Notes on a society in crisis (11): U.S. Health Care (2)
On April 1st 2012, my book,”Dagbok från USA”, came out in Sweden. It will also soon be published in English (as an e-book for Kindle and for other readers) with the title: “Diary from the United States – Notes on a society in crisis“. As an appetizer for English speaking readers, I will the coming weeks publish some excerpts from the book.
The question is whether a country that spends just about a fifth of its GDP on health care in the long run can afford not to have a rational health care system
We know that U.S. health care today costs in the range of 16-17% of GDP. This compares with 8-10% of GDP in most European OECD countries. Sweden’s total expenditure on health care was 9.4% in 2008. So roughly speaking, American health care today costs at least 50% more than in other OECD countries as shown in the graph below (Source: “Health Care Spending In The United States and Selected OECD Countries”, 2011).
How did this happen? Why is U.S. health care so expensive? There is no simple answer. However, one can, I think, explain most of the big difference with three factors.
A higher relative cost position for medical treatment is the first reason. Pharmaceutical costs and medical salaries are two examples. Why is this so? According to an interesting study (Vladeck & Rice, 2009), the high relative costs more than anything else can be explained by a too weak ordering function in the American health care system, and a significantly weaker ordering function than in most other OECD countries. The fragmented private insurance sector in the United States simply does not have enough “demand power” to resist cost increases among providers. The result is a huge transfer of resources to doctors, other caregivers and health care companies. The outward sign is constantly rising costs.
Second, there is, relatively speaking, more to do. Or should be. Americans in general are sicker than, say, Swedes in general. One of the reasons is that the proportion of adults who are obese (BMI> 30) is significantly larger in the U.S. than in Sweden, 30% vs. 10%. While the picture is not entirely uniform, we know that use of health care in the U.S. is lower than in most other OECD countries. The number of beds in acute care hospitals per citizen (“acute care beds per capita”) is the lowest along with the Netherlands. And as for visits to doctors per citizen, the U.S. figure is among the lowest. It’s remarkable that here we have a country which per capita invests substantially more on its health care system than other countries without their citizens consuming more health care. The wording “consuming” is conscious. It may be that services are available, and needed, but not financially feasible. The health care services are simply too expensive. This is the thesis in an acclaimed article from 2003 (Anderson et al, 2003) with the self-explanatory title: “It’s The Prices, Stupid: Why The United States Is So Different From Other Countries.”
The third reason, and I will devote some attention to that here because it’s too little discussed, is the very high administrative costs of the U.S. health care system. By administrative costs one means that portion of total health care costs that are non-medical, that don’t have to do with actual medical treatment
There are two types of administrative costs. First, classical transaction costs, i.e. cost of a transaction in the market between buyers and sellers. For example what it costs for a hospital to send bills to patients and insurers. Second, internal administrative costs, such as the cost of a transaction within a single organization. Like when a hospital has a system for internal debiting for services one department delivers to another department.
Medical care is special in the sense that there are always three players involved – patients, health care providers and the financing institutions (which in the U.S. is both the private insurance companies and government). All three have to make transactions with each other. We know that the administration costs in the U.S. healthcare system are extremely high, over 30% of total health care costs according to a relatively recent study (Woolhandler et al, 2003). The study shows that U.S. administrative expenses are twice as high as the corresponding costs in the Canadian health care system. It’s highly probable that the difference can be explained by higher transaction costs, especially contract and control costs, in the fragmented U.S. system. Here we have one of the main explanations for America’s high health care costs. If we assume that the U.S. figure for administrative costs as a percent of total cost is 30%, we can easily calculate, all else being equal, that the American healthcare would cost 13.5% as a share of GDP in 2008 instead of actual 16% if the U.S. have had the same level of administrative cost as Canada.
Almost certainly the single most important reason why U.S. health care costs are so high, and rising so quickly, is that the American health care system is very fragmented with many players involved. It’s said that there are around 1,500 insurance companies. Since all these companies must have relationships with many hospitals, medical centers, private clinics, and other providers, a lot of administrative work is the consequence. In addition, the insurers have contacts with thousands, perhaps millions, of patients, who in turn have relationships with their caregivers. That said, there might also be other things that raise administrative costs. “Gray areas” and ambiguities in the responsibilities of various parties in such a fragmented system may be an additional explanation. The relative ease and frequency of malpractice suits may also be a factor. The risk of getting sued may simply create a costly bureaucracy with its own administrative machinery.
The interesting question is why U.S. politicians have chosen a system for health care funding that obviously has an internal systemic error, giving low bargaining power over providers and high administrative costs. We can assume that the answer has something to do with ideology and values. The political debate before the health care reform in 2010 shows that clearly. Fierce outcries against “socialized medicine” were directed at politicians who felt that the American health care system needed radical change, for example a single-payer system much as in Canada and England, to avoid the private insurance companies’ involvement and thus increase bargaining power and reduce administrative costs. There was never, in either of the two major parties, a majority for such a proposal. Shifting from a system of private financing to a tax-funded, single-payer system is, I guess, inconceivable in the United States. It does mean however that America chooses a system that apparently is less effective and thus more expensive than it needs to be. The question is whether a country that soon spends almost a fifth of its GDP on health care can afford to act irrationally in the long run, putting ideology and values ahead of efficiency. I do not think so.
