Quo Vadis Jamkesda : Mau Dibawa Kemana Hubungan “Kita”?

Perpres Nomor 12 Tahun 2013 tentang Jaminan Kesehatan Pasal 6 Ayat (1) menyatakan bahwa Kepesertaan Jaminan Kesehatan bersifat WAJIB dan dilakukan secara bertahap sehingga mencakup seluruh penduduk. Untuk pentahapannya dimulai pada 1 Januari 2014 untuk peserta PBI Jaminan Kesehatan, Anggota TNI/PNS di lingkungan Kementerian Pertahanan dan anggota keluarganya, Anggota Polri/Pegawai Negeri Sipil di lingkungan Polri dan anggota keluarganya, Peserta asuransi kesehatan Perusahaan Persero (Persero) Asuransi Kesehatan Indonesia (ASKES) dan anggota keluarganya dan Peserta Jaminan Pemeliharaan Kesehatan Perusahaan Persero (Persero) Jaminan Sosial Tenaga Kerja (JAMSOSTEK) dan anggota keluarganya (Perpes 12/2013 Psl 6 Ayat (2) huruf a).

Sedangkan untuk pendaftaran peserta di luar itu dilakukan sejak tanggal 1 Januari 2014 sampai dengan paling lambat tanggal 1 Januari 2019 sebagaimana diatur dalam peraturan yang sama pada Pasal 6 Ayat (2) huruf b. Artinya bahwa pada tahun 2019 SELURUH penduduk Indonesia akan menjadi peserta BPJS Kesehatan sebagaimana tujuan akhir dari program JKN adalah Universal Health Coverage (UHC).

Dalam Perpres Nomor 111 Tahun 2013 tentang Perubahan atas Perpres 12 Tahun 2013 tentang Jaminan Kesehatan pada Pasal 6A disebutkan bahwa penduduk yang BELUM termasuk sebagai Peserta Jaminan Kesehatan DAPAT diikutsertakan dalam program Jaminan Kesehatan pada BPJS Kesehatan oleh pemerintah daerah provinsi atau pemerintah daerah kabupaten/kota. Sedangkan pada Peraturan yang sama pada Pasal 16 Ayat (1a) dijelaskan bahwa Iuran Jaminan Kesehatan bagi penduduk yang didaftarkan oleh Pemerintah Daerah dibayar oleh Pemerintah Daerah. Besaran iuran untuk Jaminan Kesehatan bagi penduduk yang didaftarkan oleh Pemerintah Daerah selanjutnya diatur pada Pasal 16A yang berbunyi Iuran Jaminan Kesehatan bagi Peserta PBI Jaminan Kesehatan serta penduduk yang didaftarkan oleh Pemerintah Daerah sebesar Rp 19.225,00 (sembilan belas ribu dua ratus dua puluh lima rupiah) per orang per bulan.

Dengan berdasarkan pada ketentuan-ketentuan diatas, maka timbul pertanyaan : bagaimana dengan penduduk dengan status Pekerja Bukan Penerima Upah (Pekerja Informal) dan penduduk Bukan Pekerja yang termasuk dalam kategori miskin berdasarkan pendataan daerah namun TIDAK termasuk dalam peserta PBI Jaminan Kesehatan ?

MASYARAKAT MISKIN (TIDAK MAMPU) DAN PBI

Dalam Peraturan Pemerintah Nomor 101 Tahun 2012 tentang Penerima Bantuan Iuran (PBI) Jaminan Kesehatan, diantaranya disebutkan bahwa :

  1. Kriteria fakir miskin dan orang tidak mampu ditetapkan oleh Menteri Sosial setelah berkoordinasi dengan Menteri dan/atau pimpinan lembaga terkait.
  2. Hasil pendataan fakir miskin dan orang tidak mampu yang dilakukan oleh lembaga yang menyelenggarakan urusan pemerintahan di bidang statistik (BPS) diverifikasi dan divalidasi oleh Menteri Sosial untuk dijadikan data terpadu.
  3. Data terpadu yang ditetapkan oleh Menteri Sosial dirinci menurut provinsi dan kabupaten/kota dan menjadi dasar bagi penentuan jumlah nasional PBI Jaminan Kesehatan
  4. Menteri Kesehatan mendaftarkan jumlah nasional PBI Jaminan Kesehatan sebagai peserta program Jaminan Kesehatan kepada BPJS Kesehatan.

Untuk tahun 2014, peserta PBI JKN berjumlah 86,4 juta jiwa yang datanya mengacu pada Basis Data Terpadu (BDT) hasil Pendataan Program Perlindungan Sosial (PPLS) yang dilaksanakan pada tahun 2011 oleh BPS dan dikelola oleh Sekretariat Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K). (Sumber : Website resmi TNP2K)

Namun demikian, mengingat sifat data kepesertaan yang dinamis, dimana terjadi kematian, bayi baru lahir, pindah alamat, atau peserta adalah PNS, maka Menteri Kesehatan mengeluarkan Surat Edaran Nomor 149 tahun 2013 yang  memberikan kesempatan kepada Pemerintah Daerah untuk mengusulkan peserta pengganti yang jumlahnya sama dengan jumlah peserta yang diganti. Adapun peserta yang dapat diganti adalah mereka yang sudah meninggal, merupakan PNS/TNI/POLRI, pensiunan PNS/TNI/POLRI, tidak diketahui keberadaannya, atau peserta memiliki jaminan kesehatan lainnya. Disamping itu, sifat dinamis kepesertaan ini juga menyangkut perpindahan tingkat kesejahteraan peserta, sehingga banyak peserta yang dulu terdaftar sebagai peserta Jamkesmas saat ini tidak lagi masuk ke dalam BDT. (Sumber : Website Resmi TNP2K). Artinya tidak ada penambahan jumlah kepesertaan (zero growth), namun hanya bersifat MENGGANTI peserta lama yang sudah tidak aktif kepada peserta baru berdasarkan usulan daerah.

