CA Provider Expands Telehealth Abortions Into Primary Care
Thursday, April 21, 2022
By Carrie Baker for Ms. Magazine.
Broadcast version by Lily Böhlke for California News Service reporting for the Ms. Magazine-Public News Service Collaboration
Michele Gomez is a family medicine doctor working for Family Care Associates in Burlingame, Calif., just south of San Francisco. As an "activist physician," she offers medication abortion-in person and via telemedicine-as part of her primary care practice. She is also co-founder of MYA Network, a not-for-profit that encourages and supports primary care clinicians to begin offering early abortion services, including telemedicine abortion.
Ms. spoke to Dr. Gomez about how and why she began offering telemedicine abortion services.
Carrie Baker: Tell me about your practice.
Michele Gomez: I'm a board-certified family medicine doctor, which means my specialty is treating the whole person, from birth to death. I work in a small, privately-owned family medicine office where we see everyone from babies to seniors, so of course we see patients in their reproductive years. Access to safe early abortion has important implications for physical, mental, spiritual, economic and public health, which is why the owner of the practice started prescribing mifepristone soon after it was approved by the FDA in 2000. Our office also believes that all patients deserve access to the same great care, so we see about one-third Medicaid, one-third HMO, and one-third PPO patients.
Baker: When did you start providing telemedicine abortion?
Gomez: During the pandemic a lot of us were horrified when some states deemed abortion a "non-essential" service when we knew it was a time of great uncertainty and there might be even more people who would feel unsure about continuing a pregnancy. As clinicians who have known and cared for patients for many years, we could actually feel the fear and confusion and wanted to do what we could to help. I'm incredibly fortunate to live in California, where reproductive rights are protected, so I helped our office start providing telemedicine abortions to make it easier and more accessible to patients.
Baker: How did you develop your telemedicine abortion service?
Gomez: Early in the pandemic another family medicine doctor, Joan Fleischman in New York City, put out a call to action on a listserv of abortion providers and I was really inspired by her. From there I learned about the amazing work of Plan C and got connected with other clinicians who were starting to provide telemedicine abortion for Aid Access, like Erika Bliss in Seattle and Christie Pitney in California. They were very generous in helping me develop a system that worked for my own practice. Thanks to the work of Dr. Dan Grossman and others who provided evidence for the safety of a "no test" medication abortion protocol-which basically means the patient doesn't have to come into the office for blood tests or an ultrasound-it became easier than ever-medically-to provide a safe way to end a pregnancy up to 11 weeks. It was really heartening to see so many people in the world of abortion care, each with their own expertise, working together to help each other expand access wherever and however they could. It was a sanity-saving contrast to so many other terrible things that were happening at the time.
Baker: How do you provide telemedicine abortion?
Gomez: I get some basic information from the patient via an online questionnaire and then we have a video visit to make sure the medication abortion will be safe and effective for them. During that visit I also answer any questions the patient has, I make sure they know what to expect and what would be potentially concerning, and I give them a text number where they can reach me anytime. Because we're a small primary care office and don't do a huge volume of abortions, I can provide that kind of personalized care. I think it really helps patients to feel supported. I can also do a phone visit if the person doesn't have internet access, or even an asynchronous visit (via email and/or text) if the person doesn't feel comfortable speaking with me directly or if they have privacy concerns. We'll try to accommodate whatever they need.
Baker: Can you tell me about your telemedicine patients?
Gomez: Absolutely. I remember my first telemedicine patient really well because it was in the early days of COVID when hardly anyone was going outside. She lived in San Francisco and had been houseless. She and her kids had just gotten an apartment in San Francisco, she was in recovery from drug addiction and was doing great, and didn't feel it was a good time for her to be pregnant. She didn't want to have to go out any more than necessary during the pandemic in order to protect her kids-this was pre-vaccines-and didn't want to bring in someone to provide child care for two days so she could go to Planned Parenthood, which still required ultrasounds pre and post. She couldn't afford $150 (the least expensive telemedicine abortion she could find online) and wanted to be able to use her insurance. It felt really good to be able to help her.
I just had a patient last week who is a med student at a university in California, was in the middle of finals, and didn't want to use her parents' medical insurance. She appreciated the privacy and low cost of a telemedicine abortion.
