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Although the healthcare workforce is predominantly female, and has been for many years, researchers confirmed that men still hold the vast majority of leadership jobs -- with one notable, if not numerically significant, exception.

Among U.S. healthcare systems comprising at least five hospitals, and among health insurance groups with a nationally significant market presence, fewer than 20% of their chief executive officers were women, reported Bismarck C. Odei, MD, of Ohio State University in Columbus, and colleagues in a .

It was not substantially better for most other executive-suite positions. In the 161 health systems analyzed, just over 20% of chief financial officers and chief medical officers, for example, were women; the corresponding figures for the 108 large insurance companies were about 25% to 30%.

In these private sector organizations, the only job types for which women held more than half of positions were the ones you might expect: those responsible for marketing/communications and human resources. At insurance companies, 70% of the latter were women.

But the situation was quite different for one prominent U.S. employer -- the Department of Health and Human Services (HHS). There, women occupied almost 50% of top leadership jobs, and some 75% of positions classified as division leaders.

On the other hand, there were only 31 such jobs overall at HHS, Odei and colleagues noted, compared with more than 5,000 in the health systems and insurance groups they examined.

To conduct the analysis, the researchers identified all health systems with at least five affiliated hospitals, as well as health insurance entities holding at least 0.09% of the national market. Odei's group then accessed their websites to determine the binary gender for eight top executives:

• Chief executive officer
• Chief financial officer
• Chief medical officer
• Chief operating officer
• Chief information officer
• Chief strategy officer
• Medical/communications officer
• Human resources officer

The researchers did the same for each organization's board of directors. Individuals' photos, names, and other information on the websites were used to decide if each was a man or woman. If it couldn't be determined, or if an organization had no online information on its leadership, those individuals and organizations were excluded.

In all, Odei and colleagues identified genders for 3,911 top executives in health systems and 1,303 in health insurance companies, along with 3,462 board members.

One potentially encouraging finding was that the proportion of women serving as chief operating officer was relatively high, compared with other "chief" positions: more than 30% in health systems and close to 40% in insurance firms. In the private sector, the chief operating officer is often next in line to become CEO.

Among heads of medicine, information technology, strategy, and finance, only about 20% to 25% were women (except for chief strategy officers at insurance companies, for which the proportion topped 35%).

Odei and colleagues also found that boards' gender makeup might be a factor in female executive-suite representation. As the proportion of female board members increased in health systems, so did the odds that an organization's CEO was a woman (OR 1.09, P=0.03). That wasn't the case in insurance companies, but odds that women had more executive positions were greater when there were more women on an insurance firm's board (OR 1.06, P=0.02).

Obviously, all these findings represent some degree of progress for women in the healthcare industry, if one's time frame goes back to the 1960s, when it was rare to find a woman in any executive job. But that was then and this is now, when women constitute and ; the low proportions in leadership have become harder to explain as anything other than the old-boy network in operation.

Thus, these findings are important for the future of healthcare, the researchers argued. That women are underrepresented in leadership, relative to their presence in the workforce and even in the general population, "likely diminishes their role in policy decisions that affect population and women's health."

Moreover, the group asserted, insufficient gender diversity suggests "the loss of cognitive capital" in leadership.

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