If you arrived at this page and thought it was going to be a good time, I have bad news. It’s just another learning opportunity. Got ‘em.


Lost the rules? Here’s the front and the back.

Want to be an awesome person and leave a review? Please, help me out.

Want to learn how to manufacture a card game and the economics of it? I wrote it out.

Interested in actually learning what the cards mean? Read on.

For everything else? There’s Mastercard.

Bankruptcy


The crux of the game is to avoid medical bankruptcy, and the joke is it’ll happen even if you try your hardest to avoid it. Isn’t that hilarious?

About 41% of working age Americans have problems paying their medical bills or are currently paying off medical debt. People can find themselves with expensive bills for all sorts of reasons, but I thought I’d use this game to highlight a few.

Surprise Billing - Explaining this to a normal person makes me sound insane. But even if your hospital is in-network, sometimes they’ll be staffed with physicians that may not be in your network. This will result in a surprise bill, which is especially annoying if you didn’t even get a say in the matter (like, I don’t know, if you were unconscious). Luckily surprise bills will soon be a thing of the past.

Claim Denied - Insurers are salivating at the mouth looking for reasons to deny a claim. This could be going to an out-of-network hospital or getting a surgery they deemed unnecessary. If possible, try to ensure that whatever goods or services you’re getting is covered by your insurance.

Formulary Change - Your insurance company works with a pharmaceutical benefits manager (PBM) to figure out what drugs they will cover or not and how much you’ll pay. This is called a formulary. Sometimes there are medicines that aren’t cost-effective which they don’t think warrants coverage. Unfortunately these decisions can be made abruptly and force patients to switch medications. Check to make sure your insurer has your medication covered if you take something regularly.

Lost Wages - Bankruptcy may not come from the health bills alone, but also because it’s hard to work if you’re sick. Couple that with the fact that you need to keep your job to keep your insurance and you really have a system designed to make sure people work instead of recover. U-S-A, U-S-A.

Global Event


Sometimes a macro event gives the healthcare system a lil’ shake up. These cards represent some of the systemic changes that can cause huge shifts in US healthcare.

Presidential Election - Every 4 to 8 years a new president is elected and their agendas for healthcare can totally differ. This is unfortunately why it’s so difficult to run experiments in healthcare - it’s going to be more than 4 years before you get results and a president with a different agenda might walk back your efforts completely.

Time Machine - What’s the first thing you’d do if you got a time machine? There’s only one correct answer - rewriting post-WWII tax laws so that employers don’t get tax breaks for choosing our health insurance for us. I wrote about why that’s a problem here.

Recession - A recession can totally change the payer-mix of the population. As more people lose their job, they’ll switch from commercial insurance from their employer to an individual marketplace plan or Medicaid. This discontinuity of coverage is a huge headache and can come at the worst time for families who’ve just lost their jobs.

Global Pandemic - These are so rare that we probably don’t need to think too much about them *laughs nervously*. Hopefully we’re better prepared for the next one when it eventually arrives.

Preventive Health


“An ounce of prevention is worth a pound of cure” - Benjamin Franklin, or someone selling cannabis strains with weird names. These cards show some of the ways you can potentially avoid worse health problems down the road by taking precautions preventively.

Vaccines - Some of the most horrific diseases in history have been eliminated thanks to the advent of vaccines (shoutout to Edward Jenner, you the man). Please get your vaccines, even the flu shot you lazy bum.

Genetics - Genetics play a huge role in your healthcare. Today, you can get screened for mutations like BRCA that make you susceptible to breast cancer. Or you can test to understand the risks of passing hereditary diseases to children. Maybe in the future we can use gene-editing technology like CRISPR to fix some of these issues, but we’re not quite there yet. Also when it arrives I’m gonna CRISPR myself to 6’5”.

Regular Screening - It’s important to get screened if you’re in an at-risk category. This means Mammograms if you’re at-risk for breast cancer. Colonoscopies if you’re at-risk for colorectal cancer. These factors can be based on age, family history, etc. and you should talk to your doctor about when to start screening.

Diet & Exercise - Eat more greens, do a little interval training, and you’ll be surprised at how much this can help your health down the road. Put on some “Eye of the Tiger” to get you pumped. Think about how jealous your ex would be if they saw you in shape. Whatever it takes.

