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MEDNAX (NYSE:MD)

Q1 2012 Earnings Call

May 03, 2012 10:00 am ET

Executives

David Parker -

Roger J. Medel - Co-Founder, Chief Executive Officer, Director and Chairman of Executive Committee

Vivian Lopez-Blanco - Chief Financial Officer, Principal Accounting Officer and Treasurer

Karl Wagner - President of American Anesthesiology

Analysts

Brian Zimmerman - Deutsche Bank AG, Research Division

Ryan Daniels - William Blair & Company L.L.C., Research Division

Joanna Gajuk - BofA Merrill Lynch, Research Division

Matthew J. Weight - Feltl and Company, Inc., Research Division

Brooks G. O'Neil - Dougherty & Company LLC, Research Division

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Nicholas Jansen - Raymond James & Associates, Inc., Research Division

Ralph Giacobbe - Crédit Suisse AG, Research Division

Operator

Ladies and gentlemen, thank you very much for standing by, and welcome to the 2012 first quarter earnings conference call. [Operator Instructions] And also as a reminder, today's conference is being recorded. I would now like to turn the conference over to your host, Mr. David Parker. Please go ahead.

David Parker

Good morning, and welcome to MEDNAX 2012 First Quarter Earnings 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 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. At this time, I'd like to turn the call over to Dr. Roger Medel, our CEO.

Roger J. Medel

Thank you, Dave. Good morning, everyone, and thanks for joining our call today. Our reported results from operations for the 2012 first quarter reflect an organization that continues to grow, while at the same time, pursuing a unique, durable and proven growth strategy that attracts physicians and delivers ongoing value. We're encouraged by the continued interest of physician groups that want to practice as part of our national medical group and we're excited about the progress that we're making to build our national group practice through acquisitions across all of our physician specialties. As we reported in this morning's press release, our revenue grew by approximately 11% for the 2012 first quarter. Our revenue growth was driven largely by contributions from acquisitions since last year, as well as same-unit growth. We've continued to successfully acquire and integrate physician practices within our specialties, and we've added 4 pediatrics groups during the 2012 first quarter and an anesthesia group at the beginning of the second quarter. In late March, we completed the acquisition of 3 practices that were formerly part of Children's Specialists Medical Group based in Sacramento, California. These long-standing practices brought 19 physicians, including 9 neonatologists, 4 maternal-fetal medicine specialists and 6 pediatric critical care physicians, who have been serving their communities since 1995 through our Pediatrix Division. These are outstanding private practices affiliated with the Sutter system and represent our first presence in the Sacramento area. Their annual NICU patient volume now exceeds 22,000 patient days.

In addition to this, also in late March we completed the acquisition of a pediatric cardiology practice in Orange, California. This is a well respected practice of 2 physicians that is affiliated with 11 hospitals in the area and has an extensive outreach program including multiple clinic locations throughout Orange County.

Focusing on American Anesthesiology, in early April we completed the acquisition of Burlington Anesthesia in Burlington, North Carolina. Burlington Anesthesia consists of 6 anesthesiologists who practice as part of a care team model that includes 12 full-time equivalent CRNAs providing a wide spectrum of anesthesia services. Founded in 1978, they have long-standing relationships in their community. Many Burlington physicians serve in leadership roles at their facility and are active in their local communities. As a practice, they felt that with the changing health care climate, it was the right time for them to join a national group practice like American Anesthesiology whose goals are aligned with theirs.

Each of these practices has a commitment to quality of care, customer service and patient satisfaction [ph] [Audio Gap] very much aligned with MEDNAX's core values and will provide an opportunity to share best practices among our entire medical group. We're managing a very full and robust acquisition pipeline. Throughout all of 2012, we anticipate investing approximately $300 million to complete practice acquisitions across all of MEDNAX's physician specialties. While our goal has not changed on the $300 million, the timing of the acquisitions may be impacted by the complexity and the size of some of these deals. I'll [Audio Gap] to Vivian to discuss the financial specifics in a few minutes. But first, I want to spend some time discussing how we're enhancing the value proposition that I've just mentioned.

