home email us! sindicaci;ón

The Name of the Game in PHM Is Variability: Part 8 - Evaluation

by Scott MacStravic

To a great degree, the evaluation element in PHM comprises repetition of one or more of the assessments done for the initial baseline analysis.  Ideally, this repetition, whenever it is repeated, will identify the changes of concern to payers, at least, while any added tracking of results used to sustain participants in their efforts and changes will do the same for the changes of interest to participants.  But saying this, there will inevitably be the complication of making a “business case” that credibly demonstrates that the PHM strategy overall, and its individual interventions, have been the causes of the changes discovered.

Because the value dimensions addressed in EHM efforts and evaluations are major concerns of insurers and employers all the time, it is likely that they are doing something else to reduce costs or improve productivity and performance, beyond the effects of PHM interventions.  And rarely would insurers, much less employers be willing to devote an entire year’s financial performance to the effects of a PHM investment alone.  So generally speaking, the PHM evaluation should include some effort, at least, to separate out what changes in the evaluation dimensions it addresses that were probably affected by other efforts as well.

One of the best ways to track the effects of PHM is to analyze the tracking data that connects PHM efforts, such as HRA, screenings, and other information that was shared with individual participants in the HRA, coaching interventions used with participants in particular PHM interventions, and participant-reported behavior changes, health status biometrics of self-reports, etc.  If this “value chain” of causes and effects can be shown to be connected as expected, that will make a strong case for attributing much at least of measured improvements to the PHM effort rather than “extraneous” causes.

Results such as “yes/no” behavior changes, (smoking, alcohol/drug abuse cessation) or “degree” changes, (increased physical activity, improved nutrition, longer average time slept per night, lower stress, etc.) should correlate with the amount and intensity of interventions, together with participant participation measures.  In other words, the more the inputs by coaches and participants, the more the outputs in terms of behavior change, either a higher rate of yes/no changes, or a greater degree of change in continuous metrics.

In turn, the more the changes or progress achieved in behavior, the greater should be the improvements in biometrics, risk/impairment factor status, etc. that are supposed to be affected by each. This should also appear as a correlation between the different kinds of measures.  And the measured biometrics, health/risk/impairment factor status should be well correlated with changes in healthcare cost, disability, and workers compensation costs, plus productivity and performance metrics or estimates.

The higher the degree of correlation across these changes, the more likely and credible the causal connection between them is.  Only randomized and limited intervention clinical trials will meet academic standards, but demonstrated correlation should provide stronger evidence than simply records of changes in the outcome value, and certainly be better than the most popular approach, which among employers, at least, is not to measure ROI at all.

To determine ROI, of course, it is essential to factor in all costs as well as financial gains discovered in the evaluation.  These will include all  internal costs for payers who do it themselves, and is likely to include internal costs – for staff efforts, incentives paid, internal promotion of participation, team contests, etc.—as well.  The costs imposed in the form of PHM supplier charges should be the easiest to identify, since they involve direct payments.  When all financial benefits are compared to all costs, the ROI ratios and net earnings can be calculated.

There is a further complication in PHM, however, because, as is the case with some marketing expenditures, some portion of PHM costs should probably be treated as longer-term investments, rather than this year’s costs.  While the published cases of long-term PHM results are few, they strongly suggest that when most of the participants in one year’s PHM efforts remain beneficiaries, members, or employees, the second-year results tend to be better than the first, and the third better than the second.  The only case I know of where results were tracked for longer than three years found the fourth-year results essentially flat compared to the third.

This case, however, involved a cohort of employees, roughly 6000, who were continually employed and continuously participating in the PHM program for all four years.  The pattern they produced, which was savings of $233 per participant in the first year, $375 in the second, $944 in the third, and $950 in the fourth, counted both medical care and disability/workers compensation expense savings, but not the productivity losses most likely associated. [G. Stave, et al. “Quantifiable Impact of the Contract for Health and Wellness” JOEM, 45:2 2003 109-117]

But chances are, when there are high turnover rates among health plan members or employees, the degree of improvement in that case would not be replicated.  “Veteran” participants would too often be gone, instead of in their third or fourth year of improvement.  And “novice” participants would have to replicate lower first-year results when it is their first year, even if the fifth or tenth for the payer in terms of PHM program investment.  But as long as there is less than 100% turnover in the participant population, there seems likely to be improvement in annual results for successive years, at least up to three or four.

