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Mednax Inc. (NYSE:MD)

Q4 2011 Earnings Call

February 02, 2012 10:00 am ET

Executives

David Parker – Vice President of Investor Relations

Roger J. Medel, M.D. – Chief Executive Officer

Vivian Lopez-Blanco – Chief Financial Officer

Analyst

Kevin Fischbeck – Bank of America Merrill Lynch

Kevin Ellich – Piper Jaffray

Darren Lehrich – Deutsche Bank Securities Inc.

Brooks O'Neil – Dougherty & Company

Gary Taylor – Citigroup

Ryan Daniels – William Blair & Co. LLC

Robert M. Mains – Morgan Keegan & Co., Inc.

Ralph Giacobbe – Credit Suisse

Arthur Henderson – Jefferies & Company, Inc.

Matt Weight – Feltl & Company

Operator

Ladies and gentlemen, thank you very much for standing by. Welcome to today’s 2011 fourth quarter earnings release conference call. At this time, all participants are in a listen-only mode. Later, we will conduct a question-and-answer session with instructions given at that time. (Operator Instructions) As a reminder, today’s conference is being recorded.

And I’d now like to turn the conference over to our host today, Vice President of Investor Relations and Corporate Communications, Mr. David Parker. Please go ahead, sir.

David Parker

Thank you and good morning to MEDNAX’s 2011 fourth quarter earnings call. Certain statements and information during this conference call may contain forward-looking statements. These forward-looking statements are based on assumptions and assessments made by MEDNAX's management in light of their experience and their perception 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 MEDNAX 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 most recent annual report on Form 10-K and its quarterly reports on Form 10-Q including the sections entitled Risk Factors.

In addition, during this call, we will discuss certain non-GAAP items. This morning’s press release contains a detailed GAAP reconciliation and that’s available on the Investors page on our website, www.mednax.com.

With that, I would like to turn the call over to our CEO, Dr. Roger Medel.

Roger J. Medel

Thanks, David. Good morning, everyone, and thanks for joining our call this morning. We reported solid results from operations for MEDNAX during the 2011 fourth quarter and full year, results that continue to be driven largely by the successful execution of our long-term growth strategy. As our results demonstrate, MEDNAX is a company that continues to grow.

We’re a company that has the financial strength and flexibility to fund future growth through internal cash generation on our recently expanded revolving credit facility, while at the same time building upon the solid foundation we’ve established to manage our existing operations.

While our focus on over the next few minutes is the progress that we continue to make as we execute this proven long-term growth strategy. On the acquisition front, we had a solid year in 2011 with a total of 10 group practices deciding that they would place themselves in a better position by practicing as part of MEDNAX without complement of clinical and administrative infrastructure rather than continuing to try to manage a full-time clinical load and manage the business and administrative side of their practice. We invested more than a $160 million to acquire these practices, as well as to make contingent purchase price payments on previous acquisitions.

Of the 10 groups, seven of them were on the pediatric side. We acquired three Maternal-Fetal Medicine groups, one neonatology group, one pediatric cardiology group, one other pediatric subspecialty group, and most recently in the fourth quarter, our first move into pediatric surgery, which we have previously discussed.

Focusing on recent additions and future growth prospects for American Anesthesiology, three of our 10 acquisitions were in anesthesia, with two coming in the fourth quarter. In November, we added Austin Anesthesiology Group, the first Texas-based group to join American Anesthesiology. This group practice employed 66 physicians and 71 cRNA, practicing as part of an anesthesia care team model with annual anesthesia volumes that the practice exceeding 85000 cases. In December, we also announced the acquisition of Burlington Anesthesia Associates in Mount Holly, New Jersey, the first New Jersey practice to join American Anesthesiology. This practice consists of 17 anesthesiologists who practice as part of an anesthesia care team model that employs 25 cRNAs.

Both of these groups by joining MEDNAX are seeking the stability and resources that come with our national group model so that they can focus on doing what they do best taking care of their patients.

With the addition of Texas and New Jersey anesthesia practices, we are expanding beyond the Southeast to our national model as planned. Both of these states are solid geographies for us in our historical pediatric business and now they represent an expanded footprint and the advancement of the American Anesthesiology national model.

We plan to continue this path in 2012 as we expand into states in which we currently have pediatric business while at the same time moving into states which represent a new footprint for American Anesthesiology. Overall, we are not seeing anything that would suggest the level of acquisition activity we've experienced in the recent past will slowdown.

We're managing a very full pipeline that includes practices within our historical neonatal, maternal fetal medicine and pediatric cardiology practices. Additionally, we are confident that now is the time to take our foot off the brake a bit and that we have the team in place to further grow our anesthesia operations.

As we have taken the time we've made the effort and we've identified the right infrastructure and investment that will support the growth within this anesthesiology specialty. In both recent anesthesia acquisitions and frankly in all nine anesthesia acquisitions we've made since 2007, these groups were looking to our proven model and resources to support their practices and growth prospects. These resources can come in many different forms whether at clinical quality initiative, administrative support, research and education or simply as a proven model in an uncertain healthcare environment.

While there are numerous examples to provide, one in particular that we initiated during the fourth quarter is expanding the Quantum Clinical Navigation System quality tool throughout all our American Anesthesiology division. The Quantum tool is a product that came with our acquisition of Southeast Anesthesia Consultant back in 2010.

As we grow American Anesthesiology, we believe that a rigorous quantitative continuous quality improvement program can improve outcome, patient satisfaction, and efficiencies. In simple term, Quantum is a data collection tool that achieved these benefits by following each patient through the continuum of care. Via this tool, our clinicians use the data along with evidence-based medicine to develop and implement best practices and standard operating procedures.

We believe that the Quantum Clinical Navigation System’s CQI process will provide our anesthesia practices an opportunity to integrate a systems approach to clinical care with better outcomes for our patients. It will also allow our physicians to demonstrate their value proposition to their various customers consisting of patient, hospital, surgeons, referring physicians, payers and the communities in which they practice.