We recently completed one of our most important and largest meetings of the year, our annual medical directors meeting. This is a meeting where our physicians and clinicians in leadership roles come together to share best practices across all of our specialties and to benefit from the resources, teamwork, collaboration and leadership that come with our successful national group model. As a matter fact, the theme for the meeting this year was teamwork and collaboration and the value that this brings to us as a national group model.

Healthcare today is creating questions for individual physicians about their survivability, about what will happen next. Will the Patient Protection Act destroy malpractice? Will managed care overtake me? Will further regulation burden my ability to effectively treat patients? Are hospital administrators aligned with my goals, et cetera. We all know that the business side of healthcare has imposed itself on patient care in ways that make it nearly impossible to run a practice without comprehensive systems and supporting resources to cope with the demands of contracting, government relations, credentialing, billing, compliance, collections, et cetera. Fortunately for us, our ability to execute on our group model is critical. And in today's healthcare world we believe our model leads the way. As a national medical group, we are well positioned for the future of healthcare and how these uncertainties may manifest themselves. I know that as a team of peers made up of physicians and practitioners, our interest and goals are aligned for our success. We are a growing team with the financial resources and the administrative infrastructure necessary to enhance our positioning as a group model. This enables our physicians to focus on what is most important: patient care and patient outcomes.

Our model has many examples of the value associated with our group effort, government affairs and regulatory efforts at the federal and state level. Our outcomes data warehouse drives clinical quality improvement through our continuous quality improvement program and our continuing medical education and research efforts. Our compliance team establishes the message through which the company seeks to foster the highest level of ethical and legal conduct by our associates as they focus on patient care. And last, but certainly not least, our administrative professionals provide support for the revenue cycle management functions through a myriad of nonclinical, but vitally important, functions. The value of collaboration at all levels cultivates cross-fertilization of ideas so that we're continually improving upon our success, addressing the key questions and issues in our path and defining what a strong national medical group looks like. We have many great examples of this in our company today, and I want to pass along a few that stand out and demonstrate what true professional collaboration looks like.

