My clinic saves lives. The Ford government’s funding cuts to virtual health care will shut us down
We’ve treated 1,500 trans and gender-diverse patients across Ontario and have another 2,000 people on our wait list. Where will they go?
Kate Greenaway is the founder and lead physician of Connect-Clinic, a virtual clinic that provides gender-affirming care, such as hormone therapy and surgery referrals, to trans and gender-diverse patients. Here, Greenaway explains how the Ford government’s recent funding cuts to virtual care are forcing her to close down her clinical practice, leaving thousands of patients across Ontario without critical health care services.
—As told to Nour Abi-Nakhoul
When I was at university in Halifax in the ’90s, I had many friends who were trying to access gender-affirming care. I was struck by the difficulty they had finding a local doctor who was willing and able to provide them with hormone therapy, surgery referrals or other crucial services. There was an obvious health care gap for transgender and gender-diverse patients. When I started medical school at Dalhousie, I decided to work tirelessly to fill it.
There wasn’t anyone in Halifax who could train me in LGBTQ health care. So, in 2004, I moved to Toronto to learn from specialists here. From my residency onward, my family medicine practice has specialized in gender-affirming care. That can mean helping patients navigate medical transition or even just being a supportive person in their lives. So many of the people I see don’t know anyone else they can speak to honestly about their gender. An important part of my work is being an empathetic and informed listener.
Far too many cities and towns in Ontario, particularly in rural and remote areas, don’t have a single health care provider offering this kind of care. Clinics treating patients under 18 are similarly limited: in 2019, Rainbow Health Ontario found that health care for trans and non-binary youth was underfunded and under-resourced. Even for adults, wait times for accessing gender-affirming care are untenably long—sometimes over two years.
Though we know that a lack of access can severely impact mental health and gender dysphoria, we’ve allowed our health care system to reach a place where 44 per cent of trans Ontarians report having unmet health care needs. Many patients have expressed to me that they’ve become depressed and even considered suicide while stuck on waiting lists. After working with me, they often say that their lives have improved drastically, with more fulfilling relationships and improved self-regard. This is life-saving health care, and if it isn’t readily accessible, we risk a severe mental health crisis in trans and gender-diverse Ontarians.
Early in my career, I realized that Ontario needed a consultation service to help guide health care workers on best practices in this kind of care. I was already offering informal consulting services for colleagues who were approaching me for guidance on the subject. Over the years, the number of requests I received—from patients and doctors alike—started growing, flooding in from places as far away as London and Sarnia. The demand became too much to handle on my own.
In 2019, I launched Connect-Clinic, a virtual gender-affirming care clinic, on the Ontario Telemedicine Network. The format allowed me to help guide patients’ treatment in easy 20-minute virtual sessions, saving them from having to wait a year or longer for an in-person appointment. Working virtually also helped me treat people in underserved areas, connecting patients and health care practitioners with crucial resources regardless of where they lived in the province. With my early patients, the main feeling they expressed was relief that they could access this care from within their community. They didn’t need to travel long distances away from their homes, work and families to get essential treatment.
Initially, I planned for Connect-Clinic to be a part-time gig that I could do one day a week on top of my family medicine practice. I was naïve—I had no idea just how much need was out there. When I opened the clinic, I was getting about 10 or 20 referrals a month. Within a year, as word spread, it grew to 10 times that number. I decided to go all-in, leaving my family practice in 2020 and pouring everything into virtual care. I hired a full-time clinical administrator and contracted seven physicians who worked in the field. I started seeing patients across Ontario remotely, four days a week, and spent countless additional hours managing our ever-growing waitlist.
There was simply way more community need than we were able to keep up with, even after expanding. We could see 70 new patients a month, an impressive number given our limited resources, yet in the face of 200 new monthly referrals, it barely made a dent. In 2022, we were treating 1,500 patients and had an additional 2,000 people on our waitlist. It was incredibly stressful, but I never considered giving up. We were committed to finding a way to support everyone who needed our services.
Then, in March 2022, I learned that Doug Ford’s provincial government planned to change our funding structure by the end of the year. The Ministry of Health was renegotiating the funding agreement for virtual care services in Ontario. Since we opened the clinic, we’d been able to bill for virtual consultations just as we would for in-person sessions. Under the proposed agreement, we’d now be able to bill patients only $15 or $20 for assessments, a far cry from the $67 per session we normally charged. I panicked—there was no way we could stay afloat with that kind of financial structure.
I began advocating for the clinic, circulating petitions and gathering support from other physicians. Soon afterward, the Ford government reassured me that the funding changes wouldn’t affect any virtual health care services that existed pre-pandemic. The changing fee structure, I was told, was intended only to incentivize physicians who had switched to virtual care during the pandemic to return to in-person work. They would offer specialized health services exemptions, and I was told that, since Connect-Clinic had been virtual long before Covid, our funding was safe. Ultimately, that promise turned out to be an empty one.
Other specialty health care clinics in Ontario—such as sports medicine or psychotherapy providers—did receive exemptions from the funding change, but we weren’t so lucky. The reason is frustratingly arbitrary. When health care professionals provide services, we have to use specific codes to bill OHIP and communicate the type of assessment that was done. But we can’t prove that we’re doing specialized health care to the Ministry of Health for the simple reason that no government billing codes exist for gender-affirming care. It’s a bureaucratic bind straight out of Kafka and another example of how gender-affirming care is marginalized in Ontario.
Since the end of November 2022, we’ve been unable to see anyone on our waitlist. The clinic is still open for urgent needs and prescription renewals, but we’ve been forced to stop providing routine care for our existing patients. Many of them—especially the ones who have nowhere else to turn—are distressed. One person simply refused to stop seeing me. Countless other patients reacted to the news with resignation. Given that gender-affirming care is so limited in general, they weren’t shocked when this support was taken from them as well. That broke my heart.
I’ve since gone into debt to keep the clinic running. Connect-Clinic has never been about the money, and even under the original fee structure, our programs often cost more than we brought in. It’s a labour of love, and I hope that the Ministry of Health can recognize the value of our services and reverse its decision. It’s hard to see another way out of this situation. The thought that my patients might be denied adequate health care keeps me awake at night. But, if we can’t find sustainable funding, I’ll have to shutter the clinic.
I’m so frustrated, but I’m not giving up yet. I’ve been working nonstop to keep Connect-Clinic open: trying to find a solution with the Ministry of Health, raising awareness about the necessity of our services, and meeting with many different organizations to locate other avenues of funding. I’ll do everything I can to provide trans and gender-diverse patients with the supportive care they deserve.