Study reveals steps to improve physician productivity and gender equity

Women physicians have historically been paid less than their male counterparts, a phenomenon past research has suggested may be due in part to women physicians spending more time with each patient, thus generating less revenue overall even if they generate the same per visit.

In a new study, Yale researchers have found that such factors as reducing the time spent on documentation and receiving more contributions from other team members could help all physicians boost their productivity. When researchers controlled for some of these factors, they found that differences in gender pay receded.

Recent changes to the billing code used in the U.S. health care system helped address these factors, leveling physician compensation for services performed, the study also found.

The findings were reported Oct. 16 in the Journal of General Internal Medicine.

For the study, the researchers collected data on physician productivity, their use of electronic health records, and physician and practice characteristics from general internal medicine physicians practicing in a large ambulatory network in the northeastern United States. Productivity was estimated through work relative value units (wRVUs), a standard measure used by the health care industry to quantify and valuate the work physicians do. The data spanned from August 2018 to June 2021 and included 108 physicians.

The team found that women and men physicians generated similar wRVUs per patient visit. However, men physicians completed more patient visits and clinical hours per month, compared with women, while women physicians spent more time with each patient per visit. Ultimately, this translated to men generating more wRVUs per month and per hour.

"However, when we controlled for physician age, practice characteristics, electronic health record use, and temporal trends, these gender differences went away even over units of time worked," said Ted Melnick, associate professor of emergency medicine at Yale School of Medicine and senior author of the study. "All other things being equal, gender wasn't related to hourly productivity."

This suggests that the gender gap in hourly productivity observed in the initial analyses of the study was driven in part by characteristics specific to different practices—such as the average length of patient visits and number of patients seen—and how much physicians used the electronic health record.

Factors that were related to higher hourly productivity included more contribution from team members, shorter physician notes about patient visits, and reduced time spent writing those notes.

The researchers also discovered a boost in productivity for all physicians after changes made in 2021 to the codes used across the U.S. health care system to document medical services and procedures. The changes were made so health care providers could bill for the time physicians spent on patient care rather than the complexity of a patient visit. Men physicians logged 10.3% more wRVUs per hour after these changes, while women generated 17.9% more.

"Most physicians are compensated through fee-for-service models where the number of wRVUs they generate determines their pay. And that's based on a system that assigns a certain amount of weight to certain types of activities," said co-lead author Lisa Rotenstein, an assistant professor of medicine at the University of California, San Francisco. "But we know that women physicians spend more time counseling, and their patients discuss more emotion-related content with them. That all takes time and means they end up billing less per hour."

Before the 2021 code changes, the medical complexity of a patient visit determined how that visit was billed, and more time-intensive activities may not have been adequately valued. But after the code changes, physicians could bill based on time and not just task, meaning some of the time-intensive work more often done by women physicians could be billed for in a way it previously was not. This, the researchers say, may partially explain why women physicians' productivity increased more after the code changes than their male counterparts."

Overall, the findings highlight areas both where health care practices and policy could change to increase physician productivity.

"For example, having other team members tee up orders for the physician or having scribes help with documentation could help boost productivity," said Melnick. "Our findings celebrate the code changes and show that similar policy changes could be additionally beneficial."

The researchers also note that medicine has an increasing digital component with physicians receiving significantly more electronic messages from patients in recent years.

In another new study published in the Journal of General Internal Medicine, Rotenstein and Melnick found that for women physicians, but not men, patient-reported satisfaction was linked to how much and how quickly they responded to messages. But physicians are often not compensated for that work.

"As patients, we want better access to our physicians. And as physicians, we want better connections with our patients," said Melnick. "But the current regulatory and compensation models need to catch up to current technology so we can have better doctor-patient relationships that enable both patients being connected with doctors they trust, and physicians having a sustainable clinical practice."