MEDNAX Inc
NYSE:MD
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MEDNAX Inc
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Ladies and gentlemen, thank you for standing by, and welcome to the 2024 Third Quarter's Earnings Conference. [Operator Instructions] And as a reminder, this conference is being recorded. I would now like to turn the conference over to our host, Charles Lynch. Please go ahead.
Thank you, operator, and good morning, everyone. I'll quickly read our forward-looking statements, and then we'll get into the call.
Certain statements and information during this conference call may be deemed to be forward-looking statements within the meaning of the Federal Private Securities Litigation Reform Act of 1995. These forward-looking statements are based on assumptions and assessments made by Pediatrix management in light of their experience and assessment of historical trends, current conditions, expected future developments and other factors they believe to be appropriate. Any forward-looking statements made during this call are made as of today, and Pediatrix undertakes no duty to update or revise any such statements, whether as a result of new information, future events or otherwise. Important factors that could cause actual results, developments and business decisions to differ materially from forward-looking statements are described in the company's filings with the SEC, including the sections entitled Risk Factors.
In today's remarks by management, we will be discussing non-GAAP financial measures. A reconciliation of these non-GAAP financial measures to the most comparable GAAP measures can be found in this morning's earnings release our quarterly reports on Form 10-Q and our annual report on Form 10-K and our website at www.pediatrix.com.
Now, I'll turn the call over to our CEO, Dr. Jim Swift.
Thank you, Charlie, and good morning, everyone. Also with me today is Kasandra Rossi, our Chief Financial Officer. Our third quarter operating results were modestly ahead of expectations, driven primarily by same-unit revenue growth. Similar to the second quarter, payer mix provided a tailwind to our top line, although this did moderate toward the end of the quarter. Patient volumes were stable to positive across all of our core service lines compared to the third quarter of last year.
On the hospital base side, our NICU days rose modestly, reflecting slightly positive total births, and we saw positive comparisons across Newborn Nursery, Pediatric Intensive Care and Peds Hospital Services. On the office space side, maternal-fetal medicine volume growth remained strong as we have experienced throughout 2024. Looking at our exposure to Hurricane Helene and Milton during the end of September and early October, while we did experience some office closures, those were quite brief, and we did not see any material disruptions to our hospital-based services.
More importantly, all of our team members who are in harm's way are safe. Many of our affiliated hospital-based clinicians in affected areas remained in their facilities to care for their patients during the storms. And those in office space settings undertook great efforts, both to prepare for the storms and reopen as quickly as possible on behalf of their patients. I want to thank our teams for their dedication to patient care and similarly, our hospital partners for their own such dedication.
During the quarter, we successfully completed the final wave of our transition to a hybrid revenue cycle management structure. And I am pleased that not only is the transition behind us, but we were able to complete it without any meaningful disruption to our operating results. Our internal team has worked in full collaboration with our new vendor, Guidehouse, and we will now shift our focus from transition to driving improved performance. We also remain focused on completing our portfolio restructuring plan by the end of the fourth quarter. Under this plan, we are exiting businesses totaling $200 million of revenue with an expectation of approximately $30 million in annualized improvement in adjusted EBITDA based on 2023 results. We expect to realize a portion of this in 2024 and the remainder in 2025 and beyond.
As I discussed last quarter, our operating teams have moved quickly, but thoughtfully to ensure that patient services are not disrupted during these transitions, and we have identified appropriate pathways for these exits, including transitions to private practice, new ownership for hospital partnerships.
Based on our third quarter results and the progress of our operating plans, we have narrowed our outlook of full year adjusted EBITDA to $205 million and $215 million. 2024 has been and continues to be a period of significant change for Pediatrix. Our goals, however, are unchanged. To focus our attention on those service lines with solid financial underpinnings and solidify our margin profile and create meaningful operating efficiencies for Pediatrix.
In turn, we believe that executing on our plans will enable us to support highly collaborative and critical patient services and continued investments in clinical research and education.
I'd like now to formally introduce Kasandra Rossi, our Executive Vice President, Chief Financial Officer and Treasurer. Kasandra has been with the company for more than 15 years, taking on increasing and more senior roles within our finance organization. I've had the pleasure of working with her throughout my own tenure here. And over the past several months, we have spent significant time ensuring that this leadership transition will be a smooth one.
