Sneezing, Runny Nose, Itchy Eyes are Here


  • Cough
  • Runny nose
  • Sneezing
  • Itchy nose
  • Sore throat
  • Watery eyes
  • Puffey eyes
  • Itchy eyes
  • Asthma flares
  • Difficulty breathing

One of the most common allergens is grasses and specifically timothy grass.  We are seeing these right now. While preventive treatment is ideal, treatment is currently focused on relieving the symptoms. There is a new option for allergy sufferers of common grasses for future seasons.  The middle of freezing temperatures is when the grasses are dormant.  It is that time that preventive treatment needs to start.

The newest option to treat for the timothy grass allergen is Grastek.   This is immunotherapy in a pill. For those that have endured the weekly shots this is a novel, relatively painless approach to immunotherapy that can be done in the comfort of your own home.

Grastek covers Timothy grasses but also has cross coverage to other grasses.

It should be started for seasonal care 12 weeks ahead of pollen and throughout the season or taken consecutively for 3 years.

Click on the following link for more information on administration of Grastek.


Another common allergen that is on the horizon is ragweed.  Fortunately, our timing of discussing this form of treatment is ideal.  The same manufacturer of Grastek has developed a similar treatment for ragweed with the prescription drug Ragwitek.

Ragwitek like Grastek should be taken 12 weeks before the allergen season.  In this geographic area the typical ragweed season begins about August 15.  That gives an estimated start date of the medication in mid-May.

Ragwitek is taken similarly to Grastek with pre-seasonal and seasonal administration or continuous administration for 3 years.


Many other treatments remain the mainstay for allergy treatment: Grastek4

Oral Medications:


  • Cetirizine–Zyrtec
  • Diphenhydramine–Benadryl
  • Fexofenadine–Allegra
  • Loratadine–Claritin, Alavert


  • Phenylephrine
  • Pseudoephedrine

Leukotriene Antagonist

  • Montelukast Sodium–Singulair

Nasal/Ocular Medications:


  • Flonase
  • Nasacort
  • Nasonex
  • Qnasl
  • Rhinocort


  • Astelin
  • Pataday
  • Patanase
  • Pazeo
  • Zaditor


  • Ephedrine
  • Oxymetazoline–Afrin, Sinex
  • Phenylephrine


  • Nasalcrom


  • Ipratropium Bromide–Atrovent

Nasal Irrigation

  • Navage
  • NeilMed
  • Neti-Pot


While avoidance can be difficult here are some pointers that may help:

  • Stay indoors when the pollen count is high especially between 5AM to 10 AM when pollen counts are highest
  • Wear a mask when mowing or avoid mowing altogether
  • Choose grasses for your lawn that produce less pollen–dichondra and irish moss are some examples
  • Mow frequently to keep grass short
  • Keep windows closed
  • Avoid attic fans
  • Bathe pets frequently
  • Do not dry clothes outdoors
  • Minimize alcohol intake as it leads to dehydration and increased sensitivity to allergens

Another topic to come…How do I know what I am allergic to?

Ann Riggs, DO

Patient-Driven Affordable Healthcare
Patient-Driven Affordable Healthcare

As the Sun Sets…Vitamin D Deficiency

Vitamin D Deficiency

I often joke with patients that we never checked Vitamin D levels until Dr. Oz brought it to the forefront.  Thankfully he did and we are identifying more and more individuals with vitamin d deficiency and treating appropriately.


The Centers for Disease Control and Prevention (CDC) reports that 32 percent of children and adults throughout the US are vitamin D deficient. Estimates of over 95 percent of elderly are deficient. 


Vitamin D Deficiency SymptomsVitD5
  • Fatigue
  • Bone pain
  • Muscle pain
  • Memory issues
  • Depression
  • Cardiovascular Disease
  • Diabetes
  • Hypertension
Vitamin D AKA the Sunshine Vitamin


How much sun is enough?  You need your skin exposed without sunscreen or protective clothing interfering to be able to convert/produce Vitamin D.  There is an interesting calculator here to shed some “light” on it: Sun Exposure Calculator.  Keep in mind there really are so many factors(skin color, time of year, cloud cover, time of day, etc.) and to depend on the sun for your vitamin D is not ideal.


