Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; Why Insulin Costs So Much. In Beyond Primary Care blogs I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is an insurance free, membership based family medicine and addiction medicine clinic. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

In this blog post, I wanted to discuss an important healthcare question that often gets talked about: Why Insulin Costs So Much

Why Insulin Costs So Much

First, What Is Insulin

The hormone insulin is produced by an organ in the belly called the pancreas, and insulin production is regulated through a feedback loop based on blood sugar levels in the body. Insulin assists cells in the muscles, fat, and liver to absorb glucose (sugar) in the blood, and that glucose acts as energy for these tissues. 

The most common problem associated with insulin is diabetes, and diabetes falls into two categories. Individuals with type 1 diabetes have a pancreas that no longer makes insulin and they need insulin injections to use glucose from meals. Individuals with type 2 diabetes make insulin, but their bodies have resistance to it and most individuals need to take pills or insulin injections to assist their bodies to use glucose for energy.

Insulin can not be given as a pill. Like other proteins, insulin would be broken down too much during digestion and thus it needs to be injected. For type 2 diabetes who need insulin or type 1 diabetes who require insulin, there is no alternative medication. 

The Insulin Supply Chain

In economics, inelastic demand occurs when people buy the same amount of a product, whether the price drops or rises. This occurs in many situations, from gasoline to food to medications- like insulin.

My demand for food is relatively inelastic—I will quickly die without it—but that doesn’t mean that any grocery store can extract hundreds of dollars- increasing prices from me each week. If they tried to do so, many other grocery stores will gladly win my business with lower prices and said previous grocery store will lose business (likely for good). 

Inelastic demand is only a problem for consumers if there is limited competition among the suppliers of a good. Notably, the lack of manufactures to produce insulin is one of the main culprits of out-of-control costs.

There are only three incumbent manufacturers of insulin serving the U.S. market: Eli Lilly, Novo Nordisk, and Sanofi. Pricing of insulin is very complex and involves many layers of middlemen including wholesalers, Pharmacy Benefit Managers (PBMs), healthplans, and pharmacies. Within the system, there is no agreed-upon price for any insulin formulation.

Kickbacks, Prices, and Middlemen Increasing Your Insulin Prices

According to the American Diabetes Association (ADA), the average list price of insulin has nearly tripled since 2002. In 1996, when Eli Lily’s Humalog first came out, the price for a one-month supply was $21. As of 2019, that vial is around $275, a 1,200% increase on the original price. Further data indicates when one insulin manufacturer increases the price for a given insulin preparation, the other insulin manufactures often increase their prices by a similar amount quickly afterwards. 

“Third parties and other barriers to care are not only increasing the prices of insulin, but physicians can’t really do what we believe is right and best practices for our patients and give our patients a voice in their healthcare.” ~ Dr. Jeff O’Boyle 

Worse, these manufacturers ruthlessly exploit the patent system to fend off competition. Pharmaceutical companies use lawsuits combined with incremental patent changes that enables the manufactures to extend the patient on the drug. These practices prevent insulin from going generic and other manufactures from producing more affordable versions.

In fact, insulin manufactures and pharmacy benefit managers (PBMs) such as CVS, Express Scripts, United Health, and OptumRx have been accused of artificially inflating prices for insulin in a class action suit brought in 2020. According to the suit, these manufactures aggressively increased the prices for insulin past what they would have charged had there been no scheme. 

Health Insurance Doesn’t Help The Insulin Costs

Why doesn’t competition among the BUCAH (BlueCross, United, Cigna, Aetna, Humana) health insurers force the manufactures to offer plans tailored to the different needs of patients? As example, the needs vary drastically from a person suffering from Crohn’s disease versus a type one diabetic). There are complex reasons for this- including the pharmacy benefit managers discussed above- but a major one is the tax privileged treatment of employer provided health insurance.

In 2018, nearly 160 million Americans got their health insurance through heir job, which at best puts a weak bargaining pressure on health insurers brokered through employers rather than employees. This lack of bargaining leaves the employed individual needing the lifesaving medication powerless and exposed to the expensive out-of-pocket costs. 

Moving Forward

We recognize that cost-containment for life-saving medications such as insulin is a human right. We also recognize that we, the people of Ann Arbor, greater Michigan, and this great nation must unite together to form meaningful solutions.

We commit to doing our small part here at Beyond Primary Care by continuously pushing the status quo of healthcare to seek out more affordable treatment solutions to offset the financial effects our current healthcare system has on those who are most vulnerable. 

It’s small, but it’s what we can do well and what we promise to do for those in our care.

Thank you for reading.

– Dr. Jeff O’Boyle with Beyond Primary Care

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog: Using a Health Savings Account (HSA) with Direct Primary Care. In Beyond Primary Care blogs I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is an insurance free, membership based family medicine and addiction medicine clinic. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

In this blog post, I wanted to talk about the Health Saving Accounts (HSAs), what they are and how to get one, why they are beneficial for healthcare, how to use it with Direct Primary Care. 