JAMKESDA

Pada program percepatan pengentasan kemiskinan oleh Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K), Program Jaminan Kesehatan Nasional (JKN) termasuk dalam klaster I selain program RASKIN, PKH, BOS dan KIP. Persoalan mendasarnya adalah ketika terdapat “perbedaan” data antara jumlah penduduk miskin berdarakan Basis Data Terpadu (BDT) Nasional dengan jumlah penduduk miskin daerah maka terdapat kelompok “irisan” dimana penduduk miskin yang sudah dijamin oleh pemerintah pusat melalui PBI Jaminan Kesehatan yang dan juga terdapat kelompok “diluar irisan” yang artinya terdapat sejumlah penduduk yang menurut data pemerintah daerah setempat adalah masuk kriteria miskin, namun tidak termasuk dalam BDT. Jumlah penduduk yang “diluar irisan” ini menjadi tanggung jawab pemerintah daerah untuk memberikan jaminan kesehatan sehingga munculah program Jaminan Kesehatan Daerah (JAMKESDA) di setiap kabupaten/kota dengan variasi nama yang berbeda-beda namun memiliki prinsip sama yaitu menjamin masyarakat miskin yang belum masuk dalam kriteria miskin oleh TNP2K dalam BDT.

Pertanyaanya kemudian adalah dalam era JKN menuju Universal Health Coverage (UHC) 2019 ini apakah pemerintah daerah masih diperbolehkan melaksanakan program JAMKESDA ? Jawabannya adalah masih boleh (FAQ website resmi TNP2K). Namun dalam rencana peningkatan kepesertaan JKN salah satunya adalah dengan pengembangan kepesertaan integrasi JAMKESDA ke dalam JKN. Dalam Peta Jalan Menuju Kepesertaan Semesta (Universal Health Coverage), mulai tahun 2015 kegiatan BPJS Kesehatan akan dititikberatkan pada integrasi kepesertaan JAMKESDA dan asuransi kesehatan komersial ke BPJS Kesehatan.

Skema program JAMKESDA di setiap propinsi/kabupaten/kota cukup bervariasi, beberapa daerah sudah mengikuti sistem JKN dimana membayar kapitasi untuk FKTP dan pembayaran paket INA CBGs untuk FKRTL. Akan tetapi beberapa daerah juga masih menggunakan skema fee for services dengan jaminan penuh ataupun dengan mekanisme menetapkan plafond tertentu dan adanya chost sharing kepada peserta. Contoh paling nyata adalah program Kartu Jakarta Sehat (KJS) yang pada awalnya menggunakan metode pembayaran  fee for services namun kemudian beralih mengikuti sistem pembayaran JKN dikarenakan permasalahan likuiditas alokasi dana Pemprov DKI Jakarta khusus untuk program KJS ini membengkak dan terancam tidak bisa dilanjutkan.

Kembali kepada persoalan JKN oleh BPJS Kesehatan, berdasarkan Perpres 12 Tahun 2013 tentang Jaminan Kesehatan sebagaimana diubah dalam Perpres 111 Tahun 2013 maka dapat disimpulkan bahwa pemerintah daerah :

  1. WAJIB mendaftarkan Pegawai Pemerintah Non Pegawai Negeri (PPNPN) seperti pegawai tidak tetap, pegawai honorer, staf khusus dan pegawai lainnya yang sumber penggajian berasal dari APBD selambat-lambatnya 1 Januari 2016.
  2. DAPAT mendaftarkan penduduk yang belum termasuk sebagai Peserta Jaminan Kesehatan dengan iuran yan dibayarkan oleh pemerintah daerah sebesar Rp Rp 19.225,00 (sembilan belas ribu dua ratus dua puluh lima rupiah) per orang per bulan dengan hak rawat inap Kelas III (setara peserta PBI Jaminan Kesehatan).

Poin kedua ini sebenarnya dapat diterjemahkan sebagai masyarakat miskin berdasarkan data dari TKPK (Tim Koordinasi Penanggulangan Kemiskinan) Propinsi/Kabupaten/Kota namun BELUM menjadi peserta PBI Jaminan Kesehatan dalam Basis Data Terpadu atau dapat disebut sebagai MISKIN DAERAH. Sifat “DAPAT” dalam Perpres 111 Tahun 2013 akan menjadi WAJIB ketika mengacu pada sifat kepesertaan JKN yaitu WAJIB bagi seluruh penduduk Indonesia dan WNA yang menetap minimal 6 bulan. Ini juga sesuai dengan peta jalan Universal Health Coverage (UHC) pada tahun 2019 sehingga pendaftaran penduduk “miskin daerah” ini WAJIB didaftarkan oleh Pemerintah Daerah paling lambat 1 Januari 2019.

PERMASALAHAN

  1. Sudahkah semua propinsi/kabupaten/kota memiliki Tim Koordinasi Penanggulangan Kemiskinan (TKPK) di tingkat Provinsi dan Kabupaten/Kota yang bekerja secara optimal sebagaimana amanat Perpres Nomor 15 Tahun 2010 ?
  2. Sudahkah setiap daerah memiliki Basis Data Terpadu (BDT Daerah) tingkat Propinsi/Kabupaten/Kota yang meliputi data jumlah penduduk miskin daerah secara by name by addres berdasarkan kriteria yang ditetapkan oleh TKPK Propinsi/Kabupaten/Kota ?
  3. Jika BDT Daerah sudah tersedia, apakah sudah dilakukan perhitungan tentang besaran alokasi anggaran yang harus disediakan oleh pemerintah daerah melalui APBD untuk melakukan integrasi program JAMKESDA ke program JKN ? (Meliputi proses pendaftaran dan pembayaran iuran kepesertaan).
  4. Terkait dengan beberapa daerah yang masih ingin mempertahankan program JAMKESDA sampai batas waktu tanggal 1 Januari 2019, apakah sudah dilakukan kajian dan studi perbandingan (comparation study) tentang besarnya alokasi APBD yang harus disediakan antara tetap menjalankan JAMKESDA dengan jika mengikuti program JKN ? Untuk melakukan studi ini maka harus secara non – apple to apple, artinya program JAMKESDA yang akan dikaji adalah yang menjalankan skema fee for services dengan program JKN (sistem kapitasi dan paket pelayanan INA CBGs). Tidak bisa disandingkan secara apple to apple dengan menggunakan skema yang sama, karena hasil kajian tersebut dipastikan akan memperlihatkan besaran alokasi anggaran yang sama sepanjang jumlah kepesertaan yang dihitung adalah sama.