Vitamin D in our DietsVitD2
  • Fish
  • Egg yolks
  • Fortified dairy
  • Fortified grains



 Risk Factors for Vitamin D Deficiency
  • VitD0Diets limited in the above food sources
  • Limited sun exposure due to occupation, climate, or darker pigmented skin
  • Age
  • Obesity
  • GI issues that impact absorption


Vitamin D Supplementation

First and foremost check your levels before supplementing above the daily recommended allowances.  Vitamin D is a fat soluble vitamin and too much can lead to toxicity issues.  Basic guideline for baseline supplementation is 800-1000 International Units daily.   Multi-vitamins often fall short of the baseline supplementation.  Verify how much you are truly getting.   If you are found to be deficient supplementation would be much higher.


Ann Riggs, DO

Patient-Driven Affordable Healthcare
Patient-Driven Affordable Healthcare


Tired, Foggy, and Numb?

Vitamin B12 deficiency May be Making you tired, foggy, and numb…



B12fatigueFatigue is one of the most common complaints I hear from my patients that unfortunately can be caused by many things. Vitamin B12 is one of those causes and it is quite common.  Vitamin B12 plays a crucial role in energy as it aides the conversion of our foods to energy for the body.



Patients often complain of difficulties focusing, forgetfulness, and just a general fuzziness.  Vitamin B12 helps in cognition with overall brain health. Deficiencies can also lead to general mood disorders, depression, and insomnia due to its role in production of certain natural brain chemicals.



The classic presentation of B12 deficiency is a “stocking-glove distribution” of numbness.  The hands and feet are described as numb or tingling.   Vitamin B12 is utilized by the body in the maintenance and repair of the nervous system.

Other Symptoms?
  • pale skin
  • tongue changes–smooth, burning, or red
  • heart palpitations
  • shortness of breath
  • diarrhea or constipation
  • vision difficulties
Am I deficient?

If you have any of the above mentioned symptoms it is worth getting a simple blood test to evaluate your levels.

Risk Factors:

  • age
  • vegetarian/vegan
  • medications that decrease absorption–classically antacid medications
  • disease processes that affect absorption such as pancreatitis and inflammatory bowel diseases like Crohn’s Disease or Ulcerative Colitis
  • gastric surgery for weight loss
Vitamin B12 Dietary Sources

b12def4The human body doesn’t make vitamin B12 so dietary sources are essential.  Common dietary sources:

  • meat
  • poultry
  • seafood
  • dairy
  • eggs
Vitamin B12 Supplement Options

Vitamin B12 supplements come in pill form, sublingual tablets, nasal sprays, and injectables.  Many people can’t absorb vitamin B12 through the gut so nasal absorption, oral absorption, or injections are often preferred.

Vitamin B12 deficiency is easily detected and easily treated if you look for it…


Ann Riggs, DO

Patient-Driven Affordable Healthcare
Patient-Driven Affordable Healthcare



Much Needed ICD-10 Codes

ICD-10 codes: Making the practice of medicine “better”



V97.33XD: Sucked into jet engine, subsequent encounter

How does one survive to even have a subsequent encounter?  I guess it has been done before: Jet engine survivor.




Z63.1: Problems in relationship with in-laws

We see the applicability here…this will be used often.





W61.62XD: Struck by duck, subsequent encounter

Watch out for ducks–especially during migration…


W22.02XD: V95.43XS Spacecraft collision injuring occupant, sequela

Just saw this last week…



W16.221 Fall in (into) bucket of water causing drowning and submersion

…why? just why??



R46.1: Bizarre personal appearance.

All a matter of opinion…


V00.01XD: Pedestrian on foot injured in collision with roller-skater, subsequent encounter

Beware of the roller skater this summer!





Y93.D: V91.07XD:  Burn due to water-skis on fire, subsequent encounter

One of my greatest fears!





X38.XXXA Flood, initial encounter
X38.XXXD Flood, subsequent encounter
X38.XXXS Flood, sequela

Using all three codes this year!  