Health Saving Accounts: Explained

Health Savings Accounts (HSAs) are a type of savings account where individuals or families can set aside money on a pre-tax basis to pay for qualified medical expenses. 

Yup, you read that right- PRE-TAX: if you make a dollar and need to spend that buck on healthcare, it is a full dollar you get to use, not some percentage.

How did this come about? Great question- HSAs are designed to offset some of the expenses of a High Deductible Health Plans (HDHP) such as deductibles and copayments. To qualify for a HSA, you must have a HDHP, defined as an annual out-of-pocket deductible of $1,350 for single coverage or $2,700 for family coverage. I wrote a blog co-authored by a financial advisor that details the financial benefits of HDHPs.

High deductible insurance plans allow you to be covered for major “catastrophic” medical problems: eg- hospitalizations, surgeries, etc- in exchange to agree to pay more money out of your pocket for most or all medical expenses up to a certain limit. Once that limit is met, the consumer could expect near 100% coverage.

For 2020, if you have an HDHP, you can contribute to your HSA up to $3,500 for self-only coverage, and up to $7,100 for family coverage keeping in mind the limits can change year to year.

What are Qualified Medical Expenses

Before dealing what is a ‘Qualified’ medical expenses, let’s first discuss what exactly ‘Medical Expenses’ are. According to IRS publication 502, Medical and Dental Expenses, medical expenses are the costs of diagnosis, cure, mitigation, treatment, or prevention of disease, and for the purpose of affecting any part or function of the body. These payments include payments for legal medical services rendered by physicians, surgeons, dentists, and other medical practitioners. 

‘Qualified’ or eligible medical expenses are described by IRS code section 213(d). This list is long and includes:

• Physicians
• Blood tests
• Prescription drugs
• Diagnostic fees
• Treatment of alcoholism and other drugs
• Durable medical equipment
• Chiropractic care, Physical Therapists, Dentists and much more…

How having a Health Savings Account is Beneficial

The HSA provides funds that can be used to pay day-to-day healthcare expenses. HSA benefits important to understand include:

• They are tax-free, meaning contributions go in tax-free and withdrawals are taken tax-free provided they’re spent to cover qualified medical expenses. 
• HSA don’t require you to do mandatory withdrawals every year, so you can leave your balance in there to stay put or grow until a large medical expense presents itself. 
• Highlighting the importance of the previous benefit, another benefit is that HSAs don’t have to be used up on a yearly basis. 
• HSAs can be funded through employers to varying degrees.
• There are not income limits to contribute to HSAs.

Using a Health Saving Account (HSA) with Direct Primary Care

Like hundreds of other Direct Primary Care (DPC) clinics across the nation, Beyond Primary Care DOES allow our members to use HSA funds to pay for their membership.

The US department of Health and Human Services (HHS) under the Affordable Care Act (ACA) defines DPC as a primary care service, NOT insurance (or a health plan). 

Additionally, the ACA allows coupling DPC with a ‘wrap-around’ qualifying health plan, stating that HHS “Shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home that meets criteria established by the Secretary.” Combining the definition from the HHS (not insurance) with HSA eligibility under the ACA allows DPC to embody the premise of HSA in the patient-centered free market.

If needed by the administrators of your HSA and requested by you (our member), Beyond Primary Care will provide an itemized bill with your encounter dates, billing codes, and medical service fees.

HSAs work with the Right Insurance

Many people who talk with me know I don’t hesitate for a second to discuss the unbalanced, non-transparent, maddening administrative business that is health insurance. People know that medical expenses are the #1 cause of bankruptcy in the United States. However, what people don’t realize is that 75% of those individuals actually did have some type of health insurance. Health insurance is the ONLY insurance that bankrupts folks when they use it. 

All insurance, since humans first invented it, was designed for one thing and one thing only… to protect us from catastrophic loss. 

High Deductible Health Plans are designed to protect us from catastrophic loss. When health insurance is used in this way, a significant amount of money can be saved through reduced monthly premiums and a cost-conscious individual can shop around for the best price for office visits, medications, blood work, imaging, and more.

Note: this blog post is not a substitute for tax advice nor does it suggest how to handle your own unique tax circumstances. If you require tax advice, you should seek the services of a competent professional. 

Hi, thank you for coming back for the latest edition of the Beyond Primary Cares blog; treating menopausal symptoms. In my blogs I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is an insurance free, membership based family medicine and addiction medicine clinic. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

In this blog post, I’m glad to welcome a guest blogger, my friend Liza Baker. Liza is the owner of Simply: Health Coaching and is a full-time health coach and nonprofit consultant, author, blogger, and podcaster with a soft spot for supporting women in their 40s and above. This is a collaboration blog-piece, where we wanted to educate our patients and the community on treating menopausal symptoms, specifically how role lifestyle and nutrition can positively influence those changes, and what medications can positively influence those changes.