While anesthesia care is far different from (inaudible) in the NICU, we believe that the Quantum CQI process have the potential to become the complement in our American Anesthesiology division to our clinical data warehouse on the pediatric side of the business.

In this area, we also made advancements during the fourth quarter and full year on the pediatrics front that are worth noting. Our clinical data warehouse helped contribute to some of the more than 17 research papers published during 2011 by MEDNAX physicians and also contributed to the formation of the MEDNAX Research Advisory Committee, which is an important new addition to our Center for Research, Education, and Quality.

This group made up of physicians and others will help support our objective of performing research of the highest quality possible. It will be a peer-reviewed group, independent of the concurrent institutional reviews performed at the hospital level. And importantly, it further ensures the safety of patients, while also assisting MEDNAX and giving up properly funding for the trials that we run, whether from government agencies or private organizations.

Now, before I turn the call over to Vivian, I want to give my sense of the state of the states and specifically concerns over physician reimbursement rates. It seems that for the past few years, most everyone in the healthcare sector has been trying to interpret the various reform proposals and healthcare headlines.

While I will not use this time to speculate on what may or may not happen, we are seeing a more favorable environment than last year, though state governments will continue to be under considerable budgetary pressures. We look at this as a collective group of over 30 diverse payers, the various states in which we are providing care.

As an organization, we are actively involved in the process through a government relations program that includes participation from physician leadership across our group, as well as a network of states and federal lobbyists. As States plan their fiscal 2012 budget, they will again be under pressure to make cuts in services. And I suspect, you will hear of proposed cuts to Medicaid program in many states. It’s important to grill down beyond the headline and understand where those cuts are likely to occur.

Historically, states have cut facilities, particularly hospitals, nursing, and long-term care. That is ultimately where the majority of Medicaid funds go. So it is not surprising that as states try to adjust their budgets this is where cuts may occur. Physician services are generally not a large part of a state budget in contrast.

Importantly, state must find a way to maintain an adequate network of physicians to insure that Medicaid and (inaudible) have access to care. Historically, we had seen and believed that [poor] physician reimbursement results in fewer doctors accepting Medicaid patients. State that preserve the reimbursement at current levels are more likely to maintain an adequate network of primary and specialist physicians to provide care, typically in the lower cost setting of a physician’s office.

The state pays either way because the care that is delayed becomes more complicated often needing hospitalization. We think this challenge of maintaining an adequate physician network in states across the country will once again cushioned what could be a challenging legislative cycle.

Through the first half of the calendar year we have good visibility into our Medicaid reimbursement rate since most of the state fiscal years end June 30 and they are working on their budgets already established in 2011.

We’ve realized the access to care message is nothing new but we firmly believe that state Medicaid directors are well aware of this issue. Having said that, we are taking a conservative measured view towards Medicaid rate setting for the upcoming 2013 fiscal year, which for most states, will begin in July of this year.

The state of healthcare is the latest challenge within the sector is speaks to the strength of our model, a national group practice is better able to advocate on behalf of patients with the appropriate levels of reimbursements.

As I said at the beginning of the call, we are a growth company that have the financial strength and flexibility to fund future growth through internal cash generation and our result revolving credit facility, while at the same time building up on the solid foundation we’ve established to manage our existing operations and to acquire new practices. We are disciplined in our approach and we’re confident that the value we bring to those practices that are becoming part of MEDNAX is more pronounced in today’s healthcare environment than ever before.

At this time, I’ll turn the call over to our CFO, Vivian Lopez-Blanco to review our financial results before we open up the call to take your questions. Vivian?

Vivian Lopez-Blanco

Thanks, Roger. Good morning, and thanks for joining our call. With our 2011 fourth quarter results representing a company that continues to grow the contributions from both the acquisitions completed since October 2010, as well as same unit practices. We continue to be challenged by variability with some of the same unit drivers such as patient volume and our results demonstrate that we continue to meet this challenge.

As we discuss the results for the 2011 fourth quarter, we like to point out that the growth rate in the operating results for the quarter was impacted by the lasting effect of the significant acquisition activity in the 2010 fourth quarter. For the three months ended December 31, 2011, revenue grew by 9.9% to $404.9 million.

Over 73% of our revenue growth came from acquisitions while the remainder is from same unit growth, which increased by 2.7% for the 2011 fourth quarter from the prior year. Of this 2.7% same unit growth, net reimbursement related factors grew by 2.3% while $0.04 of 1% came from volume growth.

Our same unit revenue growth from net reimbursement related factors was principally due to continued modest improvement and reimbursements received from third-party commercial payers as a result of the company’s ongoing contract renewal processes and an increase in the administrative fee received from our hospital partners due to the expansion of our services as a result of internal growth initiatives.

On a year-over-year comparison the percentage of services reimbursed under government programs remained essentially flat during the 2011 fourth quarter. The sequential shift in the percentage of our services reimbursed under government programs for the 2011 fourth quarter relative to the 2011 third quarter reflected a 20 basis points positive shift to commercial from government.

On the volume side, our anesthesiology, pediatric cardiology, maternal-fetal medicine and other pediatric physician services grew, while revenue attributable the same-unit volume decline for our neonatal physician services. The number of patient stays at neonatal intensive care unit included in our same-unit base decreased by 1.2%.

Our profit after practice expense for the 2011 fourth quarter was a $141.6 million up 7.9% from a $131.2 million for the prior year period. Profit after practice expense margin declined by 63 basis points, which can be primarily attributed to the mix of practices acquired since October of 2010. We generated operating income of $91.5 million for the 2011 fourth quarter and an increase of 6.6% from $85.9 million for the prior year period.

G&A expenses grew by 8.5% for the 2011 fourth quarter to $42.8 million from the prior year period. As a percent of revenue, G&A expenses declined to 10.6% from 10.7% for the 2010 period as a result of our model at work acquiring an effectively integrating practices into our existing administrative infrastructure.