Ann Riggs, DO

Patient-Driven Affordable Healthcare
Patient-Driven Affordable Healthcare

Direct Medical Care’s Top Ten List

TopTenDirect Medical Care’s Top Ten Patient Experiences

1—“Dr. Riggs your glow is back.  You seem so happy!”

2—A patient gets access to care for $400.00 vs $2400.00 that literally saved his life

3—A patient is reimbursed $300.00 of his $500.00 annual membership with his first claim submission.  “I feel like I hit the jackpot!”

4—Access to CT scan for cash at $350.00 vs hospital quote of $3382.00

5—The proof is in the pudding:  a patient puts families expenses into a spreadsheet with previous year’s expenses and finds marrying his plan with our services would have resulted in over $7500.00 in savings in one year

6—Our Medicare patient not only gets it but loves our model–he knows how doctoring used to be and the true costs of using your health insurance

7—Wholesale drugs that offer convenience and lower cost of short and long term medications.  $140.00 for one month of blood pressure medication dropped to $28.00 for the same medication.   Annual savings of $1344.00.

8—“The nose doctor(AKA Dr. Riggs) is right next to sonic—that is genius!”

9—“I really feel like I should pay you more.”

10—Every time a patient says, “It just makes sense.”

Ann Riggs, DO

Patient-Driven Affordable Healthcare
Patient-Driven Affordable Healthcare

Throwback Thursday on Direct Medical Care

When we were just getting off the ground Call for Action with NBC 41 Action News in Kansas City, Missouri spotlighted our focus on shopping for prices for your medical care and on the direct pay model.  Check out the news pieces:

Click here:  Why it pays to compare pricesNBC1


Click HERE:  Patients Prefer to Bypass Insurance Provider with Cash-Only Doctor

NBC2a  NBC2d


“My Personal Experience with Direct Medical Care and Dr. Ann O. Riggs”


EricCashinMy name is Eric.  I am a 48 year old male.  I have a history of chronic back pain, pre-diabetes,
recurring respiratory infections (at least annually) and many other miscellaneous health issues.  Last year I was diagnosed with coronary artery disease and had a stent placed in a major artery in my heart.

Because of my long history of health issues, having a skilled medical team and good health insurance has always been important to me and my family.

So why would I change from a traditional insurance based primary care facility to a practice using the direct pay model?

Best Doctor but Direct Pay?

I first became a patient of Dr. Riggs in 2012 when she worked for a traditional medical practice.  I was impressed with her knowledge, skill, and bedside manner.  I was cared for as a friend not just another patient to be pushed through the assembly line.  When she left the practice and started Direct Medical Care, I panicked.

She is the best physician I have ever worked with but how could I afford to pay her direct without using insurance?

A Light Came On

I was motivated to find a way to continue to have Dr. Riggs be my doctor. I began to

EricCashin2research what I had been paying out of pocket, what my insurance options were and how I could incorporate the direct pay model.

What I learned opened my eyes to the true costs of medical care.  It was like I had been sitting in a dark room and someone turned on a light.

Oh… I Think I’m Going to be SickEricCashin3

Being someone who prefers to make decisions based on sound analytical processes, I undertook the task to run a comparison between what my out of pocket expenses were with the standard medical insurance model and what they might be by marrying a High Deductible Plan with a Health Savings Account and membership at Direct Medical Care.  This is what I found out:

Out of Pocket Expenses

Actual(Standard Medical)


Comparison(HSA & Direct Medical Care)




This realization hit me like a ton of bricks.  Not only could I afford to join Dr. Riggs’ new practice, I could have saved $5,000.00!



How Is That Possible?
  • Changed to a High Deductible Plan with an associated Health Savings Account (my coinsurance dropped from 15% to 5%)
  • Insurance automatically contributes $1,500 per year into the HSA
  • Added another $2600 in HSA contributions (offset from prescription drug costs and change in dental plan)
  • All co-pays, co-insurance, prescriptions and membership in DMC paid for by HSA
  • Insurance reimbursed 65% of membership with DMC (net cost for annual family membership was $350.00)
Here Are The Numbers

DMC Membership, deductible, copay, co-insurance and prescriptions covered by $4,100.00 from HSA (no net change in monthly costs).EricCashin5

●     Save $700 family deductible
●     Save $475 on copays
●     Save $875 on prescriptions
●     Save $3,000 on co-insurance

Total Projected Savings $5,050.00

Not Just about $$

In 2013, after Dr. Riggs left the traditional practice (prior to getting DMC open) I began to see another doctor in that practice.  While this doctor was very capable, the assembly line medicine forced on physicians in these corporations caused my heart condition to be misdiagnosed for 6 months.

