Thursday, April 13, 2006

Transparency in Healthcare

Dr. Wes, a cardiologist, asks if it might make a difference in healthcare costs if we knew the actual cost of our care:

But what if costs were disclosed? What if costs were available online or during the ordering process on the Electronic Medical Record for physicians to make judgments about how many tests they REALLY need? Might it affect care negatively? I doubt it. Would it change outcomes? Probably not. Reduce cost? Absolutely. Is it difficult to implement? No.

And taking that concept one further, what if the patient could see the costs of expensive technologies? What if the costs of implantable defibrillators were available online? (For instance, it’s easier to find what a defibrillator weighs, than what it costs…. I checked Google, the big three ICD manufacturers websites [Guidant, Medtronic, St. Jude] and could find none.) Stents? Would patients always want the “expensive version” of technology or would they settle for a lesser model if it saved them or the system a few bucks? I don’t know. But to shield the ultimate consumers (the patient and their doctors) from these costs is counter-productive and serves to permit price increases to occur without public awareness and limits free-market competition. Transparency in healthcare costs is just as important as transparency on corporate financial statements. Maybe more. And this won’t just help the doctors and patients.

Incidentally , Dr. Wes, mine cost about one hundred thousand dollars--give or take a bit.

36 Comments:

Blogger TMink said...

Also, think how elective surgeries that are not covered by insurance are priced. Laser vision correction specialists advertise specials on the radio here in Nashville. Breast enhancement docs often offer two for the price of one. But I digress.

Certainly, knowing the cost and paying out of pocket share some psychology. It is easy to ignore the bills that the insurance pick up. But thank God they were there for our triplets stay in the NICU which was up there with Dr. Helen's new ticker.

6:20 PM, April 13, 2006  
Anonymous The Medical Blog Network said...

We have been beating the drum of healthcare transparency over at TMBN ever since getting started. Without openness about availability, relevance, quality, and pricing there can be no meaningful reform.

Check out my recent commentary on Health IT World: Consumers at the Gates: Resistance Is Futile

... and an older blog post outlining the vision: Open Medicine vs. Single-Payor Healthcare

7:21 PM, April 13, 2006  
Blogger Greg Kuperberg said...

Incidentally , Dr. Wes, mine cost about one hundred thousand dollars--give or take a bit.

In the interest of transparency, did that hundred thousand dollars come out of family health benefits for Tennessee state employees?

8:03 PM, April 13, 2006  
Anonymous Anonymous said...

For people covered by insurance adequate to pay the bill, what difference would it make if they knew the cost of the services?

10:23 PM, April 13, 2006  
Anonymous Anonymous said...

Costs represent expenditure of resources to provide a good or service. Price is what is charged to the consumer.

In dealing with healthcare it's important to acknowledge that one person's costs are the prices they pay to another person. So we have to be careful when we think we know the cost.

For example, the $100K defibrillator has a cost that includes the research, development, testing, regulatory compliance, manufacture, and marketing of the device. This is internal to the manufacturer, and will never be divulged.

What might be known is the unit price the manufacturer charges the hospital. Then we can look at the unit price the hospital charges the patient.

The $100K is better thought of as a price rather than a cost. I suspect it is the price the hospital charges the patient. It is probably far different than the manufacturer's cost.

All defibrillators of the same manufacturer and model will have the same cost, but the final price to the consumer may have large variations.

10:53 PM, April 13, 2006  
Blogger David said...

"a cost that includes the research, development, testing, regulatory compliance, manufacture, and marketing of the device. This is internal to the manufacturer, and will never be divulged"...although it won't be divulged for a specific device type, it could probably be estimated fairly closely from the P&L and other financial disclosures of the manufacturer.

8:41 AM, April 14, 2006  
Blogger Dave said...

Isn't this a perfect example of asymmetrical information, wherein one party (isnurers, medical device manufacturers) has more information than another party (patients, doctors)?

Information asymmetries, as I understand them, reduce efficiencies (and transparency) and exacerbate costs.

8:42 AM, April 14, 2006  
Anonymous Anonymous said...

David,

One might be able to estimate the cost of a device from the P&L if the company produced only one device. But most of these things come from very large companies with diverse operations and products.

Even within the company there will be a struggle between different project managers over how much of the company overhead will be charged to their particular product.

9:31 AM, April 14, 2006  
Blogger DrWes said...

Well, Helen, here's another tidbit - a reader on my blog mentioned his e-mail to me that in Pennsylvania, his device was billed at $77,545. Now, if INTERSTATE open competition was available for health benefits, I bet your insurer would love to have paid a lower price. But as long as our politicians and elected officials are fed by the pharmaceutical, device industry, and insurance interests, not much is gonna change. But what if our "Army of Davids" insisted on this transparency?

9:47 AM, April 14, 2006  
Blogger Helen said...

