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A biased and inadequate federal reimbursement system endangers women patients and needs an overhaul, gynecologic surgeons told policymakers at a briefing before Washington, DC, policymakers last week.

The four surgeons said the current reimbursement system makes it more likely that gynecologic surgeries will be performed by generalist obstetrician-gynecologists (OB-GYNs) — who they say make more errors due to low surgical workloads — instead of fellowship-trained surgeons.

One major problem, they said, is a payment discrepancy based on the gender of patients. “If you do a biopsy on a penis vs a biopsy on a vagina, you make 45% more money,” said Jocelyn Fitzgerald, MD, gynecologic surgeon at the UPMC Magee-Womens Hospital, Pittsburgh. “And let me just say it is more difficult to biopsy a vagina than a penis. This adds up over time in a really significant way.”

In the big picture, “systemic inequity threatens the financial sustainability of health systems, the viability of our workforce, and, most importantly, access to care and quality of care for our patients,” said Teni Brown, MD, gynecologic surgeon at Northwestern University Feinberg School of Medicine, Chicago.

However, the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) defended the current payment system and rejected accusations of bias.

Relative Value Units (RVUs) System Gets Blame for Reimbursement Problems

The advocates highlighted the role of RVUs, which are calculations that determine how much physicians are paid for surgical procedures. The Centers for Medicare & Medicaid Services (CMS) sets RVUs, and private insurers rely on them.

The Relative Value Scale Update Committee (RUC), made up in part of members of AMA and specialty societies, makes recommendations to CMS about RVUs.

Louise P. King, MD, JD, gynecologic surgeon at Harvard Medical School, Boston, said the RUC is not fully transparent since there’s no way to know what goes on “behind the scenes,” and she noted that its recommendations are based on surveys with low response rates. In addition, an estimated 12.5% of seats on the committee are held by women, she said, and gynecologic surgery doesn’t have a vote.

“There really needs to be a significant change,” King said.

Big Pay Gap Between Urologists and OB-GYNs

GYNs are among the lowest-paid physicians, reflecting a medicine-wide trend toward lower pay for women-dominated specialties, King noted in a 2024 law journal report. Nearly 60% of GYNs are women compared with about 10% of urologists.

Pay for OB-GYNs also lags many of their colleagues. According to a 2024 Medscape report, OB-GYNs made an average of $352,000 a year vs $515,000 for urologists.

According to another report, OB-GYNs without surgical specialization perform most gynecologic surgeries because lower reimbursement rates for gynecologic procedures discourage medical students and residents from specializing in the field.

But OB-GYNs often lack experience performing specific procedures, the authors reported, a potential problem because research suggested lower surgical volume translates to a higher risk of complications. King cowrote a 2022 report that found that “if we could move from a world in which hysterectomies are performed by low-volume OB-GYNs to a world where they are instead performed by fellowship-trained GYN specialists, we could prevent nearly 8000 ureteral injuries per year.”

AMA and ACOG Stand by RVU System

The RUC process is transparent since meetings are open and both votes and minutes are published, an AMA spokesperson told Medscape Medical News.

The spokesperson, who declined to be identified per AMA policy, said the surveys are not biased: “Statements that there are inequities in procedures performed on male versus female procedures are misinformed.”

A 2024 analysis by the ACOG and the American Urological Association found there was no marked disparity in the value, the spokesperson said.

However, a 2021 study found that “there is a lower relative value of work, driven by specialty-specific compensation rates, for procedures performed for women-only compared with equivalent men-only procedures.” And a 2025 study reported that “disparities persist in reimbursement for female-specific compared with male-specific procedures.”

“Additionally, the RUC took the extra step of recommending a code to capture the cost of supplies used in provision of a pelvic exam to help resolve a real supply cost difference in office visits of women vs men,” the spokesperson said.

Lisa Satterfield, ACOG’s senior director of Health and Payment Policy, also highlighted the 2024 study, which she said “found the AMA process to be agnostic of provider types.”

“We maintain that any payment system should include input from the physicians that are currently performing the procedures and be adjudicated by a physician panel of experts, which the AMA RUC process ensures,” she said in response to questions from Medscape Medical News.

Next Steps: Advocates Want Congress to Act

What should be done? For one, “CMS can eliminate these codes that discriminate by sex,” said Christopher Robertson, JD, PhD, professor with the Schools of Law and Public Health at Boston University, Boston, and a co-author of the law journal report.

For another, he said, reimbursement shouldn’t be based on surveys but instead on “objective measures of surgical time.”

Congress, he said, can take steps to implement these reforms, and it can eliminate “budget neutrality” rules that require “if we raise any rates in the system, we have to lower other rates.”

Randy Dotinga is a freelance medical writer and board member of the Association of Health Care Journalists.