Literature:
“Snapshots-Health Care Spending In The United States and Selected OECD Countries”, 2011, Snapshots: Health Care Costs, The Henry J. Kaiser Family Foundation, April 2011, (http://www.kff.org/insurance/snapshot/ OECD042111.cfm);
Anderson, G. F. et al, 2003, “It’s The Prices, Stupid: Why The United States Is So Different From Other Countries”, Health Affairs, November/December 2003, vol. 22, no. 3;
Vladeck, BC & Rice, T., 2009, “Market Failure And The Failure Of Discourse: Facing Up To The Power Of Sellersburg”, Health Affairs, September/October 2009, vol. 28, no. 5;
Woolhandler, S. et al, 2003, “Costs of Health Care Administration in the United States and Canada”, The New England Journal of Medicine, Vol. 349, no. 8, August 21, 2003, pp. 768 ff;
First published (in Swedish): October 15, 2011
comment4, where to buy super p force, >:-P, cheap furadantin, =-]], where to buy trimox, >:PPP, imodium buy, %-DD, cheap erythromycin, 62963, buy levothroid, yndj, buy ventolin inhaler online, :-))), order beloc, 9559, order lithobid, tomx, buy vigrx plus online, :[, buy zudena online, 87132, imitrex buy, :PPP, furosemide buy, tkmsh, cheap combipres, 8), buy calan, vukv, order effexor, 384, buy benicar online, iof, buy glycomet, 719887, order revia, 711, allegra buy, 667, buy hyzaar, akweh, zebeta buy, %-], tenormin buy online, yyk, cheap vigora, :PPP, where to buy suprax, ciwsk,
comment3, reosto buy, oqth, buy protonix, rkohoc, cheap dostinex, >:]]], tadora buy online, 8DD, buy voveran sr, 288, cheap ilosone, 235, order fulvicin, kuivkh, zestoretic buy online, 765, where to buy atarax, 217, where to buy tiova rotacap, 00826, buy neoral, >:-D, where to buy actigall, efyyka, abilify buy online, dzkdgo, cheap asacol, >:]]], buy sustiva, ljrlm, cheap microzide, %-OO, order inderal la, avvslm, arcoxia buy, 198, order hair loss cream, 611, where to buy voveran, %-O, buy tadapox online, 938, menosan buy online, >:[[[, order proair inhaler, :-(((, order omnicef, 215, where to buy provestra, 2541,
comment4, where to buy mentat, %-], mircette buy, 859510, buy himplasia online, 912, buy micardis, %-)), where to buy isoptin sr, >:-((, biaxin buy, =[[, cheap flonase, 379, minomycin buy online, iftddh, cheap amalaki, 612872, buy calan online, 787448, where to buy tinidazole, :-]], where to buy glucophage sr, 21201, epivir buy online, ipby, buy vpxl online, wbq, cheap cymbalta, 8986, buy lamictal online, 744, where to buy geriforte, zspd, buy cordarone, 8DDD, arimidex buy, 3421, where to buy neurontin, 02452, cheap voltarol, 2561, anafranil buy online, 21301, cheap amoxil, 58568, zovirax buy, 398, effexor xr buy, jswgjn,
buying prescription drugs in mexico online mexican rx online or buying prescription drugs in mexico
http://www.greektheatrela.org/__media__/js/netsoltrademark.php?d=mexicopharm.store medication from mexico pharmacy
[url=http://emptynestermagazine.net/__media__/js/netsoltrademark.php?d=mexicopharm.store]mexican mail order pharmacies[/url] pharmacies in mexico that ship to usa and [url=http://www.9kuan9.com/home.php?mod=space&uid=131008]buying prescription drugs in mexico[/url] best online pharmacies in mexico
comment5, order mentat, ncr, mircette buy online, %)), order himplasia, %[, order micardis, adeugp, buy isoptin sr, 570247, where to buy biaxin, 8-PP, order flonase, rqac, cheap minomycin, ldc, cheap amalaki, 93885, order calan, %-((, cheap tinidazole, mufzhs, cheap glucophage sr, wkgdw, cheap epivir, ppoe, cheap vpxl, fcnpxb, cheap cymbalta, jnvqw, buy lamictal, ngg, geriforte buy online, 746119, cordarone buy online, geo, arimidex buy, 8((, order neurontin, =DDD, buy voltarol online, :))), anafranil buy online, 7217, amoxil buy, 934, cheap zovirax, =], buy effexor xr online, 97030,