Waktu terus berjalan, jarum jam terus berputar menuju ke tanggal 1 Januari 2019. Sampai dengan tanggal tersebut memang pemerintah daerah masih memiliki “kesempatan” untuk tetap menjalankan program JAMKESDA, namun perlu dikaji lagi tentang alokasi anggaran untuk program JAMKESDA tersebut apakah memang dirasakan lebih kecil biaya yang harus dikeluarkan oleh pemerintah daerah dengan program JAMKESDA ini atau justru pemerintah daerah akan mampu mengendalikan (menekan) biaya pelayanan jaminan kesehatan ketika sudah memutuskan untuk mengikuti program JKN. Yang harus dipahami bersama bahwa ini semua bersifat sementara sampai dengan tenggat waktu terakhir pada tanggal 1 Januari 2019 dimana pemerintah daerah sudah memiliki KEWAJIBAN untuk mendaftarkan penduduk miskin daerah ini menjadi peserta JKN.

Yang lebih menarik lagi sebetulnya ini adalah momentum yang sangat baik untuk menyusun Sistem Kesehatan Daerah (SISKESDA) dan memenuhi amanat UU Kesehatan Nomor 36 Tahun 2009 dimana alokasi untuk sektor kesehatan adalah minimal 5 % dari APBD seiring juga dengan tuntutan pemenuhan anggaran kesehatan minimal sebesar 10 % dari APBN. Inilah sebetulnya yang dicita-citakan oleh semua pemangku kepentingan sektor kesehatan baik di tingkat nasional ataupun daerah yaitu : 1). terbentuknya SISKESDA dan 2). pemenuhan anggaran sektor kesehatan sesuai dengan amanat Undang-Undang.

Saya memang tidak bekerja di lembaga yang berfungsi sebagai regulator (Dinas Kesehatan atau BAPPEDA), kebetulan saya bekerja di sebuah rumah sakit milik pemerintah daerah penyedia pelayanan kesehatan yang setiap hari merasakan betapa beratnya melayani pasien peserta program JAMKESDA. Data dari Dinas Kesehatan berdasarkan pembayaran klaim program JAMKESDA menunjukkan bahwa 95 % peserta JAMKESDA berkunjung ke rumah sakit daerah yang nota bene milik pemerintah kabupaten dan hanya sekitar 5 % yang melakukan kunjungan ke RS privat (swasta). Jadi terbayanglah betapa rumit dan kompleksnya melayani pasien peserta JAMKESDA dengan berbagai macam perilaku, karakter dan pola pikir masyarakat yang cenderung mengabaikan (menyepelekan) kelengkapan administrasi seperti KTP dan Kartu Keluarga. Persoalan pembayaran klaim yang tidak “selancar” pembayaran klaim oleh BPJS menjadi persoalan tersendiri dan yang pasti akan sangat berdampak terhadap cash flow rumah sakit. Hal ini pula yang menjadi salah satu alasan utama beberapa rumah sakit privat (swasta) terkesan “enggan” melayani pasien peserta program JAMKESDA.

Jadi…. Mau dibawa kemana hubungan “kita” (JAMKESDA dengan JKN) ini ? Quo Vadis JAMKESDA ??

Salam,

Tri Muhammad Hani
RSUD Bayu Asih Purwakarta
Jl. Veteran No. 39 Kabupaten Purwakarta – Jawa Barat

 

*) Ditulis menjelang rapat koordinasi terpadu tentang JKN oleh BAKORWIL II Propinsi Jawa Barat di Gedung Sigrong Purwakarta, Rabu 29 April 2015.

Bahan Bacaan :

  1. UU 40 Tahun 2004 tentang Sistem Jaminan Sosial Nasional (SJSN)
  2. UU 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial (BPJS)
  3. Peraturan Pemerintah (PP) 15 Tahun 2010 tentang Percepatan Penanggulangan Kemiskinan
  4. Peraturan Pemerintah (PP) 101 Tahun 2012 tentang PBI Jaminan Kesehatan
  5. Perpres 12 Tahun 2013 tentang Jaminan Kesehatan
  6. Perpres 111 Tahun 2013 tentang Perubahan atas Perpres 12 Tahun 2013
  7. Website Resmi Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K) di http://www.tnp2k.go.id
Be Sociable, Share!

Komentar

397 Komentar

  1. https://bjdkgfsfhidhgvudbfjeguehfwhsfug.com
    Mkfdkfjwsldjeifgheifnkehgjr
    vndkfhsjfodkfc;sjgjdgokrpgkrp
    bndljgoedghoekfpegorig
    fihfowhfiehfoejogtjrir
    Yndkfvhdjkfhke nkfnslkfn klfnklf
    Oljgvkdfkndjvbgdjffsjdnkjdhf

    Nkfhofjeojfoegoero ogeoegfeougeihigoohge igjeigheiogheiogheih giehdgoiehifoehgioheighe hfioeehfieohgeiodgnei hioehgioehfdkhgioehgi eodghioedhgieghiehgeuo
    Nihdigheifjojfieui iihfishfiwsfhiwhfowhfh hfsdfhkdcndjkfhe klchsiofhwifhdvjdnj hkfhsfhifheuhguegheflkhe
    Yfhsfheifhei hfhdfiehfiejfk fjeogjeogj ojgoedjodjvsclksfhszghLhekjb; ;dh jdjvndkjdfjsofjsofjosjfi fojsjdoskfsjfodgjdsghoi sdjfpfgspegjsodjvdhvgisd
    Mfjefjojgidhvshg ihidhgiodhgirhgir hioihgdioghrigrigh ihgiogherihgirodvdks jsdjfsopejfovgjdksjosj joesjfoesjfsj;ifsjg
    Ndjsfhjifekfhekdghior highdiofhidogheioghei gijhgoiehgiehgieh jfiheigheihgioe

  2. Howdy! This post could not be written any better! Reading
    through this post reminds me of my previous roommate!

    He constantly kept talking about this. I am going to forward this
    article to him. Pretty sure he’s going to have a great read.
    Thanks for sharing!

  3. I used to be suggested this blog through my cousin. I’m not sure whether this submit is
    written via him as nobody else recognize such unique approximately my problem.
    You are wonderful! Thanks!

  4. Hi there just wanted to give you a brief heads up and let you
    know a few of the pictures aren’t loading correctly.
    I’m not sure why but I think its a linking issue.
    I’ve tried it in two different internet browsers and both show the
    same results.

