine.

Ishani Ganguli, MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital, and colleagues, funded in part by a grant from the Robert Wood Johnson Foundation, pulled all-payer claims and data from electronic health records and “conducted a cross-sectional analysis of 24.4 million primary care office visits in 2017 and performed comparisons between female and male physicians in the same practice.”

They looked at visit revenue, visit counts, days worked, and time spent, which was defined as the “interval between the initiation and the termination of a visit.” They “created multivariable regression models at the year, day, and visit level after adjustment for characteristics of primary care physicians (PCPs), patients, and types of visit and for practice fixed effects.”

And what did they find?

Well, the female PCPs generated less money for the practice: 10.9% less revenue from office visits than their male colleagues. The lower revenue matches up almost exactly with the numbers of visits: 10.8% fewer visits for the women compared to the men. They also had fewer clinic days — 2.6% fewer. Those were the tallies after adjusting for age, academic degree, specialty, and number of sessions worked per week.

And yet, those women “spent 2.6% more observed time in visits that year than their male counterparts (1201.3 minutes; 95% CI, 184.7 to 2218.0). Per visit, after adjustment for PCP, patient, and visit characteristics, female PCPs generated equal revenue but spent 15.7% more time with a patient (2.4 minutes; 95% CI, 2.1 to 2.6).”

The records included in the analysis involved 8,513,290 patients and 8,302 PCPs. A little over a third of the physicians (36.4%) were women and more than half of the physicians were board certified in internal medicine. Geographically, more of the PCPs were based in the South and there were fewer in the west. Medicare was the payer for 39% of the patients and more than half of the patients (56.3% were women).

Visit characteristics by female physicians versus male PCPs:

  • No significant revenue difference at visit level.
  • Female PCPs documented 5.9% more diagnoses per visit.
  • Female PCPs place 19.2% more orders per visit.
  • Time spent with patient was proportional to number of chronic conditions—more diagnoses, more time spent.
  • Female PCPs scheduled more long visits (20 minutes or longer) 26.6% versus 23.3%.
  • Female physicians spent about 2 and a half more minutes with each patient than male physicians, which worked out to 15.7% more minutes per patient per visit.

“These estimates amounted to a revenue difference between female and male PCPs of $398.5 as compared with $460.4 per hour of direct patient care,” Ganguli and colleagues wrote.

The researchers speculated that the findings may reflect patient expectations: patients may expect women physicians to spend more time with them and thus may chose a woman doctor for that reason. “In support of this hypothesis, we found a narrower difference between female and male PCPs in the visit duration among same-day visits, for which patients may have less choice in which clinician they see.”

The researchers cited evidence from observational studies suggesting that “more time per visit is associated with higher rates of screening and counseling, better patient outcomes, greater patient satisfaction, and decreased physician burnout.”

Although the analysis had the benefit of a large sample, it did have several limitations including the use of just one national EHR, which may limit its generalizability. Also, although much of published work on gender inequality in medicine focuses on pay equity, this study looked at practice revenue and “cannot observe how this translated into physicians’ compensation.” Moreover, the analysis did not drill down to determine exactly how time spent with the patient was used and if that extra time “was associated with better patient outcomes.”

Finally, they concluded that the results “suggest productivity-based payment is a modifiable structural mechanism for the gender pay gap. In the short term, clinicians could be prompted to use time-based billing when appropriate. Further research could examine ways to optimize physician time spent in visits (e.g., task sharing with clinical teams) without sacrificing patient outcomes or clinician well-being. Practice leaders and policymakers could also accelerate the development of other compensation models, such as payment for risk-adjusted panel size, and include measures of outcomes or patient experience in compensation formulas to address wage equity and to better reward time well spent.

  1. Analysis of billing records from more than 24 million primary care office visits found that female PCPs generate less visit-based revenue than their male colleagues.

  2. Note that the revenue difference was attributable to fewer patient visits and less days worked in clinic, but women were likely to spend more time with each patient.

Peggy Peck, Editor-in-Chief, BreakingMED™

Supported by a grant from the Robert Wood Johnson Foundation.

Ganguli had no financial disclosures.

Cat ID: 192

Topic ID: 86,192,192,589,590,61,925