Our neonatologists and pediatric cardiologists collaborate to identify congenital heart disease in infants, working on the screening program to determine the real impact across the country, which we do not believe has been considered as states roll out their screening programs for congenital heart disease. Our neonatologists and maternal-fetal medicine specialists collaborating on cord clamping research, working together on the timing of the clamping of the cord to determine how it affects outcomes of infants, especially premature infants. Lastly, our Center for Research, Education and Quality collaborated with our anesthesia team to assist them with their efforts in outcomes research. This value proposition has drawn groups to our model and will continue to do so for some time to come. Based on this, we believe that the question should be posed to physician groups: if you're not seriously considering joining MEDNAX, are you at risk of being left on the sidelines? Why? Because in today's environment, where survivability as an independent physician practice is a real and growing concern, there are 3 choices for a physician group: you can join with a hospital, whose primary focus is on the facility; you can join with a university, whose primary focus is on multispecialty research and academics; or you can join with a group like MEDNAX, our group of physicians and peers whose interests are 100% aligned, providing a clinical model that allows physicians to do what they do best, take great care of the patients. Together, we're adding value and reshaping the delivery of care through investments in the clinical, information and management systems necessary to advance evidence-based medicine. A national group practice is better able to advocate on behalf of the physician and advanced practitioners. I believe that our model should take center stage in leading the changes in how healthcare is delivered in communities across the country. With this unique, proven dynamic and doable growth model, we are well positioned for the future of healthcare, whatever the future holds. Now I realize, this is a financial conference call and we did report results for our most recent quarter. But I also think it's important to provide you with some perspective of the valuable work being done by our group to care for patients in our communities and the value with which our model compliments this effort. So at this time, let me turn the call over to our Chief Financial Officer, Vivian Lopez-Blanco, for a review of 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 2012 first quarter results, we're presenting a company that continues to grow strategically through our durable and proven model, with contributions both from the acquisitions completed since January 2011, as well as same-unit practices. We continue to be challenged by variability within some of the same-unit drivers and our results demonstrate that we continue to meet this challenge. As we discuss our quarterly results, we would like to remind you of something that we've pointed out on our last call and that continues to impact our results this quarter. That the growth rate in operating results for any given quarter will potentially be impacted by the variability in margins due to the mix of practice acquisitions as well as timing. For the 3 months ended March 31, 2012, revenue grew by 10.6% to $422.6 million. Over 77% of our revenue growth came from acquisitions, while the remainder is from same-unit growth, which increased by 2.4% for the 2012 first quarter from the prior year. Of this 2.4% same-unit growth, revenue attributable to volume grew by 1.8%, while net reimbursement-related factors grew by 0.6%. On the volume side, we experienced growth in each of our physician specialties and subspecialties, including hospital-based neonatal and anesthesia and office-based maternal-fetal and pediatric cardiology services. The number of patient days at neonatal intensive care units included in our same-unit base increased by 1.2%. Our same-unit revenue growth from net reimbursement-related factors was principally due to continued modest improvements in reimbursements received from third-party commercial payors as a result of our ongoing contract renewal processes and an increase in the administrative fees received from our hospital partners due to the expansion of our services as a result of internal growth initiatives, offset by a shift in payor mix to government payors from commercial payors year-over-year. The percentage of our services reimbursed under government programs increased by 90 basis points towards a higher percentage of services reimbursed under government programs during the 2012 first quarter compared to the prior-year first quarter. Sequentially, the percentage of our services reimbursed under government programs for the 2012 first quarter relative to the 2011 fourth quarter remained unchanged. Our profit after practice expense for the 2012 first quarter was $133.4 million, up 8.2% from $123.3 million for the prior-year period. Profit after practice expense margin declined by 69 basis points, which can be attributed to the variability in margins due to the mix of practices acquired since January 2011 and also as a result of a slight increase in operating expenses in the 2012 first quarter as compared to the prior-year period. We generated operating income of $79.4 million for the 2012 first quarter, an increase of 4.8% from $75.7 million for the prior-year period. G&A expenses grew by 12.1% for the 2012 first quarter to $46.9 million from the prior-year period. As a percentage of revenue, G&A expenses increased slightly to 11.1% for the 2012 first quarter from 10.9% for the 2011 period, primarily due to a onetime charge for separation costs related to organizational structure changes. Depreciation and amortization expense for the 2012 first quarter increased to 1.7% of revenue from 1.5% for the prior-year period, primarily due to the amortization of intangible assets related to acquisitions. Net income for the 2012 first quarter was $48.4 million, up 6.4% from $45.5 million for the 2011 period. We reported diluted earnings per share of $0.98 based on a weighted average 49.4 million shares outstanding, which compares with diluted earnings per share of $0.94 based on a weighted average 48.4 million shares outstanding for the 2011 first quarter.

Looking at our balance sheet, we had cash and cash equivalents of $22.4 million at March 31, 2012. Accounts receivable at March 31, 2012, were $236.7 million, an increase of approximately $6 million as compared to December 31, 2011. Days sales outstanding decreased by approximately 1 day for the 2012 first quarter from a 2011 fourth quarter as we continue to integrate our recent acquisitions. The total amount outstanding on our $500 million revolving credit facility was $83.5 million at March 31, 2012, an increase of $54.5 million from the $29 million outstanding at December 31, 2011. During the 2012 first quarter, we used $32.1 million of cash to fund our operations. We used cash to fund our operations during the first quarter as we do every year as we make performance-based incentive compensation payments principally to our physicians. We also have our normal 401(k) matching contribution payment in the first quarter. In addition to using our cash to fund operations, we invested approximately $28.5 million to acquire 4 physician group practices during the first quarter as well as to make contingent purchase price payments for acquisitions completed in prior periods. Maintenance capital expenditures were $2.9 million for the 2012 first quarter as compared to CapEx of $20.3 million in the 2011 first quarter. During the 2011 first quarter, we bought an office building, so our 2012 spend for maintenance capital expenditures is back in line with our historical levels.

Moving on to our outlook for the 2012 second quarter. As we announced in this morning's press release, we expect that our earnings per share for the 3 months ending June 30, 2012 will be in the range of $1.15 to $1.21. The range for our 2012 second quarter outlook is determined by anticipated same-unit growth for the period, which we estimate to be 1.5% higher to 3.5% higher year-over-year on a total same-unit basis. The same-unit growth range assumes combined volume across all of our physician specialties. In addition, this range anticipates variability in the midst of our services reimbursed under commercial and government payor programs, as well as improvement from commercial payor contracts. Our second quarter forecast anticipates that same-unit growth will be 1/3 volume growth and 2/3 net reimbursement growth.