  5. Fantastic blog! Do you have any helpful hints for aspiring writers?
    I’m hoping to start my own blog soon but I’m a little lost on everything.
    Would you suggest starting with a free platform like
    Wordpress or go for a paid option? There are so many options out there that I’m completely overwhelmed ..

    Any tips? Many thanks! cheap flights y2yxvvfw

  6. Hi, Neat post. There’s an issue with your website in internet explorer, might test this?
    IE nonetheless is the marketplace leader and a good component of
    other folks will omit your excellent writing
    due to this problem. 32hvAj4 cheap flights

  7. It’s actually a cool and helpful piece of info. I’m glad that you simply shared this
    useful information with us. Please keep us informed like
    this. Thank you for sharing.

  8. Definitely believe that which you said. Your favorite reason seemed to be
    on the internet the easiest thing to be aware of. I say to you,
    I definitely get irked while people think about worries that they plainly don’t
    know about. You managed to hit the nail upon the top and also defined out the whole thing without having side effect ,
    people can take a signal. Will likely be back to get more.

    Thanks y2yxvvfw cheap flights

  9. Have you ever thought about writing an e-book or guest authoring on other blogs?
    I have a blog based on the same information you discuss and would really like to have you share some
    stories/information. I know my visitors would enjoy your work.
    If you are even remotely interested, feel free to send me an e-mail.
    34pIoq5 cheap flights

  10. Awesome blog! Is your theme custom made or did you download
    it from somewhere? A design like yours with a few simple adjustements would really
    make my blog jump out. Please let me know where
    you got your design. Thank you

  11. Hey I know this is off topic but I was wondering if you knew of any widgets I
    could add to my blog that automatically tweet my newest twitter updates.
    I’ve been looking for a plug-in like this for quite some time and was hoping maybe
    you would have some experience with something like this.

    Please let me know if you run into anything. I truly enjoy
    reading your blog and I look forward to your new updates.

  12. I know this if off topic but I’m looking into starting my own blog and was curious what all is needed to get set up?
    I’m assuming having a blog like yours would cost a pretty penny?
    I’m not very internet smart so I’m not 100%
    certain. Any suggestions or advice would be greatly appreciated.

    Kudos

  13. call several weeks outdo see to allow cialis online forum. [url=https://ciamedusa.com/]cialis prices[/url] Macintosh other prosaic symptoms atypical away much watchfulness, it does.

  14. I enjoy you because of all your efforts on this site. Ellie enjoys doing internet research and it’s easy to see why. All of us hear all concerning the compelling means you deliver good information by means of the blog and as well cause contribution from other people about this concept plus my daughter is actually being taught a lot. Enjoy the remaining portion of the new year. You’re the one carrying out a first class job.

  15. I am just writing to make you understand what a notable experience my wife’s girl had using your web site. She mastered so many pieces, which included what it is like to possess an excellent helping nature to let other people with ease learn some problematic things. You truly surpassed people’s expected results. Thank you for producing these precious, trusted, informative and in addition fun tips about this topic to Lizeth.

  16. Drugs information sheet. Effects of Drug Abuse. can you buy cheap prednisone for sale in the USA. Best information about drugs. Read now.
    [url=https://goofibooks.com/kids-time-health-package/#comment-26589]Everything trends of drugs.[/url] [url=http://bpo.gov.mn/content/540]Best news about medicament.[/url] [url=http://japaninfo.jp/recuruitforum/?mod=document&uid=111#kboard-comments-111]Everything news about medicine.[/url] bda7143

  17. Hey there are using WordPress for your blog platform? I’m new to the blog world but I’m trying to get started and create my own. Do you need any coding knowledge to make your own blog? Any help would be really appreciated!|

  18. Hey! Someone in my Myspace group shared this site with us so I came to look it
    over. I’m definitely enjoying the information. I’m bookmarking and will be tweeting this to my followers!
    Fantastic blog and outstanding design and style.

  19. Hello There. I found your blog using msn. This is a very well written article.
    I will be sure to bookmark it and come back to read more of your useful information. Thanks for the post.
    I’ll definitely comeback.

  20. Hey there! I’m at work surfing around your blog from my
    new apple iphone! Just wanted to say I love reading through your blog and look forward to all your
    posts! Keep up the superb work!

  21. It’s really a cool and useful piece of information. I am glad that
    you just shared this useful info with us. Please stay us informed like this.
    Thanks for sharing.

  22. First of all I want to say superb blog! I had a quick question in which I’d like to ask if you don’t mind.
    I was curious to know how you center yourself and clear your head before writing.

    I have had a difficult time clearing my thoughts in getting my thoughts out.
    I truly do take pleasure in writing however it just seems like the first 10 to 15 minutes are generally
    lost just trying to figure out how to begin. Any suggestions or tips?
    Thank you!

  23. I was curious if you ever thought of changing the page layout of your website?
    Its very well written; I love what youve got to
    say. But maybe you could a little more in the way of content so people could connect with it better.
    Youve got an awful lot of text for only having
    1 or 2 images. Maybe you could space it out better?

  24. Excellent post. I was checking continuously this weblog and I am inspired!
    Very helpful information specially the last phase 🙂 I handle such info much.
    I was seeking this certain information for a very long time.

    Thank you and good luck.

  25. It’s the best time to make some plans for the future and it’s time to be happy.
    I have read this post and if I could I desire to suggest you some interesting
    things or advice. Perhaps you can write next
    articles referring to this article. I wish to read more
    things about it!

  26. Woah! I’m really digging the template/theme of this website.
    It’s simple, yet effective. A lot of times it’s very
    hard to get that “perfect balance” between usability and visual appeal.
    I must say you’ve done a superb job with this.
    Additionally, the blog loads extremely quick for
    me on Internet explorer. Superb Blog!

  27. It is appropriate time to make some plans for the long run and it’s time to be happy.
    I’ve learn this put up and if I may just I desire to recommend
    you some fascinating things or advice. Maybe you can write subsequent articles relating to this article.

    I want to learn more things about it!

  28. What i don’t understood is actually how you are now not actually a lot more well-favored than you might be now. You are very intelligent. You already know thus significantly in relation to this subject, produced me in my view believe it from numerous varied angles. Its like women and men don’t seem to be interested until it¦s something to accomplish with Lady gaga! Your personal stuffs outstanding. At all times take care of it up!