I had a patient yesterday who has a 6-month-old baby and a 5-year-old child and didn't want to go out in the middle of Omicron with these two kids who aren't vaccinated.
I had another patient who lives four hours from the nearest Planned Parenthood so didn't want to have to drive eight hours roundtrip, plus all the time for the appointment, on two separate days, and have to miss work.
I've also had patients tell me they couldn't get an appointment for two weeks, but they were able to get an appointment with me the same day.
The convenience of telemedicine abortion makes a very real and important difference in peoples' lives, and I'm grateful to be able to help in this way.
Baker: How does someone get an appointment?
Gomez: Patients can book an appointment online. I try to find an hour or two every day when I can be available and I post it on an online scheduling site. As soon as someone books their appointment, I get a notification, then my amazing staff calls them to get them registered in our electronic medical record system so that our correspondence will be protected, rather than using regular email, then I send them a questionnaire to complete before the video visit.
Baker: Do you have evening and weekends appointments?
Gomez: Yes, I always have some evening and weekend hours available for appointments.
Baker: How long do the videoconference appointments normally take?
Gomez: It varies. If they filled out the questionnaire I sent them it can be quick. I think the last patient I saw was under 10 minutes to go over everything, answer their questions and let them know I'd be available. I've also had some video visits that are 20-30 minutes long because the patient either really wanted to talk about their feelings or things that were going on or had a lot of questions. For some people it's an easy decision, and for others it's more complicated. If they want to talk to me about it, I'm happy to be there for them.
Baker: Are you offering missed period pills?
Gomez: Yes, we're starting to offer missed period pills, where people don't need to have had a positive urine pregnancy test first. If they believe they are pregnant, or are afraid they might be pregnant, I can give them abortion pills, with the appropriate counseling. I think this is a great option that might really change how we think about all of this. There's so much power in language and how we culturally construct what's happening, but in reality, it's a continuum from a late period that someone might just want to "bring down" or regulate to a very early pregnancy. This could avoid some of the politically-constructed negative associations with the idea of abortion. Our office will actually be part of the missed period pill pilot project that will be starting soon in California.
Baker: Do you do advance provision of abortion pills?
Gomez: I would be happy to. This hasn't come up for me yet and I'd have to check into the legal requirements, but I certainly agree with the idea.
Baker: Are you working with an online pharmacy, or are you mailing pills directly from your office?
Gomez: I had been mailing all of the pills myself but I recently started working with Honeybee Health mail order pharmacy and they're great. It's nice to have the option to do it either way. Honeybee makes the process really easy for me and the patient. But when I mail the pills myself, I can include little extras like hard candies to help get rid of the bad taste from the mifepristone, tea to help the patient relax, positive affirmations, instructions for making their own heating pad, and my own patient information. It feels like a homemade abortion kit, and patients have really appreciated it.
Baker: How long does it take to get the pills to patients?
Gomez: Depending on where the patient lives my package usually arrives in 1-2 days. Honeybee's standard delivery arrives in 3-5 days, but the patient can pay an extra $25 for expedited shipping to get it in 1-2 days.
Baker: What kind of follow-up care do you provide?
Gomez: I've gone back and forth on this one. Initially, when the no test protocol came out it recommended following up with the patient after a week just to make sure everything went okay. I now just recommend that patients follow up with me if something doesn't go as planned because I've found that most people understand what's supposed to happen, know their bodies, and know how to get help if they need it. Most people are busy and are ready to move on. I'm happy to be there for them and they can easily reach me if needed.
Baker: How much do you charge for telemedicine abortion?
Gomez: Our self-pay price is $280, which is roughly what we get reimbursed from insurance. We do have brick-and-mortar overhead costs and staff to pay in expensive Northern California and need to make ends meet. For people who have health insurance, I really think they should be able to use it and not have to self pay!
I think we're one of the few telehealth abortion options in California that accepts insurance right now. Under California law, private insurance must cover abortion. This doesn't mean there won't be a copay or deductible, but it must be covered in some form. I've been encouraging Choix and Aid Access to refer patients to me if they want to use their insurance, and I send patients to them or Forward Midwifery if they need a lower self-pay price. I like the idea of us all working together to get patients what they want and need. No one organization can do it all, but together we can accomplish a lot.
