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'08 Walk for Life * PICTURES FROM 2006 MARCH FOR LIFE * Pregnancy Centers          About Us Volunteer Donate Home |
Renee Chelian was worried about her business. With
competitors charging lower prices, she needed
something special to draw customers. So she
created an almost a spa-like atmosphere at her
offices, with low light in the rooms,
aromatherapy, candles and relaxing music.
Ms. Chelian runs three abortion clinics in the
Detroit suburbs, where competition is so fierce
that each clinic owner is looking for an edge.
In Detroit, and in other large metropolitan areas
around the country, there are not too few abortion
providers, as abortion proponents have lamented
for years. There are too many. It is still true
that fewer hospitals are providing abortions,
fewer doctors outside abortion clinics are
offering the procedure and 86 percent of counties
in the country have no abortion provider.
But, over the past few years, as the number of
abortions has declined, abortions increasingly
have been concentrated in specialty clinics in
cities and pockets of competition have developed.
So while women in rural areas must sometimes drive
hundreds of miles to the nearest clinic, in cities
and suburbs there are price wars and competition
over amenities. Doctors have refused to train
colleagues, fearing they will only help a
potential competitor in a lucrative, often
cash-only, business.
National statistics compiled by the Alan
Guttmacher Institute illustrate the clinics'
problem. The number of abortions declined by 17.4
percent in just seven years, to a low of 1.328
million in 1997 from a peak of 1.608 million
abortions in 1990, the most recent year for which
statistics are available.
Different groups give different explanations for
the drop. The National Right to Life Committee
credits the persuasive power of abortion opponents
as well as laws requiring informed consent and
parental notification. But Dr. Stanley Henshaw, a
senior fellow at the Guttmacher Institute who
analyzed abortion data, said the reason is mostly
better birth control. While it is true, he said,
that more teenagers are keeping their babies, most
of those having abortions are in their early 20's
and fewer of them are becoming pregnant.
Whatever the reason, the falling number of
abortions has come at a time when the number of
clinics in major cities has not changed. Since
1992, the number of clinics doing 400 or more
abortions a year has remained steady at 690. It is
in these clinics -- 99 percent of which are in
metropolitan areas -- that 89 percent of abortions
take place.
The Cost of Competition
Clinic owners say they have little choice but to
cluster in cities -- that is the only way they can
find enough patients. Ruth Arick, the owner of
Choice Pursuits in DeLand, Fla., which does
management consulting for abortion clinics, said
that a population of about 200,000 is needed to
support a full-fledged clinic.
Abortion clinics are not so different from other
specialty services, said Dr. William Ramos, who
runs an abortion clinic in Las Vegas.
"In the entire state of Nevada, there is only one
Lexus dealer and only one Acura dealer," he said.
But, abortion providers say, unlike other areas of
medicine, where prices have surged over the years,
competition among abortion clinics has kept prices
so low that an abortion in many cities costs less
now than it did 25 years ago, without even
adjusting for the nearly 500 percent inflation in
medical services. If abortion had kept up with
inflation in medical services, a $300 abortion in
1972 would cost $2,251 today.
"The fees are not set by the cost of the services
but by the cost of the competition," said Dr.
Warren Hern, owner of the Boulder Abortion Clinic
in Colorado. And, he said, "the competition for
patients is absolutely ruthless."
While abortion providers report that many
metropolitan areas -- New York, Northern New
Jersey, large cities in California and Florida --
have a surplus of abortion providers, few places
have more intense competition than Detroit and its
suburbs, home to about 5.4 million people. There,
two dozen clinics -- with another nine within a
two-hour drive from Detroit -- fight for a
dwindling number of patients and owners like Ms.
Chelian find themselves struggling to survive.
"As altruistic as women and feminists want to be,
the reality is that we can only stay in business
if we earn enough to keep our doors open," Ms.
Chelian said.
Fighting the Price Wars
After working at abortion clinics for 25 years,
Kathryn Allen seized an opportunity to own one.