comment6, order mentat, hwvduj, cheap mircette, qdwqf, where to buy himplasia, 01508, where to buy micardis, 957, cheap isoptin sr, :-[, buy biaxin, %PP, cheap flonase, :-DD, cheap minomycin, %-OOO, amalaki buy online, 26507, buy calan, 04277, where to buy tinidazole, %-O, cheap glucophage sr, 295, epivir buy, 8DD, where to buy vpxl, :-PPP, where to buy cymbalta, 9094, buy lamictal online, uke, order geriforte, dvfo, cordarone buy, shpdcf, cheap arimidex, tnvqab, cheap neurontin, %-DDD, order voltarol, 029, where to buy anafranil, %-]]], order amoxil, 04158, zovirax buy, 8-))), buy effexor xr, %P,
comment1, order reosto, 458879, protonix buy online, 9445, where to buy dostinex, ltlwlo, where to buy tadora, 034, buy voveran sr, zjstn, order ilosone, :-], order fulvicin, dnrm, cheap zestoretic, gqwfvx, atarax buy, :O, tiova rotacap buy, %], neoral buy, yoolet, cheap actigall, :-PP, buy abilify, >:-PPP, cheap asacol, 8PPP, buy sustiva, %-O, buy microzide, bnseqk, buy inderal la online, zaimd, buy arcoxia online, %PP, hair loss cream buy, 8(, buy voveran, mgrtw, buy tadapox, =PPP, cheap menosan, =-], where to buy proair inhaler, 010, buy omnicef online, 057723, provestra buy online, =-)),
comment5, trandate buy, >:-DDD, revatio buy, 362439, buy risperdal, lpxjw, cheap ditropan, 0563, buy sildalis, 524673, zyvox buy, %-]], cheap prevacid, qnfkmh, viramune buy online, :-(, buy anafranil online, 947485, keftab buy, cinud, amoxil buy, 710308, buy clozaril online, =-[[, cheap tentex forte, 2553, estrace buy, 310827, order detrol, 57431, cheap requip, jxxlwv, cheap molnunat, 78210, buy retin a cream, 216875, buy aldara, =-(((, cheap exelon, pqdr, buy cleocin, 837, cheap verampil, 8-))), where to buy cartia xt, =-((, order robaxin, rnh, buy lopid online, 842,
comment4, where to buy mentat, xbeojl, where to buy mircette, 8409, buy himplasia online, 831078, micardis buy, =-P, order isoptin sr, bvb, buy biaxin, %]]], flonase buy online, qzynp, minomycin buy online, ijyqvw, amalaki buy online, 33038, buy calan online, rvslb, tinidazole buy, =-OO, cheap glucophage sr, 927880, epivir buy online, :-PP, buy vpxl, 100999, cheap cymbalta, jbwy, where to buy lamictal, 5730, where to buy geriforte, gzmpt, cordarone buy online, 8-DD, buy arimidex, 338, buy neurontin online, 827, order voltarol, herpyg, anafranil buy, ozvfzd, cheap amoxil, mufwp, where to buy zovirax, :)), buy effexor xr online, tivzd,
comment2, order paxil, 981238, buy voltaren online, >:-[[[, cheap eriacta, 60291, buy decadron, =O, where to buy glucophage, exp, buy geriforte online, dspfwg, zovirax buy, :-)), maxolon buy online, %-OOO, where to buy weekend pack, >:-], buy topamax online, klnlq, buy zyban online, 8-[[, cheap proair inhaler, 702, cheap tritace, 093486, seroflo inhaler buy online, %(, cheap hytrin, 8]]], cheap ceftin, bglw, leukeran buy, zhwie, where to buy sumycin, wcwps, sinequan buy online, 862222, buy shuddha guggulu, czwme, ascorbic acid buy online, ujglr, buy buspar, 96620, where to buy suhagra, 937, azulfidine buy online, gazt, buy paracetamol online, 83902,
comment3, where to buy cardarone, hdabhc, where to buy prosolution, 9537, himcolin buy, yptrjn, buy zithromax, atwqn, buy acyclovir cream online, bsziz, order benicar, :], lanoxin buy, >:PPP, antabuse buy, ygw, buy karela online, olbolk, buy orlistat, 8], buy viramune online, :DDD, lasix buy, %-O, where to buy minipress, =-(((, buy risnia, =P, buy evecare, auvrl, arimidex buy, ucjgj, buy vibramycin, 488277, paxil cr buy online, >:]], podowart buy online, 117606, where to buy periactin, 4903, ashwagandha buy, 07997, cheap kamagra jelly, %-)), where to buy keflex, =P, cheap avodart, abml, buy terramycin, tmhga,
comment3, order reosto, jkp, buy protonix, azy, buy dostinex online, 901384, buy tadora, zpfkyv, where to buy voveran sr, aezsb, order ilosone, gmbl, order fulvicin, 622, order zestoretic, rxjgr, atarax buy, 8-PP, tiova rotacap buy online, xvux, cheap neoral, 872, actigall buy online, >:-], abilify buy online, 8O, order asacol, >:))), cheap sustiva, :-], where to buy microzide, 8-))), order inderal la, apmqj, buy arcoxia online, 437, buy hair loss cream, :[[, buy voveran online, cqtcjs, buy tadapox online, 024, where to buy menosan, xllrr, order proair inhaler, >:-P, cheap omnicef, wtqh, provestra buy, 312936,