Improvements usually occur both because it takes time for participants to gain confidence in the own abilities.  It also may take time for health status effects to occur.  Fortunately for employers, many improvements in productivity occur quickly, so this should bolster clients’ confidence.  One of the factors that take time is the influence that successful participants have on their peers who chose not to participate when first offered.  The examples of successful peers, and the word-of-mouth reports spread by them, can be the most effective, and certainly least expensive approach to promoting future participation and improved results.

In general, it may be the third or fourth year until positive or at least desired ROI levels are achieved.  Marathon Health, for example, a PHM supplier in Vermont, guarantees a 2:1 ROI, and often achieves 3:1, though not until the third year.   The huge increase in the third year cited above may have meant no significant ROI was achBy contrast, HealthMedia is willing to guarantee the results it measures, though not ROI, for whatever period it uses in measuring them should its clients desire (per e-mail from Ted Dacko, CEO). HealthMedia only has two years* history with any of its results, and less than that for interventions introduced more recently, has not yet reported long-term results, but it makes employers who want quick results happy.

Whatever method for evaluation is used, it should meet at least standards for accuracy, reliability and validity, and avoid at least the most common errors due to self-selection bias and regression to the mean.  Measuring ROI is clearly superior to pure credence that PHM works, or even relying on results others evaluate and report.  The huge variety of methods currently in use, particularly in what is measured, together with the unavoidable costs of measuring many important sources of value from PHM investments, as well as the need to be able to take a long-term view of such investments, makes choosing an approach difficult, but definitely worthwhile.

No comments yet »

Your comment

<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <code> <em> <i> <strike> <strong>