Net income for the 2011 fourth quarter was $58.4 million up 8.5% from $53.8 million for the 2010 period. We reported earnings per share of $1.19 based on a weighted average 49.1 million shares outstanding, which compares with earnings per share of $1.12 based on weighed average 48 million share outstanding for the 2010 fourth quarter. As we compare the 12 months ended December 31, 2011 to the 2010 period, we believe it is more meaningful if the 2010 GAAP net income and earnings per share is presented on a non-GAAP basis by increasing the income tax provision and decreasing net income by $10.9 million to exclude the impact from the favorable resolution of certain tax matters that took place in the third quarter of 2010.

For all of 2011, our revenue grew by 13.3%, operating income grew by 13.6%, and net income grew by 13.7% on a non-GAAP basis. Revenue for the 12 months ended December 31, 2011, was $1.6 billion, up $187 million from $1.4 billion for the priory year. Same unit revenue for 2011 grew by 3.5% with reimbursement related factors up 2.5% net.

Through 2011, this growth was primarily due to modest improvements in reimbursement from third-party commercial payers. Same unit volume increased by 1% with volume growth coming from our same unit anesthesia, pediatric cardiology, neonatal and other pediatric subspecialties, while maternal-fetal medicine volume was flat.

Operating income grew to $355.4 million for 2011, up 13.6% from $312.9 million for 2010. Our annual tax rate for 2011 was 38.3%, pretty much in line with 2010 at 38.4%. For 2011, net income grew by 13.7% to $218 million as compared to non-GAAP net income of $191.8 million for 2010.

Earnings per share were $4.47 for 2011, based on the weighted average 48.8 million shares outstanding, which compares with non-GAAP earnings per share of $4.03 for 2010, based on 47.6 million shares outstanding.

Looking at our balance sheet, we had cash and cash equivalents of $18.6 million at December 31, 2011. Accounts receivable at December 31, 2011 were $230.4 million, an increase of approximately $50 million, compared to December 31, 2010.

Our DSO increased to approximately 52 days from 45 days at December 31, 2010. The growth of our accounts receivable is primarily related to the timing of cash collections, related to integrating recently acquired practices and short-term impacts associated with payment processing by one of our states. The total amount outstanding on our $500 million revolving credit facility with $29 million at December 31, 2011.

We continue to generate solid cash flow from operations, which was $90.1 million for the 2011 fourth quarter. As Roger said, on the acquisition front, we had a productive year and we invested a $161.4 million to complete 10 practice acquisition that amount also includes continued purchase price payments for acquisitions made in previous years.

For all of 2011, cash flow from operations was $271 million, consistent with our historical patterns most of our cash flow from operations was available for investing back into the growth of our business.

Maintenance capital expenditures for all of 2011 are $31.3 million. As a remainder, this number includes $18.5 million for the purchase of a building that will have some of the administrative departments, which will expand overtime just to report our constantly growing physician base. When backing up the purchase price of the building, our maintenance capital expenditures remained consistent with historical ranges.

As we announced in this morning’s press release, we expect that our earnings per share for the 2012 first quarter will be in a range of $0.96 to $1.02. Within this outlook, we assume that total same unit revenue for the three months ended March 31, 2012 will grow by 2.5% to 4.5% from the prior year period including the impact of the additional day for the leap year.

The same unit growth forecast is expected to be evenly divided between patient volume growth across all MEDNAX's physician specialties and net reimbursement growth including improvement from commercial contract rates as well as the variability in mix of services reimbursed under commercial and government payer programs.

We are also expecting that our effective tax rate for the 2012 first quarter will be consistent with what we experienced in the comparable 2011 period, which is higher and for the 2011 fourth quarter. For the full year 2012, we expect the tax rate to be approximately in line with 2011.

Throughout all of 2012, we expect to invest approximately $300 million to complete practice acquisitions across all MEDNAX physician specialty, including one third of which we expect to invest in the Pediatrics Medical Group division and the remainder in our American Anesthesiology division. As a remainder, the mix and timing of all practice acquisitions will impact our growth rate throughout 2012.

For those of you who have followed MEDNAX for sometime you will remember that our results for the first quarter of every year are impacted by some timing issues that affect our results on a sequential basis. For the first quarter of 2012, this impact is on the expense side as our social security payroll taxes are higher at the start of every year when compared to the fourth quarter of the prior year. An estimate for this recurring expense item which impact our operating income, net income and earnings per share is included in our financial outlook for the 2012 first quarter. It’s also important to remember that we typically have negative cash flow from operations during the first quarter of every year, as we use cash and amounts under our revolving credit facility to pay bonuses that have accrued throughout the prior year.

With that I will now turn the call back over to Roger.

Roger J. Medel

Thank you, Vivian. Let's just go ahead and open up the call to your questions.

Question-and-Answer Session

Operator

(Operator Instructions) Thank you. First we will hear from the line of Kevin Fischbeck with Bank of America. Go ahead please.

Kevin Fischbeck – Bank of America Merrill Lynch

Okay, thank you. I thought the fact that you are providing an actual guidance number for anesthesiology acquisitions. I think this is the first time, I remember seeing you guys provide a specific target. Can you talk a little bit about that the visibility I guess that you have in that pipeline and why felt comfortable doing that for the first time?

Roger J. Medel

Hi, Kevin, good morning. Yeah, our anesthesia pipeline, I’m going to say is fuller than it’s ever been. We have got buckets, where we are talking to practices and buckets where we are receive confidentiality agreements and are in the process of analyzing their data and other buckets where we made offers and the offers have been accepted and we’re going through the due diligence process and I will say that every one of those buckets, is fuller than it’s been in the past and of course, we won't complete all of those deals. But it’s looking like there is just a lot of opportunity there, a lot of interest, and we continue to acquire the practices that we want to acquire, and things are looking like that’s going to be a good acquisition year for us in anesthesia.