Baker: Do you work with any abortion funds?
Gomez: No, but I'd love to, and we're working on making those connections through MYA Network. Right now, our niche seems to be helping people use their health insurance, that they already pay for, to pay for their health care.
Baker: How do patients find you?
Gomez: Sometimes they are my regular patients and have a positive pregnancy test that they weren't expecting. I can do their options counseling and if they decide not to continue the pregnancy I can discuss next steps, including getting abortion pills from me. They're so surprised-it's very normalizing and reassuring. Most of our patients now are coming through the MYA Network site or the referral sites like Plan C, Abortion Finder and I Need An A. My last patient said she found us on Instagram @myanetwork.
Baker: How have your patients responded to telemedicine abortion?
Gomez: So far my patients have been super positive about the whole experience. They don't have to wait weeks for an appointment. They don't have to spend time traveling to and from an office and waiting to see a clinician-sometimes twice if the office requires a follow up appointment. They don't have to take time off from work or arrange childcare. They don't have to risk exposure to COVID. They can be comfortable in their own home with their own music or companion or whatever is best for them when they take the medications. And they know they have support from me when they need it.
Baker: Have patients had successful abortions?
Gomez: Yes-to date they have all been successful.
Baker: What are your motivations for offering telemedicine abortion?
Gomez: I just want to provide the best medical care possible. When I learned that medication abortion could be provided safely via telemedicine, the benefits just seemed so obvious, especially during the pandemic.
I also firmly believe that people have a right to decide what happens to their own bodies. I understand that abortion is a complicated subject for a lot of people, but the idea of forcing someone to do something like continue a pregnancy against their will seems completely barbaric to me. When the world seemed to be going crazy around me, with a global pandemic and political upheaval, this was something I could focus on that felt helpful and positive.
Baker: Why should primary care providers offer abortion services?
Gomez: Abortion clinics have done heroic work, but there's no medical reason that abortion needs to be provided in a specialty practice. For some people, going to an abortion clinic means they'll have to walk past protesters. Patients shouldn't have to be harassed because they're choosing what to do with their own bodies. Just being seen at an abortion clinic can be a violation of privacy for some.
Early abortion services, both medication abortion and aspiration procedures, can be provided very safely in the privacy of patients' own doctors' offices. I believe there will always be a role for abortion clinics but they shouldn't have to do it all, and patients should be able to choose what is best for them.
If more primary care providers offered early abortion services there would also be increased access-no one should have to drive hours or days to get an abortion. It would also make it harder for abortion services to be targeted by those who want to control pregnant people-what are they going to do, stand outside of every single regular old doctor's office and assume someone might be going in for an abortion? They might just be going in for a check up, or to follow up on their blood pressure, or for a twisted ankle-it would be impossible to know.
It's easy to target Planned Parenthood, but much harder to target every primary care office in the country.
Baker: What are the advantages of providing early abortion care at a primary care practice?
Gomez: Let me answer your question with a story. A while back, I had a patient come in who was in her late teens-someone I'd known for years.
I took care of her whole family. She was really nauseated and trying to figure out what was going on. I had her do a pregnancy test and it was positive, and understandably she was surprised and upset. Because I knew her so well, I was able to help her think through her options in a way that someone just meeting her might not have been able to. It also allowed me to gently encourage her to talk to her parents, as I believed they could be a big support to her.
She was pretty sure she didn't want to be pregnant and I was able to say, "Well, if you decide not to continue the pregnancy then one option would be for you to take the abortion pill, and I can give you that here."
She looked shocked and said, "What do you mean, here?" and I said, "We prescribe the abortion pill." She just started crying, like a huge weight had been lifted off of her-it took away so many of the unknowns. I think it was such a relief because she had just been hit by the emotion of an unexpected positive pregnancy test and then all the "what am I gonna do" questions and "my family is gonna be so mad" concerns and everything else, and then to I was just able to put her mind at ease a bit.
Baker: How have you helped family practice physicians learn how to offer abortion services?
Gomez: About 15 years ago, I started working with a not-for-profit called TEACH (Training in Early Abortion for Comprehensive Healthcare) that trains family medicine residents to provide early abortions as part of a primary care practice. We've trained hundreds of doctors, but it's often challenging for them to find a job where they can provide abortions.
