CO Provider: Telehealth Abortions are Safe, Reliable
Wednesday, March 9, 2022
By Carrie Baker for Ms. Magazine.
Broadcast version by Lily Böhlke for Florida News Connection reporting for the Ms. Magazine-Public News Service Collaboration
Dr. Razel Remen has been an independent abortion provider in the Detroit Metro area of Michigan since 2016. Last year, Remen launched Pills By Post, a telemedicine abortion service for people in Colorado, Illinois, Minnesota and most recently New York. She offers medication abortion pills to people 14 and older through 11 weeks of pregnancy and charges a fee of $150 with sliding scale available to those who are unable to pay the full cost.
Ms. spoke to Remen about her telehealth abortion practice, including how why she started offering this service.
Carrie Baker: Can you tell me about your medical background?
Razel Remen: My medical background is a little unusual. I actually studied medicine at the Latin American School of Medicine in Havana, Cuba, and completed my residency in Alabama. I'm originally from New York City where, growing up, the first seven pages of the yellow pages were dedicated to abortion clinics. I didn't fully understand how bad lack of access to abortion was for most of the United States was until I lived in Alabama. I always say that if I had not done my residency in Alabama, I would not have become an abortion provider.
In Alabama, there's such a severe lack of access to reproductive health services. Undocumented immigrants make up a large part of the state's population, often working as migrant farm workers. The only time they have any access to reproductive health services is when they're pregnant. I had an interaction with one undocumented immigrant who'd just given birth. When I went in to congratulate her on the birth of her child, she was sobbing and upset. She didn't want to have another child and expressed concern over the fact that she could barely provide for the ones she already had and worried about how another mouth to feed would impact them.
The experiences I had during residency made me realize that lack of access to abortion not only negatively impacted individual people, but also their families and communities. I received very little training in contraceptive care and no training in options counseling or abortion. Sadly, this is typical for a majority of family medicine programs across the country.
After I finished residency, I went on to pursue a fellowship with the Reproductive Health Access Project and Dr. Linda Prine in New York City. After the fellowship, I knew I wanted to work in a diverse community that needed providers so I moved out to Michigan with my son, who was 7 at the time, and I have been working here as an abortion provider ever since.
Carrie Baker: How did you first become interested in telemedicine abortion?
Razel Remen: During fellowship, I came across Women on Web and Women on Waves, and I thought that it was one of the most awesome things I had ever heard of. When Aid Access started in 2018, I followed them and their founder and medical director Rebecca Gomperts almost like a groupie. I thought she was and still think she is so amazing. I was one of the first people to contact Plan C about providing telemedicine abortion. I hit all kinds of roadblocks mostly because I didn't have my own brick-and-mortar clinic and could not receive wholesale shipments of medications. The FDA requires a physical business address in order for pharmacies or distributors to ship wholesale bulk medications. It was only when the pharmacy Honeybee Health started offering to ship mifepristone and misoprostol directly to patients that I was able to join Aid Access and start providing telemedicine services in October of 2021.
Carrie Baker: Can you tell me how the telemedicine abortion service you offer works?
Razel Remen: People can schedule an appointment with me on my website pillsbypost.com. Then I do a phone consultation with them to make sure that they are eligible to take the medication-where I go through a series of screening questions to ensure they don't have any allergies or any contraindicatory health problems or risk for ectopic pregnancy.
Once the intake is done, I have them electronically sign informed consents and send the payment. Once the intake and consultation are completed, I send their prescriptions to the pharmacy.
Carrie Baker: How does the sliding scale work?
Razel Remen: Most people pay the full amount, but some people can't so we talk about it. I don't grill them. Usually, people are pretty up front. One woman said, "I'm homeless, I can't pay anything," so I just sent the medication to her free of charge. There's currently funding to cover the cost of the medications for anyone paying $75 or less. The U.S.-based Aid Access providers are in conversation with an organization to see if we can get additional funding to cover the costs of anyone who pays less than $150.
