By Carrie Baker for Ms. Magazine.
Broadcast version by Lily Böhlke for Washington News Service reporting for the Ms. Magazine-Public News Service Collaboration
Dr. Deborah Oyer is the medical director of Cedar River Clinics in the greater Seattle area in Washington state. She offers telemedicine medication abortion as part of her reproductive health practice.
Ms. spoke to Dr. Oyer about how and why she began offering telemedicine abortion services.
Carrie Baker: Can you tell me about your medical background and your practice?
Dr. Deborah Oyer: I’m a family medicine doc by training. Since my residency, I’ve just done reproductive health care. I worked for Planned Parenthood, then I had my own practice for a while, and am now the medical director for Cedar River Clinics, which is a full reproductive health clinic. We do well-person gynecology, trans care and abortions up to 26 weeks.
Baker: When did you start providing telemedicine abortion care?
Oyer: In April of 2020. It felt like it took forever but apparently, compared to much of the world, we got up and running quite quickly. Cedar River Clinics had been planning on starting a telemedicine program but expedited the launch due to COVID.
We continued to offer in-clinic appointments for medication abortion but quickly saw that telemedicine was a popular choice. We plan to continue offering it as a permanent service option.
Baker: How do you provide telemedicine abortion care?
Oyer: Early on during the pandemic, you could do things by telephone and get reimbursed for them, but now we do it by videoconference. Patients need a video connection, but virtually any computer or phone can give you that. We can mail pills or they can be picked up at one of our clinic locations.
We recognize that folks who live in a rural part of the state do not have the same access to abortion as those who live in or near the cities. Many patients travel to our clinics from around the state. We also realized that not everyone has stable internet, access to appropriate technology, or a private place in which to hold a telemedicine meeting. As a result, this summer, we opened a telemedicine satellite site in Yakima where people, who live in the more rural Eastern part of the state, can come in to use our technology to talk with our providers who are in Western Washington. The staff in our Yakima site can also help people with the technology use if they are in need of assistance and provide abortion pills during the appointment.
Baker: Did you work with any organizations to develop the service or did you do it on your own?
Oyer: I developed things mostly on my own. Everything about it was new except the actual service. At that point, we didn’t have a telemedicine platform, so we had to figure that out. I had to change our consent form because how you handle it is different on video than it is in person.
Then I had to figure out telemedicine. We had many practice sessions before we started. In addition, we worked with a variety of social service organizations to help spread the word about our telemedicine services to their clients and to other state advocacy groups around policy and funding.
Baker: How many telemedicine abortion patients have had so far?
Oyer: We have had 339 since April 1, 2020. Over half of our telemedicine abortion patients come from rural parts of the state.
Baker: Tell me more about who your telemedicine abortion patients are.
Oyer: I haven’t analyzed it but they seem like everybody else. It cracks me up because often they’re like lying in bed with their phone. Their appointment was at 9 and they set their alarm for 8:55. Some want their pills mailed to them and some want to pick up the pills up at a clinic, I think to have a bit of in-person connection. We will also always have patients that prefer an in-clinic appointment. It comes down to personal preference and being able to offer a choice is important to Cedar River Clinics.
Baker: Do you know why your telemedicine abortion patients prefer that option as opposed to coming to the office in person?
Oyer: Early on, it was safety because of the pandemic. But now, some like the idea of additional privacy and to save time so they don’t have to get time off or get a babysitter. They are very thankful of us doing this.
Baker: When somebody calls, how long does it take for them to get a telemedicine appointment?
Oyer: Usually one to three days. There’s paperwork that needs to be filled out. We also have to check their insurance coverage.
Baker: And how long do the video calls normally take for telemedicine abortion patients?
Oyer: They take up to 30 minutes, but if this is your third medication abortion, it can be done in a few minutes. An in-clinic appointment takes about an hour.
Baker: What percentage of your patients are treated fully remotely, without having to get an ultrasound to determine when their last period started?
Oyer: The vast, vast, vast majority of our telemedicine patients, well over 95 percent. Most people know when their last period started. They use an app. One of my favorites was a woman who texted her husband every month when she got her period, so she pulled up the text, while we were talking, to confirm her last menstrual period.
The most common reasons we have for bringing people into the clinic or sending them for an ultrasound are inconsistencies in the person’s medical history suggesting that their perception of pregnancy length may be off or they are having some pain that makes us want to make certain the pregnancy is in their uterus and not an ectopic. That said, when we’re doing in-clinic medication abortions, an ultrasound is automatically done unless the patient opts out.
Baker: How long does it take for the pills to reach the patients if they’re getting them by mail?
Oyer: They usually get the pills in two days. We stock pills in our clinics for people who come for in-clinic abortions, but also for telemedicine patients who want to pick them up so they have them the same day as their telemedicine appointment.
Baker: What kind of follow up care do you provide after patients get their pills?