Menopausal, peri-, and post-

First, a little bit of clarity to the menopause timeline:

• Menopause is defined as the complete cessation of the menstrual cycle for 12 months, after which time it is extremely rare for it to resume. The average age at which menopause occurs in the United States is 52.
• Peri-menopause is the period of our lives when our bodies (if not our conscious thoughts) begin to move toward the end of our child-bearing years, and it can begin as long as 10 years before the final menstrual cycle—that’s right: you can enter menopause as early as your late 30s to early 40s. And yes, you can still get pregnant during these years! (As we know from the British comedy Sex Education!)
• Women are considered post-menopausal once they have been cycle-free for 12 months.

Importance of Identifying Menopausal Symptoms

Every woman experiences menopause differently. Some of us reach the end of our cycles almost without noticing; others don’t have a period for some months and then get surprised to find that it was just loitering in there—and then we need to start the countdown over again. Your “regular” periods may have stopped years ago—regular in the sense of timing and in their length and heaviness. 

Like most women, you may have an idea what to expect:

• Physical symptoms such as hot flashes, night sweats, vaginal dryness, dizziness, nausea, breast tenderness, insomnia, skin changes, abnormal uterine bleeding, urine incontinence, and headaches. 
• Changes in mood such as increased anxiety, reduced sex drive, memory issues, and fluctuations in mood. 

These symptoms can last months to years, and even post menopause, you can still sometimes “feel menopausal.” These symptoms can be severe, disruptive, and even feel embarrassing at times. 

In a previous blog post, Liza reminds us that it doesn’t help to approach this shift in hormones as a problem, like we are entering this stage of life from the perspective of “we’re broken.” Instead, it’s important to approach this as a woman’s health experience within the context of identifying your own symptoms and getting clarity about possible therapies for treating menopausal symptoms.

Treating Menopausal Symptoms —and causes

You may have mined the women’s health section of your local bookstore looking for informed (dare we say evidence-based) resources to guide you. What you likely found is a broad spectrum of seemingly science-based approaches from “here is why you should be on hormone replacement therapy (HRT)” to “here is why you absolutely should NOT be on HRT!”

Liza is a firm believer that when advice falls on a spectrum (HRT: YES! NO!), the truth likely lies somewhere in the middle. And having learned that many of the top health problems in our country are so-called “lifestyle diseases”—meaning that they can be reversed and/or prevented through our food and lifestyle choices.

Putting Experience Into Practice

Liza’s personal experience with peri-menopause involved a large number of the most commonly recognized symptoms listed above—including raging migraines after decades of their absence and an appearance by anxiety and panic attacks, neither of which she’d ever experienced before.

And perhaps because Liza had been raised with fairly good food and lifestyle choices and began to make even better ones once she had her own family, many of my/her symptoms were quite mild.

That said, as a health coach, her work with clients is based on the principle of bio-individuality: your perimenopause is not my perimenopause; what works for you may not work for me; your kale may be my kryptonite. Dr. O’Boyle explains it this way: “Discussing the scope of treatment … is extensive and always carries asterisks for certain populations…. Treatment is multi-dimensional and must be individualized, your classic N of 1 trial.”

What matters most is that we—as patients/clients and as practitioners—take a holistic approach: yes, it’s about reducing the severity of symptoms—and about taking a longer view of what caused them and how we can shift that in a more positive direction. It’s as much (more?) about prevention as it is about a cure.

And it’s about giving you—the patient—permission to have some agency over your health care. As Dr. O’Boyle says, “Mainstream medicine has a challenge: continue to ignore your story and lose you to a subjective fantasy built on the mistakes of our brain, or join you in your life story ensuring you are taking responsibility for your wellbeing while making you central to the care and cure.”

Treating Menopausal Symptoms with Medications

The stress involved with menopause can be disruptive on many levels. Some women feel awful, and don’t want to be subjected to a physical exam, let alone interact with a physician when they can’t interact with their families, co-workers, and friends in a way that has meaning. At Beyond Primary Care, you can be assured there will be no judgement, no unnecessary physical exams, just compassion and an opportunity to share your story.

At Beyond Primary Care, I use an eclectic and personalized approach—not a “canned” conversation- towards accessing and resolving life changes and stressors. In a thorough health history, I am going to ask about your family, where your quality of life is being most affected, and—most importantly—what you want to do. I find validation of your concerns and education are often powerful methods in support when you are not feeling well. As you read above, some women prefer enhancing their diet and exercise along with support in allowing their symptoms to play out more naturally.