comment3, buy paxil cr, 292676, keflex buy, acjk, buy ponstel online, =-]]], cheap noroxin, vxty, zyloprim buy online, 6495, buy prandin, 8-]]], celebrex buy, =PPP, tiova inhaler buy, 35929, glucotrol xl buy, 8]]], buy thorazine online, =-PP, eskalith buy, >:-[, flibanserin buy online, lqlr, order danazol, 88116, buy luvox online, senq, where to buy catapres, =-((, cheap voltaren sr, 1036, where to buy thorazine, 8-(, plan b buy, 623, where to buy wellbutrin sr, vbaixk, astelin buy, 343209, cheap naprosyn, 4653, where to buy claritin, 311184, buy augmentin, 7141, order neem, 8-]]], order detrol la, 8-)),
comment4, buy mentat, 047, buy mircette online, :-OOO, himplasia buy online, 036354, order micardis, iewpuz, cheap isoptin sr, mfuf, buy biaxin online, dexkd, order flonase, fch, minomycin buy online, %O, where to buy amalaki, =-]], where to buy calan, ruz, buy tinidazole online, mglk, glucophage sr buy, 234, buy epivir, >:-)), where to buy vpxl, 70681, buy cymbalta online, >:), lamictal buy online, 8569, cheap geriforte, 412901, cheap cordarone, 8937, arimidex buy online, >:-], where to buy neurontin, mpdrn, voltarol buy online, 03354, anafranil buy, dsh, amoxil buy online, 725544, cheap zovirax, =DD, cheap effexor xr, >:-((,
comment6, order mentat, vkmax, buy mircette online, 2315, buy himplasia, ptpocg, micardis buy online, nnfsls, where to buy isoptin sr, 522, biaxin buy online, :DDD, flonase buy online, 301, minomycin buy, 709, where to buy amalaki, rrtwo, calan buy online, >:D, tinidazole buy online, 89576, buy glucophage sr, 01912, cheap epivir, =-], cheap vpxl, 8[, order cymbalta, 8]], order lamictal, 3714, order geriforte, >:[[, cordarone buy, =-(, order arimidex, loy, neurontin buy online, jqn, buy voltarol online, 7179, buy anafranil online, olbkfm, buy amoxil online, 937146, order zovirax, :-DDD, effexor xr buy online, 519,
comment3, order paxil, :DD, cheap voltaren, bgeyd, eriacta buy, 135, buy decadron, %-]]], order glucophage, jkemtk, geriforte buy online, 4473, buy zovirax, 8-(, maxolon buy online, 202, order weekend pack, 839, buy topamax online, 72774, cheap zyban, 655, buy proair inhaler, 796, where to buy tritace, 2335, order seroflo inhaler, qdo, buy hytrin online, chxf, order ceftin, 3775, cheap leukeran, >:(, sumycin buy, 15941, cheap sinequan, fkfufu, shuddha guggulu buy, 8((, where to buy ascorbic acid, >:-)), order buspar, %(((, where to buy suhagra, edf, azulfidine buy, cdber, order paracetamol, 444837,
comment2, buy trandate, :-D, buy revatio online, 0187, risperdal buy, 830372, ditropan buy online, %O, sildalis buy, wilvk, buy zyvox, :[, buy prevacid, uoqcg, order viramune, qfn, buy anafranil, =-], where to buy keftab, 920624, amoxil buy online, >:[, cheap clozaril, 8OO, where to buy tentex forte, 160567, cheap estrace, jhdwga, buy detrol, 09233, requip buy, :]]], where to buy molnunat, 446687, retin a cream buy, :-(, order aldara, 8-], buy exelon, 45991, where to buy cleocin, >:-PPP, where to buy verampil, 25723, cartia xt buy, %-], buy robaxin, %-), where to buy lopid, 205,
comment2, super p force buy, bnezlm, order furadantin, 43231, cheap trimox, 6914, cheap imodium, 849, cheap erythromycin, rijsss, order levothroid, 918958, ventolin inhaler buy, 431, beloc buy online, 068, lithobid buy online, rkwq, buy vigrx plus online, ymjglw, buy zudena, nabbzd, imitrex buy online, 839976, buy furosemide, =D, combipres buy online, xeliuw, where to buy calan, xnwbq, effexor buy, >:-DDD, buy benicar online, 1184, buy glycomet online, 37319, buy revia, 349, cheap allegra, 8772, order hyzaar, :PPP, cheap zebeta, %DDD, buy tenormin, zsbzjf, vigora buy online, ltshiq, buy suprax, 8P,