Kevin Fischbeck – Bank of America Merrill Lynch

Okay, that’s interesting, that you actually have some I guess letters of intent out there. Is this, would you say this is kind of similar to how your pediatric pipeline is as far as having a mix of early stage, late stage transactions and is there something about this year or do you think that going forward, you might have some more visibility and what that pipeline looks like going forward?

Roger J. Medel

Well, the pediatrics pipeline is more mature, no doubt. What you see there are number of different specialties. The reality is you’re dealing with neonatology, pediatric cardiology, maternal-fetal medicine. So it is just not focused on neonatology.

We do have some neonatal deals in the pipeline that we expect to continue – to compete this year. But it is just the reality is it’s a different kind of a pipeline. It is – it still has a number of deals in it and we expect that fully a third of what we estimate will spend in 2012, will be on the pediatric side. But it’s not just neonatology deals.

Kevin Fischbeck – Bank of America Merrill Lynch

Okay and then shifting gears here on the mixed number, the payer mixed number was good. But I guess so executed all because of the growth in the different business lines, I guess would you have, I guess same-store payer mix?

Vivian Lopez-Blanco

Yeah, but Kevin, good morning. This is Vivian. So the payer mix shift basically has not been so much because of the mix of practices. My statement there on mix was more related to the operating income margin. The mix overall for the year, we are very happy with how it turned out as you know there has been a lot of variability with that over the last couple of years. So 2011 was a very good year as it related to lack of mix shift to government. So it was more a statement on that.

Kevin Fischbeck – Bank of America Merrill Lynch

Okay. So the same store is pretty close to the reported number as far as [payer mix goes].

Vivian Lopez-Blanco

Yeah, that’s basically the number, right.

Kevin Fischbeck – Bank of America Merrill Lynch

Okay and then, yeah, I know you might have know the answer to this, but I guess, as part of Healthcare Reform there was provision that would increase Medicaid rates for certain primary care docs up to where the Medicare rates are in 2013 and 2014. And I know that the language is pretty vague and whether you guys will be included in that or not. Do you get a sense of when we would know the answer to that question and how would that be communicated?

Roger J. Medel

Yeah, our sense is that we’re going to get an answer pretty soon here, probably, before the end of this month. The people we talked to and the lobbyists we talked to tell us that it looks good, but it’s not done and until it’s done we’re not going to tell you about it, but the early information that we’re getting is that it looks good for us.

Kevin Fischbeck – Bank of America Merrill Lynch

Okay. And then how would that work, would that be similar to any kind of normal revenue increase or you kind of assume half of that goes to physician bonuses and half of that comes back to you or would there be a different thought process about how that increase might be created in compensation?

Roger J. Medel

Well, it depends upon the profitability of the specific practices you know our bonus program is based upon the profitability that we expect to generate from an acquisition and anything above that of original threshold we share with them on a 50-50 basis. So if they practices over the threshold and therein what we call in bonus then yes we would share that with them just as part of their overall profitability of the practices. If the practice is not in bonus then obviously that would not be something that we would share with the physicians.

Kevin Fischbeck – Bank of America Merrill Lynch

Okay, great. Thanks.

Operator

Thank you very much. (Operator instructions) So next, we’ll hear from the line of Kevin Ellich with Piper Jaffray. Go ahead, please.

Kevin Ellich – Piper Jaffray

Good morning. Thanks for taking the questions. So I was just wondering if you could provide any color on the same unit, NICU patient days, obviously, you had a tough year-over-year comp. But looking at the annual stat you provided in your press release, the number of births actually increased 1.3% on a year-over-year basis and the NICU admissions actually also picked up 4%. Just wondering what’s driving that and [where is it] disconnect this quarter.

Roger J. Medel

Hey, Kevin, good morning. I think that you may have misread that. I think the birth volume is actually down 1.3%.

Kevin Ellich – Piper Jaffray

Yeah, 1.2%.

Roger J. Medel

Right. So both birth and admissions were down. What we see is what I’ve been talking about for the last four years which is a continued variability on a month-to-month, quarter-to-quarter, region-to-region basis. This is exactly what we’ve been saying for the last four years that we have not seen any consistent trend either up or down across our states where one quarter, I’ll look at a state and it will be flat and next quarter that same stat will be up and the next quarter, it will be down regions, et cetera.

Now, the magnitude of the variability has in fact slowed what it was back in 2008, 2009, but the variability still continues. And so as you see during the third quarter, our same-store volume was up over 2% in the third quarter and now in the fourth quarter, same-store volume is down 1%. All I – when I’m giving you, what I think, this first quarter of 2012 looks like, all I can do is just based upon what the current numbers are. It could be that, it could be more, it could be less, and so we’re – and that’s why the range is the way that it is.

Kevin Ellich – Piper Jaffray

All right. Actually, Roger, what I was talking about in terms of the 1.3% increase and the 4% growth in the NICU admissions, that’s for the full year, you guys provided another operating data table in the press release?

Roger J. Medel

Okay.

Vivian Lopez-Blanco

Yeah. Kevin, what that is that when we’re referring to the numbers that Roger is talking about, those are on the same unit basis.

Roger J. Medel

Yeah.

Vivian Lopez-Blanco

The number that you are looking at, another operating data on the press release is all in, and so of course every year it’s higher, because we’re adding practices. So we look at it from the same unit comparison, which is, the practices that have been in there for the full 12 months.

Kevin Ellich – Piper Jaffray

Got it. Yeah, okay. Now that makes more sense so.

Vivian Lopez-Blanco

Yeah.

Kevin Ellich – Piper Jaffray

Okay. And then actually just shifting gears back to the anesthesia side, more of a big picture question, when the birth rate was going down back, five, ten years ago, historically same-store growth had been in the range of 3% to 5% for the business when it was just pediatrics?

Roger J. Medel

Yeah.

Kevin Ellich – Piper Jaffray

As you see more of a mix shift to anesthesia, and things start to normalize and come back in terms of volumes, do you think we could actually see some acceleration in same-store growth as things become more dependent on surgical volume?