If more holistic approaches of treatment don’t work, I [Dr. Jeff O’Boyle] can get innovative with estrogen and progesterone hormone replacement therapy (HRT), depending on your needs. Getting the dosage right using hormone patches, pills, and creams is always individualized, and I [Dr. Jeff O’Boyle] works with my [his] patients to customize how much or how little may be needed. While HRT is sometimes a last resort for a woman, the relief it gives can be life-changing. Additionally, just like a great chef (shamless cook book plug) with their ingredients, I am constantly measuring and remeasuring your for safety and goal achievement.

Decisions, decisions

Consider this your permission to make a decision about treating perimenopausal symptoms based on what’s right for you—because you do have options!

If you suspect some of what you are experiencing may be due to perimenopause, or if you notice any coworkers, friends, or family members silently struggling, send them a link to this post so that they can join the conversation!

Please share comments and questions below. You can also contact Dr. O’Boyle or Liza Baker directly. We look forward to hearing from you!

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; where can I find The Sinclair Method Doctors. In my blogs I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is an insurance free, membership based family medicine and addiction medicine clinic. Beyond Primary Care is the only Direct Primary Care clinic serving patients in Ann Arbor, Ypsilanti, Saline, Dexter and the rest of Washtenaw county that offers virtually unlimited office visits, wholesale medications dispensed from the clinic, and wholesale blood work completed at the time of visit.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

In this blog post, I wanted to answer a common question, where can I find The Sinclair Method Doctors?

What is The Sinclair Method?

According to the C3 foundation, the Sinclair Method (TSM) is a treatment for alcohol addiction that use a technique called pharmacological extinction- the use of an opiate blocker to ‘turn habit-forming behaviors into habit-erasing behaviors.’ The effect returns a person’s cravings for alcohol to its pre-addiction state. The Sinclair Method is named for the researcher, John Sinclair, Ph.D, who first developed it and helped it gain momentum, most notably in Europe. The Sinclair Method utilizes taking a medication,  Naltrexone, prior to drinking alcohol- which for some people may be everyday.

In America, many physicians have a very narrow ‘one size fits all’ approach to substance abuse, in that a person needs to totally quit the drug in order to be considered successful. While good natured and in some cases necessary, this maxim is dangerous when applied to every person. Instead, the American term for what The Sinclair Method accomplishes is better known as ‘harm reduction.’ As comparison, the idea being 5 cigarettes is better than 20 cigarettes if you refuse to quit smoking. Still not a great habit, but long term there is less harm from a quarter pack than a full pack. 

How does Naltrexone Work?

Naltrexone competes with other drugs for opioid receptors in the brain. 

Wait right there! 

This is a blog about alcohol treatment, why would we consider a medication that is meant for pain pills? 

Multiple bodies of evidence such as this, this, here too, suggest alcohol reinforcement mechanisms – what we call cravings- involve activation of our endogenous opioid system. Alcohol binds to and alters functioning of opioid signaling receptors. Originally use to treat opioid dependence, Naltrexone is also FDA approved for the treatment of alcohol dependence. 

Will Naltrexone Work For You?

As a board certified addiction doctor, I see hear the different stories all the time. As example:

• The young executive who drinks too much at the end of the day
• The liquor distribution salesman where drinks are a part of the job
• The 67 year old grandmother drinking a case of beer a day and her family has no idea

You may of scoured every internet article for information that looked informed and accessible. In fringe support groups there are people enthusing about elixirs and ‘ten-day’ fixes. In ‘recovery’ websites you may feel like a marketing person’s dream- marginally desperate: open to attempt anything.

When you feel vulnerable trying to make sense of the treatments, take some confidence that Naltrexone is a very real possibility for changing your life for the better. 

Naltrexone is a great medication for a lot of reasons. It’s a generic medication- so it is affordable. It is not habit forming nor a drug of abuse. It’s side effect profile is comparable to many other medications, and are typically mild and short in duration. As long a you start it under the guidance of a trained physician, you will likely not discontinue for tolerance reasons. It has little impact on other medications. 

It is also important to know that taking Naltrexone alone does not guarantee success nor any successes will be long term. What improves the chances of success and duration of success? Follow-up with an addiction-trained physician and counseling with a certified therapist who has a substance abuse background are huge starts. From there, we can guide you on sleep health, journaling, support group meetings, exercise, diet, dealing with set-backs, and importantly- recognizing successes. 

Where to find The Sinclair Method Doctors

You can always click through TSM website and look for providers that way. In addition to being a board certified family medicine doctor, I am also a board certified addiction doctor and have been utilizing The Sinclair Method for years. At my clinic Beyond Primary Care in Ann Arbor, Michigan, I use an eclectic and personalized approach- not a ‘cookie cutter’ conversation- towards accessing and resolving your life changes and stressors. In addition to a thorough health history, I am  going to ask about your family, where your quality of life is being most affected, and—most importantly—what you want to do.