DrWes,

I have heard of other devices costing more and some less from others in my cardiac wellness program--one patient mentioned his was 125,000 but I believe what some people think is the price--is actually what is billed to the insurance company--most do not pay near that amount.

The hospital I go to gives me a printout of every charge prior to charging me or my insurance company for it. I doubt this is typical but it is one reason, I use this hospital because at least I know what the charges are for each procedure etc.

10:02 AM, April 14, 2006  
Anonymous Anonymous said...

I think knowing the cost would help. I went in to the ER last fall for chest pains and after a couple EKG's and a thorough exam, the docs determined that I had a strained intercostal ligament from moving furniture a couple days prior. The doc said he was "99.5%" sure that's what it was. He offered me a chest x-ray and another test to rule out any other problems but I declined -- I've worked on the periphery of health care for years and I know how much these things cost, and I couldn't justify the expense in my head for 0.5%, when the doctor's explanation made perfect sense to me.

10:03 AM, April 14, 2006  
Anonymous Anonymous said...

I suspect the price of a defibrillator in a hospital is similar to the price of a tablet of Tylenol. We all know what Walgreens charges for Tylenol, yet hospitals charge between $2 and $5 per tablet.

They are spreading their total costs over as many items as possible. The $2 price for Tylenol has no relation to the price the hospital pays for Tylenol, but it has a huge relationship to the costs the hospital incurs to keep the whole operation running.

The same is true of sophisticated medical devices. The hospital will spread operating costs over the prices it charges for its medical devices. All those costs get spread, but different hospitals may have different allocations.

Knowing the specific price of a medical device would be useful only within the confines of a single hospital. If DefibA is priced at $100,000 while DefibB is priced at 125,000, then the consumer could say the entire procedure could have a price variance of $25,000, and could make a choice.

A patient can't get a defibrillator from hospital-A, then get a surgeon from hospital-B, then get an operating room from hospital-C, then get post-operative care at hospital-D. It's a package deal, and all the consumer will care about is the total price of the package.

However, for high priced items, all the consumer will really care about is his out of pocket expenses after insurance pays the hospital.

12:48 PM, April 14, 2006  
Blogger DrWes said...

"... all the consumer will really care about is his out of pocket expenses after insurance pays the hospital."

Anonymous is right. And therein lies the nearly impossible double-bind doctors (and yes patients) encounter when trying to "fix" the healthcare system.... insurance. The patient doesn't have to pay... or do we?

I agree that markup of prices for hospitals in inevitable (and even necessary) if they are to keep their doors open... after all, they must pay their bills, too. But to think that these price elevations that exceed the rate of inflation can continue and don't effect society at large (look at the number of uninsured) is also flawed.

I think that if a "retail price" of a defibrillator system (generator and leads) was posted publically at, say, $39,000, then the markup for YOUR hospital can be estimated WITHOUT reviewing company financial statements, and if the billed price becomes say, $200,000 next year (even though a wide range of prices can be found in great blogs like this), you might want to know why and are now empowered to negotiate, or if needed, litigate.

2:08 PM, April 14, 2006  
Blogger gs said...

Not having time to look for references, I submit the following as barely a step up from a rumor. (Reader beware!) Months or years ago, I read that medical societies like the AMA compile cost-of-treatment statistics for standard procedures, but these organizations try hard to keep the data out of the public eye: in one case, by claiming that the information is their intellectual property.

2:12 PM, April 14, 2006  
Anonymous Anonymous said...

drwes,

Health care costs will continue to increase, and these will be reflected in prices. The only way to keep health care costs down is to curtail innovation and the delivery of that innovation to the public.

When did implantable defibrillators become available? I don't know, but let's say 1990. Before then people just died. There was no additional care delivered, hence no additional costs. Innovation offer possibilities that didn't exist before, and people want to buy them.

The same is true of CAT scans, MRIs, angiograms, artificial joints, and drugs. When they didn't exist, there was neither cost nor price.

The next innovation down the line will be snapped up just as quickly as those mentioned above. Costs are not being driven up, rather total available treatments have multiplied. Each additional treatment has a cost, and it adds to the aggregate.

There may be a future tipping point where treatments maintain and increase health rather than correct problems. That could result in decreasing costs as current and future corrective therapies are no longer needed.

For those who personally don't want to wait for that tipping point there is always healthy eatig and exercise.

Regarding the $200,000 billed price of a $39,000 device:

Pushing that price down through any means is just a game of mole bashing. Push one price down, and another pops up as the hospital covers its operating costs. Push them all down, and service is curtailed since the hospital can no longer maintain the level of service.

2:33 PM, April 14, 2006  
Blogger DrWes said...

Anony-

Your points are cogent and right on. And technology is awesome: we've seen longevity increase to unprecidented levels through this unbelievable innovation. But there ARE options in therapy that might save money (does every patient need a dual chamber defibrillator when a single-chamber device might suffice?) In the old days, there were not "lifetime limits" to insurance policies, but $200K is a healthy chunk out of a commonly-available $2 million dollar lifetime policy. What happens when you hit your max?

