As a brand new doctor, Devery Mitchell was frustrated by her patients' struggles in Alaska's irrational health care system, so she set out to document their stories on recordings. We sat down together to listen to Richard Keith, who recently lost his right foot.
Keith is a Vietnam veteran who worked on jets, service that first brought him to Alaska in 1970.
"I came up here with the Phantoms. Way back," he said.
He met his wife, Taka, while serving in Japan. They were married 51 years, until she died two years ago. Her Buddhist shrine still occupies a room in the trailer they bought new in 1977.
That was where we met, in Manoog's Isle Mobile Home Park in East Anchorage, where Mitchell had come for a house call to check on the other foot, which was swelling.
Keith's health went downhill after Taka died. His diabetes caused kidney failure and he went on dialysis. Circulation failed to his right foot and it became infected. He went into the hospital in February to have the infected part removed, but too much tissue had died and he lost the whole foot.
"I can't remember it. I can't remember what happened," he said.
"Well, I was there with you," Mitchell said.
"I woke up, and they said it was four days. And I reached down and said, 'What happened to my leg?' " he recalled.
Keith has no complaints about his medical care — on the contrary, Providence Alaska Medical Center served him well — but he was frustrated that he couldn't get out of the hospital.
Roughly the last two weeks of his 37-day stay in Providence was unnecessary, hospital records show. Mitchell said it was closer to a month.
That's common, I later learned.
"Every day there are patients in the hospital who don't need a hospital level of care and are waiting for a placement and can't get out," said Dr. Harold Johnston, head of the Providence Medical Group and a founder of Mitchell's residency program.
On Thursday, there were 28 patients in that category at Providence, representing an accumulated 592 days of unnecessary hospitalization. The average cost of those stays is about $2,000 a day, according to Providence's Kirsten Schultz.
The hospital absorbs the cost for indigent patients, who can be stuck for months with nowhere to go, driving up prices for everyone else. In Keith's case, military benefits paid the bill, but he was just as stuck.
"I went stir-crazy up there," he said. "I got a little mad at the doctors. I shouldn't have done it. But I just said, 'Let me go home.' "
In his new wheelchair, Keith wouldn't be able to get up to the door of his trailer, Mitchell said. But if going home wasn't safe, the best alternative, a skilled nursing facility, was also unavailable. No room.
The irrational way that medical services are reimbursed in Alaska makes skilled nursing facilities difficult to run profitably. That causes a lack of nursing beds, which traps patients in the hospital, which costs the system much more.
In addition, Providence often lacks nurses to staff all of its skilled nursing care beds, Johnston said. Since nurses make higher wages in the hospital, the nursing shortage hits the nursing homes first.
The occupancy rate at Providence Extended Care is 99 percent. At Providence Transitional Care Center, for rehabilitation after surgery, the rate is 85 percent, but beds often can't be used due to staff shortages, Schultz said. (And about five patients are usually stuck there, as at the hospital.)
Keith finally got home with help from his neighbors in the trailer park.
Some big guys carried him through the door. A neighbor handy with tools built a plywood ramp for the wheelchair. A woman agreed to drive him to dialysis and to the grocery store. A teenager cleared the snow from his roof. A fisherman brought him chowder for his dinner.
"I even got friends who can give me weed if I want it," Keith laughed. He said they were disappointed he refused. "Are you sure you don't want any?"
Mitchell prescribed antibiotics for the other foot, which a home health aide had flagged as worrisome. She hoped to keep it healthy until the next available appointment with an orthopedic specialist, two weeks away.
House calls are part of the Alaska Family Medical Residency program at Providence, where Mitchell is learning to be the kind of all-around rural doctor who can handle almost anything.
Mitchell grew up in Napa, California. The rural residency program brought her here from UCLA Medical School. After a year, she never wants to leave. Her goal is to work in a small Alaska community.
"She is extremely passionate. She is a person who is going to be a doctor who is going to do a lot of good in her life," Johnston said.
Seeing how her low-income patients feared losing their medical coverage after the November election, Mitchell became an advocate. She won a fellowship to document their stories of frustration. She caught my interest with her recordings.
What I learned from her, and from Richard Keith and Harold Johnston, is that Alaska has plenty of caring people who want the best for patients. But that's not how we spend our money.
Everything Keith wanted would have saved money for the government — to get out of the hospital and into rehabilitative care, to get home, to take care of himself with a little help. Good people finally made that happen.
Why can't we have a medical payment system as smart as that?
Now Keith just wants to save the other foot. And to keep Mitchell at his side.
"I appreciate you," he told her. "What's going to happen when you graduate from that place? That's going to hurt."
"It's going to hurt," Mitchell agreed. "But I'm not going far."
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