Kasandra leads a very experienced and dedicated finance organization, and all of us on the leadership team look forward to her continued contributions to the company. And with that, I'll turn the call over to Kasandra.
Thanks, Jim, and good morning, everyone. First, I'd like to thank Jim, our Board and the Pediatrix team for the opportunity to serve as Chief Financial Officer. As Jim noted, I've spent a considerable part of my career here, and it's an honor to continue to support such a valuable organization, particularly at such an important time in our evolution. I'm a true believer that our finance organization should play an important role, not only in strategic decision-making, but in decisions across our entire organization, all of which have financial implications.
We have a talented group of dedicated employees that are part the CFO organization, accounting, finance, enterprise data analytics, information technology and revenue cycle management. These functions overlap with every single part of the business, and I consider it my responsibility to ensure that we bring a full suite of financial data and analytics to the table as well as identify innovation and automation opportunities so that our operators and shared services partners can make timely and informed decisions. And ultimately work towards our shared goal of operating more efficiently.
With that said, I'll provide some additional details on the quarter. Our consolidated revenue growth of just under 1% reflected strong same-unit growth, offset primarily by the impact of our portfolio restructuring activity. In total, this impact was just over $20 million during the quarter, reflecting both practice dispositions completed and the divestitures of our former primary and urgent care clinics.
On the cost side, practice-level SW&B expenses declined year-over-year, also reflecting our portfolio restructuring. On a same-unit basis, these expenses did increase year-over-year, but at a slower pace than same-unit revenue. And we did see a year-over-year deceleration in underlying salary growth. Not only as compared to the prior year period, but on a sequential basis as compared to the first and second quarters of '24.
Our G&A expense increased modestly year-over-year, primarily reflecting the additional staffing we have put in place as part of our hybrid revenue cycle management structure and incentive compensation on financial results. This was partially offset by efficiencies we've created through the year through staffing reductions across shared services as a result of our smaller footprint across fewer service lines.
We continue to anticipate that full year 2024 G&A expense will be comparable to 2023 G&A on a dollar basis. For those of you keeping models, I'll note that our depreciation and amortization expense declined to $6.3 million compared to $9.2 million in the prior year.
This decline primarily reflects lower depreciation expense related to our practice dispositions and our third quarter level of G&A should be fairly consistent going forward, all else being equal.
Moving to cash flow. We generated $96 million in operating cash flow during the third quarter compared to $81 million in the prior year. As Jim noted, we completed the final wave of our transition to a hybrid revenue cycle management structure during the quarter with no disruptions to cash generation. We ended the quarter with cash just over $100 million, reducing our net debt to $515 million from $600 million at June 30. This reflects net leverage of just under 2.5x based on the midpoint of our outlook of adjusted EBITDA for the year.
With respect to the cash on our balance sheet, we are currently investing that cash in very attractive time deposit accounts at interest rates that are substantially similar to our debt service costs. We expect to use this cash and any cash accumulated during the fourth quarter of '24 early in 2025 to make physician incentive compensation payments and other benefit payments, mainly our 401(k) matching contributions.
Our intent is to reduce any potential borrowing needs in Q1 2025 before we turn to expected free cash flow generation in Q2 '25 and beyond.
Finally, I'll reiterate that based on our results for the first 9 months of the year, we have narrowed our expectation of full year 2024 adjusted EBITDA to a range of $205 million to $215 million. With that, now I will turn the call back over to Jim.
Thank you, Kasandra. Operator, let's now open up the call for questions.
[Operator Instructions] And our first question will come from the line of Ryan Daniels with William Blair.
This is Jack Senft for Ryan. You mentioned that you increased internal staffing, I believe, as part of the RCM transition. Are you at okay levels now, like as we look into fourth quarter and into 2025? Or is this still going to be an area that you want to bolster up kind of throughout the next year or so?
Yes. So we actually believe we are fully staffed. I know when we initially moved to this hybrid revenue cycle management structure, we noted that we should add approximately 150 heads we have actually been able to fully staff our team up, and we are in the mid-130s and we feel that, that is appropriate moving forward. And of course, we will keep an eye on that as we gain additional efficiency as we move into 2025.