As a reminder, for the remainder of 2012, the growth rate in operating results for any given quarter will be potentially -- be impacted by the variability in margins due to the mix of practice acquisitions, as well as the timing. Now I'll turn the call back over to Roger.

Roger J. Medel

Thank you, Vivian. With that, let's just open up the call for questions, please.

Question-and-Answer Session

Operator

[Operator Instructions] And our first question comes from the line of Darren Lehrich with Deutsche Bank.

Brian Zimmerman - Deutsche Bank AG, Research Division

This is Brian Zimmerman in for Darren. My first question is can you frame the 100 basis points year-over-year decline in operating margins in the context of payor mix and practice mix? And how should we think about these margins and these components going forward?

Vivian Lopez-Blanco

Yes. I think that if you guys go back to the fourth quarter, we kind of introduced that concept when we talked about the lapping [ph] Effect, with the significant acquisitions that were flowing through all of 2011 for some of the larger anesthesia practices that we acquired at the end of 2010. And so there basically, Brian, you saw some of that gross margin impact and also the operating income impact. So most of it is related to, as I said, the mix of these practices and as we talked about -- as I visited some of you guys, I always talk about what impacts this. And on the anesthesia side, it's related to the anesthesia care team model that these practices have, and that would be whether the CRNAs are employed by the practice or whether they're employed by the hospitals. And so that would be the biggest impact. As I mentioned we do have a slight increase in operating expenses, but pretty much that's the bigger impact. Obviously, on the operating income line, as we talked about, there was that onetime charge that we talked about in G&A, which is not a recurring charge.

Brian Zimmerman - Deutsche Bank AG, Research Division

Okay. That's helpful. My next question is, I know you're limited on what you can say regarding upcoming acquisitions. But I was hoping you could provide some additional commentary around the pacing of acquisitions. It seems that the pace has been different than you've been characterizing in the last couple of years. And I was just wondering if I could get your updated thoughts on what you're seeing to complete these deals.

Roger J. Medel

Yes. It's Roger. Look, we're still very bullish on our projection to complete the $300 million in acquisitions that we talked about this year, not this quarter, but this year. Meaning we got 8 months left to get our goal in place and I am very comfortable that we'll get that done. The acquisitions are more complicated as we have stated in the past. And so that means that there's more contracts to be done, more signatures that we have to get from different hospitals and other providers, just more work to be done in getting the acquisitions completed. The more physicians and nurse anesthetists that there are, the more employment contracts that need to be negotiated, often on an individual basis, et cetera, et cetera. So the timing is the variable here. But from my standpoint, the pipeline is very full, very robust. There are a number of larger practices in that pipeline, with 50, 70, 100 physicians and more than that in the nurse anesthetists' side. And so we won't complete all of those but it makes me very comfortable in telling you that I think we will complete our $300 million goal before the end of the year.

Brian Zimmerman - Deutsche Bank AG, Research Division

Okay. And then my last question is regarding the same unit revenue to be down a little bit, and -- I was wondering what was influencing this view? We're hearing from some of the hospitals that they're seeing a slight rebound in berths [ph] -- which would imply directionally that it'd be stable to up. So what's influencing this view?

Vivian Lopez-Blanco

Well, as far as -- I mean we did see a slight favorability in the berths [ph] in our same units versus some of the quarters last year. But I just have to keep telling you guys what I've been saying over the last year, is that -- some of these things I don't think we're out of the woods on as it relates to continued variability in it. So basically, we did have positive volume in all of our specialties in the first quarter and certainly seeing in within some of our specialties, very good volume. And so I think that some of that is still going to be variable.

Operator

And our next question comes from the line of Ryan Daniels with William Blair.