Roger J. Medel

Well, we believe that there are some numbers out there which show that it’s expected that, the number of surgical procedures this decade is expected to grow by some significant percent.

Vivian Lopez-Blanco

Right. Yeah, right, 29%...

Roger J. Medel

30%. So definitely, we expect that and that’s driven by the agent, boomer population. And so we definitely expect that those numbers are going to grow based just on those statistics of increased aging in the population, and again the numbers are 30%, 29% growth, this decade in surgical procedures.

Kevin Ellich – Piper Jaffray

Got it, okay. Thank you.

Roger J. Medel

Thank you.

Operator

Thank you very much. Next we will hear from the line of Darren Lehrich with Deutsche Bank. Go ahead please.

Darren Lehrich – Deutsche Bank Securities Inc.

Thanks and good morning everybody. I wanted to ask a question about margins. It was nice to see that your practice salaries and benefits were really inline certainly after seeing some of, what your peers reported thus far. I guess, I wanted to just ask you about practice supplies expansion, other operating expenses, you’ve sort of break that out in your income statement that that’s where it looks like if there was a little bit of mix relative to term model. So what change is there, how should we be thinking about that line, giving your mix of business and then I do have a follow-up about margins more broadly?

Vivian Lopez-Blanco

Yeah and good morning, it is Vivian Darren.

Darren Lehrich – Deutsche Bank Securities Inc.

Hi.

Vivian Lopez-Blanco

That basically fluctuates with the mix of practices that we have and so depending if you have office based practices that you’re buying on the pediatric side of the house and anesthesia practices. Overall, as you know that supplies number is still in the 4% there. So it can fluctuate a little bit in any given quarter, but it is more related to the mix of practices than related to pretty much on the acquisition side.

Roger J. Medel

If you buy an office based practice, whether it is cardiology or maternal fetal medicine, that number is going to go up, whereas the acquisition is more of hospital based practice, those expenses are as you know in the hospital side.

Darren Lehrich – Deutsche Bank Securities Inc.

Sure I understand that. I guess, it’s certainly has been closer to four, and now it’s in the mid-four. So is the mid-four is now a better run rate, or do think there was anything unusual beyond just mix of business in the quarter, just trying to square that?

Roger J. Medel

No, I think it’s more related to the mix of businesses and so you’re going to have a little fluctuation. As you see there, for the year, it was still 4.2. So in that range, it could fluctuate, but it shouldn’t be big dollars.

Darren Lehrich – Deutsche Bank Securities Inc.

Okay. That’s helpful. And then I guess my follow-up here just on margins is, as you think about your acquired practices and really anesthesia specifically, how should we be thinking about margins both short term and long term as your activity picks up in M&A here. I think initially we all – when you started getting into the anesthesia business several years ago, we all thought that the margins would be structurally lower.

And Roger, I guess I just want to hear from you an update on how – you’re thinking about it given the practices that you are looking at, is it still the case there? They are slightly lower or are looking about the same in terms of your base business?

Roger J. Medel

We’ve said all along that we think that margin will get to be reasonably comparable to what the neonatology margins are. The interesting thing for us has been that, as we grow the anesthesia practices and we now have 9 groups in our company, the margins just haven’t been affected that much. So as we move forward here, we still think that, yeah, the margins may fluctuate a little, they might be a little lower, but I don’t think we are – I think when we first got into this business, there was a lot of concern that the margins were going to erode significantly and we certainly don’t see that happen.

Vivian Lopez-Blanco

Yeah, let me explain on that a little bit just because I think it’s important, I highlighted that in my section of the script. In any given quarter that that, that changes because of the mix of practices and the one things is to note on anesthesia, as I talk to you guys as we’ve been on the road is that it does depend on the anesthesia care team model, whether the CRNAs are employed by the hospital or whether the CRNAs are employed by the practice. And so that also has a varying degree of impact on the margin percentage and depending on the size of that practice in any given quarter, any given year that causes some fluctuations, also will causes fluctuations then is what’s happening on the pediac side of the house depending on, how we’re doing with volume and rate, because of as we said on the pediatric side of the house, specially neo, there is a very big fixed component on the physician side. So I think that hopefully that gives a little bit more color as to what to expect from a quarter-to-quarter basis.

Darren Lehrich – Deutsche Bank Securities Inc.

Okay, thanks. And then my last follow-up on just margins again, can you tell us what the M&A related expense was in the fourth quarter. I know you’re having new expense for a lot of that activity. So just want to get a sense for what it was in the period?

Vivian Lopez-Blanco

Well, we don’t break that out. But what I can say though is that the M&A expense activity really haven’t changed that much from year-to-year. We’ve been expensing that as you know when the accounting rules changed in the beginning of ’09. So we have been take – we took that last year as well and at last year, we had some pretty big deal activity as you know. So that, it’s not a big factor there.

Darren Lehrich – Deutsche Bank Securities Inc.

Okay. Thanks for taking my questions.

Operator

Thank you. And next we will hear from the line of Brooks O'Neil with Dougherty. Go ahead please.

Brooks O'Neil – Dougherty & Company

Good morning everyone. And I was just curious to start off with whose foot has been on the break as it relates to the acquisition?

Unidentified Company Representative

Roger’s, Roger’s foot has been on the break.

Brooks O'Neill – Dougherty & Company

No, I know that. So I am just curious if you could just talk to us a little bit about both the state of your business in the anesthesia and the infrastructure development and all of that as well as your outlook for the anesthesia business going forward? And help us to understand you its a little bit better why now, why do you really believe now is the time to accelerate the growth of that business?

Roger J. Medel

Well, we think first of all that we have over the last three, four years made the necessary investments to manage the business. We are careful about understanding it, convincing ourselves that we were in fact able to bring value to these practices. At the end of the day, as I stated in the past, this business is about bringing value to the physicians if they perceive that they are better off by being a part of your company then they’ll stay, it’s not they’ll walk.