Outreach

If you think some of what you may be experiencing may be due to excessive alcohol consumption, or if you notice any coworkers, friends, or family members silently struggling, send them a link to this post so that they can join the conversation!

You can also contact Dr. O’Boyle directly. I look forward to hearing from you!

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; where I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is an insurance free, membership based family medicine and addiction medicine clinic. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

In this blog post, I wanted to talk about the coronavirus, what it is, how is it spread, what are symptoms, and how to protect yourself.

What is the Coronavirus?

Coronaviruses represent a large group of viruses, not just one we are hearing about in the news and media lately. These Coronaviruses are categorized as “Zoonotic diseases,” meaning they are transmitted between animals and people. The Coronavirus this blog is referencing (COVID-19) initially occurred in an animal or seafood market in the city of Wuhan, China. The disease has since spread throughout China and to a number of other countries.

On the ‘skin’ of the Coronavirus are a huge number of spikes (proteins) that give it the appearance of a ‘crown.’ Crown in latin = Corona. Just like the Human Papillomavirus (HPV), which is the causative agent such as non life-threatening conditions like foot (plantar) warts or very dangerous conditions such as cervical cancer, there are many subtypes of Coronavirus. 

Think of subtypes like the seasoning, basil. There is cinnamon basil, Greek basil, lemon basil, well- you get the point.

Some of the subtypes cause respiratory illnesses as minor as the common cold, while others cause pneumonia. These tend to be mild. However, just like HPV, there are some types of Coronavirus that can cause severe disease, such at the China 2019 Novel Coronavirus. This new Coronavirus being spread has not been previously identified in humans.

Situation in the United States

There are 59 total cases of the China 2019 Novel Coronavirus. Eight U.S states have confirmed cases including Massachusetts, California, Washington, Arizona, Texas, Wisconsin, Illinois, and Nebraska. 57 cases have been diagnosed as a result of travel or being evacuated from high-risk countries. 2 cases are believe to have spread person to person within the U.S.

Being present on public transport areas is a major risk factor for transmission. This Coronavirus appears to be spreading easily in China, but not as much in the United States.

The Centers of Disease Control (CDC) states to prepare for the ‘inevitable’ spread of the coronavirus within the United States. 

The CDC calls this Coronavirus “a serious public health concern.” 

The City of San Francisco, despite not having any confirmed cases of the Coronavirus, has declared a local emergency because it is a major travel connection hub. 

How is the Coronavirus spread?

The exact mechanism (as of publication of this blog post) has yet to be discovered. In general, it is thought respiratory droplets – such as what comes out your nose or mouth when you cough or sneeze- or objects that have been contaminated with the virus, are the source of the Coronavirus. 

How does the Coronavirus present?

A number of symptoms can present ranging from mild to severe. Symptoms typically take between 1 and 14 days to appear once the virus is contracted. Mild symptoms include fever (anything over 100.4F), cough, body aches, fatigue, sore throat, cough, and shortness of breath. Severe symptoms include pneumonia, kidney failure, and even death. 

Currently, the only means of diagnosis is testing through a technique called Reverse Transcription-Polymerase Chain Reaction tests that can diagnose the Coronavirus from respiratory samples. This test is currently not available at any outpatient clinics in the United States.

These tests are only at selected U.S. States and local public health laboratories, Department of Defense (DOD) laboratories, and some international laboratories. 

Protect Yourself

Currently there is no specific medication to combat the Coronavirus. Additionally, there is yet to be a vaccine- although these are in development. Treatment if someone is infected is supportive care.

A number of hygiene practices to help prevent the spread of the Coronavirus include covering your mouth and nose when sneezing or coughing (such as the vampire cough depicted above), washing your hands with soap and water frequently, and wearing masks if you could have the virus or around other people you care for who may have the virus.

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; where I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is a new approach to family medicine and addiction medicine that creates the time and space your healthcare deserves. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

In this blog post, I wanted to talk about an actual patient of mine about to fish antibiotics for humans, the barriers of obtaining affordable medications, and how to obtain affordable medications.

My Patient’s Fish Antibiotic Story

A kind man in his 30s finds out about my clinic last month saying ‘direct primary care’ is perfect fit because even though he works full time, his employer does not offer him health insurance. He explains his employer is a contractor for a major shipping company (think top 3), but since they are contractors, they are not entitled to the same benefits.

He has been without any healthcare for the past 3 years saying “I can’t afford BlueCross.”

The newly enrolled patient says discovering Beyond Primary Care was serendipitous, because he has been experiencing left ear pain so bad for the past 2 weeks, that he was going to do something about if finally. Curious, I ask what he plan was and he replied he had been reading about ‘fish antibiotics for humans’ on the internet.

Since you don’t need a prescription for that he could avoid the healthcare costs associated with establishing care with a new physician and price of medications at a retail pharmacy.