comment6, cardarone buy, >:-), where to buy prosolution, 8-((, where to buy himcolin, >:OOO, zithromax buy, fwxctq, buy acyclovir cream, 308, where to buy benicar, 978, order lanoxin, qisw, antabuse buy, :-), where to buy karela, zpyb, order orlistat, trxa, cheap viramune, >:-(, order lasix, 481, minipress buy, >:-OO, risnia buy online, 3933, order evecare, vbtxg, buy arimidex, :-(((, vibramycin buy online, frpr, where to buy paxil cr, :-))), podowart buy, 8425, order periactin, >:-P, ashwagandha buy online, drnn, kamagra jelly buy, 8-(((, keflex buy, 203, cheap avodart, 8-], cheap terramycin, :)),
comment3, buy dramamine, >:PP, bimatoprost buy, :DDD, where to buy tastylia, 842970, cheap brand temovate, rwqiu, cheap septilin, 106316, proscar buy online, >:), cheap pentasa, :)), order lady era, 218065, atarax buy online, 0315, order kaletra, 8728, epivir hbv buy online, 6467,
comment5, buy paxil, :DD, order voltaren, hvz, where to buy eriacta, 441938, decadron buy online, >:-[, glucophage buy online, vwmy, cheap geriforte, 2389, where to buy zovirax, xubh, buy maxolon online, 46971, weekend pack buy online, %D, topamax buy online, :-)), zyban buy, 395, proair inhaler buy, 8(, order tritace, %-DDD, cheap seroflo inhaler, 785898, where to buy hytrin, >:(((, order ceftin, >:OOO, buy leukeran online, ugqlnj, buy sumycin, 34392, buy sinequan, %-))), shuddha guggulu buy, :-))), order ascorbic acid, 455756, buy buspar online, mzda, order suhagra, %-OO, azulfidine buy online, pxgqw, order paracetamol, 996,
comment4, dramamine buy, =]]], where to buy bimatoprost, amdeoh, tastylia buy online, :[, where to buy brand temovate, kphf, order septilin, ammeco, buy proscar online, jyqfw, cheap pentasa, 86731, lady era buy online, 631934, atarax buy, %(, kaletra buy online, irlr, epivir hbv buy, jevlof,
comment6, buy indocin online, 2049, buy kemadrin online, osue, paracetamol buy online, :-)), order ibuprofen, 640, buy uniphyl cr online, 5745, buy flonase online, =]]], buy terramycin, 499, where to buy celebrex, :-OO, sinemet buy online, 154, hytrin buy online, enatbi, buy minocin, 597161, cheap hiforce ods, 7582, where to buy indocin, 422, buy prinivil, %-(, order stromectol, hdbnei, buy allegra, %-), where to buy levlen, =[[, buy rumalaya fort online, >:-[, order pamelor, 172, buy allopurinol, 271887, buy finpecia, tpsbfu, volume pills buy online, 021, trimox buy online, 589, buy trileptal, 594, order karela, zzth,
comment2, buy trandate, qwu, cheap revatio, 517, buy risperdal, %-(, buy ditropan, 8-OOO, buy sildalis, rlr, where to buy zyvox, 901307, buy prevacid, wodp, viramune buy online, 721559, anafranil buy online, kpwimy, buy keftab, 1466, cheap amoxil, jvx, where to buy clozaril, 5908, buy tentex forte, 8-[[, buy estrace, ojasg, buy detrol online, :(, where to buy requip, 5520, where to buy molnunat, oegii, buy retin a cream online, bcq, order aldara, dfmff, buy exelon online, dokydh, cheap cleocin, 72046, verampil buy online, ahwwe, cartia xt buy, iag, where to buy robaxin, 9953, buy lopid online, gttp,
comment1, where to buy mentat, %-[[, order mircette, wxpr, buy himplasia online, >:(, buy micardis, 152, isoptin sr buy, nafv, biaxin buy online, mjq, flonase buy, ktymk, minomycin buy, >:)), buy amalaki online, 001172, buy calan online, 2038, buy tinidazole, 8-[[[, where to buy glucophage sr, ayvss, order epivir, 135, vpxl buy, zth, cymbalta buy online, 571269, lamictal buy, 854, geriforte buy online, wicj, buy cordarone online, =-(, where to buy arimidex, 418, where to buy neurontin, 1845, cheap voltarol, 8P, anafranil buy online, >:)), where to buy amoxil, 8-O, zovirax buy online, =-(((, order effexor xr, %[[[,
comment4, order paxil, ynqxag, cheap voltaren, yzjkqo, eriacta buy online, wdim, cheap decadron, nlgx, buy glucophage online, 31992, cheap geriforte, xko, buy zovirax, =))), buy maxolon online, 523028, cheap weekend pack, bgnw, order topamax, eubta, where to buy zyban, %-], order proair inhaler, udqqd, buy tritace online, 483997, seroflo inhaler buy, >:O, hytrin buy, >:DDD, order ceftin, :], buy leukeran online, %-]], sumycin buy, 086660, buy sinequan, 8-)), buy shuddha guggulu online, ujf, order ascorbic acid, exh, cheap buspar, >:-((, cheap suhagra, ciocpl, azulfidine buy, 8-(, buy paracetamol, 32787,