Ryan Daniels - William Blair & Company L.L.C., Research Division

Roger, quick follow-up question for you on the M&A front. You had a lot of color in your prepared remarks on why doctors should consider choosing MEDNAX over some of the other alternatives. Is that just helping shareholders understand your value proposition? Or should we read into that, that maybe there's a little bit more competition in the market with hospitals and other entities buying physician groups today than perhaps a year ago?

Roger J. Medel

Okay. That's a good question. No, I mean, I'm trying to get our shareholders to understand why we think we're winning. And we're going to win this game. We think that we have a long-term, proven strategy that brings physicians together that adds value to what they're doing. And that in this era where everybody's shooting at you, the lawyers want to sue you, the federal government wants to investigate you, the payors don't want to pay you out. So being a part of a team of your own peers that has the infrastructure to fight back against some of these pressures is the reason why we believe that we'll continue to be successful. So, no. Is there more competition? Yes. I mean we said from the beginning that we thought that there'll be some private equity money, and we're seeing that. There is private equity money snooping [ph] around and we believe they will get some deals done. We aren't really seeing too many hospitals getting involved in acquiring anesthesiology practices. So, I don't think we've seen that. But there is competition. And fortunately it's a big market, there's 40,000 anesthesiologists. But for me it's an easy decision. You want to join a private equity firm, where you know you're going to get selected 3 or 4 years. You don't know who you're going to be working for. You're not talking about building research and quality assurance and education and having compliance forums and all that stuff or do you want to join a group of your own peers that has a proven track record of what we do and how we do it.

Ryan Daniels - William Blair & Company L.L.C., Research Division

Okay. That's helpful color and it definitely sounds like a good sales pitch for the physicians who're working. Maybe that's well rehearsed. Maybe another...

Roger J. Medel

Maybe I've said that a couple of times.

Ryan Daniels - William Blair & Company L.L.C., Research Division

So I guess, a couple of more quick ones. I don't know if Karl's in the room, but I'm curious -- there's been a lot of debate recently in several states going to the supreme courts about the ability of CRNAs to administer anesthesia without the supervision of physicians. I'm curious if you have any thoughts on that? And if that would impact your business positively or negatively depending on how that trends throughout the various markets?

Karl Wagner

Yes, there is some talk. I think there are 2 states right now that are in courts [indiscernible] in California and in Colorado. Some states making a decision to opt out of the requirement for supervision of a nurse anesthetist by a physician. I guess a few comments on that. One, clearly, and I'm not going to get into clinical components [indiscernible] from talking to our physicians and people here, I truly believe that the best model is having a physician involved with the care of the patients. There's no question from our standpoint that that's the model that provides the highest level of care in the situations that requires that full-scale training of the physician that doesn't necessarily going to be there if it's a CRNA-only model. As far as the dynamics of that, there are several states that have opted out, so California and Colorado are not new. There really hasn't been a big change in the dynamic in those states, how places where CRNAs have been moving to take over the care in hospitals. They -- clearly, this will require hospital credentialing changes and by-law changes to allow that to happen in a lot of places. And that really hasn't happened in those states. It really would be more likely to impact rural locations. And it's harder to find a full-scale of providers, whether that be even nurse anesthetists but as well as physicians on the surgical specialty and the anesthesiologists. And that's the places that they've seen some impact. But even without, I don't think there's been a huge impact in the change in the states that have opted out. So we don't see that changing our dynamic in our practices.

Ryan Daniels - William Blair & Company L.L.C., Research Division

Okay. Super helpful, Karl. And then last one, I guess, for Roger. In the past, around this time of year, you've given us your kind of forward-looking thoughts on the state budget as we go into the new fiscal year in July and October. Any broader thoughts on kind of the outlook on the Medicaid front as we go forward?

Roger J. Medel

Yes. We're not really seeing too much activity right now. We know from Florida that they have talked about having an impact on the hospital side of the business, but none on the physician side. So what we know right now is that Florida is not talking about any kind of cuts for physician reimbursement. We've had some conversations with our Medicaid directors, and it looks right now like Nevada is saying no cuts for physicians. As you know, last year South Carolina carved out OB and neonatology, Georgia has said no cut. And I think of the remaining top 5, Texas, Washington, North Carolina, they've all said no cuts to physician services. So I think the environment is a lot better for the Medicaid reimbursement to physicians this year than it was a year ago.

