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Text: In today's remarks by management, we will be discussing non-GAAP financial metrics.
In fact, in the second quarter, patient volumes across our total span of services has now exceeded pre-pandemic levels.
On a same-unit basis, total volume was up 1.3% versus the second quarter of 2019 with hospital-based services up by 10 basis points and office-based services up by 5.2%.
I'll add that other key metrics that were particularly volatile through last winter continued to show stable improving trends coming into the summer.
Payer mix remained favorable on a year-over-year basis for the second consecutive quarter and the rate of admission into our NICU did so as well.
As a result, our revenue for the quarter of $473 million was above our internal expectations, as was our adjusted EBITDA of $66 million.
There are, of course, the risks that we face, most importantly, the recent rise in COVID-19 cases driven by the Delta variant.
But that said, our updated view for the full year includes our experience to date.
Looking forward beyond 2021 and count for the same risks, there are a number of factors that give me increased confidence that we'll see additional growth in adjusted EBITDA in 2022 that will get us pass the $270 million run rate we achieved pre-COVID.
I'll expand on these in three areas.
First, we're building momentum in our core.
While demand has recovered faster than we had anticipated earlier in the year, we are also helping to drive additional growth across our practices.
I talked earlier this year about the investments we've made in improving patient access, better scheduling and a drive for increased pace and efficiency.
Q2 is the first quarter where we can estimate the impact of these initiatives, and we think we've just begun by adding roughly $2 million to the top line in the quarter.
I'm very confident that this is just the beginning of a long-term payoff.
And please remember that we call this initiative patient access because it's really just that.
We want to make sure that patients that need our care receive our care as soon as possible.
Our reengineered and focused sales efforts are accelerating our pipeline of organic growth.
We have such a superb focused and organized team that make this a reality.
Halfway through this year, our new business bookings and by that, I mean new contract sales have already approached our total bookings for 2020.
Our win rate has increased.
Our time to close has decreased, and our pipeline remains robust and diversified across multiple specialties.
Our M&A pipeline also continues to build with several acquisitions of important specialty groups completed for the year-to-date.
As an example, last week, Child Neurology Consultants of Austin joined the MEDNAX family.
This group of 12 physicians and three nurse practitioners are among the premium groups of neurologists in the country.
The lack of local neurology coverage is a major reason in time to transfer the way from the birth hospital.
This is the most recent example of investing to further support our hospital-based practices with subspecialty consultation to allow infants to stay near their homes.
But we believe this is also a plan for growth, both geographically and via telehealth.
Second, we're still in the early stages of building our presence in children's primary and urgent care.
Following our acquisition of NightLight, we're now in the planning stages for new clinic openings outside of NightLight's hometown of Houston.
We're also working on additional investments and initiatives for primary urgent care that we believe will meaningfully accelerate this expansion.
We also believe that our breadth and depth in women's and children's health will enable us to actually change nationally many aspects in pediatric care.
I look forward to doing the calls to cataloging our progress.
Third, we're making significant progress on improving the efficiency of our practice support infrastructure.
Mark Richards will detail some of this progress, but I'll highlight our previously announced agreement with R1 to transfer our RCM operations to them, which not only gives us immediate G&A savings, but also enables improved bottom line results that I'm certain would not have been possible had we continued on our own.
To put these things together, I think you should view our expectations for 2021 as far from the finished products.
Beyond this year, we believe the full benefit of our efficiency improvements will be paired with our ongoing and compounding growth initiatives that today are only just beginning to bear incremental fruit.
These factors together support our confidence that in 2022 we can achieve adjusted EBITDA above the $270 million that I just referenced.
Of course, none of this is possible without the strength in our core and a singular unwavering focus on our top priority, taking great care of the patients.
It's so timely to me to reiterate this to you today.
But the fact is that in talking to our clinicians and clinical leadership, it's becoming clear that as the country continues to evolve through this pandemic period, the need for many, many of the highly specialized services our doctors provide is only increasing, which makes it that much more important that these doctors are able to operate as part of a highly integrated collaborative network in order to ensure that patients have access to the services they need exactly at the time they need them.