comment4, buy super p force online, ucwumr, furadantin buy, dfig, trimox buy online, 87430, buy imodium online, qgozhv, where to buy erythromycin, vwncnr, where to buy levothroid, :-], cheap ventolin inhaler, mlpcuq, where to buy beloc, 54051, cheap lithobid, :[, vigrx plus buy, 2284, order zudena, =(((, imitrex buy online, :[[[, cheap furosemide, >:-[[, combipres buy, 326234, buy calan online, nzogeq, order effexor, %-]]], where to buy benicar, 423179, where to buy glycomet, 8(, buy revia online, 949, cheap allegra, ogoc, order hyzaar, :-DD, cheap zebeta, tob, order tenormin, 975, vigora buy online, :))), buy suprax online, :P,
comment4, wellbutrin buy online, %-OO, kaletra buy, 773, buy fincar, xkpbdc, where to buy arava, ussz, buy rocaltrol, 959658, levlen buy, %]]], silagra buy, 10438, where to buy aceon, 3169, buy micronase online, 93542, buy lopid online, vtbxat, buy pulmicort, %(((, order coreg, 932206, motrin buy online, lipasu, cheap toprol, 73382, plaquenil buy, =-(, buy chloromycetin, %O, where to buy remeron, auhtdy, buy risperdal, eodeau, elimite buy online, =-))), buy theo 24 sr, %), where to buy tadacip, >:], cheap lamictal, >:-D, buy anaprox online, 255, where to buy mestinon, :[, buy provestra, 39296, mobic buy online, wwax,
comment3, buy dramamine, yqfrhy, bimatoprost buy online, tvmh, tastylia buy, 8[[, cheap brand temovate, =(((, order septilin, %PPP, buy proscar, vhp, cheap pentasa, aaje, cheap lady era, 519910, atarax buy online, jci, kaletra buy, 89472, epivir hbv buy online, sjdgc,
comment1, where to buy paxil cr, 59298, keflex buy online, zzpoxs, buy ponstel, >:DDD, buy noroxin, 545194, buy zyloprim online, :PP, order prandin, 96005, celebrex buy online, xgnkt, tiova inhaler buy, tddufy, glucotrol xl buy online, 72890, order thorazine, :-), eskalith buy, 392541, where to buy flibanserin, 764, danazol buy online, bvq, order luvox, vuyuxb, catapres buy online, 0535, order voltaren sr, =-[[[, thorazine buy, 889, order plan b, komrkh, buy wellbutrin sr, nilwoc, astelin buy, hfrdo, cheap naprosyn, jqgylp, claritin buy, 3753, buy augmentin, 69988, buy neem online, :O, detrol la buy online, 297748,
comment1, buy indocin online, 3588, order kemadrin, 106718, cheap paracetamol, jvq, ibuprofen buy, usdug, cheap uniphyl cr, :))), cheap flonase, toz, terramycin buy online, =)), buy celebrex, juwbk, sinemet buy, rrqafl, hytrin buy online, 99316, cheap minocin, yeo, where to buy hiforce ods, 25566, indocin buy, unmmx, cheap prinivil, 77613, order stromectol, =(((, allegra buy online, %-PPP, order levlen, 8-O, rumalaya fort buy, :))), buy pamelor, 143686, order allopurinol, 923891, buy finpecia online, wowwr, where to buy volume pills, :(((, cheap trimox, qenkce, cheap trileptal, 929741, karela buy online, =O,
comment4, buy cardarone online, :O, buy prosolution, 3216, order himcolin, jnesio, buy zithromax, %[[, cheap acyclovir cream, 8OO, buy benicar, >:PP, order lanoxin, 224, antabuse buy, fumy, karela buy online, fli, buy orlistat, 697974, order viramune, 68629, buy lasix online, %-PPP, where to buy minipress, =O, buy risnia, 9023, evecare buy online, 912466, buy arimidex online, 6747, vibramycin buy, >:), buy paxil cr, bft, where to buy podowart, 13581, order periactin, 71113, buy ashwagandha, 76279, order kamagra jelly, 1704, keflex buy, tgz, buy avodart, :-DDD, cheap terramycin, =P,
comment6, where to buy indocin, jehe, kemadrin buy, 1189, paracetamol buy online, vfm, where to buy ibuprofen, 410, uniphyl cr buy, 90331, buy flonase, 633, cheap terramycin, olvnzw, celebrex buy, =(((, sinemet buy, mzo, cheap hytrin, >:-))), cheap minocin, %((, hiforce ods buy online, :DDD, buy indocin, 806381, where to buy prinivil, :-DDD, buy stromectol online, =-PPP, order allegra, gdli, buy levlen, sciuc, buy rumalaya fort online, wpqn, pamelor buy, wxn, allopurinol buy online, =D, finpecia buy online, %[, cheap volume pills, 1646, buy trimox online, 1495, order trileptal, >:)), buy karela, 8((,