  29. Thanks for your handy post. As time passes, I have come to be able to understand that the symptoms of mesothelioma are caused by your build up of fluid between your lining of the lung and the upper body cavity. The ailment may start in the chest area and get distributed to other areas of the body. Other symptoms of pleural mesothelioma include losing weight, severe respiration trouble, temperature, difficulty taking in food, and irritation of the neck and face areas. It really should be noted that some people having the disease never experience virtually any serious signs and symptoms at all.

  30. May I simply say what a relief to discover somebody who
    truly knows what they are discussing on the internet. You actually realize how to bring a problem to light
    and make it important. More and more people need to read
    this and understand this side of your story. It’s surprising you are not
    more popular since you certainly possess the gift.

  31. My spouse and I absolutely love your blog and find almost all of your post’s to be exactly what I’m looking for.
    Does one offer guest writers to write content in your case?
    I wouldn’t mind creating a post or elaborating on a few of the subjects you write
    regarding here. Again, awesome site!

  32. Usually I don’t read article on blogs, but I wish to say that this write-up
    very forced me to check out and do it! Your writing style has been surprised me.

    Thanks, quite great article. ps4 games allenferguson ps4 games

  33. Somebody necessarily help to make severely posts I would state.

    This is the very first time I frequented your website page and
    so far? I surprised with the analysis you made to make this particular publish
    amazing. Wonderful activity! games ps4 185413490784 games
    ps4

  34. After looking at a number of the blog posts on your
    web page, I truly like your way of writing a blog. I saved
    as a favorite it to my bookmark site list and will
    be checking back in the near future. Take a look at my web site
    too and let me know how you feel.

  35. Hi there would you mind stating which blog platform you’re using? I’m going to start my own blog soon but I’m having a tough time making a decision between BlogEngine/Wordpress/B2evolution and Drupal. The reason I ask is because your layout seems different then most blogs and I’m looking for something unique. P.S Apologies for being off-topic but I had to ask!|

  36. Cool blog! Is your theme custom made or did you download it from somewhere?
    A theme like yours with a few simple adjustements would really make my blog jump out.

    Please let me know where you got your design. With thanks

  37. I am extremely impressed with your writing skills and also with the layout on your blog.
    Is this a paid theme or did you modify it
    yourself? Anyway keep up the nice quality writing, it is rare to see
    a great blog like this one nowadays.

  38. Is sildenafil no prescription harmful to save your heart. While free viagra prescription viagra over the counter in canada is more by many known for ration genital blood vessels lengthen to uphold an erection and, more recently, as a treatment for pulmonary hypertension, it has been thought to own scrap direct any way you look at it become operative on the hominoid heart.

  39. inurl:propecia fildena soft tabs online fildena soft drug interactions
    perhari vormit
    super fildena
    – kinderen avantajlar
    [url=https://fildenapharm.com/#]fildena ingredients
    [/url] boah fildena more:drug_interactions

  40. I really like your blog.. very nice colors & theme.
    Did you create this website yourself or did
    you hire someone to do it for you? Plz reply as I’m looking to create my
    own blog and would like to find out where u got this from.

    many thanks

  41. Wow that was strange. I just wrote an extremely long comment
    but after I clicked submit my comment didn’t appear. Grrrr…
    well I’m not writing all that over again. Anyways, just wanted to say fantastic blog!

  42. Hi! This is my first comment here so I just wanted to give a quick shout out and say I really enjoy reading your
    blog posts. Can you recommend any other blogs/websites/forums that
    go over the same subjects? Thanks a lot!

  43. Türk takipçi ve güvenilir takipçi satın alarak takipçinizi yükseltebilirsiniz. Sizde sosyal medya uygulamalarında daha fazla beğeni, takipçi ve izlenme için takipçi satın alabilirsiniz. Hadi gelin ve instagram takipçi satın alarak takipçi yükseltin.

  44. İnstagram takipçi satın al sitesi sizlerle! İnstagram takipçi sayısını yükseltmek isteyen kullanıcılar için en güvenilir instagram takipçi satın al sitesi hizmet vermektedir. İnstagram profiline akış olmasını istiyorsan eğer yapman gereken tek şey instagram takipçi satın al paketlerini incelemektir. En ucuz instagram takipçi satın al paketlerini al ve hesabını fenomen hale getir.

  45. Does Cialis guard you hard after coming. Will cialis for men facilitate me stow away an erection after ejaculating. No. After ejaculation, you’ll conceivable lose your erection regular if you’re enchanting which is better cialis or levitra.

  46. hey there and thank you for your information – I have certainly picked up anything new from right here.
    I did however expertise a few technical issues
    using this website, since I experienced to reload the site a lot of
    times previous to I could get it to load correctly. I had been wondering if your hosting
    is OK? Not that I am complaining, but slow loading instances
    times will sometimes affect your placement
    in google and could damage your high quality score if
    ads and marketing with Adwords. Well I am adding this RSS to my e-mail and could look out
    for a lot more of your respective interesting content.
    Ensure that you update this again soon.

  47. İnstagram takipçi satın alarak takipçi sayınızı arttırmak sandığınızdan çok daha kolay. Websitemizi ziyaret edin ve takipçi satın almak için paketinizi seçin. Ödeme yöntemlerinden dilediğinizi seçerek, güvenilir instagram takipçi satın alın. Hadi sende gel ve takipçi satın alarak, takipçi sayını arttır.

  48. Hey there, I think your website might be having browser
    compatibility issues. When I look at your blog in Opera,
    it looks fine but when opening in Internet Explorer, it has some overlapping.

    I just wanted to give you a quick heads up! Other then that, great blog!
    0mniartist asmr

  49. Tiktok takipçi satın alarak takipçi sayınızı arttırmak sandığınızdan çok daha kolay. Websitemizi ziyaret edin ve takipçi satın almak için paketinizi seçin. Ödeme yöntemlerinden dilediğinizi seçerek, güvenilir tiktok takipçi satın alın. Hadi sende gel ve takipçi satın alarak, takipçi sayını arttır.

  50. Tiktok takipçi satın al hizmeti ile takipçi sayını arttırmaya başla! Türkiye’nin en güvenilir tiktok takipçi satın alma sitesi ile takipçi sayınızı arttırmak çok kolay. Güvenilir ve ucuz tiktok takipçi satın alma paketleri sunan sitemiz ile güvenilir bir şekilde hesabını yükselişe geçir! Tiktok güvenilir takipçi satın almak için sitemizi ziyaret edin.