overnight valium delivery online phentermine and cymbalta flomax and ambien grupodes viagra impotencia ambien sleeptalking phentermine phentermine diet pill adipex mg cialis wholesale diazepam generic online valium cialis drug interaction rx phentermine 37.5 3.34 cost low phentermine generic viagra mg blue pill grneric viagra headache with ambien tadalafil cialis vs viagra air day in next phentermine stock viagra 10mg 20mg brand cialis name online order viagra drug zenegra free sample of viagra valium images order phentermine and ship to arkansas venetian las vegas information viagra buy valium no presciption zocor alternative viagra phentermine no doctor needed buy tramadol online cod ultram viagra mail order generic online viagra 4.40 buy online viagra cheapest price phentermine kamagra viagra supplier pharmacy search cialis cialis price canada phentermine at cost with no prescription can i buy viagra cialis comparison viagra valium necklace pendant compare phentermine and adipex tramadol opiates phentermine without prescription september tramadol 100mg fedex delivery phentermine no prescription usa pharmacy can you take valium when pregnant can i buy viagra online ambien prescribing information viagra flomax ambien and gastritis cialis nextag viagra on line pharmacy safe splitting viagra cialis effects ambien on the internet without prescription ambien next day news release viagra woman cheap drug retin viagra wellbutrin 3 cost generic lowest viagra sleep eating related to ambien buy phentermine overnight by phone phentermine and zoloft us approved pharmacies phentermine with prozac cheap phentermine mg tablet purephentermine cialis discount vioxx buy cialis tadalafil taking phentermine with wellbrutrin phentermine rating valium on line buy ambien cr online no rx purchase cialis on line ambien cr sleepwalking message boards cialis price comparison viagra problems cialis generic overnight shipping tramadol hcl forum tramadol percocet online search tramadol find search viagra edinburgh pages news bontril phentermine ionamin meridia cialis cialis tadalafil phentramin vs phentermine funny viagra candanian phentermine generic cialis pills drug tramadol heath solutions network phentermine in stock california overnight phentermine and money order apcalis levitra viagra buying phentermine online better ambien stillnox fed ex dhl inndia viagra samples online alcohol and ambien low carb dieting diet phentermine pill phentermine usa pharmacy bush fetches porn viagra adipex phentermine no script cialis with viagra classification of valium sides effect of viagra internetresults tramadol ambien sleeping pills phentermine watson viagra online no prescription ocd tramadol side affects ambien cr overnight delivery cialis questions sildenafil viagra and the heart what happens after you take cialis ambien and alcohol don't mix viagra erections lily icos cialis enhance effects of viagra cialis phentermine free shipping no prescription enzyte viagra cialis 3generic sildenafil viagra online medicines rx cialis viagra order low cialis cost buying medicine ambien compare tramadol prices good price on ambien phentermine without a percription no membership phentermine phentermine echeck cash delivery hydrochloride phentermine pumpkin pie viagra phentermine pill slimming uk tramadol genetic whats better than viagra purchase phentermine onli cialis active ingredient diet pills phentermine best price viagra patent pfizer large high valium waterpumps viagra levitra cialis compare phentermine order without perscription buy ambien online overnight delivery valium drug abuse herbal viagra affiliate prescription free valium cocaine phentermine order viagra overnight delivery online rx valium valium death overdose 0 mtch phentermine pravachol bontril cialis online pharmacy ambien sat fed ex cialis levitra sale viagra buy cheap domain valium 6x to valium effectiveness cialis approval difference between viagra and cialis ambien dosages no prescription viagra sample phentermine louisiana tramadol shipped cod inject tramadol cheapest phentermine cod augmentin cialis valium and depression valium overnight shipping ambien cr alcohol personal review cialis tramadol hcl chemical supplier cialis singular interactions actos phentermine actos claritin d hr online adipex meridia phentermine prescription viagra viagra reminder ads cialis comparison levitra viagra good burn desert ephedra phentermine cialis y la respiracion didrex phentermine compare or viagra xenical tramadol hgh-saizen generic viagra online phentermine buy uk generic cialis softtabs online viagra eye exam best price on diet pill phentermine hemodynamics viagra 5cialis levitra federal express phentermine does phentermine contain amphetamines buying cialis online guide viagra lavetra cialis buy ambien on line usa phentermine and prozac for weight loss generic cialis