Telemedicine regulations tighten restrictions on medication abortion

Michigan is the latest state to pass a ban on using telemedicine to prescribe abortion-inducing medication, a relatively small move with broader implications in the incremental fight to undo Roe v. Wade. The ban, if signed into law, will extend one already in place in Michigan, one of 19 states that require an abortion provider and patient be physically together when the provider prescribes the medication.

In an environment where threats to Roe v. Wade are frequent, the ban and others like it could represent a slow chipping away at abortion rights—and a slow chipping away at access for patients.

The benefit of telemedicine medication abortions, proponents say, is similar to the benefit of any service provided virtually: increased access. Especially in rural areas, patients seeking abortions could benefit from abortions from medications prescribed after virtual visits with providers, much as other patients in rural areas benefit from telemedicine visits for other healthcare needs.

"It's the same question as when anyone is limited in their access to healthcare," said Mei Wa Kwong, executive director of the Center for Connected Health Policy. "They can either go without, go an unsafe route, or go farther away."

Medication-induced abortion performed through telemedicine works like this: A patient seeking an abortion goes into a medical facility—not necessarily an abortion clinic—where abortion drugs but not abortion providers are on site. There, the patient gets laboratory tests and an ultrasound to confirm pregnancy. An offsite abortion provider assesses the results and video chats with the patient. If the patient is deemed a good fit for a medication abortion, the provider prescribes two drugs, mifepristone and misoprostol, which facility staff distribute to the patient.

Anti-abortion groups see that process as a dangerous one and say bans like Michigan's are necessary.

"Telemedicine is designed to make it easier for you and your doctor to connect, not for a stranger to give you potentially dangerous pills as cheaply as possible," said Chris Gast, director of communication and education for Right to Life of Michigan, which worries that having providers and patients physically far from one another will take a toll on the quality of follow-up care. "If the ban isn't made permanent, we'd be taking an industry with a bad record and allowing them to avoid even more responsibilities."

But research doesn't bear that out. Telemedicine-assisted medication abortion has been deemed safe by many in the field. One group of researchers studied the nearly 20,000 people in Iowa who've received medication abortions between 2008 and 2015, finding that there were just 49 complications. Another group of researchers found a 99% success rate for a completed abortion among women who'd been prescribed medication through telemedicine, compared with a 97% success rate for those who'd met with providers in person.

Overall, medication abortion accounts for between a fifth and a quarter of all abortions. But the Food and Drug Administration strictly regulates mifepristone, the first of the two drugs taken. A "healthcare provider who prescribes and who meets certain qualifications" must be the one to prescribe and dispense either of the medications, and they must be dispensed in medical facilities "by or under the supervision of a certified healthcare provider," according to the FDA.

But that language leaves some room for interpretation, said Dr. Elizabeth Raymond, senior medical associate for Gynuity. For instance, could a provider in a medical facility dispense the drugs by mailing them to a patient?

That's exactly what Gynuity is doing with a research study, permitted by the FDA. The reproductive research organization is studying the effects of sending patients the drugs by mail after initial telemedicine consultations. Successful results from the study, which has been running since 2016, could be the evidence the FDA needs to allow providers to mail the medications to patients, rather than requiring in-person dispensing.

"It's going very well," Raymond said. "The doctors like it, and the patients like it, and it seems to be going pretty efficiently."

One sticking point is insurance reimbursement. "This is telemedicine, and it's a drug that's not prescribed in the normal way, and it's not normally mailed, so this is throwing some insurers for a loop," Raymond said.

Another limitation is geography, just as it is with any type of medication abortion. Right now, the study operates in just five states. Meanwhile, in other states, women may face roadblocks because of laws like Michigan's.

The biggest challenge is that where abortion access is most constrained is where telemedicine abortion is also banned, said Dr. Daniel Grossman, director of Advancing New Standards in Reproductive Health, a research group at the University of California-San Francisco's Bixby Center for Global Reproductive Health.

State bans on using telemedicine for abortion could affect more than just abortions, as they might set a precedent for banning specific use cases of virtual care, Grossman said.

Abortion isn't the only service available through telemedicine lawmakers have gone after. In early 2018, Washington state lawmakers introduced a bill—which was never passed—that would require eye exams to be conducted in person, rather than virtually. Earlier, in 2016, eye health startup Opternative, which lets people go through a self-conducted vision test on its website, sued South Carolina for prohibiting it from operating there.

"All healthcare providers and administrators should be concerned when legislators start banning the use of telemedicine for a specific procedure," he said, "especially when it's not based on evidence, because it really is a slippery slope."