Gender Representation and Regional Affluence as Dual Drivers of Reimbursement Equity in Urology.

OBJECTIVE: To elucidate disparities in physician compensation and workforce distribution across gender, subspecialties, affluence, age, payers, and geographies. METHODS: The NPI registry was linked with the U.S. Census small-area income estimates to evaluate associations between median household income and urologist density, stratified by gender. Commercial reimbursement was gathered across national payers. Reimbursements were compared between female and male urologists using Mann-Whitney U tests stratified by CPT code, subspecialty, and years in practice. Logistic regression modeled the likelihood of positive year-over-year reimbursement growth by state-level female representation. RESULTS: Women's relative reimbursement growth ranged from +12.5% to -12.9%. Greater female representation predicted higher reimbursement growth for women (OR = 1.04, p = 0.014). Median household income was positively associated with urologist supply (β = 935.9, p < 0.0001), with a threefold stronger association for female urologists (β = 3464, p < 0.0001). Female urologists were nearly half as likely as male counterparts to practice outside urban areas (4.8% vs. 8.3%). In urban settings, female urologists commanded higher median reimbursement; however, this advantage reversed in small rural settings. CONCLUSIONS: Regional affluence, female workforce concentration, and commercial reimbursement trends appear mutually reinforcing, concentrating female urologists in higher-income markets while widening access gaps in underserved areas. Targeted workforce incentives and reform are needed to advance equitable urologic care.