absolute lowest price phentermine lowest cheap next day snorting valium efficacy wellbutrin aciphex phentermine nasonex altace web md viagra connecticut meltabs generic viagra tramadol used generic viagra versus tadalafil canadian viagra store plavix and viagra valium medical name viagra and heart problems va regulations viagra phentermine no prescription ship to indiana discount phentermine no rx needed narcotic tramadol canine ambien ce free seven day trial office pill phentermine buy viagra xanax is cialis a controlled substance generic viagra overnigh sertraline tramadol and online phentermine pharmacy best cheapest medications that interfere with ambien cr phentermine chat room phentermine money orders overnight rx online buy valium tramadol 60 tablets ducation sp cialis e viagra vaginal suppositories side effects tramadol effects on dogs viagra a-z kamagra generic viagra 100 mg sildenafil order phentermine no script united states cialis vs viagra valium date rape drug order cialis on line buy phentermine 37.5 in tennessee klonopin valium vs ambien cause snoring low cholesterol diet buy phentermine cialis obsessive compulsion phentermine how does it work dangers phentermine 24 hour delivery buy phentermine cod medipharm bags buy phentermine venetian las vegas effects viagra buy tramadol rss feed counterfeit viagra identify four tramadol no prescription florida cialis vs viagra on line no prescripton buy online phentermine gt ecstacy and viagra viagra forums 3generic propecia viagra abuse phentermine abuse bob viagra 37 5 159 a phentermine effects phentermine psychological side cheap but effective alternative to viagra edinburgh uk news viagra site search viagra silagra drug reactions between phentermine and metabalife addicition to phentermine health insurance coverage of viagra cialis viagra heartburn where can i buy viagra uk no prescription phentermine online sales phendimetrazine or phentermine valium dependence money online order save viagra 180 37.5 order phentermine pill buy phentermine 37.5mg adipex p meridia phentermine valium stay in your system ambien sanofi-aventis lunesta takeda phentermine and fibromyalgia does ambien cause mastalgia cialis viagra levitra compare clenbuterol phentermine can u take ambien and melatonin tramadol cheap discount can i take ambien with lexapro cialis dosage information ambien buy cheap delivery line overnight cialis prevacid viagra alternative herbal supplement phentermine adipex ionamin addiction valium phentermine blue fedex online pharmacy generic viagra caverta caverta pillshoprxcom 3.46 phentermine prescription ultram sniffing tramadol generic tramadol effectiveness valium 5mg pictures phentermine clinics in louisville ky viagra to bill gates buy cialis softtabs information overnight delivery valium no prescription new song called viva viagra cialis generico sildenafil generic cialis tadalafil free pack starter viagra valium animation peyronies and viagra phentermine drug-test on line doctor phentermine school finance what is tramadol comparison viagra cialis levitra zantac valium in phentermine sale uk natural viagra substitute vitamins herbs cheap cod phentermine viagra caverta tonytigeraz viagra 2007 mexican iv valium complications no prescription phentermine 32 ambien and oxycodone paradoxical reaction of valium purchase phentermine on line mix tadalafil and generic viagra free try viagra 35 ad psychoneurotic single valium europe cialis central valium effects of free tramadol delivery what is ambien lighting approved phentermine insurance health viagra coverage viagra canada online pharmacy discount price viagra order phentermine by cod buy cheap phentermine online pharmacy online phentermine perscriptions cialis free trial grande librairie sp cialis e tunisie viagra the latest developments online phentermine money orders origin of viagra cr ambien man health buy tramadol funny farm cialis viagra buy tramadol ultram valium panic disorder crush up viagra ambien have sex viagra and blood pressure cialis commentscgi generic mt tadalafil phentermine delivered overnight cialis drug generic propecia 50mg capsule hydrochloride tramadol canada cialis generic best price generic viagra or cialis herbal herbal viagra viagra viagra women take cialis drug drink alcohol with viagra generic cialis viagra viagra substitute unsecured loan nasacort aq cialis cialis pros and cons cialis canada online pharmacy viagra cialis levitra strong strong viagra purchace phentermine shipped fedex pregnancy and ambien females being prescribed valium pregnancy test ambien for anxiety phentermine information all information about phentermine does phentermine cause skin problems endometrium viagra viagra history buy cheap phentermine shipped overnight indications for ambien use viagra retail discount generic sildenafil viagra viagra instructions for use ambien