Oyer: Whether you do your abortion in-clinic or over a video, we’re there for you. We have someone on call 24/7. If patients have questions, they can call us. We also do follow up appointments, if they want one, by video or in-clinic. Seven days after taking the pills, I ask patients to do a self check-in. Did you bleed and cramp at least as much as a normal period? Are your pregnancy symptoms gone? And if the answer to either question is no, I need to hear from you. If the answer is yes, but you want reassurance, we’re here and can do an appointment by video or in person. We also provide a pregnancy test with the pills. If you’re not coming in for a follow up in a month, do that pregnancy test, it should be negative. If it is not negative, I need to hear from you.
Baker: How have your patients responded to telemedicine abortion? Do they like it?
Oyer: I would say for the most part, it’s no different than in-clinic. I don’t think it’s particularly different populations. Medication abortion patients are medication abortion patients, and that’s the way it is. Cedar River Clinics has seen 79 percent increase of medication abortion since we added telemedicine versus in-clinic only before COVID.
Baker: How much do you charge for telemedicine abortion?
Oyer: We charge $600 for cash pay patients for telemedicine medication abortions. This is an all-inclusive fee. If they come in for a follow-up, if they need a surgical completion (at our facility), there is no extra charge.
Baker: Do you take insurance for telemedicine abortion?
Oyer: Yes. And Medicaid insurance in Washington state covers abortion. When they call to make an appointment, if they don’t have insurance, we can help them get on Medicaid if they are eligible. The process of getting them on Medicaid is pretty quick and you can do it online. But there are people always who fall through the cracks by making $5 a month too much to get covered, for example. But once you’re pregnant, your chances of being eligible for Medicaid go up because you are now considered a household of two instead of just one. We also offer a sliding fee scale.
Baker: Do you work with an abortion fund for people without insurance?
Oyer: We do. We work with the Northwest Abortion Access Fund-NWAAF, often for people from Idaho and other states. When they call to make an appointment, we provide NWAAF’s number. The patients call them directly, then NWAAF calls us with the amount they are giving. NWAAF also offers to pay for hotel stays for patients using our telemedicine satellite site if they are in communal or complicated living situations, such as agricultural workers, who may want more privacy to deal with cramps and bleeding. We are grateful for all they do for us and our patients.
Baker: Are you glad you added telemedicine abortion when you did?
Oyer: It was the right thing to do at the right time. And I think medicine will be better for patients having the choice of coming in or not coming in. For centuries, we have honored the provider’s time, and we have not honored the patient’s time.
Baker: Why is it important to offer telemedicine abortion?
Oyer: Abortion is still a shameful thing in our country, so the fewer people that have to be involved, the better. If I have to go into the clinic, I need childcare, I need time off from work. It’s a whole afternoon minimum. They’re driving there, they’re parking, they’re filling out paperwork, they’re waiting, they’re going to have an ultrasound. After the ultrasound, they wait to go to consent. After that they wait to see me. Then they have to go back to their car and drive home.
Particularly with the stigma of abortion, telemedicine is even more important with abortion than with other care. We have talked for many years, even probably a decade or two about patient-centered care. And that’s what this is.
Baker: Do you have protesters outside your clinic?
Oyer: Yes, we do. The numbers vary at our different location. We have one elderly woman with ugly signs that has been picketing us for almost 30 years. At our main clinic, we have a private driveway, so it’s a little better but still hard for some people to drive pass those signs. Telemedicine abortion does allow patients to avoid that.
Baker: Why do you offer telemedicine abortion?
Oyer: Telemedicine abortion allows patients to be more in control in every way-they’re in control of their time. They’re in control how they get their medications.
My goal always has been to have more patient-centered care, even before that was a thing. Telemedicine abortion allows patient autonomy, it allows patient control. For years now, we’ve talked about being partners with our patients in their health care. A lot of people just give lip service to that. But it’s hard to be an abortion provider and not really honor that. In doing telemedicine medication abortions, it’s really clear that the person on the other side is in control. Telemedicine provides a choice. In abortion care, we have been fighting defense for so long. Choice of options within abortion care is something we need to fight for as well, especially now.
Baker: How does it feel to be able to help people this way?
Oyer: I would have to say really no different than when they’re in clinic. I cannot begin to put into words the honor and privilege of being an abortion provider. People let me into their lives in the most intimate way. In some ways, there is a little more intimacy doing a telemedicine abortion right now versus an in-person one, because I actually get to see their unmasked faces.
Baker: Any final thoughts?
Oyer: I think what everyone needs to know is how common abortion is and how safe it is.
People don’t know how dangerous pregnancy and giving birth is. While we go into this vast amount of information on informed consent for abortion, no one gets informed consent for having a baby! Ever! When you come in for your first obstetrical appointment at eight weeks, your doctor does not sit you down and say, you might die and here are your choices.
You should be getting an actual informed consent at a time when you can still end the pregnancy safely. Informed consent includes telling patients about the risks, benefits and alternatives. The risk of having a baby, even with no medical issues, even being young and healthy, is so much greater than the risk of having an abortion. And no one understands that because what they believe is people die from abortion from back in the day when the mob was doing abortions and people without training were doing abortions. The lack of understanding of how common and how safe abortion is just shocking to me.
Carrie Baker wrote this article for Ms. Magazine.
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