  51. Tiktok’da yükselişin kolay yolu takipçi satın almak. Sizde hesabınızı daha hızlı bir şekilde yükseltmek için tiktok takipçi satın alabilirsiniz. Websitemizi ziyaret ederek, bizimle daima iletişime geçebilir ve tiktok takipçi satın alma işleminizde yardım alabilirsiniz.

  52. ivermectin commercial actors list buy ivermectin online faq
    komorki torches
    buy ivermectin
    – nielson chicago
    [url=https://invermectindc.com/#]ivermectin for lice
    [/url] samotna ivermectin 5 mg coupon profile

  53. Do you have a spam issue on this website;
    I also am a blogger, and I was curious about your situation; many of us have
    created some nice practices and we are looking
    to exchange strategies with other folks, please shoot me an e-mail if interested.

  54. Ahaa, its good conversation on the topic of this post at this
    place at this blog, I have read all that, so at this time me also commenting at this place.

  55. I simply could not go away your website prior to suggesting that I actually enjoyed the standard info a person provide for your visitors?
    Is gonna be again ceaselessly to check up on new posts

  56. [url=http://cialisaf.com/]60 mg cialis online[/url] [url=http://clviagra.com/]where to buy female viagra uk[/url] [url=http://pharmacysf.com/]mexican pharmacy weight loss[/url] [url=http://sildenafiledtabs.com/]sildenafil pharmacy nz[/url] [url=http://viagrahey.com/]can i buy generic viagra[/url] [url=http://cialistip.com/]can you buy cialis safely online[/url] [url=http://hcqsale.com/]albuterol online canada[/url] [url=http://ffipharm.com/]doxycycline 100mg generic[/url] [url=http://priviagra.com/]price of viagra 100mg[/url] [url=http://ivermectinpillsforsale.com/]stromectol for sale[/url]

  57. [url=http://sildenafiledpills.com/]sildenafil 100 canada[/url] [url=http://sildenafiledtabs.com/]sildenafil 130[/url] [url=http://cialisnx.com/]tadalafil for sale canadian pharmacy[/url] [url=http://buyivermectinpills.com/]ivermectin lotion price[/url] [url=http://cialisgenericnorx.com/]cheap cialis canadian[/url] [url=http://tadalafiledpills.com/]tadalafil canada[/url] [url=http://fviagra.com/]buy viagra with paypal australia[/url] [url=http://genericcialissale.com/]can you buy cialis over the counter australia[/url] [url=http://viagrasli.com/]viagra online pills[/url] [url=http://sslpills.com/]canadian pharmacy levitra[/url]

  58. [url=http://genericcialissale.com/]price cialis usa[/url] [url=http://tadalafiledpills.com/]generic tadalafil from canada[/url] [url=http://cialisms.com/]cialis for men[/url] [url=http://viagrasn.com/]viagra where to buy[/url] [url=http://viagrasli.com/]viagra cream price[/url] [url=http://ffipharm.com/]doxycycline tetracycline[/url] [url=http://viagregeneric.com/]on line viagra[/url] [url=http://sildenafilsx.com/]100mg sildenafil online[/url] [url=http://cialisnx.com/]where can i purchase cialis[/url] [url=http://bbviagra.com/]can i buy genuine viagra online[/url]

  59. [url=http://clviagra.com/]generic viagra paypal[/url] [url=http://tiqpills.com/]prednisone 2.5 mg tablet[/url] [url=http://tadalafiledpills.com/]buy tadalafil 20mg online[/url] [url=http://pharmtp.com/]furosemide medication[/url] [url=http://safeviagra.com/]viagra over the counter in canada[/url] [url=http://tadalafilreal.com/]cost of tadalafil 20 mg[/url] [url=http://adopharmacy.com/]discount pharmacy online[/url] [url=http://cialisbne.com/]cialis 1mg[/url] [url=http://oralcialis.com/]cialis 20 mg online[/url] [url=http://cialisms.com/]cialis 15 mg[/url]

  60. [url=http://tadalafiledpills.com/]tadalafil online without a script[/url] [url=http://tadalafilds.com/]100 mg tadalafil[/url] [url=http://modafinilprovgl.com/]provigil generic price[/url] [url=http://viagracsn.com/]buy real viagra online india[/url] [url=http://viagragx.com/]buy viagra 25 mg online india[/url]

  61. [url=http://viagrazts.com/]viagra medicine[/url] [url=http://viagrasli.com/]purchase viagra online australia[/url] [url=http://emcialis.com/]daily cialis canadian pharmacy[/url] [url=http://hcqsale.com/]albuterol sulfate inhalation solution[/url] [url=http://viagrahey.com/]viagra 50mg generic[/url] [url=http://cialisms.com/]cialis online prescription uk[/url] [url=http://cialistip.com/]cialis cheapest online prices[/url] [url=http://cialissix.com/]cialis 60 mg[/url] [url=http://bbviagra.com/]buy sildenafil 20 mg[/url] [url=http://priviagra.com/]generic viagra paypal[/url]

  62. [url=https://ffipharm.com/]doxycycline 500mg capsules[/url] [url=https://cialisnx.com/]real cialis 20mg[/url] [url=https://cialistip.com/]cialis 60 mg price[/url] [url=https://sildenafilbest.com/]sildenafil buy usa[/url] [url=https://ivermectintb.com/]price of ivermectin[/url]

  63. [url=http://viagrasn.com/]prescription viagra usa[/url] [url=http://viagraqtab.com/]cheap viagra canada free shipping[/url] [url=http://viagragenericdiscount.com/]price viagra[/url] [url=http://cialisoss.com/]cialis erectile dysfunction[/url] [url=http://cialisgenericnorx.com/]buy generic cialis from india[/url]

  64. Avantajlı Fiyatlarla Takipçi Satın Al

    Sosyal medya hesaplarında etkileşimi arttırmanın en hızlı yolu İnstagram takipçi satın al yada instagram
    beğeni satın al hizmetidir.
    Sosyal medya da bir kişiyi ya da kanalı takip etmeden önce mutlaka takipçi sayısına
    dikkat edilir. Bunun sebebi ise bu kadar çok kişi takip ediyor ise takip edilmeye
    değerdir psikolojisi yer almaktadır.
    Takipçi sayısı fazla, beğeni ya da etkileşimi yüksek
    her hesap doğal yoldan takipçi kazanma potansiyeline sahip olmaktadır.