zr viagra starter cheap tramadol soma best viagra delivery phentermine saturday ambien equivalent imovane ambien crash morning pepare tramadol for injection phentermine and wellbutrin doctors giving viagra checkup 100 10mg roche valium dosage for oral valium prescription for phentermine in virginia 1buy canada cialis cialis pills taladafil v-care surgical private ltd phentermine generic and phentermine and scam buy cialis on line uk difference between ibuprofen and tramadol cialis the new viagra ambien alert cheap online viagra viagra phentermine no prescription free overnight delivery adipex bontril ionamin meridia phentermine received fake phentermine paid visa valium siwa protocol 4.01 buy online phentermine extasy and viagra cheap cialis for you benzodiazepine withdrawal valium diazepam phentermine online free consultation knockoff cialis seresta valium phentermine and heart disease acetaminophen per tramadol hcl off shore ambien forex buy valium phentermine no longer available online tramadol 500mg information pharmacology ambien obstructive sleep apnea viagra cialis differences viagra free sites results find over the counter cialis london cheap man viagra cheap viagra kamagra phentermine meridia vs phentermine no prescriptions florida cheap viagra sales in england instead of viagra arachnoid cysts phentermine online pharmacy us ambien medication potency ambien foreign websites viagra levitra patients cialis valium chest pain viagra online asap board cialis contractor licensing state what is tramadol hcl50mg side effects prozac phentermine ambien safe nursing prozac phentermine cheap free shipping celexa phentermine gt british natural viagra effects welcome phentermine buy cheap phentermine online buy phentermine without rx viagra 50mg uk phentermine without a primary valium 10 rosario castellanos viagra cialis generica online ambien brand herbal viagra reviews ambien cr medication ambien cr no effect cialis and levetra ambien male menopause duromine phentermine generic viagra levitra and tadalafil is phentermine also called speed cheapest online pharmacy phentermine valium health search genieknows com online phentermine prescription valtrex zyban ultram tramadol hci tablet 8080 buy cialis viagra average cialis prices 125 ambien cr mg lowest prices viagra phentermine buy online no prescription drug interaction valium and prilosec ambien fedex shipping real viagra paypal phentermine and water pills tramadol 180 tablet buy cheap cialis generic levitra viagra buy non prescription generic viagra paypal phentermine testimonails cialis and viagra valium dental crown side effects of tramadol hcl 50mg transsexual viagra tramadol hydrocloride side side effects to taking viagra valium carisoprodol purchase phentermine online ship fedex cialis attractive brunette levitra ad phentermine no prescriptio n boom phentermine dependency on ambien buy cheapest cialis no precription phentermine cheap cialis generika ambien cr how does it work 30 ml phentermine no script phentermine pravachol aciphex actos diovan hct c d o phentermine cod diet phentermine pill shipped phentermine 37.5 pharmacy viagra best way to use cheap online phentermine with no prescription viagra in south africa ambien new england journal medicine drug testing phentermine phentermine capsule pills does tramadol thin the blood phentermine no prescription required phentramine phentermine dangers viagra pinup gay men viagra vs cialis buy phentermine online cheap diet pill cialis online bestellen your source for phentermine adipex viagra 100mg viagra driving and valium ambien keyword cialis and levitra viagra order pharmacy viagra viagra driving valium effects impairment ambien directions phentermine online with mastercard phentermine ephedrine valium sold in usa cialis liver disease phentermine 37.5 online consultation compare valium and xanax order phentermine online no presciption cialis testimonials softtabs cialis cialis propecia viagra book buy online order viagra aeroflot open view topic order viagra vicoden xanax valium king viagra cialis generic impotence kamagra viagra viagra keywords buy tramadol penis enlargement pills viagra men phentermine 37.5 180ct tramadol dosing directions 661 viagra levitra cialis 953 generic name tramadol ambien equivalent adipex versus phentermine viagra naturale competitors of viagra phentermine in hair follicle drug test valium numbers cialis cialis viagra generic in usa viagra viagra length zestril and viagra herbal viagra canada when will generic viagra be available regals cialis tramadol dog dosage cialis discount online generic viagra purchase 2cialis comparison levitra viagra ambien online zolpidem tartrate mastercard buy online viagra securely buy phentermine buy side viagra xanax boots sell viagra free promotions viagra phentermine no prescription necessary price of viagra compared to cialis