Unfortunately, the multiplicity of testing we do if often unnecessary, but is performed streamline patient visits and limit liability. (Don't get me started about liability reform). We can and should do more to curb costs in conjunction with the hospitals and insurers. I'm just saying, that awareness of the costs of these tests when I order them might help limit expenses, and that is good. And real costs to the patient provide a useful starting point when these decisions are made.

Infestation with 'moles' can be beaten by removing the food that keeps 'em alive and multiplying, yet the strong (responsible) will adapt and survive. Efficient, responsible hospital systems and insurers will survive in a free, open-market system. (Why have Certificate of Need states?) But finding the bad moles without restricting their access to unlimited food (our dollars) is, as you say, impossible.

3:14 PM, April 14, 2006  
Anonymous Teresa said...

Years ago (nearly 20) I was being treated at a large University hospital. I was referred there by my original doctor for treatment he supposedly could not provide. So, I went. It was 50 miles from my house and (due to traffic) took me nearly 2 hours to get there.

They wanted me to have a scan that meant I would have to go to the hospital there for 2 consecutive days in a row. The scan cost $895 and took up 2 complete days because of travel and waiting room time. They wanted me to do this every 3 months! And even though the insurance was picking up the tab - I was still having to take huge chunks of time to get it done. (did I mention I had young children at home back then?)

The second time, I asked them to call either or both of my local hospitals to see if they had this scanner available. I could get it done there and have the results sent to them. They resisted mightily saying that - outlying hospitals just don't have the good equipment their hospital had... (this is BS by the way) I told them - I didn't have the time to waste entire days everytime they wanted to do a test.

Well, it seems that not only did both local hospitals have the scanner - they were both newer and in much better physical shape then the one at the University hospital. AND it cost $495 for the scan!!! A nearly 50% difference in price.

I didn't go to that University hospital for long - they finally ticked me off enough that I went looking for a doc closer to home. But the lesson was - always check on prices - especially if your insurance only pays a percentage of your bill!

6:05 PM, April 14, 2006  
Anonymous Anonymous said...

With costs increasing insurance companies are becoming coyer. Often they are willing to pay their percentage of ""fair and reasonable"" costs rather than what is charged. Often their fair and reasonable is 25 % or thereabouts of charges. To appeal the patient has to show comparable charges at other facilities which are virtually impossible to get. Itis a system out of control. Transparency can only help.

11:37 PM, April 14, 2006  
Blogger Maj.BertramPudgeman said...

Was the 100k the cost or the price? The reason I ask is that my mother's recent catherization and overnight hospital stay was billed at $40,000!!! Then discounted to medicare to be about $3,500. (No there is not an extra zero in the 40k.) I wonder what the true cost was and I know what the price is. Unbelievable.

7:26 AM, April 15, 2006  
Blogger SMSgt Mac said...

Dr Wes is correct. Increased transparency of medical costs is desirable. There are four relevant possible cost outcomes to having increased cost awareness. 1. Costs keep rising out of control, 2. costs keep going up but at a manageable rate, 3. costs are stable and change only due to inflation/deflation, or 4. costs go down.
The first outcome is no change from the current condition. It would be impossible to discern if the out of-control-rise in costs was abetted or mitigated by incresed transparency unless the costs were brought under control which is by definition another outcome. Unless someone can identify a mechanism by which increased transparency would cause costs to rise faster, I would say the such a case would be infeasible: hence there is absolutely no risk to having increased transparency on the one hand, While there is a high probability of improvement on the other, since all other possibile outcomes are desirable.

12:10 PM, April 15, 2006  
Anonymous Anonymous said...

smsgt mac,

1. What do you mean by control of costs? Whose control? Towards what purpose? Do we usually see control of costs in our economy? How does one control the resources expended to deliver a chest X-Ray?

Are you sure you aren't referring to prices? If so, our overwhelming experience shows that control of prices leads to shortages of goods and services.
----------------------------
2. What is a manageable rate of cost increases? Costs actually tend to go down over time as efficiencies are realized and fewer resources are necessary to deliver a given service. So, I will presume you mean managable price increases. What does that mean? Managable by whom? Managable over a fixed set of services, or including new treatments, technlogies, and drugs that are added? Mangable for a single service, or managable for the aggregate of all services?
-------------------------
3. Any expectation that aggregate prices will move only with inflation is based on a fixed level of service that does not change with added technology. If we stayed with X-Rays only, this might apply. However, when Cat scans and MRIs became available, the X-Ray was supplanted in many cases because of a better service. Limiting aggregate prices to inflation means freezing service quality and prohibiting the introduction of new technology.