Primary Care Visit - It’s important to get a yearly assessment of your health done so you can see how it’s changing over time. Now with telemedicine it’s easier than ever. And that means an ADULT doctor, stop seeing your pediatrician.

Risk Shifting


Insurance only works if there are enough healthy people in the pool to balance out the much sicker people who cost more. As traditional health insurance becomes more expensive, healthy people are leaving these risk pool to find other options that are cheaper but more barebones. Careful what you sign up for.

These cards show some of the ways the risk pool gets distorted by removing the healthy people.

Health Sharing Ministries - These are typically religious-affiliated health sharing plans (though many non-denominational ones exist today as well). The general gist is these plans help coordinate payment of hospital bills between members instead of the insurer being on the hook for the bill themselves. There’s a wide quality variance between these plans, and you can learn more here.

Skip Insurance - Well, technically the cheapest insurance is no insurance at all. This is generally not a good idea and you should be able to find some kind of coverage or subsidies that works for you.

College Health Plan - In a somewhat hilarious loophole, you can sign up for just enough college credits to qualify for their health insurance. This insurance tends to be cheaper since it’s mostly students. What a functional system! You can learn more here.

Short Term Insurance - These plans are relatively cheap and don’t need to be compliant with the Affordable Care Act. This means some might prevent people with pre-existing conditions from joining or set annual limits on the amount they will cover per year. If something unexpected happens to you, you might have less coverage than you think.

Block


Trying to move things forward in healthcare is very easy and everyone will be extremely willing to accommodate you. There are definitely no entrenched interests that will set up as many obstacles as possible to keep themselves relevant and make sure money passes through their part of healthcare. These definitely aren’t example of things that make it tough to bring change to healthcare.

Data Blocking - If you’ve ever tried to get your health data from a hospital, you’ll find out all the creative hoops they use to make it difficult for you. Charging weirdly high amounts, taking months to get back to you, giving it in practically unusable formats, etc. You have a right to your data, and thanks to new regulations hospitals will have to give it to any third-party application you want to give it to in a standardized format.

Patent Extension - If a drug company has a really profitable drug that’s about to go off patent, they’ll do all sorts of funny things to extend that patent like try to transfer it to a Native American tribe for sovereign immunity. Patent extensions, especially when no real improvements have been made to a drug, make it more difficult for cheaper generics to enter the market.

Certificate of Need (CON) - In some states you need regulatory approval before you’re allowed to build new facilities or offer new services. The idea was to prevent excess supply from artificially creating new demand or cause providers to charge more to justify the cost of the facility/service. However, this also makes it more difficult for new entrants to enter a market and make it more competitive.

Lobbying - Healthcare spends a lot of money on lobbying. Considering how many people are employed in healthcare as a whole and how much money healthcare organizations donate, they have a lot of sway when it comes to how laws are written.

Need Evidence - No matter what it is, people in healthcare refuse to use anything new unless there’s an expensive study that proves it works. There’s a great joke study about how you can’t actually test if parachutes work using a randomized control trial, a bit of a meta comment that maybe we’re over relying on them. It’s as niche as niche humor gets.

Saved


A hallmark of a dysfunctional healthcare system is the ad-hoc and equally dysfunctional ways to avoid a bill. Here are some ways you might be able to avoid it.

Clinical Trial - While you or your insurer may be on the hook for some parts of a clinical trial, the study drug is almost always covered if you’re part of a trial. If you need a particularly expensive drug, it might be worth seeing if there are trials for your disease nearby. Phase I trials, which are more risky, will also pay for you to be a part of the trial.

Cash Pay - Sometimes if you ask what the cash pay rate is or you say don’t have insurance, a provider will actually offer you a cheaper price. Check out companies like MDSave, Turquoise Health, or Sesame Care to see how much the cash price is vs. what you’d pay with insurance. You can do this with GoodRx and your prescriptions as well.

Malpractice Suit - Unfortunately sometimes your doctor is going to mess up and you’ll sue them. Most cases like this will end up settling outside of court. You can learn more about how malpractice actually works in this interview I did with Dr. Eric Funk, an expert in the space.

GoFundMe - GoFundMe has become an unintended safety net for medical bills. 1 in 3 campaigns on the site are for healthcare. There’s nothing more dystopian than someone begging on social media for money to help cover basic healthcare necessities.