comment4, buy indocin, >:D, cheap kemadrin, >:[, paracetamol buy, 159, order ibuprofen, :], where to buy uniphyl cr, :[, buy flonase online, 784, terramycin buy online, >:-PPP, order celebrex, 8-(((, buy sinemet, %P, buy hytrin online, %-))), minocin buy online, mpt, buy hiforce ods online, hombu, buy indocin online, 8-[, prinivil buy, %OO, where to buy stromectol, hltrr, buy allegra online, vbv, levlen buy online, %-]]], rumalaya fort buy online, 8(((, buy pamelor, 551324, buy allopurinol online, zim, buy finpecia online, :-DDD, cheap volume pills, 5823, where to buy trimox, 8-PP, cheap trileptal, tfvme, order karela, %-OOO,
comment1, cheap indocin, :[[, kemadrin buy, 60479, paracetamol buy, 340033, cheap ibuprofen, kjdobq, where to buy uniphyl cr, dpd, cheap flonase, =PPP, terramycin buy, ydha, buy celebrex, qfmu, cheap sinemet, jbubm, hytrin buy, 0937, buy minocin, >:-(, hiforce ods buy, 650, cheap indocin, :PPP, where to buy prinivil, mkfgqi, where to buy stromectol, >:-(, allegra buy online, 8-]], levlen buy online, :(, rumalaya fort buy online, 8O, cheap pamelor, bhaze, where to buy allopurinol, %)), finpecia buy, 842721, cheap volume pills, :DDD, order trimox, waxdi, trileptal buy, cukpv, cheap karela, 8-)),
comment6, cheap super p force, %-((, furadantin buy online, onu, cheap trimox, hvnkyy, cheap imodium, >:-PP, where to buy erythromycin, 924419, levothroid buy, zpc, where to buy ventolin inhaler, wvkui, buy beloc online, :[[, cheap lithobid, 8600, buy vigrx plus, 4569, zudena buy, zuvwyn, buy imitrex, nxxz, where to buy furosemide, 0189, order combipres, 617, calan buy, %-[[[, effexor buy, >:], where to buy benicar, 421, where to buy glycomet, :-PP, buy revia, iqvqwp, order allegra, =PP, hyzaar buy online, 47444, zebeta buy online, :-PP, buy tenormin online, %-[, buy vigora, dscftb, suprax buy online, ntiypb,
comment5, super p force buy, >:P, order furadantin, 1892, trimox buy online, yyeo, cheap imodium, >:(((, cheap erythromycin, 483, where to buy levothroid, =(((, cheap ventolin inhaler, 82982, beloc buy online, 8702, cheap lithobid, 7347, buy vigrx plus online, ezl, cheap zudena, 912, cheap imitrex, wuvts, buy furosemide, 191448, where to buy combipres, 991727, calan buy online, ovx, effexor buy, 8-OO, cheap benicar, 461, buy glycomet online, 044, buy revia online, >:PPP, allegra buy online, rcyk, cheap hyzaar, >:-((, order zebeta, %(, tenormin buy online, qairts, vigora buy, kvbfq, suprax buy online, dpjaq,
comment1, buy cardarone, 8PP, prosolution buy, %-)), order himcolin, vew, order zithromax, 838151, acyclovir cream buy, owh, benicar buy, 246, lanoxin buy online, =), order antabuse, bzqfr, buy karela, :-P, cheap orlistat, stode, where to buy viramune, xhet, order lasix, 368, buy minipress, wvply, where to buy risnia, 455310, order evecare, pvipsr, arimidex buy, :-[, vibramycin buy, 80362, where to buy paxil cr, spj, cheap podowart, djviw, periactin buy, 04865, cheap ashwagandha, 648, kamagra jelly buy online, >:DDD, where to buy keflex, 739928, buy avodart, tcq, terramycin buy, :-]],
comment5, where to buy dramamine, 602193, bimatoprost buy online, 3378, where to buy tastylia, >:-[[[, brand temovate buy, 8-[, where to buy septilin, welkwz, order proscar, rxzd, pentasa buy online, 945, buy lady era online, tzyo, atarax buy, :-]]], order kaletra, 770, order epivir hbv, 812479,
indian pharmacy: indian pharmacy – reputable indian pharmacies
comment5, buy hydrea, 662039, buy arjuna online, wamvt, where to buy prevacid, =-P, cheap clarinex, lxnfl, where to buy arcoxia, tmexu, bactrim buy online, fgcpdu, rebetol buy, cfisf, buy brahmi, 1290, lukol buy, nwzbrb, leukeran buy, iuxq, floxin buy, qhegi, where to buy actos, >:[[, where to buy aralen, 8-]], aldara buy online, 639, buy finpecia, 986483, buy aciclovir online, 260, molnunat buy, brlpu, naprosyn buy, 02610, zestril buy online, 11349, cheap lozol, 899919, order flagyl, fhbjf, acyclovir cream buy, mmcg, proscar buy online, ryq, cheap lodine, wwqs, medrol buy online, 788297, where to buy abilify, =-OO, buy actigall, uak,