A Dangerous Idea

Yes, so taking fish antibiotics for humans is a real thing. A quick google search turned up numerous unscientific medical survival guides. I read the reviews for aquarium antibiotics. However, taking medications that are 1) not for humans, 2) not prescribed by a licensed physician and 3) not properly dosed is incredibly dangerous. 

Misuse of any medication can cause serious illness. The medications used for many animals and vertebrates do NOT require FDA approval, so there is no regulation over the manufacturing of the medication that one would take.

I always tell my patients for any medication that they have effects, thus they may have side effects. Additionally, using antibiotics for self-diagnosed illnesses may lead to antibiotic resistance, which ultimately hurts the individual using the medication and society in the larger picture. 

Improving Affordable Healthcare and Transparency

Antibiotics are not necessarily all expensive either. Some large retail pharmacies in the state of Michigan even offer certain types of antibiotics for free (you still need a prescription from a physician). The patient did have an ear infection. Because we are a ‘Direct Primary Care’ clinic, the patient was prescribed AND dispensed the antibiotic from our office at the time of the visit.

The cost of the drug prescribed to this particular patient through Beyond Primary Care was $1.95.

Many of us are accustomed to thinking that we pay health insurance premiums to get access to a lower cost for health care medications — that being the “negotiated rate” or “contracted rate” that the insurance company and the payer agree to in contract talks. But increasingly we are hearing that insured people are paying more than uninsured people.

Additionally, evil organizations out there called Pharmacy Benefit Managers (PBMS- more on them on a later post) are yet another middlemen in our insane medical billing industry that can increase the prices we pay for medications.

No Quick Legislative Road

In late 2019, the current white house administration released new rules requiring hospitals to be more proactive with price transparency by publishing their charges and negotiated rates. Great right? If we go on Amazon, we can see the description, reviews, and price for everything. We expect and demand price transparency with all our other transactions. Same for healthcare now.

However, even within a few weeks of this executive order, hospital systems and insurer across the nation are suing to keep their prices a secret. The hospital systems and insurers know that if their costs become public knowledge, they stand to lose millions of dollars because people will simply shop around for the best market price, something we do for every other service.

Is there an easy solution?

In my opinion, the best advocates for patients to obtain affordable and transparent healthcare are those independent from a large hospital/health system– such as those who operate as Direct Primary Care (DPC) physicians.

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; where I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is a new approach to family medicine and addiction medicine that creates the time and space your healthcare deserves. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services. 

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

This featured recipe is Pork Tenderloin. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Pork Tenderloin with Brussel Sprouts and Butternut Squash

Adapted from Family Circle: Sheet Pan Pork
Prep time: 30 minutes
Total time: 1 hour

Ingredients:

1 Butternut squash
1 lb of brussel sprouts (approx. 4 cups)
1.5 – 2 lb pork tenderloin
Olive Oil
1 tbsp mustard
1 tsp paprika
1 tsp garlic powder
1 tsp salt
1 tsp tumeric
1 tsp thyme
½ tsp pepper

Instructions:

1) Peel and Chop Butternut squash into 1 inch cubes. Trim brussel sprouts as needed. Set aside.
2) Mix Mustard and all spices.
3) Trim silverskin and excess fat from tenderloin. Rinse off and pat dry with a paper towel. Spread mustard mix all over tenderloin.
4) Heat pan to medium-high. Add tenderloin. Brown all sides (6 – 8 minutes, 2-3 per side). Remove from pan and set aside.
5) Add veggies to the sheet pan. Add olive oil, additional salt, pepper, and thyme. Toss to coat. Spread veggies around the perimeter of the pan, leaving room in the middle for tenderloin. Add tenderloin. 
6) Bake at 350 for 25-30 minutes. Give generous drizzle of olive oil over the entire pan. Check the doneness of pork (should be 145 internal temp). Remove pork, wrap in foil, rest for 10 minutes. Turn oven temp up to 400. Return the pan of veggies to the oven for 5-10 minutes until caramelized.
7) To serve sliced pork against the grain and serve up with a scoop of veggies. Drizzle pan juice over top.

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; where I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is a new approach to family medicine and addiction medicine that creates the time and space your healthcare deserves. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

In this blog post, I wanted to talk about severe allergic reactions, namely anaphylaxis and epinephrine.

Anaphylaxis

Anaphylaxis is a severe, sometimes life-threatening, allergic reaction that occurs within minutes to several hours of exposure an allergy-causing substance (allergen).

In any body allergic reaction, your immune system will respond to the presence of an allergen (whether food or environmental) by releasing histamine and other body chemicals. These chemicals cause the symptoms of allergies, in their mild form are annoying, such as the runny nose of hay fever (allergic rhinitis) or the itchy rash of poison ivy. 

