How value-based care might close the gender pay gap

For decades, studies have told the same story. Women doctors, despite delivering excellent care, consistently earn less than their male colleagues. The gap isn’t small; it adds up to millions of dollars over a physician’s career. A new study published in JAMA Health Forum seems to add a twist to the narrative. Under certain payment systems, that gender wage gap doesn’t just shrink, it reverses.

Medicine has long struggled with gender pay inequity. Even in fields where women now make up a large share of the workforce, they still earn less. For primary care physicians, the doctors who serve as the first stop for most patients, the difference can be stark. One widely cited estimate found that over a 40-year career, female physicians earn about $2 million less than their male counterparts.

Part of the answer lies in how doctors are typically paid. In traditional “fee-for-service” models, physicians bill for each visit or procedure. That system tends to reward quick, high-volume care. Research shows women doctors often spend more time with each patient and devote additional hours outside the exam room to follow-up, charting, and coordination of care. These important but less visible efforts don’t always translate into higher billing.

The result is that women provide more of the invisible “glue” that holds patient care together, yet their paychecks lag behind.

In recent years, a new approach to physician payment has gained traction: value-based care. Instead of rewarding doctors solely for the number of visits, value-based models pay physicians based on how healthy their patients are and how well the doctors manage costs.

It works under Medicare Advantage (a form of private Medicare insurance), and some primary care physicians agree to take full financial responsibility for their patients’ medical spending. They receive a fixed, risk-adjusted monthly payment for each patient. If their patients stay healthier and avoid expensive hospital stays, the doctors and their organizations can come out ahead financially. If patients need more costly care, the practice shoulders the loss.

This system flips the incentive structure. Quality, not quantity, drives success. As this new study suggests, it may also hold the key to closing the gender wage gap in medicine.

The researchers behind the study looked at data from 872 primary care physicians across seven states who were working under full-risk Medicare Advantage contracts. These doctors cared for more than 223,000 patients.

The researchers compared male and female doctors on several fronts including earnings from both traditional fee-for-service and value-based payments, quality of care (measured by Medicare’s Star ratings, including things like diabetes management and preventive screenings), patient outcomes: such as emergency department visits and hospitalizations, and patient ratings, that is, how patients scored their doctors in satisfaction surveys.

By analyzing the data, the researchers discovered four interesting facts. First, in terms of Quality of Care, patients of women doctors had slightly better outcomes. They were more likely to have good diabetes control, to get their recommended eye exams, and to hit overall quality benchmarks. Second, these patients also went to the emergency department and hospital less often. Third, when it comes to earnings, there is the big headline. Under fee-for-service, men and women earned about the same. But under value-based care, women doctors actually earned more per patient than men. And finally, as far as patient ratings are concerned, despite delivering equal or better outcomes, women doctors received lower satisfaction scores from patients, a reminder of persistent gender bias in perceptions of care.

So, why did women do better under value-based care? The researchers suggest it comes down to alignment. Women doctors, on average, spend more time per visit and engage more deeply in follow-up and coordination. Those behaviors may not rack up billable visits under fee-for-service, but they pay off in the value-based world by keeping patients healthier and out of the hospital. Value-based care finally rewards the kind of medicine women physicians have often practiced all along.

The study has significant implications for fairness and equity. Pay equity is not just about money; it’s about recognition and respect. If women consistently deliver excellent care, they deserve to be compensated accordingly. Also, there are consequences in terms of burnout and Retention. Primary care is grueling work, and burnout is common. Equal pay may reduce stress and help retain more physicians, especially women, in the workforce. That’s crucial as America’s population ages and demand for primary care skyrockets. And finally, this study adds weight to arguments for expanding value-based payment models. If the system can both improve patient outcomes and correct gender-based inequities, that’s a powerful case for change.

In summary, picture two doctors working in the same clinic. Dr. Smith, a man, sees as many patients as possible in short visits. Dr. Johnson, a woman, spends extra minutes listening to her patients’ concerns and follows up with phone calls in the evening. Under fee-for-service, Dr. Smith might take home a bigger paycheck because he can bill for more visits. Under value-based care, Dr. Johnson’s patients stay healthier and avoid costly hospital visits, meaning her practice earns more. That’s the real-world difference this study highlights. It’s not about women working harder; it’s about systems that finally reward the kind of thorough, patient-centered care that many women already provide.

Indeed, no single study is definitive, especially on such contentious topics. The authors note a few caveats. The physicians in this study voluntarily chose full-risk contracts, so they may not represent all doctors. The data focused on Medicare Advantage patients, who are mostly older adults. The study looked at practice earnings, not individual take-home pay (though comparing doctors within the same groups helps reduce this concern). Still, the findings suggest that as more of the healthcare system shifts toward value-based care, the gender pay gap could shrink or even disappear. Future studies will need to track what happens as these models expand.

The takeaway is both hopeful and practical: payment systems matter. When we design healthcare models that reward quality instead of speed, we not only improve patient care but also take a meaningful step toward gender equity.

If you want to learn more, read the original article titled "Gender Differences in Primary Care Physician Earnings and Outcomes Under Medicare Advantage Value-Based Payment" on JAMA Health Forum at http://dx.doi.org/10.1001/jamahealthforum.2025.2001.