Minna Lee Jamison spent years in pain waiting for a diagnosis. When a specialist finally approved her for surgery, she was forced to wait three more years.
Lee Jamison has endometriosis, a chronic disease that occurs when tissue similar to the uterine lining grows outside of the uterus. People with endometriosis can experience extreme pain, inflammation, scarring, and even infertility.
Many people need excision surgery to remove the tissue—Lee Jamison included. But she had to battle insurance denials and long surgery waitlists, ultimately delaying her physician-recommended surgery from 2020 to 2023.
“There are already few specialist surgeons out there, and fewer surgeons that accept insurance,” Lee Jamison told Rewire News Group in an email. “I was 96th on the waitlist for a consult appointment.”
Lee Jamison is not alone. An estimated 11 percent of women of reproductive age in the U.S. suffer from endometriosis and many need surgery. But patients face exceedingly long wait times and high out-of-pocket costs. Now, gynecologic surgeons are speaking out about one factor they believe is contributing to the problem: inequitable distribution of surgical reimbursements.
An antiquated system
I will begin my training as a resident physician soon, and after four years of medical school, I have a deep understanding of who pays for health-care in the U.S., how—and of the many flaws built into this system.
In the U.S., insurance reimbursements for surgical procedures are driven by a decades-old federal structure known as the relative value units (RVU) system. The system uses physician work, practice expenses, and malpractice insurance costs to determine physician reimbursement.
Dr. Louise P. King, a gynecological surgeon, lawyer, 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 portion of the Social Security Act,” she said. “Prior to that time, physicians would charge whatever they thought was the right amount of money.”
To ensure procedures had an objective, standard cost, researchers at the Harvard School of Public Health in 1985 designed studies to decipher how much different procedures and clinical work would be worth in RVUs.
Under the system Harvard developed, which first applied to 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 a yearly dollar amount determined by the Centers for Medicare and Medicaid Services.
For example, an office visit between a doctor and their existing patient has an assigned value of 1.96 RVUs. Multiplied by the 2026 CMS amount of $33.26, the provider can expect Medicare to reimburse about $65 for the visit.
In theory, the longer and more complex a procedure was, the more RVUs would get assigned, leading to a higher payment for the surgery. But the system had some glaring omissions.
“They did studies of cardiology and colorectal surgery … things that were for all people but were used disproportionately by men,” King said. “They ignored obstetrics and gynecology, and just slapped some numbers on it.”
As a result, women’s health care was severely undervalued from the start of the RVU system’s implementation, King said.
Under federal law, the RVU system is only required to be applied to Medicare payments. But many states have set Medicaid payments based on these rates. Private insurers have also followed suit, making the system a national standard for what patients pay for their health care.
And while an updates committee has since been formed to allow for changes to RVU fees, the leading professional organization for OB-GYNs—the American College of Obstetrics and Gynecology—has only one vote on the 32-member panel.
“We don’t have enough voice to make the changes we need to see,” King said.
That problem is exacerbated by regulations that cap the total number of RVUs that can be doled out for procedures. If gynecological surgeons need more RVUs allotted to endometriosis surgery, they have to be taken from other specialties.
This problem doesn’t only impact endometriosis patients. Any patient needing gynecological surgery—fibroid removal, hysterectomies, prolapse repair—is impacted by the current RVU system. But the gynecological surgeons RNG interviewed said endometriosis is the most obvious and egregious example.
Gynecologic surgery doesn’t carry ‘value’
The RVU system’s undervaluation of gynecologic surgery ultimately leads to a disparity in patient care. When a gynecological surgeon operates on someone with female anatomy, their surgery is worth less to insurance and hospitals than a surgery for someone with male anatomy, urogynecologist and OB-GYN Dr. Jocelyn Fitzgerald told Rewire News Group.
“Our patients just don’t carry the same level of value in the hospital,” Fitzgerald, who is vocal about disparities in RVU reimbursement on social media, said.
In a 2025 study on reimbursements for surgeries on male versus female anatomies, RVUs for procedures on male patients were 30 percent higher on average. The study also found that the disparity has persisted for more than three decades, despite the continuous growth and development of gynecological surgery.
“If I’m walking into the hospital alongside my husband—he has a male reproductive issue, and I have a female reproductive issue—already all the money that goes to the hospital is a third more to 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 surgery was worth 12.15 RVUs. A shoulder-joint surgery that typically takes 30 minutes to 1 hour is worth 15 RVUs. That means a hospital can make ten times the amount of money in eight hours of an orthopedic surgery than it can for one eight-hour endometriosis surgery.
As a result, endometriosis surgeons say, their cases are deprioritized by administrators. It also means facilities might have fewer surgeons and support staff, and those providers are given less time in the operating room, causing excision surgery wait times to go up.
Many surgeons feel they cannot sustain their practice with in-network insurance billing alone. As a result, many leave to seek better pay in cash-based private practice where many patients pay out-of-pocket for their surgeries.
“There has been a meteoric rise in cash-based endometriosis excision practices,” Fitzgerald said. “There are some who are really extorting women in pain for a cash-based surgery.”
At the most recent national American Association of Gynecologic Laparoscopists conference, Fitzgerald noted there were exhibit halls of people trying to recruit specialist gynecological surgeons out of academia. A surgeon working at a public, academic institution gets paid a quarter of what a surgeon makes at a cash-based practice, said Fitzgerald.
The cost eventually lands on the patient. Patients are funneled into paying out of pocket, waiting years for specialist surgery. In some cases, they may seek surgery from less experienced surgeons, risking harm.
“Endometriosis is as common as diabetes, and it’s completely debilitating,” Fitzgerald said. “Women will do anything for high level excision … they are mortgaging their homes, and going into credit card debt.”
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Shifting incentives
Gynecological surgeons say there are ways to get this problem addressed.
Patients can petition their congressional representatives and tell their stories through letters, King said. Campaign fundraisers are a good place for congressional leaders running for office to listen to patient stories as well.
King added that patients can call hospital administrations to ask them to hire surgeons who specialize in gynecological surgery to decrease wait times for patients who need to see endometriosis excision specialists and increase access to safe surgeries for complex patients.
Physicians also have work to do, said King, who herself has extensively researched the RVU reimbursement system’s disparities. Her research and publications are featured in a 109-page article in the Emory Law Journal from 2024 that includes legal approaches to what patients, physicians, and the federal government can do to change this system.
Currently, King is working with other physicians and lawyers on the Surgical Parity Project, a new advocacy group that raises awareness about sex discrimination in health-care reimbursement. The project is in its early stages, but it will help people engage and advocate for change.
“We need to rethink the way we incentivize the care that we provide people,” King said. “If they don’t fix it within my lifetime, I will dust off my law degree and get out there, because it’s just got to change.”
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