Limiting individual service prices to inflation inhibits the introduction of new technologies, since the hospitals tend to spread the very high cost of new technologies over the existing services until the new technology begins to experience efficiencies of scale.
----------------
4. Prices of individual services may go down as technology provides more cost efficient means of delivery. However, those services will usually be used to subsidize the higher costs of new technologies.
---------------------
5. Increased transparency will probably hurt nothing, but it will also do nothing to change the basic forces at work. It might add a level of understanding that is currently absent, but it would probably also create competing interests, as particular patient groups fight to keep the price of their own treatment low regardless of what happens to the prices of other peoples' treatment. We would have the defibrillator folks fighting the artificial hip folks over how much over the direct costs of their treatment they should bear.

We see a similar situation today with drugs. Interest groups for a given disease tout the fact that it costs twenty-five cents to produce a particular pill. So, they want to pay only thirty cents. They ignore 1)development costs, 2) profit incentive, and 3) the fact that part of the price of the pill that solves their malady is being used to develop treatments for currently untreated maladies.

The new drugs on the market were financed by the prices charged for the old drugs that have been on the market. People are content that others paid for the development of their drug, but want the chain to stop with them and their malady. They don't want to pay anything that pays development for new drugs.
----------------------------
6. So, should we oppose price transparency? I don't think anyone really knows what is meant by the term, and at present it is undefinable since the assumptions behind the idea have not been defined in economic terms.

1:36 PM, April 15, 2006  
Blogger quadrupole said...

Anonymous

1) For chest x-ray delivery there are several components to the cost. First, you have the capital investment in the x-ray machine, I expect this to decline over time as we get better at making the equipment. Second, you have the cost of the rad-tech, there may be room for decline by better managing the rad-tech as a resource, but probably not much. Third, you have the cost of interpretation by the radiologist (an MD). We already have VERY good expert systems to interpret x-rays. However, it turns out that the expert systems tend to miss things radiologists catch, and catch things radiologists miss, so while they improve care, they don't replace a radiologist. There is now a growing industry in outsourcing x-ray interpretation to radiologists in India, who do comparable work to US radiologists at a fraction of the cost. So there's a lot of room to squeeze down the cost of chest x-rays.

3) I can point to several industries where costs have dropped and the quality of the good or service delivered has dramatically increased.

2:52 PM, April 15, 2006  
Blogger SMSgt Mac said...

Whoa there Anon!

First off, I hope your spleen is back where it belongs- that had to hurt. ;-)

You spilled a lot of ink and incurred a lot of Opportunity Cost in response to a very short, very top-level analysis.

First off, recognize I’m talking System Analysis, Ops Research and Game Theory. You are talking Econ 101 & 102. We are viewing the same landscape but describing different things while speaking different languages. It also doesn't help, as you recognized in your comment, that there is indeed a fairly high level of abstraction to the concepts (health care, transparency, etc) we are discussing at this time.

Second: I never confuse "price" and "cost". “Price” is what one pays for a "Cost".

Third: Methinks “Cost Control” are trigger words for your ears. Re: What do you mean by control of costs? Towards what purpose? Whose control?

“Control” should not be interpreted as some single entity with their hand on the switch – and it surely doesn’t mean 99% of what any Legislator or 99.9% of any Legislative Committee could come up with on their own. In fact, about the only thing they could do that was positive is remove or weaken some laws and regulation – but they’d probably screw that up too.

Actors within the health care system, by negotiated and/or iterated design, exert pressure (including possibly changing the system design and adding or removing actors within the system) on the system through either new or changed behaviors or technical/material innovation(s) that alter the performance of the system, to meet one or more desired objectives.

In this case the desired objectives are to ensure the sustainability of an effective health care system while attenuating/eliminating the growth in the resources involved in the operation of the health care system for the benefit of the actors within the system. Responsibility is shared (this is where legislation usually screws things up) among all the actors in the system. Ultimately, one might say the designers and actors are the ‘controllers’. Within an ideal closed system, I believe the designers and actors would be the same.

Increased transparency (knowledge about) of the health care system design and associated costs can only allow the actors within that system to identify system design weaknesses and strengths, and then motivate them to act on that knowledge and improve the system.

My apologies to our host for eating up her bandwidth.

6:13 PM, April 15, 2006  
Anonymous Anonymous said...

Mac,

By your definition I'd have to say the health care system is controlled. The actors do negotiate, iterate, and exert pressure. However, there is no reason to think control exists only if it is aimed at an objective of "the sustainability of an effective health care system while attenuating/eliminating the growth in the resources involved in the operation of the health care system for the benefit of the actors within the system."

The control could be aimed at many different objectives. I don't think you can say control exists only when it aims at one chosen objective.

We might also recognize that in a large system it is reasonable to expect people to negotiate, iterate, and exert pressure towards many different objectives.