EricCashin6After joining DMC in December 2013, Dr. Riggs was able to determine that the symptoms I was having could be related to heart disease.  Her office scheduled an appointment with a cardiologist.  The condition was found and a blockage in my heart was repaired.  A potentially catastrophic heart attack prevented.

How Have The Numbers Worked Out?

In 2014,  I saved $7,522.23 compared to what I would have spent out of pocket on my old plan (that does not include the money DMC saved me by shopping prices and negotiating on my behalf for 2 tests – an additional $3,600.00 in savings).

My experience may be extraordinary, however, I am convinced that any individual or family will benefit from the superb medical care and cost savings found through joining Direct Medical Care.


Not everyone’s situation will result in the same savings that I have found.  But here are some examples of how DMC may make financial sense for you:

  1. I don’t have an HSA option where I work.
    • You can benefit by joining DMC and saving on copays and coinsurance for primary care services.  Additionally, membership costs count towards your deductible or may be covered by your insurance.
  2. I am in good health and never meet my deductible.
    • Fantastic, consider selecting a High Deductible plan and save on monthly premiums.  Savings will offset membership or you can join as a “non-member” and pay for a la carte services.
  3. I have Obamacare with a high deductible plan already.
    • DON’T WAIT!  You can’t afford not to join.

DMC Logo

Patient-Driven Affordable Healthcare


How the Adventure Began…

Every story has a beginning and this is Direct Medical Care’s…

Summer of 2013 was a major crossroads for me professionally as a primary care physician.  I contemplated where I wanted to take my career and ultimately weighed the three options I had–traditional, overseas, or private practice.

Option 1:  Stay in the traditional insurance based practice set-up where the focus was on insurance and its reimbursements rather than the patient.   A system that reimbursed by not only the number of patients seen but by the amount of unnecessary details I put in the patient’s office notedoctorwait.  I was expected to spend more and more of my time with regulatory compliance rather than patient care.  A visit about a broken toe required a discussion about end-of-life wishes, exercise goals, and smoking cessation.   The system was not ideal and job satisfaction poor, but the guaranteed income and sense of security was comforting.


Option 2:   Overseas medicine was very attractive to me.  What better way to escape the day-to-day battles of practicing traditional medicine in America than to go overseas?  The opportunity to experience a new system, different culture, and grand adventures was thrilling–it was Australia after all. AussieMy family was all on board with the idea but the details in that reality were overwhelming.  We would not get financially rich nor secure but sure to be rich with experiences.

Option 3:  To embark on private practice under the direct primary care model–a concierge practice for the masses.  Opening up a private practice as such was a huge Private Practice risk.  The financial outlay was significant and with student loans still to be paid, additional debt was daunting.  The projected struggle to pay for staff and overhead for the first 18-24 months added to that debt burden.  Concerns definitely existed for going against the status quo and expecting individuals to be open to a cash based practice. No wonder the whole idea was perceived as ludicrous by many, but the ability to truly care for patients and the professional satisfaction that would be derived from that was not to be overlooked.  Add to that the ability to decrease the healthcare costs for individuals and their families–it really was exciting to ponder.


I literally stood with three distinct paths to choose from–each had its pros and cons.  Was it the encounter along the running trail, the passerby at the grocery store, or the facebook message from a patient expressing their desire to see me stay in the community as their doctor? Most likely all of them, as I truly wanted to care for the people and the community that I had come to love–not to mention great staff that wanted the same.  The only viable and honest way to do that was by employing the Direct Primary Care model.

I am now one and a half years down the path and I have more conviction now that what I am doing is the right thing in the interest of true healthcare reform.  It is exciting and scary times in healthcare and we are happy to be moving forward as Direct Medical Care.

Ann Riggs, DO


Patient-Driven Affordable Healthcare