And so it doesn’t matter that you pay a bunch of money for their practices, six months later everybody forgot, how much money they have got and the question is am I better off by being a part of this group or not. And so for us it’s about making sure that that they have the resources necessary and that they are not having to spent time doing all the back office functions and that they have opportunities to do research that they are not worried about buying more practice insurance and policy.

And it takes time and it takes time to build your own back office to get comfortable negotiating, manage your contracts to understand that you are doing the coding correctly and that your collections programs are in place and you’ve got CQIs and you are looking at data et cetera. And so rather than just coming out here one and betting the farm that we would be able to do that, I picked the best people that I had on my team and gave them the keys to that division. And we’re building it I think the right way. We’ve been a publicly traded company for 17 years you have followed us with those 17 years.

Unidentified Company Representative

Don’t say that. Yes, and you know that we, our trend is for growth we like to do things the right way and we like to grow.

Roger J. Medel

So I think that what’s happened now and we renegotiated our credit facility last year and we’re comfortable that we know what we’re doing that we’re in the right business that we have long-term growth opportunities and we’ve hired other people for our business development team. And we’re taking a bit our foot off the break at this point in time, my foot off the break and before we did, we completed three acquisitions in anesthesia last year I said, a number of times I think we will do more then that this year.

And we’ve got some good solid practices in our pipeline and we think that we’re bringing a lot of value to our physicians and we’re getting those reports from our physicians on a ongoing basis that they our anesthesiologists believe today that they’re getting value and they themselves are out there. We just had an American society of Anesthesiologist meeting, their annual meeting and our physicians were our best sales persons, they were a number of them were at that meeting and they were having meetings with others, practices, friends of theirs et cetera and it’s nice and fun to see when your guys are out there doing your sales work for you.

Brooks O'Neill – Dougherty & Company

Yeah, I think you are doing it exactly right I am excited about it all these 17 years have been great. Let me just ask one last one on the anesthesia, we saw the Texas acquisition and the New Jersey acquisition, that looks like your in addition to doing more deals, you are spreading the wings on the deals. Should we just expected to be a national platform, they’ll hear quickly or you’re going to try to grow in more sort of concentric circles away from Florida overtime?

Roger J. Medel

No. We have a lot of opportunities in many different states, some we already have a presence in and many we don’t and I think you can expect to see the national footprint continue to expand, and at the same time, if there are opportunities within existing states that would fit nicely into those infrastructures we’ll take advantage of those as well.

Brooks O'Neill – Dougherty & Company

Great. Thank you very much.

Roger J. Medel

Thanks, Brooks.

Operator

And next, we’ll hear from the line of Gary Taylor with Citigroup. And go ahead, please.

Gary Taylor – Citigroup

Hi, good morning.

Roger J. Medel

Hi, Gary.

Gary Taylor – Citigroup

Just a couple questions I guess lost my train of thought momentarily. The first one is, just looking at the total revenue. This was the first sequential decline in total revenue, since 2006 and I guess is there anything to think about with respect to that outside of the fact that obviously the NICU days were probably a little less than you were anticipating or hoping for?

Vivian Lopez-Blanco

Yeah. I mean, there is nothing else other than that obviously. The acquisition activity, I don’t know what you guys had modeled in there, as far as the breakout between same-unit and acquisition because overall, the same-unit increased itself we were pretty happy with that for the fourth quarter at 2.7 obviously light on the NICU volume, but 2.7 was great growth there was pretty much in line and for the year. So as I said in my piece of the presentation Gary, I think it’s just related to some of the timing of the acquisition activity.

Gary Taylor – Citigroup

And typical 4Q seasonality would be for higher sequential revenue, is that fair or is that not necessarily true?

Vivian Lopez-Blanco

Well, as you know typically you have the same number of days in Q3 and Q4 just it’s – we typically look at quarter three and four similar.

Gary Taylor – Citigroup

Okay.

Vivian Lopez-Blanco

So its quarter one as you know and two that have some seasonality there, but three and four are typically inline.

Gary Taylor – Citigroup

Okay, and my second question is on the $300 million of contemplated acquisitions spend, is it unreasonable to think that these dollar amount of annualized revenues, you would acquire would be in the $200 million range?

Vivian Lopez-Blanco

It’s an unreasonable to think that. Well again, we are trying to stay away from that as you know. We don’t tell you guys, how to model that and I know that some of you guys have tried to do a model based on per physician count, which I’m sure you could take the average of what we have as far as the nine practices we have in anesthesia. But we fear you away from that because we pay for practices as you guys know, based on what we think the contribution is going to be for that practice. So it is a practice that has higher commercial mix, the dollars could be impacted. So I’m not willing to talk about that.

Gary Taylor – Citigroup

Okay, I was just trying. And finally…

Vivian Lopez-Blanco

We’ll try Garry.

Gary Taylor – Citigroup

The first quarter guidance, just remind us is there any unannounced acquisition activity that’s in that guidance?

Vivian Lopez-Blanco

Well, no, no, right.

Gary Taylor – Citigroup

Okay. Thank you.

Operator

Thank you. And next let’s see Ryan Daniels with William Blair. Your line is open. Go head please.

Ryan Daniels - William Blair & Co. LLC

Yeah, good morning, everyone, and thanks for taking the questions. Let me start just on the same-store revenue growth due to the reimbursement related factors. You’ve typically talked about the mix shift and better commercial reimbursement, but this time you also called out administrative fees and I [remember] all seeing that before, so I guess a multi-prong question being, can you give us a little bit more color on what those are? And then number two, has that grown in importance as a percentage of the increase or did you just mentioned in the press release not meaning to intend, it’s a bigger importance?

Vivian Lopez-Blanco

Well, there is a couple of things. I do think that Roger introduced that concept, I believe it was in the second or the third quarter of this year when he talked about that we typically don’t really expand on it, but we do have initiatives that each one of our regions where hospitals come to us and want for us to expand our services there.