That's why I'll ask Mack, who is a longtime neonatologist and pediatrician, to talk about the why behind the resurgence in volumes we've seen across many specialties as well as the why behind the importance of having access to the full continuum of care for expecting parents, newborns and children.
I'll start with what we're seeing across the country today.
And then for the benefit of all of our stakeholders, give some thoughts about what we truly are as a national medical group, and how MEDNAX is uniquely positioned to address this current and future environment.
I would describe the market trends we see today as twofold.
First, as isolation measures became less restrictive, our pediatric specialists are seeing a surge in respiratory illnesses during the summer, illnesses that we typically see during the winter months.
We've also seen a significant number of behavioral health issues that have resulted in both pediatric intensive care and pediatric hospital service admissions.
In addition to that, the American Academy of Pediatrics now recommends that any child with COVID has a cardiac evaluation prior to returning to sports.
Our pediatric cardiologists, hospitalists, critical care physicians, surgeons, urgent care physicians and other pediatric specialists are all seeing the near- and long-term consequence of COVID-19.
Regardless of the immediate rate of infection in our communities, we believe the consequence of isolation and delayed healthcare will continue to require access to the entire spectrum of our pediatric specialty services.
These services are scarce national resources and access to them is filed for the health of the children and our communities.
Second, alongside the significant increases in total births and NICU admissions we reported this quarter, our maternal fetal medicine volumes have now far surpassed pre-pandemic levels.
Here, too, for at least the near term, it's clear that trends in pregnancies and deliveries have turned upward.
And across the country, access to highly trained obstetrical specialists is vital for the health of expecting parents facing a high-risk pregnancy.
And in fact, a number of states have highlighted the risk of higher child-work complications that can result from insufficient access to proper care.
And all the payers we work with, both commercial and governmental, stress the importance of access to high-quality maternal care.
To put some statistics behind these two phenomena, I'll point out that compared to the second quarter of 2019 on a same-unit basis, volumes in our pediatric intensive care units were up 11.5% and pediatric hospitalist volumes were up 4%.
On the office space side, pediatric surgery volumes were up 8% and maternal-fetal medicine was up 9%.
Pediatric cardiology volume is still down slightly by 2%, but we anticipate that, that could increase as we move into the fall.
All of these statistics went to the breadth of specialty services provided across our organization and across the country, and the demand for these services has been increasing in this rapidly evolving environment.
But beyond these numbers, I'll speak to you now as a physician who's been fortunate to have been a leader of MEDNAX for many years.
There's a broad spectrum of care that is absolutely essential for prenatal, newborn and pediatric populations.
And that is exactly what our pediatrics at Stafford's medical groups provides every day of every year.
We are far more than a collection of practices and clinicians to ensure our clinicians trust for lives of thousands of women and children every year.
But more than that, we are a highly integrated group of affiliated maternal pediatric practices that work together to deliver care across the whole spectrum of pregnancy, childhood and in some cases, even adulthood.
This includes maternal-fetal medicine doctors, or the hospitalists and neonatologists, all working closely to provide diagnostic care to mothers who are at risk of the complicated pregnancy and to provide routine and emergency triage evaluation and care to pregnant patients presenting to the hospitals as well as to provide a complete inpatient spectrum of maternal in the neonatal care.
It includes pediatric hospitalist to cover smaller community pediatric services to large tertiary referral services, emergency medicine physicians who see patients in dedicated pediatric emergency departments, and pediatric critical care physicians who care for severely ill children and adolescence with a large range of medical and surgical problems, including patients requiring cardiac surgery.
With the addition of NightLight Urgent Care, it now includes pediatric urgent care clinicians who see pediatric patients at a time and place convenient for parents in an environment that's the right place for their child.
As Mark spoke to earlier, we see an enormous opportunity at MEDNAX to change the way pediatric primary and urgent care is practiced in our country, and this is totally complementary to our core business.
It includes developmental medicine specialists who evaluate and treat disorders of development and you see many of our former NICU patients.