I would also disagree that your objective is optimal. Creating resources within the system for the benefit of the actors can have a positive or negative effect. It can be positive when a new MRI center is opened by actors seeking to maximize personal wealth by providing an incremental service. Growth in rsources also happens each time a newly minted doctor hangs out his shingle in seeking personal benefit. It can be negative when an administrator seeks to pad staffing by employing relatives.

I'd say the consideration of personal benefit of the actors tells us little.

Do you consider the health care system to be a closed system? If so, why?

10:32 PM, April 15, 2006  
Anonymous John G said...

Having just gone through two hospitalizations/surgeries, I look somewhat askance at the notion that, had I known the cost of particular items beforehand, my use of hospital/medical resources might have been different. Frankly, that's nonsense.

The first hospitalization was emergent care and an extended stay due to my condition and complications. Most of the time I was sedated and, even when conscious, probably incapable of making serious decisions due to the combination of the after effects of anesthesia, prolonged sedation, narcotic pain killers, scads of other meds, and extended immobilization in bed. In a word, I was "out of it".

The 2nd hospitalization was the reversal of the 1st procedure - a reconnection of sorts. I chose to undergo it rather than live with the appliance I had been left with following the 1st surgery. I chose it knowing it would involve at least a week in the hospital, surgery, recovery, sedation, narcotic pain killers, scads of other meds, and the risk of complications (some of which arose). I chose it knowing that after the 1st $140,000 procedure/hospitalization, this one would run probably a third of that (actually, it ran about $60k).

Had I been able, would I have chosen anything different? Definitely not. First, who am I to tell my physicians what to do and not do? Second, as mentioned, I was in no condition mentally to add 1 plus 1 for much of the time (I'm told when I woke up from an extended unconsciouness following the 1st surgery, and asked my name, I persisted in replying that I was Sir Thomas More, Exchequer of England. Although I don't remember that happening, I'm heartened by the fact that at least I was selective in my choice of identities.) Now, if only my subjects had obeyed...

The only significant choice I made during the entire time was to refuse to have a nasal gastric tube replaced (a vile procedure) when it became apparent that it had been removed too soon. I lived, somewhat uncomfortably, for a day or two until things normalized, but I did live.

Choices, prices, alternatives were meaningless. I was insured, this is what my physicians wanted, therefore I mostly went along. That's all that mattered to me.

In actuality, I later learned that what Blue Cross paid the hospital was something less than retail. Significantly less. I'm pleased at that development, but it still doesn't change things.

JohnG

10:09 AM, April 16, 2006  
Blogger look said...

情趣用品,
性感睡衣,
免費視訊聊天,
視訊交友網,
美姬圖影,
情境坊歡愉用品,
花美姬情趣用品,
成人圖片,
臺灣情色網,
嘟嘟情人色網,
色情網站,
情境坊歡愉用品,
徵信,
徵信公司,
徵信,
外遇,
徵信,
徵信,
抓姦,
徵信,
外遇,
徵信,
徵信社,
徵信社,
抓姦,
徵信社,
徵信社,
徵信社,
,
,
整型,
視訊聊天,
視訊交友,
AV女優,
色情,
A片,
A片,
情趣用品,
情色,
A片,
色情影片,
情趣用品,
A片,
AV女優,
視訊聊天室,
聊天,
情趣用品,
情惑用品性易購,
情侶歡愉用品,
A片,
情趣,
情惑用品性易購,
辣妹視訊,
自慰套,
情侶歡愉用品,
寄情築園小遊戲,
aio交友愛情館,
美女視訊,
色情A片,
情趣用品,
徵信社,
情趣用品,
A片,
美女視訊,
色情A片,
AV女優,
A片,
辣妹視訊,
自慰套,
情侶歡愉用品,

12:00 AM, March 15, 2009  
Blogger mmbox said...

本土成人貼圖站大台灣情色網台灣男人幫論壇A圖網嘟嘟成人電影網火辣春夢貼圖網情色貼圖俱樂部台灣成人電影絲襪美腿樂園18美女貼圖區柔情聊天網707網愛聊天室聯盟台北69色情貼圖區38女孩情色網台灣映像館波波成人情色網站美女成人貼圖區無碼貼圖力量色妹妹性愛貼圖區日本女優貼圖網日本美少女貼圖區亞洲風暴情色貼圖網哈啦聊天室美少女自拍貼圖辣妹成人情色網台北女孩情色網辣手貼圖情色網AV無碼女優影片男女情色寫真貼圖a片天使俱樂部萍水相逢遊戲區平水相逢遊戲區免費視訊交友90739免費視訊聊天辣妹視訊 - 影音聊天網080視訊聊天室日本美女肛交美女工廠貼圖區百分百貼圖區亞洲成人電影情色網台灣本土自拍貼圖網麻辣貼圖情色網好色客成人圖片貼圖區711成人AV貼圖區台灣美女貼圖區筱萱成人論壇咪咪情色貼圖區momokoko同學會視訊kk272視訊情色文學小站成人情色貼圖區嘟嘟成人網嘟嘟情人色網 - 貼圖區免費色情a片下載台灣情色論壇成人影片分享免費視訊聊天區微風 成人 論壇kiss文學區taiwankiss文學區

7:04 AM, March 22, 2009  
Blogger mmbox said...

