Break-even and revenue-coverage analysis of a hybrid operating room under the Korean National Health Insurance fee schedule: a single-centre financial sustainability appraisal

Abstract Background Hybrid operating rooms (HORs) are increasingly central to interventional and vascular practice, but the decisive barrier to adoption is the capital decision faced by administrators. Published HOR economic evidence is sparse, dominated by cost measurement rather than revenue-based recovery, and almost entirely from diagnosis-related-group settings, leaving fee-for-service single-payer environments unaddressed. Methods We performed a single-centre, room-attributed break-even and revenue-coverage analysis (hospital perspective) of a HOR at a Korean tertiary hospital over 18 months (November 2024–April 2026), testing financial sustainability with no comparator. Revenue comprised National Health Insurance (NHI) procedure fees only (excluding device, pharmaceutical, non-covered, and anaesthesia charges); a physician incentive was booked as a cost. Construction and salaries were actual; the biplane platform used the institution’s approximate outlay (KRW 3.0 billion). Sensitivity analyses (scenario, one-way, probabilistic) used staged maintenance; reporting followed CHEERS 2022. Results The 335 high-acuity index cases generated KRW 699.7 million in insured procedure-fee revenue; with other room activity (677 cases), attributed room-level revenue was KRW 51.1 million/month, rising to KRW 76.8 million with reimbursed surcharges. Throughput (18.6 index cases/month) exceeded the cash break-even (10.3–15.3). Under the most favourable revenue-attribution scenario (100% incremental), staged-maintenance capital was recovered in 5.6 years with surcharges (probabilistic median 6.3 years; 88% within 10 years) but not within the 10-year service life on base fees. Recovery was highly conditional: probabilistic median 12.1 years and 35% 10-year recovery at a 75% incremental fraction, and capital not recovered within the service life at 50%. Conclusions The rationale for a HOR is primarily clinical; this appraisal addresses the parallel financial-sustainability question. At the observed activity level the room was financially self-sustaining: attributed revenue covered its operating cost, and under the reimbursement actually received the capital outlay was projected to be recovered within the equipment service life, under the most favourable (100% incremental) revenue-attribution scenario—the shortest modelled estimate. Because that projection depends on the emergency surcharges and on how much of the attributed revenue is genuinely new to the hospital, the robust findings are the operating threshold, the required incremental fraction, and the 10-year recovery probability. The parameterised framework is transferable under single-payer fee schedules.