The doctor running the Scotsdale Women's Center, a
small brick building painted a dusky rose on a
bleak treeless street in Detroit, was in his 60's
and his practice had dwindled.
So, in 1997, Ms. Allen and her daughter, Shelly
Miller, took over, getting a doctor to do
abortions and deciding to charge $275 for a
first-trimester abortion -- significantly less
than the average fee in the United States, which
was $316 in 1996.
But then a nearby clinic, which had been charging
$250 for students and $285 for others, dropped its
fee to $175. Ms. Allen could not compete.
"We were not making it, we were just getting
killed," Ms. Allen said. "There was one week
when we did just eight patients. We owned the
building, we were paying peoples' salaries and we
were really scared."
The only way to survive, Ms. Allen decided, was to
meet her competitor's fee and forgo her own pay.
The competing clinic finally raised its fee to
$230 for a first-trimester abortion, and so Ms.
Allen and Ms. Miller did the same. Their clinic
now does about 1,200 abortions a year.
Ms. Allen and Ms. Miller still have to watch every
penny. Like other clinics, the owners save money
by training a low-paid staff to do everything but
the actual surgery, from drawing blood to doing
lab tests. Most of the time, no patients are
scheduled and the staff cleans and does paper
work. But when the doctor comes, a parade of
patients is ready for the procedure, which takes
just two or three minutes in the first trimester
of pregnancy.
In Detroit, as in many other large cities,
abortion protesters have not been a problem. The
main problem is competition from other clinics. In
New York, two of the largest clinics, Parkmed and
Eastern Women's Center, coexisted for more than a
decade, about two blocks from each other near Park
Avenue South and 30th Street. But last year they
had 30 percent fewer abortion patients than they
did in peak years in the late 1980's and early
1990's, said Ted Weiselberg, who owned Parkmed.
So the two New York clinics decided that the only
way they could survive was to merge, forming
Parkmed Eastern Women's Center. The new clinic not
only does abortions -- about 15,000 a year, said
Mr. Weiselberg, one of its owners -- but it offers
gynecological services as well.
"It's like any other service," Mr. Weiselberg
said. "You have to lower your fee to attract
enough patients to allow the office to pay its
rent and you have to diversify to be successful."
Abortion Pill Dilemma
Now, clinics are grappling with the mifepristone
dilemma. Owners feel they have to offer the
recently approved abortion pill, formerly known as
RU-486, because women are asking for it and seem
to expect it. But its price -- $270 for three
pills -- will be a problem. Many owners say that
if they charge what it costs to provide the three
pills plus the three office visits, the lab work,
and the counseling, they will lose customers to
competitors who say they will keep the price much
lower.
Some have found creative solutions. Ms. Chelian
said she is considering offering women just one
pill instead of three and to have them sign a form
saying they understand that one pill is not the
approved dose but that studies have shown that one
pill is effective. Then she can charge them just
$80 more than for a surgical abortion.
Carmen Franco, who owns six clinics in Detroit,
said she expects to charge women $450 for a
mifepristone abortion with the full three-pill
dose. It is less than her costs. But, she said, by
making it available, she expects to draw patients
to the clinic where they can see the full range of
options she provides. "We probably will use it as
a loss leader," she said.
A Subsidized Competitor
Dr. Hern used to have plenty of patients for
first-trimester abortions at his clinic in
Boulder, where he was charging $375. Then, a
Planned Parenthood clinic opened in nearby Fort
Collins, charging less than $300. Subsidized by
the nonprofit Planned Parenthood Foundation, the
clinic was able to keep its fees lower than Dr.
Hern could even contemplate.
"Within a month after that clinic opened, my
patient numbers dropped by 25 percent," Dr. Hern
said.
Independent abortion providers say Planned
Parenthood clinics can easily undercut them.
