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Medical Quality Drill-Down Analysis

Finding Sources of Treatment Variation 

By Brent A. Metfessel MD, MS, CMP™ (Hon)

If a medical provider or healthcare facility is found to have a significant variance from the norm on a measure, such as economic cost, drill-down analysis is important to find the reason behind the variance. 

Episodes of care case-mix adjustment is naturally suited to this kind of analysis, but other population-based groupers such as DCGs also allow drill-down if the clinical categories that are precursors to the assignment of a risk score are used. 

The Concept

The conceptual idea behind drill-down is to obtain greater and greater detail on an area of interest.  Thus, if a provider is found to have a high overall cost variance or performance ratio, a user can select the provider and drill-down into emergency room usage, hospitalization frequency, types of illnesses seen, or procedures performed. 

Case-mix is useful even for the more detailed reports since if, for example, ER use or the utilization of specified procedures is not adjusted for illness burden the “my patients are sicker” argument can easily hold. 

However, if the procedures are related to illness classes, providers can be compared to their peers on procedure use for that illness class.


Dr. Jones is a family practitioner who had a high patient load from a single large health plan.  These patients under his care had a total of 450 episodes over a two-year period.  His case-mix adjusted performance ratio was 2.28 and cost variance was $157,400.  Dr. Jones requested a drill-down analysis to determine why his practice patterns showed such a high variance from the norm.

One area that the health plan data analysts found had high variance were patients he saw with tendonitis of the lower extremity.  He saw 30 episodes of care for this condition, having a total performance ratio for the illness class of 6.0 and a cost variance of $25,300. 

On further drill-down, the analyst found that the major cost center included the frequency of MRI scans of the lower extremity for the tendonitis patients.  His scan rate was 0.4, which means an average of 4 out of 10 episodes received scans, making a total of 12 scans in all.  His peers of the same specialty showed 0.1 scans per episode of tendonitis of the lower extremity.

Dr. Jones showed a performance ratio of 3.0 and a cost variance of $10,800.  On learning this information, Dr. Jones decided to alter his referral patterns so that his scan rate was brought closer to the norm.


What has been your experience, if any, with drill down analysis; helpful quality improvement adjunct or physician bane?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Financial Planning: http://www.jbpub.com/catalog/0763745790

Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Administrative Terms: www.HealthDictionarySeries.com

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Reverse Mortgages

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How They Work – When Best Used

[By Staff Writers]

A reverse mortgage is a loan that pays the mortgagor (doctor-client) cash and at the same time does not require a payment. Instead, the loan accrues interest until the loan term is complete. The only security the mortgagee (lender) has is the home itself. It has no legal right to any asset or income. To visualize a reverse mortgage, think of it as having rising debt and falling equity. When you take out a reverse mortgage, you still own your home and are responsible for the upkeep, taxes, and insurance.

Several Options

There are many different payment options available. A doctor-client can get a lump sum at closing, periodic payments, a line of credit, or a combination of these three.


The costs of a reverse mortgage are very similar to a regular mortgage. The physician-client will have to pay many of the following: origination fees, closing costs, servicing fees, interest, and risk pooling fees.

Risk-pooling fees are a new type of fee unique to the reverse mortgage. It allows the mortgagee to self-insure loan losses due to varying circumstances.


According to expert Larry Fowler, CPA, CFP™, a great way to analyze the cost of reverse mortgages is to use the “Total Annual Loan Cost” (TALC) rate. The TALC rate is a rate equivalent to the amount of interest that must be charged on the cash received by the physician-client to grow the cash to the level of the final amount due at the end of the loan term. A physician needs to know three items to be able to calculate the TALC rate: the amount owed; the cash advances made to the borrower, and the term of the loan. The federal Truth-in-Lending laws now require lenders to give TALC rate projections for every reverse mortgage.

Left-Over Provisions

Most reverse mortgages have provisions that explain how the leftover cash is distributed in the event that the home owner moves, sells the home, or dies. These provisions can become very important if any of the previous three situations occur. For this reason, it is very important that these provisions be clearly understood.



Reverse mortgages should be used when a physician needs extra money, plans to stay in his/her home for a long period of time, does not want to make payments, and does not want to sell his/her home and move to a different one. The reason a doctor should stay a long period of time is that the TALC rate is usually highest in the beginning of the loan and drops off in the latter part of the loan.


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