Unfortunately though, the symptoms can progress and be much worse and involve the entire body. Anaphylaxis is the most severe allergic reaction. In anaphylaxis, body chemicals cause serious skin symptoms, such as hives and swelling, as well as severe breathing problems, such as swelling in the throat, narrowing of the lower airways and wheezing. Anaphylaxis is a life-threatening medical emergency.

The Physical Reaction

There are different shapes and forms of a severe reaction. Symptoms of anaphylaxis usually occur within seconds to minutes of exposure to the allergen, but symptoms can be delayed for several hours.

• Feeling light headed, faint, difficulty breathing, couching, wheezing, weakness
• Confusion, anxiety, panic, or a feeling of impending doom
• Measurable symptoms such as rapid pulse or profuse sweating.
• Itchy hives, which may blend together to form larger areas of skin swelling
• Swelling of the lips, tongue or eyes
• Nausea, vomiting, stomach cramps, diarrhea
• Paleness, bluish skin color
• Throat swelling -like a golf ball stuck in your throat, hoarseness 

Treatment

Symptoms of anaphylaxis usually require treatment with epinephrine, by injection. People who have had anaphylaxis can carry a pre-loaded syringe containing epinephrine.

Epinephrine

You have probably heard about this drug before, but some of what you think you know may not be correct.

Epinephrine is safe, and you already have epinephrine in your body

Epinephrine is a naturally occurring hormone. At-rest plasma epinephrine levels are 0.035 ng/mL. It is the hormone that is part of our fight-or-flight response. When you are scared or excited, and also when you are exercising, your epinephrine levels surge, but even when you sleep, there is a little epinephrine circulating in your body. Levels over 10 times that amount have been measured in persons exercising, and even higher than that in people under mental stress. 

The standard adult dose of self-injecting epinephrine (0.3 mg of 1:1000 epinephrine) raises the level of epinephrine in the body from an average of 0.035 ng/mL to about 10 times that amount.  It would require more about 20 such injections to reach a toxic level.

If you were given the injection right now, all that would likely happen is that your heart rate and blood pressure would increase to a moderate degree and that you might feel slightly shaky. Epinephrine is metabolized very quickly, and you would not feel this effect for long.

You Should Not Wait to Use Your Epinephrine

You might hope the allergic reaction won’t be “that bad,” and you might be right, but it’s important to know that a delay in use of epinephrine is linked to poorer outcomes and prolonged hospitalizations.

You Should Not Be Afraid of the Epinephrine Device

The device itself might look big, but the injection needle is not. It’s just like getting a flu shot. As mentioned above, the main side effect you might experience is feeling a bit shaky after using the device.

You Should Go to the Emergency Room (ER) After Using the Epinephrine for Anaphlaxis

You may have been told that you have to go to the ER after using your epinephrine device. That’s not because of the epinephrine; it’s because the allergic reaction probably requires further monitoring. In the past, I have talked about why NOT to go to the emergency rooms. Anaphylaxis is not one of those scenarios. Many patients also need more than one dose of epinephrine for anaphylaxis or other emergency treatments; that may be due to the severity of the allergic reaction or simply because the device was not used correctly (the most common mistake is not holding the device against your thigh for the time required for the full dose of medication to be delivered). So a trip to the ER is the safest thing to do after using epinephrine.

Epinephrine Cost

You may of heard EpiPen’s manufacturer, Mylan Pharmaceuticals, had increased the price of a two-pack over several years to $600 or more—even for people with insurance. For some families—especially those who needed more than one EpiPen pack to protect their kids during severe allergy attacks—that price was still way too high. As a Direct Primary Care doctor, I have worked towards making epinephrine affordable to my patients, with a 2 pack of injectors costing less than $100. 

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; where I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is a new approach to family medicine and addiction medicine that creates the time and space your healthcare deserves. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services. 

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

This featured recipe is a Tuscan Tortellini Soup. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Tuscan Tortellini Soup

Adapted from Cooking classy
Prep: 10
Total: 35 min

Ingredients

2 Tbsp olive oil
1 ½ cups chopped carrots
1 ½ cups chopped yellow onion
1 cup chopped celery
2 cups chopped green beans, about 1-inch pieces
2 cups chopped zucchini
4 cloves garlic, minced
3 (14.5 oz) cans vegetable broth
2 (14.5 oz) cans diced tomatoes 1 tsp each dried basil and rosemary, crushed
½ tsp dried thyme
Salt and freshly ground black pepper, to taste
1 (9 oz) package refrigerated 3-cheese tortellini
3 cups packed spinach
Shredded Parmesan cheese, for serving

Instructions:

1) Heat olive oil in large pot over medium-high heat. Add carrots, onion and celery and saute 3 minutes.
2) Add green beans and saute 3 minutes longer. Add zucchini and garlic and saute for 1 more minute. 
3) Pour in broth and tomatoes. Add basil, rosemary, thyme, and season with salt and pepper to taste
4) Bring to a gentle boil, then reduce heat to medium and allow to boil, about 8 minutes.
5) Add tortellini and boil 5-7 minutes longer.
6) Stil in spinach and cook 2 minutes longer.
7) Serve warm with parmesan cheese.