Okay. Perfect. And then just a quick follow-up. I know like in the release, you noted the same unit revenue from net reimbursement-related factors increased just from the improved payer mix and then modest improvements in hospital contract admin fees. On both of these fronts, are these 2 dynamics something we should expect going forward? I think the favorable payer mix was evident last quarter as well. So maybe just to clarify that. And then is -- like is the contract administration fees, like is that improvement mainly from renegotiations? Or is there something additional underlying there?
We'll split this up a little bit. This is Jim. I'll handle the contract revenue with our hospital partners. We spent a fair amount of time end of '22 into '23, renegotiating some of those contracts and feel that we're at levels that are appropriate from the services we provide. On a go-forward basis, obviously, what we see is pretty stable pricing. And remember, we're not orientation-wise on a lot of contract revenue. However, if a hospital wants to increase the service or looks for additional services, that's always in play. So again, we look at those judiciously as we move forward which will be the same pace in 2025.
And I can take the payer mix question. I think you could say, we've pretty much seen about a 4-quarter reset of sorts for payer mix I know that we've been very transparent in the past that we know what is happening is a little bit tougher for us to put our fingers on the why. I think we're going to need to watch this and see how it plays out over the next couple of quarters, but we think it's probably some type of a reset that will level off.
Okay. Understood. And then if I could just flip one final question in there. The same unit revenue increased again at a pretty decent clip this quarter. I think it was up a little over 5%. Can you just maybe talk about what is in your control to keep the same unit revenue steady and kind of stabilize going forward? Or is this kind of more like a function of just market growth and what's happening in terms of volume?
Yes. So I mean, of course, on our volumes for our neonatology business, we are pretty much takers of volume, so it is really what's happening in the market. I think in the one area we have had some strength is MFM. We have seen a little bit -- acuity is a bit higher there, so we have had some additional visits, and we do expect that, that will hold as we head into 2025.
We do have a question from Jack Slevin with Jefferies.
Welcome to Kasandra, and congrats to everyone on the quarter. A couple of things I want to touch on here, probably just the 2 biggest moving pieces, I think, that are in folk's minds on the restructuring plan and then on the RCM front, on the restructuring plan, the commentary is pretty clear, I guess, 2 things on that. How do you think about modeling that into the fourth quarter on the revenue line? Are we approaching that sort of run rate around the $200 million that you think on a quarterly basis? Or is it still a little below that trend like it was in the third quarter? And then in terms of EBITDA contribution, can you confirm if there was any benefit in the third quarter or if you'd expect any benefit in the fourth quarter that's embedded in the guidance on that front?
So I think on the practice dispositions and on the revenue topic, you will see that the impact of the practice dispositions in our non-same unit activity. We mentioned that during the quarter, that was about $20 million. And if you look at the year-to-date on that, it's about $50 million. We did last quarter, let you know that most of that activity is slated toward the end of the year, and it is really backloaded mostly in the fourth quarter.
So while we do anticipate getting to that $200 million of revenue, it will be by the end of the year with the most of that to come in the fourth quarter. And on the EBITDA contribution, we have put out a number in May about $30 million is our expectation and what would flow through from the full suite of our portfolio restructuring. We do expect that we will see about 1/3 of that in '24, but the rest of that will roll into '25.
Okay. Got it. That's really helpful. And then maybe from the RCM front, I mean it sounds like everything is going according to plan there. Obviously, '22 and '23 were both years where that was a pretty material headwind to revenues and earnings. How should you think about the opportunity on a, call it, 12- to 24-month basis if everything continues to go according to plan in rev cycle, what sort of -- what's -- is there any framework you can build out for how we should think about what that could mean on either a revenue or an EBITDA front?
Yes. So we're a little early on being able to kind of quantify what we expect we will have in terms of improved performance as we move out of '24. One thing we were clear about in 2024 was just going to be all about stabilization. The fact that between March of 2024 and September of 2024, that we moved $1.6 billion of revenue and $800 million a day are with no material disruption is a feat. So we're very pleased about the collaboration and now we're going to move to automation, looking for ways we can improve performance, while the guide house our vendor staffing gets up to speed and fully trained and our teams are up to speed. We're looking to the future. We absolutely expect there will be improved performance, but we're really not ready to quantify what that may be and when.
