Minna Lee Jamison spent years in pain waiting for a diagnosis. When a specialist finally cleared her for surgery, she had to wait another three years.
Lee Jamison has endometriosis, a chronic disease that occurs when tissue similar to the lining of the uterus grows outside the uterus. People with endometriosis can experience extreme pain, inflammation, scarring, and even infertility.
Many people surgical excision is required to remove the web—including Lee Jamison. But she had to contend with insurance denials and long surgical waiting lists, ultimately delaying her doctor-recommended surgery from 2020 to 2023.
“There are already fewer specialty surgeons out there and fewer surgeons who accept insurance,” said Lee Jamison Rewire News Group in an email. “I was 96th on the waiting list for a counseling appointment.”
Lee Jamison is not alone. An esteemed one 11 percent of women of reproductive age in the US have endometriosis and many require surgery. But patients face excessively long waiting times and high out-of-pocket costs. Now, gynecologists are speaking out about a factor they believe is contributing to the problem: the unequal distribution of surgical reimbursements.
An outdated system
I will be starting my residency training soon, and after four years of medical school, I have a deep understanding of who pays for healthcare in the US, how, and the many flaws built into that system.
In the US, insurance reimbursements for surgical procedures are guided by a decades-old federal structure known as relative value unit (RVU) system.. The system uses the physician’s labor, practice expenses, and malpractice insurance costs to determine the physician’s compensation.
Dr. Louise P. King, a gynecologic surgeon, attorney, and Harvard Medical School professor who teaches medical ethics, has been at the forefront of identifying and studying RVU disparities.
“The RVU system was created in the 1980s through a section of the Social Security Act,” he said. “Before that time, doctors charged what they thought was the right amount of money.”
To ensure that procedures had an objective, standard cost, researchers at The Harvard School of Public Health in 1985 designed studies to decipher how different procedures and clinical work would be worth in RVUs.
Under the Harvard-developed system, which was first implemented in Medicare in 1992, RVU values are assigned to the various diagnostic codes used by providers to bill for their services. To determine how much the provider is then paid, the RVU value is multiplied by an annual dollar amount determined by the Centers for Medicare and Medicaid Services.
For example, an office visit between a physician and his existing patient is assigned a value of 1.96 RVUs. Multiplied by the 2026 CMS amount of $33.26, the provider can expect Medicare to reimburse approximately $65 for the visit.
In theory, the longer and more complex a procedure was, the more RVUs would be assigned, leading to a higher payment for the surgery. But the system had some glaring omissions.
“They did studies of cardiology and colon surgery … things that were for all people but were disproportionately used by men,” King said. “They ignored obstetrics and gynecology and just threw in some numbers.”
As a result, women’s health care was severely undervalued from the beginning of the RVU system, King said.
Under federal law, the RVU system is required to apply only to Medicare payments. But a lot States have set Medicaid payments based on these values. Private insurance companies followed suitmaking the system a national standard for what patients pay for their health care.
And while information committee has since been created to allow changes in RVU fees, the leading professional organization for OB-GYNs—the American College of Obstetricians and Gynecologists—has only one vote on the 32-member panel.
“We don’t have enough of a voice to make the changes that we need to see,” King said.
This problem is compounded by regulations limiting the total number of RVUs which can be made available for procedures. If gynecologic surgeons need more RVUs available for endometriosis surgery, they must be obtained from other specialties.
This problem does not only affect patients with endometriosis. Every patient who needs gynecological surgery — fibroid removal, hysterectomy, prolapse repair — is affected by the current RVU system. But gynecologists RNG of respondents said endometriosis is the most obvious and glaring example.
Gynecological surgery has no ‘value’
The devaluing of gynecological surgery by the RVU system ultimately leads to inequity in patient care. When a gynecologist operates on someone with a female anatomy, their operation is worth less to insurance and hospitals than a surgery on someone with a male anatomy, a urogynecologist and an OB-GYN Dr. Jocelyn Fitzgerald he said Rewire News Group.
“Our patients just don’t get the same level of value in the hospital,” said Fitzgerald, who has been vocal about the differences in RVU reimbursement on social media.
In one Study 2025 regarding reimbursements for surgery on male versus female anatomies, RVUs for procedures on male patients were 30 percent higher on average. The study also found that inequality has persisted for more than three decades, despite being continuous growth and development of gynecological surgery.
“If I go into the hospital with my husband — he has a male reproductive problem and I have a female reproductive problem — already all the money that goes to the hospital is a third more for him,” King said. “Just because he has a penis and I have a vagina.”
When Lee Jamison’s surgeon operated on her endometriosis — a complex surgery that can take up to eight hours to complete — her operation was worth 12.15 RVUs. A shoulder-joint surgery that usually takes 30 minutes to 1 hour is worth 15 RVUs. This means that a hospital can make ten times more money in eight hours of orthopedic surgery than in eight hours of endometriosis surgery.
As a result, endometrial surgeons say, their cases are being de-prioritized by administrators. It also means facilities may have fewer surgeons and support staff, and those providers are given less time in the operating room, increasing wait times for surgical resection.
Many surgeons believe they cannot sustain their practice with in-network insurance alone. As a result, many are leaving to seek better pay in cash-based private practice, where many patients pay out of pocket for their surgeries.
“There was one meteoric rise in cash-based endometriosis practices,” Fitzgerald said. “There are some who actually extort women in pain for cash-based surgery.”
In the most recent national American Association of Gynecologic Laparoscopes conference, Fitzgerald noted that there were showrooms of people trying to recruit specialist gynecologic surgeons from outside academia. Surgeon working in a public, academic institution he is paid a quarter of what a surgeon makes in a cash-based practice, Fitzgerald said.
The cost ultimately falls on the patient. Patients are forced to pay out of pocket, waiting years for specialized surgery. In some cases, they may seek surgery from less experienced surgeonsrisking harm.
“Endometriosis is as common as diabetes and it’s completely debilitating,” Fitzgerald said. “Women will do anything for high-end removals…mortgaging their homes and going into credit card debt.”
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Shifting motivations
Gynecological surgeons say there are ways to deal with this problem.
Patients can petition their representatives in Congress and tell their stories through letters, King said. Campaign fundraisers are a good place for congressional leaders running for office to also hear patients’ stories.
King added that patients can call hospital administrations to ask them to hire surgeons specializing in gynecological surgery to reduce wait times for patients who need to see endometriosis specialists and increase access to safe surgeries for complex patients.
Doctors also have work to do, said King, who herself has extensively researched the inequities of the RVU reimbursement system. Her research and publications are presented at a 109 page article in Emory Law Journal from 2024 that includes legal approaches to what patients, doctors and the federal government can do to change this system.
Currently, King works with other doctors and lawyers the Surgical Parity Projecta new advocacy group raising awareness about gender discrimination in health care reimbursement; The project is in its early stages, but it will help people get involved and advocate for change.
“We need to rethink how we incentivize the care we provide to people,” King said. “If they don’t fix it in my lifetime, I’m going to dust off my law degree and get out there, because it just has to change.”