So those are typically related to some of the hospitals’ programs that we are doing OB hospitals’ programs, and we had several start up in several other regions. It does impact the top line, it also does, obviously it has contributions, but there are expenses related to that, because a lot of these things are related to coverage too. So it is an on-going initiative that we have. It just happened to be that in this fourth quarter, Ryan, we did have several programs that started up.

Ryan Daniels – William Blair & Co. LLC

Okay, that’s helpful color. And then, I guess my follow-up just on the M&A front and maybe State of the Union as it relates to Medicare reimbursements. Obviously, a lot of noise continues around the sustainable growth rate formula and potentially fixing that obviously that could still have an impact to Anesthesia division, and I realize you don’t have a kind of exposure to Medicare there yet. But number one, hoping to get any view you might have on that, then number two, if there is long-term clarity to the SGR fix, would that potentially open up your anesthesia pipeline even further, because you’d be more likely to look at those more Medicare dependent practices with that increase visibility? Thanks.

Roger J. Medel

Well, as far as the SCR is concerned, we do think that there is probably just going to be a patch fix here and probably through the end of the year there is probably not a lot of appetite to doing anything and an election year beyond just getting, as you know, the latest fix was just through the end of February and what our people are telling us is that we can really just expect at the most ten month extension since nothing is typically accomplished in that election year.

Ryan Daniels – William Blair & Co. LLC

Yeah, right.

Roger J. Medel

Let me remind you from a Medicare standpoint, though, that the vast majority of our managed care contracts are negotiated fixed on a specific Medicare year reimbursement. So our reimbursement does not fluctuate with Medicare reimbursement. When I negotiate a contract, it’s based on the 2010 or whatever Medicare reimbursement rate. And so it’s not open to fluctuating from one year to another depending upon what happens in Washington. So I don’t think we have a lot of exposure to that. And then as far as whether if there is a fix, there it will be more interested in looking at practices that are heavy Medicare. Typically that is not a variable that we look at when we are looking at practices, because if a Medicare, it’s the same thing as Medicaid, if a practice has a high Medicare or Medicaid component they tend to be less profitable and so that variable is taking care of during the valuation process.

So if we’re paying, whatever, four times our forward-looking earnings for a new anthology practice and they have just less earnings, because it’s highly medicated, it’s just taking care of doing that – doing the evaluation process, and the same thing happens with Medicare. So it isn’t really something that we pay a lot of attention to it. I mean if there are expected to be significant changes, if it’s a in your city kind of hospital where the potential is that, there will be some changes, then we’ll pay some attention to that. But in general terms, that doesn’t what drives what our appetite for practices.

Ryan Daniels – William Blair & Co. LLC

Okay, great. That’s helpful color. Thanks, Roger.

Operator

Thank you. Next, we’ll hear from Rob Mains with Morgan Keegan. Go ahead, please.

Robert M. Mains – Morgan Keegan & Co., Inc.

Thanks. Good morning.

Roger J. Medel

Good morning.

Robert M. Mains – Morgan Keegan & Co., Inc.

Vivian, one numbers question, could you explain the blip in DNA in the quarter?

Vivian Lopez-Blanco

Yeah, that’s just again related to the acquisitions and what we value there pretty much for us on the – it’s not so much on the depreciation side, it’s more on the amortization side, depending on the mix of acquisitions at any point, Rob, how much administrative fees contracts that they might have and those vary from deal to deal.

Robert M. Mains – Morgan Keegan & Co., Inc.

Okay. So that explains why it could jump in one quarter and then go back in the next?

Vivian Lopez-Blanco

Right, exactly, Rob.

Robert M. Mains – Morgan Keegan & Co., Inc.

Gotcha, okay. And then just following up on this question about supplies expense and margins and everything, when you acquire a practice, beyond at some practices our margins below where you can get them to and there’d be some improvement. Are there any expenses that come above the DNA, the EBITDA line that you incur like buying supplies anything like that, that would suggest that the quarter in which an acquisition occurs, you take a little bit of a margin hit that might not be replicated in the following quarter?

Vivian Lopez-Blanco

No. It’s not so much a buildup of the expenses, it’s more of what Roger said, if you get into an office space practice, they typically will have more expenses as you would imagine then hospital-based practices. So albeit, we obviously look at that, it’s just not a big line item, and so typically it’s not really a big blithe in or decrease after we buy them, it’s just that those practices come with more office type related expenses.

Robert M. Mains – Morgan Keegan & Co., Inc.

Okay. So there is not anything you are obligated to purchase in expense immediately?

Vivian Lopez-Blanco

No, no, no. I mean, yeah, it’s just their typical running. It’s just like when you go to a doctor’s office, some of the expenses that they will have from running an office.

Robert M. Mains – Morgan Keegan & Co., Inc.

Yeah, that makes sense. Okay. That’s all I had. Thank you.

Operator

Thank you. Next, let’s see Ralph Giacobbe with Credit Suisse. Your line is open.

Ralph Giacobbe – Credit Suisse

Thanks, good morning. Just to clarify the 1.2% decline in the NICU days was a function of admissions and no real change to link this day and then just in terms of the top line guidance for next quarter, it does assume a little bit of an up-tick in growth, and I guess just, what gives you sort of that comfort just in the context of the NICU volume being under a little bit of pressure that we saw this quarter?

Roger J. Medel

That’s correct. We haven’t seen any real difference in link this day or percentage of admissions or anything like that, it’s still just lower volumes. We just see this constant variability and we’re looking at what the current numbers are, and so we’re giving you our best guess here as we move forward for what the first quarter is going to look like. But there is constant variability, and so there is any real trend that I can point to and tell you that in the Western states or whatever the numbers are up, [they’re] up still up one quarter and down the next.

Vivian Lopez-Blanco

Yeah and the other thing I’d like to say on that is that remember when we talk about same-unit, we’re talking about all of our MEDNAX specialties. And so like I said for the quarter, when I gave my run down there of what’s happening with volume I mean we did have a good volume in the other specialties and so you have to look at that overall same-unit number for all of the MEDNAX specialties.