I'm also trying to work out independent funding with the Chicago Abortion Fund and another fund in Colorado which has mentioned they might be able to cover Colorado minors seeking judicial bypass. I wish we just had universal healthcare like Cuba.
Carrie Baker: Since you offer telemedicine abortion in Colorado, are you getting women from Texas?
Razel Remen: Yes. I've noticed patient with IDs from outside of the states I serve are asking for medication. I don't inquire as to where they are as long as their shipping address is in a state where I'm licensed.
Carrie Baker: How does it work with minors?
Razel Remen: llinois recently eliminated their parental consent requirement for minors, but Minnesota and Colorado still require parental notification. They don't require consent. Parents just have to be notified. I'm in contact with a lawyer in Colorado, who said that she would help with judicial bypass if a patient needs it. And then I'm going to also get in contact with someone in Minnesota to see if they can help people with judicial bypass if they need it.
Carrie Baker: Do you do same day consults?
Razel Remen: Yes. I put in a six-hour window so I don't get surprised last minute.
Carrie Baker: Do you offer evening and weekend appointments?
Razel Remen: Most of my appointments are in the evenings and on weekends.
Carrie Baker: How long do the calls normally take?
Razel Remen: Usually they take about 15 to 20 minutes. It really depends on how many questions people have. Some people are very anxious about it, understandably because the service is very new. Maybe they're not familiar with medication abortion, so they're afraid of what the pain will be like, or will this actually work and is this dangerous? People who need more reassurance require longer visits.
Carrie Baker: What kind of patient education do you offer?
Razel Remen: I have materials that I email to them. I also go over how to take the medication and then also encourage them to call or email if they have any questions.
Carrie Baker: How far into pregnancy do you prescribe abortion pills?
Razel Remen: 11 weeks. I was tempted to do 12 weeks because the World Health Organization endorses it through 12 weeks. Studies from overseas show abortion pills are effective up to 20 weeks. There's currently a study underway in the United States showing the pills are effective through 13 weeks. The FDA recommendation is currently up to 77 days from the first day of the last menstrual period, but the FDA guidelines are always behind the evidence because of money-it takes about a million dollars to change an FDA recommendation.
Carrie Baker: Once you submit the prescription to Honeybee, how long does it take for patients to get the pills?
Razel Remen: Usually three to five business days. There have been people who wanted the medication sooner so I can overnight it to them. The pharmacy charges an extra $25 for overnight delivery.
Carrie Baker: What kind of follow-up care do you provide to the patient? Do you have a helpline for patients to call?
Razel Remen: If they need assistance, I recommend that they call the Miscarriage and Abortion Hotline during the day because I'm in clinic and I might not be able to answer the phone. But if it's after business hours, then they can just call me directly with any questions they might have. Two days after they receive their medications, I call or email them asking how things went. I had one person who was very anxious and they weren't sure as to whether or not the medication worked. So we worked through that to try to figure out where they could get an ultrasound if they needed it. I think it's really essential for the entire movement to compile a database of pro-choice, friendly, inexpensive places where people can go to get ultrasounds.
Carrie Baker: How has telemedicine abortion worked for your patients?
Razel Remen: They seem to really like it and appreciate the service. Aid Access does a patient satisfaction survey and the feedback is positive. Medication abortion has a very, very high success rate. I send eight misoprostol pills if someone is below nine weeks and 12 if they're above nine weeks, so if they have an issue, they have it if they need it.
Carrie Baker: How many patients have you seen so far since you opened in October?
Razel Remen: I see about 90 a month.
Carrie Baker: Do you take insurance?
Razel Remen: I don't take insurance. We do a sliding scale. If I did insurance, that would just increase the cost because it's very time consuming. A lot of states have regulations that make it difficult for insurance to cover abortion. In New York and California, Medicaid does cover abortion. I might eventually look into signing up for Medicaid in New York. I'll have to see if it would be time and cost effective.
Carrie Baker: How do you afford the sliding scale?