It includes pediatric cardiologists who evaluate and treat the entire spectrum of childhood cardiac disease as well as adult congenital heart disease patients, and additionally support both neonatology and hospitalized pediatric patient population, including intensive caring cardiac intensive care patients.
We continue to add multiple other pediatrics specialties, include neurology, endocrinology, gastroenterology, hematology and infectious disease to better serve our patients and their families.
And this includes rapidly growing pediatric surgical services across general surgery, urology, ophthalmology, orthopedics, E&T and plastic surgery.
Each of these represents a scarce and highly specialized surgical specialty that's very important to our pediatric communities in their own right, but are also supportive to our inpatient services.
I hope all of this can help you appreciate how interconnected our organization is.
It is this network of care from pregnancy to delivery to childhood and sometimes even beyond that makes what we do special and, in fact, essential.
And of course, we do this in a very close partnership with our hospitals.
When they choose us, the vast majority of the time they stay with us because of our shared commitment to our patients, because of our work to maintain strategic alignment with them, and because they rightly expect and demand the robust resources we at MEDNAX provide to our affiliated clinicians everyday.
Rather than going through each line of our P&L, I'm going to focus today on our G&A restructuring and stabilization efforts during the quarter and our expectations as we move through the second half of this year.
And then, I'll touch on our financial position as it stands today.
We had a lot of activity during the quarter that I'll globally describe as the culmination of efforts to refine our support services and create efficiency going forward, all while keeping a priority on service to our practices.
First, as previously disclosed, in May, we finalized an agreement with R1 to transition our RCM functions to them.
This agreement followed a thorough decision-making process, from which we concluded that R1's scale, technology investments and dedicated focus on revenue cycle can give our affiliated clinicians capabilities we would never match.
Under the terms of our agreement, we realized near-term G&A savings.
And we also expect to benefit over time from future improvements in RCM performance, yield and revenue enhancements.
In terms of the impact of this transition on our P&L for the second quarter, it was a net savings to our G&A.
But as with any major transformational project, we did record certain onetime expenses within our transformational and restructuring line item, primarily related to expected terminations of other existing third-party RCM contracts.
In addition to this agreement, we passed two other important milestones related to information technology and infrastructure modernization.
We completed a significant data center consolidation, and we went live on our Oracle ERP solution that represents a far more advanced financial platform.
The planning and implementation of both of these have been in the works for some time.
But we did incur a surge of IT-related spend in the second quarter to bring all of this over the finish line, which all sized, is roughly $3 million to $4 million over the year-over-year increase in our total G&A when compared to last year.
Third, we have substantially completed the support services related to the PSA arrangement attached to last year's sale of our anesthesia organization and plan to wind down any remaining services through Q3.
As I noted in the past couple of quarters, there will still be some period of time when we're still incurring some of those expenses, but not being reimbursed for them.
Finally, we sold a secondary corporate office building in Florida during the quarter.
We received $25 million in cash proceeds and recorded a $7 million gain on the sale.
And on a go-forward basis, we'll realize approximately $2 million to $3 million in annual G&A savings from the building sale.
With all of these actions moving toward in our rearview mirror, we expect our dollar G&A spend for the second half of this year to be below $137 million we incurred during the first half.
I'll finish with a comment on our financial position.
We generated a strong $70 million in operating cash flow for the second quarter.
We ended up the quarter with $338 million in cash, up from $270 million at the end of the first quarter, and net debt of $662 million, implying leverage of less than three times.
In addition, you'll see on our balance sheet that we also have a $29 million income tax receivable primarily related to the tax elections made with respect to the sale of our Anesthesiology Medical group last year, and we anticipate receiving that cash sometime in late '21 or early '22.
Based on our expectations of second half adjusted EBITDA and cash flow, this tax receivable and normal uses of cash for capex and M&A, we would expect to end this year with leverage below 2.5 times.
We are ready to respond to any questions.

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q2 revenue $473 million versus refinitiv ibes estimate of $448.9 million.

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