[Operator Instructions] And we do have a question from Pito Chickering with Deutsche Bank.
This is Kieran on for Pito. I just wanted to ask if you've seen any improvement in maybe your ability to secure additional funding from hospitals, whether that be in the form of subsidies or something else? I know you've commented before that you don't get subsidies from the majority of your hospitals, but still sounds like to us. There's still a lot of specialty groups out there that are kind of asking for these and getting them in a lot of cases. So I was just wondering if you think that might be an opportunity in 2025.
Yes. Kieran, it's Jim. We know there's a lot of noise out there on other specialties, particularly on the adult side for some of that contract revenue from the hospitals. Our relationship with our hospital partners has been very stable and where we have needed again, because of inflation in wages or inflation in the needs of staffing, we have been successful in negotiating increases to those. And again, as I said earlier on the call, we've largely got a number of those done in late '22 and through the beginning of 2023. And again, if we believe we need those associated with increased costs, we will approach our hospital partners. If it's a new service line that would require us to have contract revenue, we always negotiate those fully at the beginning of the contract. So there's an opportunity there, but I don't think that we have the same requirements that some of the adult service lines have.
Got it. That's helpful. And then second, just on another good cash flow quarter. It seems like the cash flow generation should benefit from RCM and the divestitures. So just wanted to see how you're thinking about getting back into M&A in the near term now that you're under 2x leverage. And any commentary you can provide on the pipeline would be great.
Yes. We're pretty happy with the pipeline we have on the core services. And so we think there's a real opportunity there. Coming up in the tail end of the year here and then into '25. So our focus is really looking at both our inorganic and organic pipeline, but we think there's a meaningful number of acquisitions that we can start down the path on. Now that we've ride the ship in terms of some of these other headwinds we are facing.
We do have a question from A.J. Rice with UBS.
There's been a little echo there. But anyway, can you maybe just more broadly on the cash flow question, obviously, there's a revenue cycle management that you've reworked. There's the portfolio restructuring. Do you have a sense of what a normalized cash flow, either from operations or even free cash flow run rate is that you're generating at this point?
A. J., it's Charlie. I can give some historical reference, which is that our experience in general has been our conversion of EBITDA and operating -- GAAP operating cash flow has typically been in the kind of 60% to 2/3 range. That's probably a good baseline to think about. Clearly, this year, we've got a lot of moving parts. But I think looking forward, that's probably a good kind of set of guardrails to think about.
Okay. And then as you said, you've got a couple of things that are committed -- the cash flow is committed to through the first quarter of '25. You just talked about M&A, but on a more broadly share repurchases, other things, capital deployment. Maybe just give a little update on your goal of thinking about capital deployment strategy from here.
Yes. So as we actually head into '25, we, of course, expect to use all that cash on our balance sheet early in the year. But as we move into '25 and we get our budget finalized see if we're in a place where we may have excess cash We, of course, will look at all of the options available to us to deploy capital. We were talking a bit about M&A. We look always at share repurchases, potentially paying down debt or some combination of those. But I think the message there is that we have optimal flexibility as to what we should do with our excess cash.
Okay. And maybe just 1 final point of clarification. On the $30 million from the portfolio restructuring, is there any stranded overhead that -- or does that incorporate getting rid of any corporate expense that doesn't need to continue because of the downsizing of those practices, I guess, I would -- yes, just the $30 million is a hard number? Or is there, maybe other opportunities over the next year or 2?
I know the $30 million was our estimate. I wouldn't call it a hard number. There is -- we have the potential for that to actually come out a little bit better when we get through all of this activity, but it is intended to be the full suite of costs that supported the practices that are exiting the organization. We will always look for opportunities for additional efficiency as we moved into '25, and that's really part of what we're doing right now with our '25 budget planning.
[Operator Instructions] And we have no further questions at this time. Please continue.
So thank you, operator, and thank all of you for joining the call this morning. Have a great day.
Thank you. That does conclude our conference for today. Thank you for your participation and for using AT&T Executive Teleconference. You may now disconnect.