2008真情寫真aa片免費看捷克論壇微風論壇大眾論壇plus論壇080視訊聊天室情色視訊交友90739美女交友-成人聊天室色情小說做愛成人圖片區豆豆色情聊天室080豆豆聊天室 小辣妹影音交友網台中情人聊天室桃園星願聊天室高雄網友聊天室新中台灣聊天室中部網友聊天室嘉義之光聊天室基隆海岸聊天室中壢網友聊天室南台灣聊天室南部聊坊聊天室台南不夜城聊天室南部網友聊天室屏東網友聊天室台南網友聊天室屏東聊坊聊天室雲林網友聊天室大學生BBS聊天室網路學院聊天室屏東夜語聊天室孤男寡女聊天室一網情深聊天室心靈饗宴聊天室流星花園聊天室食色男女色情聊天室真愛宣言交友聊天室情人皇朝聊天室上班族成人聊天室上班族f1影音視訊聊天室哈雷視訊聊天室080影音視訊聊天室38不夜城聊天室援交聊天室080080哈啦聊天室台北已婚聊天室已婚廣場聊天室 夢幻家族聊天室摸摸扣扣同學會聊天室520情色聊天室QQ成人交友聊天室免費視訊網愛聊天室愛情公寓免費聊天室拉子性愛聊天室柔情網友聊天室哈啦影音交友網哈啦影音視訊聊天室櫻井莉亞三點全露寫真集123上班族聊天室尋夢園上班族聊天室成人聊天室上班族080上班族聊天室6k聊天室粉紅豆豆聊天室080豆豆聊天網新豆豆聊天室080聊天室免費音樂試聽流行音樂試聽免費aa片試看免費a長片線上看色情貼影片免費a長片

7:04 AM, March 22, 2009  
Blogger 平平 said...

^^ nice blog!! ^@^

徵信, 徵信網, 徵信社, 徵信社, 感情挽回, 婚姻挽回, 挽回婚姻, 挽回感情, 徵信, 徵信社, 徵信, 徵信, 捉姦, 徵信公司, 通姦, 通姦罪, 抓姦, 抓猴, 捉猴, 捉姦, 監聽, 調查跟蹤, 反跟蹤, 外遇問題, 徵信, 捉姦, 女人徵信, 女子徵信, 外遇問題, 女子徵信, 外遇, 徵信公司, 徵信網, 外遇蒐證, 抓姦, 抓猴, 捉猴, 調查跟蹤, 反跟蹤, 感情挽回, 挽回感情, 婚姻挽回, 挽回婚姻, 外遇沖開, 抓姦, 女子徵信, 外遇蒐證, 外遇, 通姦, 通姦罪, 贍養費, 徵信, 徵信社, 抓姦, 徵信, 徵信公司, 徵信社, 徵信公司, 徵信社, 徵信公司, 女人徵信,

徵信, 徵信網, 徵信社, 徵信網, 外遇, 徵信, 徵信社, 抓姦, 徵信, 女人徵信, 徵信社, 女人徵信社, 外遇, 抓姦, 徵信公司, 徵信社, 徵信社, 徵信社, 徵信社, 徵信社, 女人徵信社, 徵信社, 徵信, 徵信社, 徵信, 女子徵信社, 女子徵信社, 女子徵信社, 女子徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信社,

徵信, 徵信社,徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 外遇, 抓姦, 離婚, 外遇,離婚,

徵信社,徵信, 徵信社, 徵信, 徵信社, 徵信,徵信社, 徵信社, 徵信, 外遇, 抓姦, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信社, 徵信社, 徵信社,徵信,徵信, 徵信, 外遇, 抓姦

1:56 AM, March 30, 2009  
Blogger nini said...