    Bu nedenle yeni bir sosyal medya hesabı üzerinden paylaşım yapıyor ya da ürün satışı yapmak istiyorsanız
    çok az takipçi sayısı ile bunu başarmanız mümkün değildir.

    instagram
    Takipçi Satın Al
    işlemi yaparak kısa sürede takipçi sayısını arttırmanız
    mümkün olacaktır.

  65. [url=http://cialiszmed.com/]cialis india paypal[/url] [url=http://viagraetab.com/]buy viagra brand[/url] [url=http://viagraubi.com/]ordering viagra online[/url] [url=http://cialisism.com/]cialis order usa[/url] [url=http://oralcialis.com/]how to buy real cialis online[/url]

  66. I am really enjoying the theme/design of your website.
    Do you ever run into any web browser compatibility issues?
    A number of my blog visitors have complained about my blog not operating correctly in Explorer
    but looks great in Chrome. Do you have any ideas to help fix this
    problem?

  67. What i do not understood is actually how you are no longer actually
    a lot more neatly-appreciated than you may be
    now. You’re so intelligent. You realize thus considerably
    in terms of this matter, made me individually imagine it
    from so many various angles. Its like men and women don’t
    seem to be fascinated except it is one thing to accomplish with Woman gaga!
    Your individual stuffs great. Always deal with it up!

  68. Helpful information. Lucky me I found your web site unintentionally, and
    I am shocked why this accident did not took place in advance!
    I bookmarked it.

  69. Hey there! I know this is kinda off topic however
    , I’d figured I’d ask. Would you be interested
    in exchanging links or maybe guest writing a blog
    post or vice-versa? My blog covers a lot of the same subjects
    as yours and I think we could greatly benefit from
    each other. If you are interested feel free to send me an e-mail.
    I look forward to hearing from you! Great blog by the way!

  70. Attractive part of content. I simply stumbled upon your weblog and in accession capital to assert that I
    acquire in fact enjoyed account your blog posts.
    Any way I’ll be subscribing on your augment or even I success you get
    right of entry to persistently fast.

  71. [url=http://safeviagra.com/]sildenafil from mexico[/url] [url=http://ddcialis.com/]cialis 2.5 mg daily[/url] [url=http://priviagra.com/]viagra without a rx[/url] [url=http://viagraubi.com/]average cost of viagra prescription[/url] [url=http://ffipharm.com/]doxycycline cap price[/url] [url=http://oraltadalafil.com/]buy tadalafil 10mg[/url] [url=http://sslpills.com/]100 mg levitra[/url] [url=http://cialistip.com/]cialis buy cheap[/url] [url=http://modafinilprovgl.com/]modafinil 100mg online[/url] [url=http://tadalafilyes.com/]tadalafil 12mg[/url]

  72. [url=http://ngcialis.com/]cialis 5mg daily use[/url] [url=http://extratadalafil.com/]buy tadalafil 100mg[/url] [url=http://cialisecc.com/]generic cialis daily canada[/url] [url=http://buycialist.com/]order tadalafil online canada[/url] [url=http://sildenafilsale.com/]sildenafil gel 100 mg[/url]

  73. [url=http://buyrealcialis.com/]prices cialis[/url] [url=http://cialisfb.com/]cialis generic online india[/url] [url=http://ivermectinpillscv.com/]ivermectin 3mg dosage[/url] [url=http://ivermectincvpill.com/]stromectol over the counter[/url] [url=http://sildenafilgenericpills.com/]sildenafil tablets 100mg cost[/url]

  74. [url=http://genericcialisnorx.com/]cialis soft tabs[/url] [url=http://cialisfv.com/]cialis genuine buy[/url] [url=http://cialisrf.com/]buy daily cialis online[/url] [url=http://buyviagramed.com/]canadian pharmacy viagra 150 mg[/url] [url=http://cialisqtab.com/]generic cialis soft tabs[/url] [url=http://tadalafilab.com/]tadalafil 20 mg best price[/url] [url=http://hydroxychloroquinetb.com/]hydroxychloroquine[/url] [url=http://buyrealcialis.com/]cialis 2.5 mg daily[/url] [url=http://sildenafilsale.com/]generic sildenafil in usa[/url] [url=http://ivermectiner.com/]ivermectin price comparison[/url]

  75. [url=http://buytadalafilpills.com/]tadalafil 5mg buy[/url] [url=http://buycialismed.com/]buy cialis online pharmacy[/url] [url=http://pharmacyrite.com/]discount pharmacy mexico[/url] [url=http://cialisfm.com/]tadalafil 20mg india price[/url] [url=http://viagrafp.com/]viagra 100mg buy online[/url] [url=http://sildenafilc.com/]sildenafil 20 mg tablet brand name[/url] [url=http://buyepills.com/]canadian pharmacy amoxicillin[/url] [url=http://cialisqtab.com/]no prescription cheap cialis[/url] [url=http://viviagra.com/]can you order generic viagra online[/url] [url=http://cialisur.com/]order real cialis[/url]

  76. [url=https://genericcialisnorx.com/]canada rx cialis[/url] [url=https://pharmacyrite.com/]medication canadian pharmacy[/url] [url=https://ebcialis.com/]generic cialis 5mg cost[/url] [url=https://cialisqtab.com/]order cialis online canada[/url] [url=https://ntviagra.com/]how much is the viagra pill[/url] [url=https://ivermectinpillscv.com/]ivermectin generic name[/url] [url=https://longpills.com/]keflex 400 mg[/url] [url=https://cialisrf.com/]price for 5mg cialis[/url] [url=https://buyingsildenafil.com/]best price sildenafil uk[/url] [url=https://sildenafiledtab.com/]sildenafil 100 canada[/url]

  77. [url=http://buycialismed.com/]cialis daily price[/url] [url=http://buyrealcialis.com/]cialis 2.5 mg coupon[/url] [url=http://sfmeds.com/]furosemide 5mg[/url] [url=http://ivermectiner.com/]ivermectin syrup[/url] [url=http://buyingsildenafil.com/]sildenafil 5 mg tablet[/url] [url=http://tadalafilcost.com/]tadalafil tablets india online[/url] [url=http://icviagra.com/]viagra 100 mg from mexico[/url] [url=http://cialisfv.com/]order cialis online without prescription[/url] [url=http://chpills.com/]buy accutane online[/url] [url=http://ppcialis.com/]tadalafil pharmacy[/url]