I hope more primary care offices will start doing this work. Our practice at Family Care Associates is one model for how to integrate early abortion care into a regular primary care office. I'm even hoping to add aspiration procedures in the next year or so, as the demand for abortion services in California is expected to increase almost 3000 percent if Roe is overturned, due to people coming from other states.
Baker: How did you start the MYA network?
Gomez: MYA Network got started after Dr. Joan Fleischman from New York City reached out at the start of the pandemic with a call to action to primary care providers. She, like many others, believed that the pandemic and the no test protocol provided an opportunity for those of us who've wanted to integrate early abortion services into primary care to do it.
There was a great response: Around 60 clinicians wanted to help make it happen. Three of us-myself, Joan and Dr. Erika Bliss in Seattle-were able to get started relatively quickly and decided to set up an organization to help other clinicians do the same. With the help of Joan's talented staff, we created a website that explained our vision and helped patients find primary care clinicians who provide abortions. We were grateful to get lots of input from other clinicians with years of expertise in the abortion movement, and through that process we met Christie Pitney, a nurse practitioner who also provides telemedicine abortions and became part of our advisory board.
Baker: What is the goal of the MYA Network?
Gomez: We are a network of activist clinicians who want to expand early abortion services into primary care settings, for all the reasons I've mentioned. Early abortion is not medically complicated and can be safely provided by any primary care clinician with the right training.
Telemedicine abortion is particularly easy. Family medicine doctors, primary care internal medicine doctors, and advance practice clinicians like nurse practitioners and physician assistants are perfectly capable of providing early abortions.
Early abortion can be part of a regular primary care practice so the patient doesn't have to be referred anywhere else. Because it's medically simple, you don't need to have a high volume to be good at it. There are several medical procedures I only do a few times a year but I still feel perfectly comfortable doing them.
Baker: How do you help people find these providers?
Gomez: That's one of the most important functions of the MYA Network-to let people know that primary care clinicians can and do provide early abortions and to help patients find those clinicians. The MYA Network website lists providers by state. We currently have clinicians in seven different states, including an academic institution that has integrated early abortion services into their primary care clinics on campus.
Baker: Are regular doctors anxious about being targeted by anti-abortion groups?
Gomez: I'm sure that's a concern for some, and I certainly respect everyone's right to make their own decision about whether offering early abortion services is right for them.
Baker: Have you ever experienced any anti-abortion targeting for offering telemedicine abortion?
Gomez: Not in my primary care office, only in my work at Planned Parenthood when I'm training residents for TEACH, as there are often protesters outside.
Baker: How has the FDA recently lifting the in-clinic dispensing requirement changed the landscape for your work with the MYA Network?
Gomez: The in-person dispensing requirement was suspended during the pandemic so a lot of us have been mailing mifepristone for a while now. It's great that the FDA has permanently lifted that requirement because now we know we won't have to go back to dispensing in person and clinicians who want to set up a virtual-only practice can do that. There's no need to rent an office space if all the care you provide is virtual, and that sure keeps costs down for patients!
Even so, a lot of us wanted to see the FDA do more. Mifepristone has 20 years of safety data-having a medication abortion is safer than carrying a pregnancy to term-so there's no reason it shouldn't be dispensed in a pharmacy like any other medication. The restrictions that still exist are medically unnecessary and simply designed to make it more complicated to prescribe. Clinicians have to set up an account with one of the two manufacturers of mifepristone (Danco or Genbiopro), which is just a lot of paperwork, and keep records on every patient they mail it to, which is also just more unnecessary paperwork. It's frustrating when bureaucracy gets in the way of real patient care.
Baker: Any final thoughts?
Gomez: I imagine that many people who read Ms. magazine may be wondering how they can support abortion access at this critical time. There are lots of ways to help-by voting, by volunteering, by talking to family and friends, and by making financial contributions. I'd be honored and grateful if they'd consider donating to TEACH or MYA Network or any of the other many great organizations who work to support abortion access. And thank you, Carrie, for this series - it's great to hear about all the innovations in telemedicine abortion care!
Carrie Baker wrote this article for Ms. Magazine.
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