Razel Remen: Someone has donated money to Honeybee to cover the cost of the medication for those who need assistance.
Carrie Baker: Do you know why your patients are choosing telemedicine abortion?
Razel Remen: I haven't asked them specifically why they choose telemedicine. I do know from dealing with patients in clinic that it's often very burdensome to go to the clinic if someone has children, or work, or other people that they have to take care of. Sometimes it's the issue of travel. At the clinic I work at in Michigan, people sometimes are coming from the Upper Peninsula, which is an eight-hour drive! It can be quite a burden for somebody to get to a clinic. The TRAP laws also make things difficult. People have to take time off of work or school to show up to clinic only to find out because of some absurdity in the TRAP laws they can't be seen. It's really heartbreaking.
Carrie Baker: Can you tell me about who your patients are?
Razel Remen: It's a mix. I get a higher concentration from the bigger cities like Chicago, Denver and Minneapolis because there are more people there, but I do also get people from rural areas. They are in their late teens all the way up to their 40s. Some people have had children and for some this is their first pregnancy. It's all over the place.
Carrie Baker: Does anybody in Michigan offer telemedicine?
Razel Remen: Not that I'm aware of. I do know that there's a provider that's working on getting their Michigan license to start offering the service.
Carrie Baker: What motivated you to start offering telemedicine?
Razel Remen: I think it's really important in terms of increasing access. I see how people really struggle. They have a really hard time accessing services.
Carrie Baker: Was it difficult to meet the FDA requirement that physicians distributing mifepristone must be certified with a distributor?
Razel Remen: No, it's not difficult. It's just paperwork. They ask you for your medical license and your business entity, if you have one. And now that the pharmacy Honeybee Health exists, you don't have to worry about having a brick-and-mortar location.
Carrie Baker: Have you experienced any harassment for offering telemedicine abortion?
Razel Remen: No. I don't think many people know about it. I expect that I may get some kickback. I hope not.
Carrie Baker: Have you experienced harassment working at your brick-and-mortar clinic?
Razel Remen: Yes. I was living in an urban apartment complex and antis mailed my neighbors. One neighbor knocked on my door and she was really concerned. She handed me a piece of anti-abortion "fan mail" that'd been delivered to her and told me to be careful. At the clinic where I work, we get protestors every week. People sometimes come in sobbing because of the protesters. I mean, they're literally crying. This makes me really angry. The one that upsets me the most as a woman of color is when they start saying "Black Babies Matter." The hypocrisy of that statement especially bothers me considering Flint. Flint is a Michigan city that is predominantly Black and still has dirty lead filled water. Lead crosses that placental barrier and can cause miscarriages as well as severe brain damage to infants and children. If they want to protect Black babies, then why don't they go protest the dirty water in Flint? I've had quite a few Black women come in feeling horrible after they see those signs. I ask these women, "Do you really believe those protestors think that Black babies matter?" They all get it and say, "No."
Carrie Baker: What do you think is the future of abortion rights in light of what's happening at the Supreme Court?
Razel Remen: First of all, I am not as optimistic as some about what the Supreme Court will do. I think they're going to say the fetus is a person and therefore abortion should be universally illegal. I don't think it'll fall back to the states. But if that doesn't happen, then it will go to the states. In Michigan, it'll become illegal. We're currently in the process of trying to amend our Constitution to protect abortion rights. It looks like we have a pretty good chance of that passing in November. We have a lot of conservative people who are against vaccine mandates. They really get the concept of "my body, my choice." Those people are often Trump supporters, very conservative, but they get the idea that the government should not interfere in somebody's bodily autonomy and personal choices. I think we have a very good chance of amending the Michigan Constitution to protect abortion rights.
Carrie Baker: Any final thoughts?
Razel Remen: I want people to know that telemedicine abortion is safe and reliable. If you want to find a good service, go to Plan C because all of the providers they list have been vetted so you can feel confident.
Carrie Baker wrote this article for Ms. Magazine.
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