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Text: In today's remarks by management, we will be discussing non-GAAP financial metrics.
Total births at the hospitals where we provided NICU services were up 2.8% on a same-unit basis, and our NICU days were up 5.6%.
Key metrics such as payer mix and rate of admissions continue to be favorable compared to last year.
In fact, for MEDNAX as a whole, our patient volumes, revenue and adjusted EBITDA were all ahead of the same period in 2019, which suggests that at this time, our business has more than recovered from the significant negative impact to the COVID-19 pandemic that we experienced in 2020 and earlier this year.
Mark will give some details of our comparisons to pre-pandemic levels.
Our revenue for the quarter of $493 million was above our internal expectations as was our adjusted EBITDA of $73 million.
Based on our results, we now expect that our 2021 adjusted EBITDA will exceed our prior internal expectation of being above $240 million, and we now expect 2021 adjusted EBITDA of at least $250 million.
We also fully expect adjusted EBITDA next year to exceed $270 million, absent any major external events.
This is still a preliminary view into 2022, and we'll be in a better position to provide a more specific outlook after we finish our budgeting process, but I believe we're building momentum in our business.
Demand for the critical services that our affiliated clinicians provide not only recovered from last year's disruptions, but continues to grow.
We also estimate that the broader growth efforts we have in place have supplemented this demand so far in 2021.
I'll give some detail here as we see our growth concentrated in several areas.
First, we target opportunities to expand practices or add practices and enhance our hospital relationships and also directly improve care through the coordination of different subspecialties that many patients need to access.
Second, in our daily operations, we strive to provide the best 24/7 support possible to our practices, which combines our patient service access initiatives, improving technology support, improving revenue cycle management efficiency, recruiting the best talent and old-fashioned focused managerial actions.
And third, we look for acquisition opportunities where we see a clear combination of bolstering hospital relationships, adding to our patient care and support and a demonstrable growth path within that acquisition.
Acquisitions haven't been a major part of our activity so far this year, but they could play just as important role as organic growth when we do see them strategically.
The sum of these efforts is continuing to ramp up post-COVID.
And importantly, after all of our reorganization activities, pre-COVID.
For the 2021 year-to-date, we estimate that we have added approximately three percentage points to our adjusted EBITDA growth versus 2020, over and above the pure same-store growth that our affiliated practices have experienced.
In addition to all this activity, we recently announced our investment in Brave Care, and I want to explain why this is actually a very key piece of our growth plan.
We again believe that we are totally uniquely positioned to grow in the combined pediatric and primary emergent care space.
In our major markets, MEDNAX, under our pediatrics brand alone has the concentration of pediatrician population density, hospital relationships and partnerships and an enormous and growing base of vital patient relationships and our market managerial support that's already in place in our major markets.
With our NightLight acquisition in place and in fact, thriving, we have a nucleus from which recent growth.
But for this to grow, we needed the engine and the talent to enable building something really meaningful.
Brave Care brings scalable internal controls and patient-facing technology, systems and protocols that will otherwise take us years to create.
The proprietary technology systems and operating platform that Brave's team has built over a two-plus-year period gives patients and their parents a truly seamless experience when they visit.
It also gives great remote connectivity to clinicians through an extremely user-friendly remote mobile app, so parents always have a resource at their fingertips.
Brave Care systems are integrated with all facets of clinical operations.
And my view of the power of the Brave system is not theoretical.
It's proven and up and running in their existing clinics in the Northwest.
Our investment in Brave the company by an operating partnership agreement that provides Brave a long-term incentives to help us plan, develop, equip and open pediatric clinics over the coming years.
The clinic will be ours, and will be led and managed by our team working alongside the Brave team.
At a high level, looking at our geography of existing services, we believe that there's an opportunity for us to open more than 100 pediatric clinics across our footprint within a few years.
And as we move forward, we'll share with you how this will materialize.
We believe that our growth will include both De novo development and acquisitions, and we're already in discussions with certain existing platforms that we think overlap well with us and they can integrate into our strategic growth.
In summary, looking at all these factors, strength in our core of amazing patient relationships served by our sector leading clinicians, strength in our balance sheet, our growth efforts, efficiency and a smart strategic expansion into primary urgent care that together gives me confidence in our diversified growth potential in '22 and beyond.
Now, Mark will provide additional details on our third quarter activity.
I'll begin by providing some detailed volume comparisons to 2019 to flesh out Mark's earlier comments.
I'll then walk through where we stand on the number of projects we've discussed so far this year and how they flow through the income statement and finish with our financial position as it stands today, and how we're looking at our capital structure as we look forward.
Compared to 2019 on a same unit basis for the quarter, our hospital volumes were up 4.4%, and office-based volumes were up 2.8%.
Within hospital-based services, our NICU days were up 1.4%, pediatric intensive care was up 42% and pediatric hospitalist volumes were up 14%.
On the office-based side, maternal fetal medicine volume was up 8.6%, while pediatric cardiology was down 9%, with this decline likely reflecting some deferrals of appointments during the quarter due to the surge in Delta cases.
Turning to G&A, our overall spend in Q3 was down about $4 million sequentially.
This primarily reflects sequential reductions in certain operating and legal expenses as well as RCM savings related to our agreement with R1, which should increase further in Q4.
In terms of the transition of our revenue cycle activities to R1, to date, our metrics reflect that there hasn't been any disruption in service to our practices.
DSOs and cash collection activity in the third quarter were in line with our expectations and with the prior quarter.
I'll also reiterate that under the terms of our agreement, we realized near-term G&A savings, which are reflected in our current P&L.
And we also expect to benefit over time from future improvements in RCM performance, yield and revenue enhancements.
During the third quarter, we also completed the support services related to the PSA arrangement attached to last year's sale of our anesthesia organization.
Our Q3 G&A still reflects a comparable run rate of cost to what we were incurring previously, and we'll refine our views on an appropriate G&A level as we finish up our budgeting for '22.
But you'll see that our reimbursement for those costs in Q3, which we record in our investment in other income line, declined substantially.
It was $0.5 million this quarter versus about $9 million in a year ago period.
However, the strength of our core operations more than offset this decline, and in fact, enabled both year-over-year and sequential growth in adjusted EBITDA.
Finally, our transformational and restructuring expense in Q3 was $4.2 million, which predominantly reflects the cost of terminating other third-party agreements as part of the R1 transition.
All told, within our updated internal expectation of 2021 adjusted EBITDA, we expect our fourth quarter G&A expense to be flat to down compared to third quarter, based largely on our expectation of RCM cost savings.
This reinforces our prior view that the second half G&A will be lower than the $137 million we incurred in the first half of the year.
Turning to our capital structure, we continue to improve our leverage position in the third quarter.
We generated $67 million of operating cash flow, which exceeded the investments we made in capex, acquisitions and our Brave Care transaction.
Based on 9/30 debt of $642 million and our 2021 adjusted EBITDA expectation, net leverage stands at about 2.5 times.
And we would anticipate that to decline by year-end based on fourth quarter cash flows.
During the quarter, we also reduced our revolving credit facility capacity from $1.2 billion to $600 million, all of which is currently available to us with no remaining covenant restrictions.
As most of you know, we have $1 billion in outstanding 6.25% coupon senior notes due 2027, making our debt structure fairly inefficient given our cash position and current net leverage.
Given that our notes are callable in January of '22, we will be reviewing the best debt structure for our size, profitability and growth in capital plans.
While we haven't made any determinations yet, I anticipate that we'll be able to achieve meaningful savings and interest expense once we determine the most appropriate capital stack for our business as it exists today,and in the foreseeable future.

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q3 revenue $493 million.

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