Ralph Giacobbe – Credit Suisse

Okay, that’s helpful. And then just in terms of the AR and DSOs being. Was that only related to acquisitions or was there anything else that sort of provided or was there rationale for the uptick?

Vivian Lopez-Blanco

Well, I did say there is a piece of it that’s related to same-unit and it’s pretty much because, well we had one of our state government payers that had a change in their system. And so they had an upgrade to how they were processing payments and group numbers et cetera. And so because of that they had a delay in processing and so we’re working through that.

Ralph Giacobbe – Credit Suisse

What state was that?

Vivian Lopez-Blanco

I don’t want to get into the specific states.

Ralph Giacobbe – Credit Suisse

Okay. Thank you.

Operator

Thank you. We will go to the line of Art Henderson with Jefferies & Company. And go ahead, please.

Arthur Henderson – Jefferies & Company, Inc.

Hi, thanks for taking the question. Going back to Gary’s last question, I just want to make sure I heard this correctly. Vivian in the first quarter, you do not have anesthesiology acquisitions built in to the guidance?

Vivian Lopez-Blanco

That’s correct Art.

Arthur Henderson – Jefferies & Company, Inc.

Okay, good. Thanks. And then going back to the margin question again kind of comment at this sort of little different angle. As far as sort of the first quarter is concerned, when I look at the G&A expense from the fourth quarter, 42.8, is that kind of a number that would be appropriate to the run rate number to – that would be appropriate to use in Q1, or does it go up to any degree, because of the acquisition – acquisitions that you did later in the year?

Vivian Lopez-Blanco

Well, it kind of – as you know, it’s driven by some of the acquisitions and it’s also driven just by just overall increases that you could have on some typical line items as merits and things like that. But yeah, the acquisition activity would also slightly impact that as well.

Arthur Henderson – Jefferies & Company, Inc.

Okay, okay. But the bulk of the impact, I guess just in terms of all the seasonal factors and stuff, does that hit you mostly in the practice salaries and benefit front, is that where most of it occurs?

Vivian Lopez-Blanco

Well, yeah, a big chunk of it occurs there and but you do have some on the DNA line. But a big chunk of it is more related. It’s more prominent in the cost of service line, because those are all the physicians you know.

Arthur Henderson – Jefferies & Company, Inc.

Right. Okay.

Vivian Lopez-Blanco

On the DNA, you have different types of people there.

Arthur Henderson – Jefferies & Company, Inc.

Okay, fine and then, just a couple of a little ones here. Back on the CapEx number, you described, I know, what the full year was last year, just in terms of how we should think about CapEx spend for this year. Is there any guidance you can give us on that just in terms of how we should look at that – look at that on a quarter-to-quarter basis?

Vivian Lopez-Blanco

Yeah, it’s not changed much. If you go back once, like I’ve said, once you back out the building that we bought, earlier in 2011, I mean roughly we’re in the same range. So there is, I mean the quarterly mix sometimes shifts. But we don’t expect it to be outside of the range that we’ve had before $13 million or so for the year.

Arthur Henderson – Jefferies & Company, Inc.

Right, okay and then last question for Roger. I know in your prepared remarks, you’ve talked about sort of a conservative view for Medicaid in the back half of the year. When you say conservative, are you just kind of thinking flat reimbursement rates on a Medicaid basis?

Roger J. Medel

Yeah, historically that’s what, that’s all I think about Medicaid, ever since 2008, we were, there was the time there when we were seeing increases from Medicaid, but we’re not expecting that.

Arthur Henderson – Jefferies & Company, Inc.

Okay, got it. Thank you.

Roger J. Medel

Thanks.

Operator

Thank you. And our final question today will come from the line of Matt Weight. Go ahead please.

Matt Weight – Feltl & Company

Thank you. How much of the $200 million that you take for anesthesia M&A would be for contingent payments for prior acquisitions?

Vivian Lopez-Blanco

No, I mean when we give the spend it’s pretty much for acquisition spend.

Matt Weight – Feltl & Company

Okay.

Vivian Lopez-Blanco

We’re not including that. When we give it in the guidance, obviously, when we give it and what we’ve actually spent, we do need to put it in there because it’s just GAAP issue, but…

Matt Weight – Feltl & Company

Sounds that perfect and then just last question here. In terms of you’re saying unit revenue guidance up ticking a little bit, looking at the comparisons, especially it looks to be more challenging here in the first quarter, split evenly between price and volume, volumes are actually probably consistent with the fourth quarter. Is it just that you have more visibility on the other specialties outside of the NICU side that gives you the confidence there, or is there anything else that you can kind of share on that?

Roger J. Medel

Well, we think that we do have visibility and also the trending is different in those practices than for (inaudible) so we can look at it the appointments made in those kinds of things. So it is a little bit different, we just, yeah, so but that is basically what it is.

Matt Weight – Feltl & Company

Okay and then just the follow-up on that. I think you made the comment you’ve taken a look at your, the current data that you have there so would it be safe to assume that current data here in 2012 is more positive than what you had seen in the fourth quarter of fiscal ’11.

Roger J. Medel

Yeah, What I really don't want to comment on that.

Vivian Lopez-Blanco

Yeah, we’ve talked about that before I mean we don’t want to be speculating on any monthly data that we have. Frankly, we haven’t even closed. We are in the process of closing the month of January. So even though we do have some visibility on NICU volume, we don’t really have a visibility on all of our volume mix and so we really don’t want to speculate on that at all.

Matt Weight – Feltl & Company

Okay. Thanks.

Unidentified Company Representative

Thanks. Okay operator that that is it.

Roger J. Medel

Thank you all for listening this morning. I appreciate your attention and we will look forward to speaking with you next quarter.

Operator

Thank you very much. And ladies and gentlemen that concludes your conference today. We appreciate your participation and you are using the AT&T Executive Teleconference and you may now disconnect.

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