tramadol buspirone ssri viagra save chrismas keywords cialis levitra sales viagra ambien long-term side effects tramadol ultram sexual side effects buy viagra without prescription online pharmacy high from phentermine online games buy vitamins viagra sale valium safe in pregnancy tramadol 50 mg pliva 616 interactions with methadone and viagra actos phentermine aciphex imitrex girl phentermine cialis doseage safe tramadol american pharmacy online phentermine 37.5mg on line phentermine carisoprodol phentermine for alertness getting a free sample of viagra phentermine script buy viagra safeway pharmacy phentermine nasonex altace custom crt phentermine viagra free sites edinburgh search find cheap mexican phentermine buy tramadol now macha natural viagra is viagra cheaper in mexico cialis 30 oral ambien prices valium logo cialis valtrex alesse generic valium picture viagra 100 pic buy phentermine mexico 2006 followup march post viagra weight loss pharmacy phentermine pictures tramadol bupropion cialis online buy adipex phentermine 37.5 mg capsule phentermine actos actos ranitidine buy non generic ambiens dosage phentermine orexis vs viagra viagra bicycle shirt cialis viagra levitra pump phentermine cs 37.5mg viagra in the water blondes cheap cialis the best quality pills ambien online overnight delivery prescription phentermine 37.5mg no rx tramadol false positive pcp xenical online pharmacy phentermine meridia long term use of ambien affiliate free join program viagra compare viagra cialas levitra valium and liver damage cheap 30mg yellow phentermines purchase phentermine in store cheap viagra without a pr best buy for viagra phentermine site buy canada phentermine warnings for ambien buy cialis buy cialis online dreampharmaceuticals brand name tramadol phentermine typical results tramadol without presciption free online viagra pill sample cialis viagra mastercard accepted tramadol prescribing information viagra levitra cialis pharmacist prescription drug va viagra phentermine with doctor approval diazepam phentermine no prescription phentermine canada best online pharmacy hide the cialis make phentermine yourself xenical cialis phentermine interactions does ambien increase testosterone ambien equivalent imovane effects side cheap domain onlineatspacecom phentermine ambien 24 hours illinois mortgage lender tramadol ingredient in phentermine ranitidine tramadol valium experiences medil journals viagra generic cialis pills erection phentermine on line without a physician phentermine by phone phentermine kosmix topic page china viagra patent litigation next day air ups tramadol orlistat xenical phentermine and sibutramine meridia 120 buy cheap tab tramadol viagra take offs phentermine absorbed under the tounge phentermine in long beach ca consultation phentermine buy didrex phentermine adipex cheap online phentermine without prior physician side effects of taking phentermine phentermine shipped cod best online pharmacy phentermine delivered sat by fed x cheap deal discount viagra viagra overnight phentermine no doctor atenolol viagra viagra online cod tramadol images buy phentermine ifastnet com danger phentermine gt fda dosage recommendation for ambien phentermine order without rx phentermine with ambien sleeping mdicine generic name online qoclick tramadol phentermine amerimed cialis viagra combo phentermine purchasing crime tips on using viagra viagra vs cilais ambien bloating phentermine mg tablet online pharmacy pictures of pill valium ambien not working kgr 100 viagra viagra induced brain anuerysm consult free phentermine cheap online phentermine free doctor consultation buy phentermine no physician or rx buy cheap cialis generic tramadol and kidneys search results buy phentermine qualitest phentermine tramadol ingestion method smoke xanax ambien together dangerous ingredient phentermine where to buy phentermine cheap free viagra domain does viagra cause desire phentermine physician 32082 phentermine perscription online md viagra bournemouth ads kamagra phentermine used for ambien like ghb tramadol and prozac viagra on line uk viagra cialis levitra comparison paxil tramadol phentermine without doctors perscription buy phentermine online paypal valium 5620 valium suppositories tramadol hcl-acetaminophen par and weight loss phentermine without prescription fda approved real viagra online for americans valium cipro flexiril tramadol tramadol indicat buy tramadol online overnight fedex delviery group group health health viagra woman discount tramadol without prescription cialis research looking for diet pills called phentermines free viagra alternative sample generic safe viagra cialis depression viagra cialis espa ol prescription medications medical fed ex tramadol viagra and cialis compared personal experience viagra snorting viagra woman's viagra depression symptom phentermine diet pill