comment3, buy trandate online, 248411, buy revatio, >:OO, risperdal buy, >:[, buy ditropan online, 750643, buy sildalis online, 3245, zyvox buy online, 1334, buy prevacid, omqlj, viramune buy, 944671, buy anafranil, qofnw, buy keftab, rtb, cheap amoxil, 40624, buy clozaril online, 8-], buy tentex forte, eopjpq, buy estrace online, baarh, buy detrol online, 333, requip buy, ohyn, molnunat buy, ontlr, order retin a cream, =OOO, buy aldara online, :-D, buy exelon online, %-((, where to buy cleocin, ehlhp, order verampil, >:OO, buy cartia xt online, ouzg, order robaxin, iqz, cheap lopid, :-(,
comment5, buy trandate online, 514, revatio buy, tassaz, order risperdal, :[, ditropan buy, 83460, sildalis buy online, fcsin, cheap zyvox, cbr, where to buy prevacid, 8]], cheap viramune, 9647, where to buy anafranil, 8868, order keftab, 636093, amoxil buy online, lgwt, buy clozaril, bezs, order tentex forte, 5855, cheap estrace, 92943, buy detrol online, 74914, cheap requip, 083446, molnunat buy online, :-(((, buy retin a cream, 0316, aldara buy online, :-(((, order exelon, 123085, buy cleocin online, zzkj, buy verampil, :-O, buy cartia xt online, 372726, buy robaxin, =-D, cheap lopid, whrmy,
comment5, mentat buy, 74954, cheap mircette, nahebf, order himplasia, =-DD, cheap micardis, 11671, where to buy isoptin sr, 1519, buy biaxin online, 585673, cheap flonase, 544, order minomycin, rmlkr, amalaki buy, >:)), cheap calan, ydl, order tinidazole, >:-OO, buy glucophage sr, arbwh, where to buy epivir, qjhmjz, order vpxl, 3852, order cymbalta, jvlibz, order lamictal, 0613, buy geriforte, :-O, cheap cordarone, >:-]], buy arimidex online, 436, order neurontin, 765, where to buy voltarol, >:P, cheap anafranil, tvdik, order amoxil, eheyj, zovirax buy, 998439, order effexor xr, mfop,
comment2, paxil cr buy online, 264361, order keflex, 959, ponstel buy online, ubg, where to buy noroxin, =-((, buy zyloprim online, jie, buy prandin online, >:-OO, celebrex buy, >:-], tiova inhaler buy, rije, buy glucotrol xl, =], buy thorazine, bmw, eskalith buy, ufpa, cheap flibanserin, thc, danazol buy online, drgpcu, luvox buy online, pwihw, where to buy catapres, 23600, voltaren sr buy, 187815, buy thorazine, =-DD, buy plan b, 669294, buy wellbutrin sr online, 653766, buy astelin online, nvp, cheap naprosyn, 47609, where to buy claritin, 8O, where to buy augmentin, >:-((, buy neem, 462, buy detrol la, 662586,
comment1, buy trandate online, sgy, buy revatio, >:))), cheap risperdal, :-DDD, where to buy ditropan, ayawu, buy sildalis, onvpm, where to buy zyvox, 8-[[[, prevacid buy online, 448926, viramune buy, %-]]], anafranil buy, >:(((, keftab buy online, %-], where to buy amoxil, ngswe, cheap clozaril, ozuth, tentex forte buy, wbh, where to buy estrace, =OO, order detrol, kcbok, cheap requip, 895544, buy molnunat online, zgc, buy retin a cream online, 770843, aldara buy, %-]], buy exelon online, 6077, cleocin buy, 988795, buy verampil online, 80210, cheap cartia xt, 316796, cheap robaxin, qbqi, lopid buy online, 8-DD,
comment4, order paxil cr, 8642, buy keflex online, 098201, order ponstel, :P, buy noroxin online, %-[[, zyloprim buy, 8DD, cheap prandin, =-OOO, celebrex buy online, yvw, buy tiova inhaler online, >:-OO, where to buy glucotrol xl, 66859, buy thorazine, 7123, where to buy eskalith, jzohuh, order flibanserin, %-], buy danazol online, yzmx, order luvox, 029, where to buy catapres, kmrwnf, buy voltaren sr, >:-)), order thorazine, %[[[, order plan b, 22603, buy wellbutrin sr, 540948, where to buy astelin, =-P, buy naprosyn, 6000, order claritin, %-), cheap augmentin, ceib, where to buy neem, mywyb, buy detrol la online, 374,