Thoughts & Prayers - We keep expecting thoughts & prayers to solve our health issues when we haven’t run a double-blind placebo controlled trial to see if they worked. C’mon now.

Charity Care - If you can’t afford to pay, many hospitals will have charity care options where they provide some sort of financial assistance to you. Google “hospital name charity care” and you should find out their eligibility and programs. Hospitals will heavily use their charity care programs to justify why they should be considered non-profits (even though they decide the pricing in the first place). I wrote about how they abuse their non-profit status here.

Steal


Healthcare is like an onion, there are more and more layers no matter how many you keep peeling back. Also it makes me cry and I want to cut it down. These are some of the middleman companies that end up taking fees in the process.

Consulting Fees - Healthcare is really confusing, which is why there are so many pockets of specialized consultants that are experts in telling companies how they can increase their revenue per patient or lower their operating expenses. 2x2 squares guiding us to the promised land.

Medical Association Dues - Almost every specialty has its own group to represent the interests of physicians as a collective. These specialty groups have outsized influence on how things get reimbursed, which laws get passed, etc. They seem to have less members joining nowadays, which is why their mail campaigns have gotten a touch more aggressive.

PBM Clawbacks - Pharmaceutical Benefits Managers (PBMs) work with payers to manage the drug spend of the payer’s members. One thing they do is set copay amounts. If the drug is actually cheaper than the copay a patient pays, a PBM will “claw back” whatever the difference between them is from the pharmacy and give it back to the payer. In order to make this work, there were even “gag clauses” that would prevent pharmacists from telling patients they’re overpaying. What a joke.

Private Equity Buyout - Private equity has become a bigger and bigger part of healthcare. In many cases they’ll buy out a majority stake of some healthcare service provider and invest in ways to get more patients through the door or collect more money from a given patient. This can get especially dicey if the patient doesn’t have a choice where they get health service from (e.g. needing an ambulance).

Pass


Sometimes the gods will smile down on you and find ways for you to avoid expensive hospital bills. These cards are just a few of them.

Avoid the Hospital - I mean...yes technically you can avoid going medically bankrupt this way.

Telemedicine - A telemedicine visit can tell you if your issue is serious enough to go see the doctor in-person. It’s possible to avoid costly emergency room admissions this way or get low-risk things diagnosed completely over a video call/text.

Second Opinion - Just like any profession, doctors will sometimes disagree on what you have. A second opinion from a doctor that’s an expert in your area might save you an expensive surgery or course of treatment if it’s not something you actually need.

Negative Biopsy - Sometimes you get a test done and the results are negative. You breathe a sigh of relief. Go out and dance the night away if this happens.

Consolidation


In healthcare, leverage is the name of the game. Everyone is trying to negotiate prices with everyone else, and the best way to do that is acquire companies so you grow and have more leverage. Healthcare has become extremely consolidated as a result.

Hospital - In the last 15-20 years the overhead for running an independent practice became untenable and insurers became larger, tougher negotiators. This made it easy for hospitals to buy up smaller practices in their area, become pseudo-monopolies in their geographes, and increase prices. I wrote about hospital consolidation here.

Pharmacy - Unfortunately the outlook for independent pharmacies has gotten worse. PBMs are reimbursing less for medication dispensing and foot traffic has been ceded to e-commerce companies and grocery stores. Large chains are some of the only ones that remain and now players like Amazon have entered the space. But community pharmacies are important and they’re adapting.

Pharma - Pharma companies are massive, and will typically buy smaller biotech companies with promising Phase I or Phase II data for their assets. The pharma companies will put up a lot of the money needed to run the Phase III trial and help commercialize the drug if it gets FDA approval. They keep acquiring to keep their development pipeline fresh.

Insurer - Until recently, health insurers were actually exempt from federal antitrust scrutiny. This caused more and more acquisitions so that insurers could build their book of business and increase the number of patient lives they cover for negotiating purposes. Insurers have more recently been acquiring into other service lines like owning pharmaceutical benefits managers and buying up physician groups themselves.

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Hopefully this dumb game actually taught you a thing or two about healthcare! And if you really liked it, do me a favor and leave a review on Amazon. It’ll help me lots.

Thinkboi out,
Nikhil