Obstructive Sleep Apnea

Hi, thank you for coming back for the latest edition of Beyond Primary Cares blog; where I highlight healthy and fun recipes, healthcare news, advice for medical conditions, as well as how membership for care works! Dr. Jeff O’Boyle is the owner of Beyond Primary Care, which is a new approach to family medicine and addiction medicine that creates the time and space your healthcare deserves. Beyond Primary Care is the only Direct Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne County giving families and employers peace of mind with healthcare costs by providing affordable, accessible, and authentic primary care services.

The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions I receive from patients that I believe are important. I want to start discussions that will help educate, benefit, and improve your well-being. 

In this blog post, I wanted to talk about Obstructive Sleep Apnea (OSA).

Your Spouse Says You Snore, a LOT

Everybody snores, right? How bad can it be though? You never hear it.

The changes are gradual, so gradual you may not see the pattern. You finally get tired of the criticism so you make your way to an ear, nose, and throat specialist to tell you have a deviated septum. Maybe they tell you you have a uvula (that dangling skin in your throat) that needs trimming. You consider surgery, but that is a big step. 

Eventually you may start getting depressed. Maybe your personal or work relationships start deteriorating. You start to see a therapist who recommends you back to a psychiatrist, who dutifully puts you on a cocktail of anti-depressant medications. 

At some point you make it back to your primary care physician, where you relay some of this information during a yearly physical. The spouse says they are worried because you seem to stop breathing at night (Apnea), then suddenly gasp for air followed by resuming your slumber as if nothing had happened.

Your physician says your sleep may be a key to your problems.

Other symptoms of Obstructive Sleep Apnea include:

• Excessive and inappropriate daytime sleepiness
• Insomnia
• Problems with memory and/or concentration
• Impotence
• Headaches
• Fatigue

What Causes Obstructive Sleep Apnea

According to the American Academy of Sleep Medicine, Obstructive Sleep Apnea is a sleep-related medical condition that results in an almost complete blockage of airflow despite your body’s effort to breath. This is caused when the muscles in the pharynx (throat) relax during sleep, allowing all the supporting tissues of the throat to collapse and block the upper airway. These apnea episodes, or pauses, can last between 10 and 30 seconds, but some may progress longer. 

This lack of breathing drops your blood oxygen saturation that ultimately sounds an alarm in your brain to cause a temporary arousal from sleep that typically restores normal breathing. This can occur hundreds of time in a single night resulting in poor and episodic sleep quality resulting in the above symptoms.

Diagnosis

You will be advised to undergo a sleep study. This sounds absurd on the face, what doctor would routinely want to observe anyone while they sleep? In fact, you may never see the ‘sleep doctor.’ There are many ‘sleep laboratories’ around the nation, often staffed with sleep technicians where you can have up to 36 separate electrodes placed on you while you are asleep. The laborites sleep technician will likely be helping you with all of this. 

I personally encourage my patients to complete home based sleep studies, as example using Somno Services. With Somno Services, they ship all the necessary equipment to you at your home. This allows my patients to complete the assessment in the comfort of their own homes at a fraction of the cost a sleep laboratory would charge, around $175 versus $1,000+ at a sleep clinic. Following completion, you simply repackage the materials and send it back.

After a few days, the sleep doctor will review the data collected and be able to confirm a diagnosis.

Realistic Treatment Options

CPAP therapy (Continuous Positive Airway Pressure) as pictured below is a standard of therapy. Once you have a diagnosis, you will have to get the proper equipment from a medical supply store. Finding a proper fitting mask is key to this. 

Wearing an oral or dental appliance can be an alternative to CPAP. Oral devices work by holding the tongue in place or by sliding the jaw forward while you sleep. Again, this is a device that may need some fine-tuning by a trained sleep specialist or supply store.

Surgery. Some surgeons may say that corruption of nasal structures or throat structures can reduce or eliminate extra tissues in your throat preventing the collapse that leads to Obstructive Sleep Apnea. While surgery may indeed help in some cases, I encourage all my patients to review the harms and benefits of the surgery vs non surgical options, ask about success rates, and ultimately factor in costs.

Weight loss. I absolutely hate the old doctor’s adage of ‘eat less and move more.’ Weight shaming is not a motivating strategy. Know though, reductions is weight and ultimately body mass can significantly reduce or even eliminate the weight of the tissue pressing onto the airway. Losing weight, like any other medical condition, requires a multi-dimensional approach including potentially mental imagery and therapy, nutritional support counseling, a safe exercise program, and regular biometric feedback.