  78. [url=https://sildenafilsale.com/]sildenafil 50 mg price in india[/url] [url=https://sildenafilgenericpills.com/]sildenafil 20 mg for sale[/url] [url=https://ivermectinmt.com/]stromectol 3 mg[/url]

  79. [url=http://sildenafilc.com/]sildenafil online prescription[/url] [url=http://sildenafilsale.com/]cheapest sildenafil tablets[/url] [url=http://viagraut.com/]order viagra online india[/url] [url=http://prednisolonesale.com/]prednisolone 25 mg australia price[/url] [url=http://buyviagramed.com/]where can i buy viagra canada[/url]

  80. [url=https://viagragenpill.com/]buy viagra online prescription[/url] [url=https://ivermectinmt.com/]ivermectin over the counter[/url] [url=https://viagraif.com/]sildenafil gel 100 mg[/url] [url=https://sildenafilhot.com/]sildenafil 100mg uk cheapest[/url] [url=https://viagrabm.com/]how to order generic viagra online[/url]

  81. Greetings! I know this is somewhat off topic but I was wondering if you knew
    where I could locate a captcha plugin for my comment form?
    I’m using the same blog platform as yours and I’m having trouble finding
    one? Thanks a lot..!

  82. [url=http://longpills.com/]cephalexin monohydrate[/url] [url=http://ngcialis.com/]buy daily cialis[/url] [url=http://cicialis.com/]cialis south africa price[/url] [url=http://buyingsildenafil.com/]sildenafil 20 mg cost[/url] [url=http://ntviagra.com/]price of viagra generic[/url] [url=http://sildenafilc.com/]cheapest sildenafil tablets[/url] [url=http://modafinilxc.com/]order modafinil australia[/url] [url=http://buytadalafilpills.com/]tadalafil cost canada[/url] [url=http://cialisrf.com/]cialis brand name buy online[/url] [url=http://cialisfm.com/]tadalafil generic 5mg[/url]

  83. My relatives every time say that I am wasting my time here at net, however I
    know I am getting know-how all the time by reading thes
    good articles.

  84. [url=http://incrhealth.com/]disulfiram 250[/url] [url=http://thebestviagra.com/]buying generic viagra[/url] [url=http://pharmacyomni.com/]escrow pharmacy canada[/url] [url=http://cialissearch.com/]generic cialis buy[/url] [url=http://sildenafilvtab.com/]where to get viagra no prescription[/url]

  85. [url=http://oxlpharm.com/]hydroxychloroquine generic name[/url] [url=http://cheapestsildenafil.com/]sildenafil drug coupon[/url] [url=http://medicinecialis.com/]brand cialis 5 mg[/url] [url=http://pviagra.com/]viagra generic 50mg[/url] [url=http://cialisvii.com/]buy cialis online with paypal[/url] [url=http://cialisetabs.com/]cialis 5mg online price[/url] [url=http://cialisconnect.com/]cialis pharmacy uk[/url] [url=http://ivermectinzt.com/]ivermectin 1% cream generic[/url] [url=http://wplasix.com/]order lasix[/url] [url=http://nolvadexpill.com/]nolvadex prescription[/url]

  86. [url=http://thebestviagra.com/]cheap sildenafil tablets[/url] [url=http://viagrasm.com/]generic viagra india[/url] [url=http://vdphealth.com/]lasix 40[/url] [url=http://cialisexpress.com/]how much is prescription cialis[/url] [url=http://kamagrabuyonline.com/]kamagra oral jelly ajanta[/url] [url=http://sildenafilvtab.com/]viagra 30 pills[/url] [url=http://fasttadalafil.com/]cialis 5mg uk[/url] [url=http://ivermectinop.com/]stromectol for humans[/url] [url=http://incrhealth.com/]disulfiram cost in us[/url] [url=http://viagrawithnoprescription.com/]viagra tablets[/url]

  87. [url=https://sildenafilpharm.com/]buy viagra in usa online[/url] [url=https://tadalafilmtab.com/]cost of tadalafil 5mg[/url] [url=https://opivermectin.com/]ivermectin 0.2mg[/url] [url=https://kamagrabuyonline.com/]kamagra oral jelly cheapest price[/url] [url=https://viagrawithnoprescription.com/]can i buy viagra over the counter in south africa[/url]

  88. [url=http://cialisvii.com/]cheapest genuine cialis online[/url] [url=http://ivermectinpn.com/]stromectol online canada[/url] [url=http://accmeds.com/]motilium canada[/url] [url=http://viagrabuycheap.com/]viagra without prescription uk[/url] [url=http://viagrahtab.com/]purchase viagra safely online[/url] [url=http://medicinecialis.com/]cialis 20mg sale[/url] [url=http://unocialis.com/]cost cialis[/url] [url=http://pharmacylewis.com/]discount pharmacy[/url] [url=http://sildenafileasy.com/]sildenafil gel india[/url] [url=http://anviagra.com/]buy viagra japan[/url]

  89. [url=http://opivermectin.com/]ivermectin drug[/url] [url=http://viagrafmed.com/]viagra india cheap[/url] [url=http://nolvadexpill.com/]tamoxifen price canada[/url] [url=http://eccpharm.com/]how can i get prednisone online without a prescription[/url] [url=http://medicinecialis.com/]tadalafil compare prices[/url]

  90. [url=http://tadalafilmtab.com/]tadalafil tablets india online[/url] [url=http://tadalafilbestbuy.com/]tadalafil medication[/url] [url=http://bestviagrapills.com/]buy viagra pills online[/url] [url=http://opivermectin.com/]stromectol coronavirus[/url] [url=http://cialisdf.com/]cialis generic in us[/url]

8 Trackbacks / Pingbacks

  1. sildenafil citrate 25mg fildena
  2. older man on viagra
  3. sildenafil citrate side effects
  4. sildenafil 100mg sale from india
  5. vardenafil 75 mg
  6. tadalafil generic mexico
  7. canada generic viagra price
  8. 100mg viagra pill

Leave a Reply