ultram tramadol select health insurance coverage cialis cialis genuinerx net viagra free consultation cialis buy card debit online phentermine tramadol cialis viagra sampler does ambien cr cause tremors ambien drug side effect equivalent to valium back pain from taking cialis paroxetine viagra viagra tramadol phentermine 40 mg ambien safe online ordering viagra phentermine pill buy cheap phentermine cialis advertisement commercial bad effects side viagra valium tablets cialis mg to take viagra g n rique d'ordre herbal lotion natural viagra tramadol and seizures tobacco edinburgh search thought viagra ambien and birth defects buy cialis href online xenical viagra zyban proscar viagra for sale uk cialis viagra side effects legal rx and viagra tramadol 50 mg tablets comparosons viagra comments blue pill some from of viagra for woment fda approved cialis female viagra phentermine and atrial fibrillation penis viagra sildenafil phentermine and diet weight loss pill phentermine fedex shipping clip art of valium ambien onlilne order cheap fast keyword ambien side effect boards qoclick 5 cialis generic viagra ketamine valium valium us pharmacies fast shipping fda approved generic cialis ambien for brain injury diet forum phentermine cialis personal review fastest delivery purchasing cialis online carisoprodol valium zyrtec viagra facts buy real viagra pharmacy online phentermine sexual side effects phentermine no rx next day ship valium drug information buy diazepam valium best online deal for phentermine phentermine rxscripts mg phentermine herbal phentermine ultra medical cialis order site viagra bottle viagra erection lenght fed oysters viagra side effects of snorting phentermine capsules ranitidine cheap tramadol article viagra weekend generic soft tab cialis compare xaxax and valium uses indian viagra best buy meridia phentermine propecia viagra 37.5 phentermine online perscription phentermine angina internet viagra source get approved online compare prices viagra tramadol hcl chemical supplier white buy phentermine shipped u chewing valium cialis eckert can ambien kill you recreational use of viagra cheap phentermine california i want to buy phentermine buy no prescription phentermine hci eon mo phentermine shipped doctors prescribe phentermine corpus christi phentermine and online sales viagra competitors legitimate viagra valium pills cialis usage rapid tabs viagra ivax viagra tramadol prescriptions in el paso ambien victims cialis on an empty stomach phentermine for sale phentermine ambien cr patient rating immediate phentermine overnight delivery viagra and heart medicines can phentermine cause yeast infections phentermine with no precription ambien complex sleep-related behaviors buying phentermine with e check tramadol 5 500 drug testing for tramadol phentermine no prescription required muscle cramp with ambien compare levitra cialis is phentermine legal online cheaper viagra levitra cialis collect on delivery phentermine 99 cod phentermine phentermine 24 7 cheap phentermine drugs viagra product insert tramadol auses acid reflux viagra pills cialis viagra phentermine w o rx phentermine hcl generic trusted generics viagra sildenafil acetaminophen hcl par tramadol phentermine quick fda approved medications phentermine hcl on staff phentermine weight loss pi ll viagra online way to end impotence viagra experiences phentermine on line without prescription a description of pharmacy phentermine overview free viaga cialis generic ambien from germany phentermine no prior script buy cheap cialis softtabs prescription phentermine online phentermine buy phentermine viagra heart attacks ambien during nursing meds by mail phentermine interaction of viagra with lorazipam phentermine low price cheap phentermine online ambien half life ambien cr 6.25 cheap inexpensive viagra diet ingredient phentermine pill pregnancy valium taking viagra daily viagra illegal substance ambien dosage for date rape delivery phentermine order phentermine no prescription needed discount phentermine no doctor viagra travel viagra free sites computer find href cialis from canadian pharmacy compare generic cialis prices tramadol hydrochloride uk mail order prescriptions ambien phentermine and pregnancy tests ambien equivalent imovane effects buy phentermine no prescription overnight delivery canadian medications without prescription phentermine phentermine world wide shipping red devil tadalafil generic cialis pharmacy buy phentermine in the uk cialis viagra levitra trusted pharmacy catalog generic online phentermine tramadol 180 fre overnight shipping 99.00 medical journals viagra ambien and cognitive dulling phentermine sibutramine be combined tramadol cheap that delivers to arkansas order phentermine 37.5 mg online diazepam valium sales generic cialis soft from india cialis and premature ejaculation cod discount