Operational costs of four-dimensional flow cardiovascular magnetic resonance: A break-even analysis

Aortic hemodynamics derived from four-dimensional (4D) flow cardiovascular magnetic resonance (4DF) have shown advantages for risk stratification and treatment planning. However, clinical adoption has been limited due to high costs, long scan and post-processing times, and low reimbursement. We quantify these barriers to identify break-even points and assess methods of improving clinical adoption.

We modeled the costs, resource utilization, and reimbursement under case scenarios of base cardiovascular magnetic resonance (CMR) scans, magnetic resonance angiography (MRA), adult congenital, and 4DF add-on to the CMR protocol. Price estimates were generated from market research by the purchasing department at an academic medical center. Time estimates were derived from workflow efficiency studies at the same center. Reimbursement rates were from the Centers for Medicare and Medicaid Services for 2024b. The opportunity cost of 4DF was calculated as the margin from utilizing incremental scanner time for a mixture of alternate studies. Break-even points were modeled as the number of scans needed for the yearly margin of performing 4DF to exceed performing the base scans alone. Sensitivity analyses were performed for ranges of current procedural terminology (CPT) 75565 reimbursement code, 4DF exam time, and 4DF annual software cost.

The incremental variable cost per 4DF scan was $101.40 at a scan time of 15 min, after accounting for the opportunity cost of scanner utilization. Break-even points were calculated across reimbursement ranging from $40-65/unit of CPT 75565, annual software costs of $10,000-$70,000, and 4DF scan times of 5-20 min. At a scan time of 15 min and reimbursement of $47.87/unit of CPT 75565, break-even points ranged from 112-778 scans as software cost increased from $10,000-$70,000. Highly accelerated 4DF with a 5-min scan time would break-even with about half of the scans, with break-even points ranging from 64-444 as software costs increased from $10,000-$70,000.

Long scan times and high resource utilization limit the financial viability of 4DF outside of high-volume academic medical centers. Further development of accelerated 4D flow imaging techniques and expanded reimbursement criteria are needed to enable wider clinical adoption.