Sex-Based Variation in Neurosurgical Practice Patterns and Patient Characteristics

Sex-based differences in Centers for Medicare and Medicaid Services reimbursement in neurosurgery have been interpreted as evidence of inequitable pay. However, differences in aggregate Centers for Medicare and Medicaid Services reimbursement may reflect variation in practice patterns and patient populations rather than unequal payment based on sex alone for equivalent services. This study aimed to determine whether observed sex differences in Medicare reimbursement reflect unequal reimbursement for identical services or arise from differences in practice patterns.

This cross-sectional study analyzed reimbursement patterns of Medicare-participating neurosurgeons from 2013 to 2023 using the National Centers for Medicare and Medicaid Services Physician/Supplier Procedure Part B Summary datasets. Provider sex was identified through the National Plan and Provider Enumeration System using the National Provider Identifier. The primary outcomes were Medicare reimbursement adjusted by Healthcare Common Procedure Coding System and practice patterns.

Male neurosurgeons had a higher mean annual total reimbursement than female neurosurgeons (P < .001). However, Healthcare Common Procedure Coding System-adjusted analyses demonstrated no significant differences in standardized reimbursement for all identical procedures (P > .05). Procedural mix differed significantly, with men having a larger share of services in the highest reimbursement tier (34.31% vs 28.49%, P < .001) and women having a larger share in the lowest tier (27.74% vs 14.14%, P < .001). Furthermore, female neurosurgeons treated a significantly higher proportion of dual-eligible beneficiaries (26.1% vs 22.8%, P < .001) and patients with several psychiatric and medical comorbidities (P < .05).

Sex-based Medicare reimbursement differences in neurosurgery seem to arise from differences in procedural volume, subspecialization, and patient complexity.