"I would sort of compare them to Wal-Mart coming
in and taking over from all the mom and pops',"
said Dr. William West, who works at an abortion
clinic in Dallas. The Planned Parenthood issue,
said Carole Joffee, a sociologist who is a
visiting professor at Bryn Mawr College in
Pennsylvania, is part of "the identity crisis of
abortion. All other forms of health care are part
of a market. Is abortion part of the health care
industry? Or is it part of a social movement?"
Gloria Feldt, the president of Planned Parenthood
Federation of America, said that her group has a
slightly different focus than independent
providers.
"As a nonprofit organization our mission is to
make sure that every woman has access to
reproductive health services -- including abortion
-- regardless of their ability to pay," she said.
In keeping with that mission, Planned Parenthood
has expanded its abortion services over the past
decade, Ms. Feldt said. In 1991, 91 out of 199
Planned Parenthood health centers offered
abortions. In 1999, 147 out of 876 offered them.
But, Ms. Feldt said, she does not see a conflict
between her group and independent clinics since
they often coexist peacefully, even sharing
doctors. "We each fill an important niche in the
community," she said. In addition, Ms. Feldt
said, Planned Parenthood advocates and litigates
to provide a social climate that enables abortion
clinics to exist.
Many independent clinic owners say they survive
only by finding a way to distinguish themselves
from Planned Parenthood.
Dr. Hern decided that because his Planned
Parenthood competitor did only first-trimester
abortions, he would compete by focusing on
abortions in the second and third trimester. While
the vast majority of women who have abortions are
in their first trimester, the thought was that
those who were later in pregnancy would be drawn
to Dr. Hern. But now even that niche is starting
to erode, he said. At a recent medical meeting,
Dr. Hern said, doctors crowded into a session on
late-term abortions. "The startling thing to me
was that a very large room was filled -- packed,"
Dr. Hern said. "Twenty years ago, there were just
two or three doctors in the country doing late
abortions."
A Lucrative Business
Dr. Ramos said the situation at his clinic in Las
Vegas is close to ideal. There are no protesters.
Business is good -- he does about 3,000 abortions
a year, charging $300 for a first-trimester
abortion. And with four clinics in the city,
everyone is getting by. Dr. Ramos says he made the
perfect career choice when he began doing
abortions nearly three decades ago. "There is
less work and more income," he explained.
While few want to talk about the money that
abortion doctors can make, clinic owners and
doctors agree that doctors can make several
hundred thousand dollars a year working part time,
a few hours a day with their fees averaging $60
for a first-trimester abortion. Although they do
have hefty fees for malpractice insurance, doctors
who travel from clinic to clinic have no overhead
and no record keeping.
But it can be hard to enter the profession.
One doctor in Detroit, who spoke on condition he
not be identified, saying he feared hostility from
his colleagues, said that when he finished medical
school, trained in obstetrics and gynecology, he
asked abortion doctors in the area to train him.
He was turned away.
Eventually, he found a clinic whose doctor was
retiring and the owner let him do abortions. Now,
he travels from clinic to clinic terminating
pregnancies.
Ronald Fitzsimmons, executive director of the
National Coalition of Abortion Providers, said he
gets calls from doctors looking for work but often
he cannot help them.
"There are places in this country where there are
more doctors who perform abortions looking for
work than we can handle," Mr. Fitzsimmons said.
Dr. Ramos said that he understands why. "Anything
that's not managed care is exquisitely popular."
In fact, he said, the only thing that is keeping
more doctors from entering the abortion arena is
the social stigma.
"My patients say, 'How do you feel doing
abortions all day?' " Dr. Ramos said.
He tells them that he feels fine -- that he is
helping women at a difficult time of their lives
and that, he said, is very gratifying.
"I find this to be a very rewarding practice,"
Dr. Ramos said. "Emotionally rewarding and
financially rewarding."
Correction: This article referred incorrectly to
the number of Planned Parenthood clinics that
offered abortions in 1991. It was 99 clinics out
of 911, not 91 out of 199. The article also
included a physician's erroneous reference to a
comparably sparse service -- Lexus dealers in
Nevada. There are two, not one.
Copyright 2001: The New York Times Company
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