85cc免費影城 愛情公寓正妹牆川藏第一美女 成人影片 情色交友網 美女視訊 美女視訊 視訊情人高雄網 JP成人影城 383成人影城 aa片免費a片下載 a片線上看aa片免費看 ※a片線上試看※sex520免費影片※ aa片免費看 BT成人論壇 金瓶影片交流區 自拍美女聊天室 aa片免費a片下載 SEX520免費影片 免費a片 日本美女寫真集 sex520aa免費影片 sex520aa免費影片 BT成人網 Hotsee免費視訊交友 百分百貼影片區 SEX520免費影片 免費視訊聊天室 情人視訊高雄網 星光情色討論版 正妹牆 383成人影城 線上85cc免費影城 85cc免費影城 85cc免費影城 85cc免費影城 ※免費視訊聊天室※ ※免費視訊聊天室※ 免費視訊聊天室 85cc免費影片 85cc免費影片 080苗栗人聊天室 080苗栗人聊天室 080中部人聊天室 080中部人聊天室 免費a片下載 免費a片 AA片免費看 aa片免費看 aa片免費看 aa片免費看 aa片免費看 日本av女優影片 av女優 av女優無碼影城 av女優 av女優 百分百成人圖片 百分百成人圖片 視訊情人高雄網 電話交友 影音電話交友 絕色影城 絕色影城 夜未眠成人影城 夜未眠成人影城 色咪咪影片網 色咪咪影片網 色咪咪影片網 色咪咪影片網 色咪咪影片網 免費色咪咪貼影片 免費色咪咪貼影片 色情遊戲 色情遊戲 色情遊戲 色情遊戲 影音視訊交友網 視訊交友網 080視訊聊天室 ※免費視訊聊天室※ ※免費視訊聊天室※ 視訊聊天室 成人影音視訊聊天室 ut影音視訊聊天室 ※免費視訊聊天室※ 視訊ukiss聊天室視訊ukiss聊天室 視訊交友90739 視訊交友90739 情人視訊網 168視訊美女 168視訊美女 168視訊美女 視訊美女館 視訊美女館 免費視訊美女網 小高聊天室 小高聊天室 aio交友聊天室 aio交友聊天室 交友聊天室 交友聊天室 線上a片 線上a片 線上a片 線上a片 線上a片 免費線上a片 免費線上a片 嘟嘟成人網站 成人漫畫 情色文學 嘟嘟成人網 成人貼圖區 情色文學成人小說 微風成人區 情色貼圖區 免費視訊聊天 免費成人圖片區 愛情公寓 愛情公寓聊天室 寄情築園小遊戲 免費aa片線上看 aa片免費看 情色SXE聊天室 SEX情色遊戲 色情A片 免費下載 av女優 俱樂部 情色論壇 辣妹視訊 情色貼圖網 免費色情 聊天室 情人視訊聊天室 免費a片成人影城 免費a片-aa片免費看 0204貼圖區 SEX情色 交友聊天-線上免費 女優天堂 成人交友網 成人情色貼圖區 18禁 -女優王國 080視訊美女聊天室 080視訊聊天室 視訊交友90739 免費a片 aio 視訊交友網 成人影城-免費a片※免費視訊聊天※85cc免費影片日本線上免費a片 免費色咪咪影片免費色咪咪影片aaa片免費看影片aaa片免費看成人影城免費色咪咪影片

1:45 PM, April 05, 2009  
Blogger 天天看正妹 said...

免費視訊聊天 ut聊天室辣妹視訊UT影音視訊聊天室 吉澤明步QQ美女視訊秀 85cc免費影片aa影片下載城sex免費成人影片aaa片免費看短片美女視訊 sex383線上娛樂場av969 免費短片日本免費視訊aa影片下載城視訊網愛聊天室影音視訊交友 咆哮小老鼠分享論壇sex520免費影片aa免費影片下載城aio辣妺視訊 aio辣妹交友愛情館 jp成人影片aio交友愛情館馬子免費影片免費線上a片18成人85cc影城0204movie免費色咪咪視訊網pc交友s383視訊玩美女人34c高雄視訊聊天jp成人免費視訊辣妹 kk777視訊俱樂部xxxpandalive173影音視訊聊天室 sex520-卡通影片成人免費視訊 完美女人13060 免費視訊聊天sexy girl video movie辣妹妹影音視訊聊天室UT視訊美女交友視訊情色網百事無碼a片dvd線上aa片免費看18禁成人網ut聊天室kk俱樂部視訊激情網愛聊天 情人小魔女自拍卡通aa片免費看夜未眠成人影城aio性愛dvd辣妹影片直播拓網視訊交友視訊聊天室ggoo168論壇視訊辣妹love104影音live秀 美女show-live視訊情色yam交友辣妹妹影音視訊聊天室s383情色大網咖視訊aaa俱樂部台灣情色網無碼avdvdsexy diamond sex888入口Show-live視訊聊天室

4:11 AM, April 14, 2009  
Blogger 天天看正妹 said...