phentermine cialis pharmacy sale cialis mix viagra ambien marijuana over the counter viagra buy viagra at safeway does herbal phentermine work gt cheap loan phentermine pomegranate concentrate and viagra 0 herbal viagra phentermine 37.5 mg 90 days generic meltabs viagra php wesites selling no perscription phentermine adipex adipex between difference phentermine ionamin phentermine yellow phentermine from canada no prescription lipitor phentermine remeron lotensin xalatan aricept 36 hour cialis 2737 aid renova renova retin viagra ambien and leg pain tramadol alcohol valium article tramadol drug test results nz viagra cialis multiple times natural viagra for women can tramadol cause cystitis ultracet tramadol hcl free doctor consultation for phentermine what does valium look lik phentermine orders fastest turn around time order cheapest phentermine no prescription buy cheap phentermine the offical site phentramine vs phentermine cialis levitra viagra index cialis allergic lesions viagra in the waters kareoke viagra yybbs tramadol prescription dosage valium overdose mg uk viagra tramadol black box warnings by cod phentermine purchase phentermine online with no prescription 30 generic cialis softtabs effectiveness viagra levitra cialis cheapest phentermine onli ambien hypnotics phentermine 37 2e5 echeck lung problems from phentermine what is stronger tramadol or vicodens patent for ambien cr no rx phentermine 30mg 90 120 phentermine discussion forum viagra cialis levitra online buy us phentermine 50mg viagra retail price discount cialis cheap day next valium phentermine hcl prescription diet pills information channel 2 ambien weight loss cialis silagra silagra cumwithuscom ambien cr overdoe valium dilaudid interactions cialis dosing information torrance california tramadol doctors who prescribe phentermine in nc mark marti viagra car ambien combo pfizer viagra patent tramadol no prescription with ups shipping buying viagra in the uk phentermine 37 5mg web board adipex meridia online phentermine prescription viagra generic research viagra viagra cialis levitra href new york kamagra about viagra gifts ambien viagra man on viagra bangs his wife buy cheap domain online order valium cheap cod fedex tramadol very generic valium yellow scored generic viagra sildenafil citrate depression and ambien buy onlinecom phentermine viagra tramadol cheapest online phentermine buy phentermine phentermine online discount 1 cialis tadalafil jpg london uk buy generic viagra phentermine fastin mix cocaine and viagra cheap i us phentermine very viagra and reduced ammunity cheap viagra online a href cialis and levitra ventajas desventajas viagra and other ed drugs charles randolph viagra viagra natural substitute ups delivery phentermine next day phentermine generic tramadol or ultram 37 5 phentermine phentermine at washington edu org paracetamol tramadol viagra hotline viagra precautions ambien canadian pharmacy 30 phentermine resin ambien mixed with caffeine effects mdma and valium tramadol ship to florida 477 mylan pill valium pot viagra cialis norwegian cruise no primary care physician phentermine wall street journal viagra tramadol drug information valium and vicodin combination valium phenobarb aspirin interaction valium pill identification enhance valium generic cialis softtabs tramadol valium buy phentermine no prescriptions naproxen and ambien ultram ultram tramadol hci tablets phentermine forums does it work phentermine and consultation caverta versus viagra lortab phentermine tramadol tablets 50 mg contraindications side affects of cialis order ambien cheap phentermine wiht no prior prescription viagra and blurry vision order ambien fedex overnight shipping breastfeeding and valium cheap phentermine mastercard accepted phentermine 37.5mg cheap 2737 amerimedrx online pharmacy tramadol yasmin free samples viagra find local charles linskaill search viagra valium roche maximum dosage taking viagra with cialis buy phentermine click here buy phentermine online sale tramadol overnight cod canadian pharmacy phentermine online phentermine phentremine phentramine cheap tramadol rss feed viagra cuddly chemical tramadol non-narcotic order cheap phentermine no prescription plavix and cialis taken together koerier viagra cialis amsterdam adipex phentermine weight loss viagra covered california hmo price tramadol discount phentermine non pharmacy phentermine order easy generic viagra buy online beitrag buy hinzufgen name text tramadol depression with ambien 2003 cialis levitra market sales viagra valium sale valium fact valium diazepam diazepam valium fedex online phentermine cheap online discover payment method tramadol and hydrocodone drug interactions drug information medline plus tramadol medicare coverage ambien ambien sleep duration continue valium after embryo transfer line phentermine scrip <a href="http://ken-jenn