免費 a 片aaaaa片俱樂部影片aaaaa片俱樂部dodo豆豆聊天室sex520網路自拍美女聊天室天堂免費線上avdvd援交av080影片aa影片下載城aaa片免費看短片成人圖片區18成人avooogo2av免費影片sexdiy影城免費線上成人影片bonbonsex0951影片下載日本av女優sex888免費看影片免費視訊78論壇辣妹有約辣妹no31314視訊dudu sex免費影片avdvd情色影片免費色咪咪影片網av080免費試看日本美女寫真集辣妹脫衣麻將視訊聊天室性福免費影片分享日本美女寫真集,kk視訊aio交友愛情館免費成人美女視訊bt論壇色情自拍免費a片卡通tw 18 net卡通18美少女圖色情漫畫777美女小護士免費 aa 片試看百分百成人情色圖片a片免費觀賞sexy girls get fuckedsexy girl video movie情色文學成人小說sex888免費看eyny 伊莉論壇sexdiy影城自拍情色0204movie免費影片aio免費aa片試看s383情色大網咖sexy girl video movie草莓牛奶AV論壇台灣論壇18禁遊戲區環球辣妹聊天室 90691拓網aio交友愛情館拓網學生族視訊777美女 sex888影片分享區hi5 tv免費影片aa的滿18歲卡通影片sex383線上娛樂場sexdiy影城免費a片線上觀看真人美女辣妹鋼管脫衣秀比基尼辣妹一夜情視訊aio交友愛情館

4:11 AM, April 14, 2009  
Blogger 天天看正妹 said...

小魔女免費影城免費看 aa的滿18歲影片sex383線上娛樂場kk777視訊俱樂部aa的滿18歲影片85cc免費影片a片免費看A片-sex520視訊聊天室v6 0plus論壇sex520免費影片avdvd-情色網qq美美色網ut13077視訊聊天A片-無碼援交東京熱一本道aaa免費看影片免費視訊聊天室微風成人免費視訊聊天 ut聊天室av1688影音視訊天堂免費 a 片85cc免費影城亞洲禁果影城微風成人av論壇sex520免費影片JP成人網免費成人視訊aaa影片下載城免費a片 ut交友成人視訊85cc成人影城免費A片aa的滿18歲影片小魔女免費影片85cc免費影片aaa片免費看短片aa影片下載城aaaaa片俱樂部影片aaaaa片俱樂部aa的滿18歲影片小魔女免費影片台灣論壇免費影片後宮0204movie免費影片免費卡通影片線上觀看線上免費a片觀看85cc免費影片免費A片aa影片下載城ut聊天室辣妹視訊UT影音視訊聊天室 日本免費視訊aaaa 片俱樂部aaaa片免費看影片免費視訊78論壇情色偷拍免費A片免費aaaaa片俱樂部影片aa影片下載城色漫畫帝國av俱樂部aaaa彩虹頻道免費影片 杜蕾斯成人免費卡通影片線上觀看85cc免費影片線上觀賞免費線上歐美A片觀看免費a片卡通aaa的滿18歲卡通影片sex520免費影片免費 a 片

4:11 AM, April 14, 2009  
Blogger 徵信 said...

外遇外遇外遇外遇外遇外遇外遇外遇外遇 外遇
外遇 外遇外遇 外遇 外遇
外遇 外遇 外遇
外遇


外遇 外遇
外遇
外遇 外遇外遇
外遇

外遇 外遇外遇 外遇 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 ,
外遇 外遇 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇外遇 外遇外遇 外遇 外遇

外遇 外遇

外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇劈腿劈腿劈腿劈腿劈腿劈腿劈腿劈腿喜帖囍帖卡片外遇外遇 外遇 外遇外遇 外遇
外遇 外遇 外遇 外遇剖析 外遇調查 外遇案例 外遇諮詢 偷情 第三者外遇話題 外遇發洩 感情挽回 徵信社 外遇心態 外遇 通姦 通姦罪 外遇徵信社徵信社外遇 外遇 抓姦徵信協會徵信公司 包二奶 徵信社 徵信 徵信社 徵信社 徵信社 徵信社 徵信 徵信 婚姻 婚前徵信 前科 個人資料 外遇 第三者 徵信社 偵探社 抓姦 偵探社 偵探社婚 偵探社 偵探社偵探家事服務家事服務家電維修家事服務家事服務家事服務家事服務家事服務持久持久持久持久持久持久持久離婚網頁設計徵信社徵信社徵信徵信社外遇離婚協議書劈腿持久持久持久持久持久劈腿剖析徵信徵信社外遇外遇外遇外遇徵信社徵信社徵信社徵信社徵信社徵信社徵信徵信社徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信社徵信社徵信社徵信社徵信社徵信社徵信社徵信社徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信公會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信公會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿

2:32 AM, April 20, 2009  
Blogger 1314 said...

視訊做愛視訊美女無碼A片情色影劇kyo成人動漫tt1069同志交友網ut同志交友網微風成人論壇6k聊天室日本 avdvd 介紹免費觀賞UT視訊美女交友..........................

10:38 PM, May 19, 2009  
Blogger 1122 said...

成人制服系列成人新人系列成人新人系列成人野外系列成人野外系列成人記錄片系列成人記錄片系列成人乳交系列成人乳交系列成人美乳系列成人美乳系列成人凌虐系列成人凌虐系列成人變態系列成人變態系列成人美腿系列成人美腿系列成人多P系列成人多P系列25xxx成人影城25xxx成人影城

10:47 PM, June 07, 2009  

Post a Comment

<< Home