Operator

And our next question comes from the line of Kevin Fischbeck with B&A (sic) [BofA] Merrill Lynch.

Joanna Gajuk - BofA Merrill Lynch, Research Division

Actually, this is Joanna Gajuk today for Kevin. A quick follow-up in terms of the charge for the separation cost. Would you be able to share the size of this charge in the quarter?

Vivian Lopez-Blanco

No. But basically, we thought that we did want to mention it as a variance because again, I think more importantly for you guys, you want to understand what you can expect from the G&A margin going forward. And so I think that we'll be back at relatively in the 11% range to the high 10%s, remember like it was last year, low 11%. So I think that was more relevant for you guys to understand going forward what to expect there.

Roger J. Medel

And let me just add that, that wasn't at a corporate level. That was at a divisional level.

Karl Wagner

Yes.

Joanna Gajuk - BofA Merrill Lynch, Research Division

So what was the -- what was the changes that was made that required that separation charge?

Vivian Lopez-Blanco

Yes. There's just some changes in personnel that we made.

Joanna Gajuk - BofA Merrill Lynch, Research Division

Okay. That's very helpful. And then in terms of your commentary for second quarter guidance for the same-store revenue guidance. It sort of implies that the pricing would be better than this quarter. So should we read into it and say that you might have some better visibility into payor mix maybe getting better going forward? Is that the right way to think about it?

Vivian Lopez-Blanco

Okay. So payor mix is one of the variables that as you guys know, we always talk about one of the ones that we feel have been volatile over the last couple of years. But as seasonality goes though, we do typically see less movement in the p-mix from the first quarter to the second quarter. So yes, some of that is reflected there. Obviously, we had a 90-basis increase in the first quarter of this year, which basically last year was favorable versus negative. But the year before that, we had a very big shift towards government. And so we kind of look at these trends when we pull out what we think is happening currently. But the seasonality of it is a factor in our decision, Joanna. So, no question. And obviously, we continue to be optimistic in our discussion with our commercial payors and we've seen favorable results from that. And so that's continued in there as well.

Joanna Gajuk - BofA Merrill Lynch, Research Division

All right. And then in terms of your guidance for the $300 million of deals this year, so is it still same split, $100 million for new acqui [ph] Deals and the rest for anesthesia?

Roger J. Medel

Yes, more or less. More or less, yes. The $200 million or more for anesthesia and maybe $100 million for base, or less.

Joanna Gajuk - BofA Merrill Lynch, Research Division

All right. And then so are you seeing increased competition in your anesthesia deals? And can you comment on multiples? I mean I guess it depends also on the size and you indicated that there are a couple of larger deals there in the pipeline. But if you can just make some maybe general comments also if you can.

Roger J. Medel

Yes. Our multiples haven't changed. We're very disciplined about how we are going about forming this national group practice. So there's no change in multiples. Because of the competition we don't really talk about what multiples we're paying for these practices. But that hasn't changed. There is private equity money that has come into the market as we expected, and we said all along that we would expect that. We know that they are -- there's at least one deal of a group of anesthesiologists that supposedly has the handshake with a private equity firm. That's all I know right now. But I expect that there'll be -- if that doesn't happen, there'll be others because we clearly have spoken to the attractiveness of the market and it's drawing people into this area.

Joanna Gajuk - BofA Merrill Lynch, Research Division

Great. That's helpful. And just the last question to follow-up on something we asked I believe last quarter. In terms of the proposal from CMS or rather the regulation that is expected to come out soon in terms of the Medicaid primary care payment increase under the reform. It seems like it might be coming out fairly quickly. So is there an update you can provide in terms of what your expectation is for your physicians to qualify. And also for the services that your physicians provide to qualify under these provisions.

Roger J. Medel

Yes. Our government affairs team, which is who we look to for this question, remains very hopeful and very optimistic. We believe that we comply with the letter and the provision of the proposed rule. And there really has been no specific reason for the delay. They supposedly had 90 days to get the answer. Those 90 days expired June 1 -- I mean, pardon, May 1. So the 90 days now have passed and we haven't heard from the government. But, it's the government. So, if they want to take another 30 days or whatever they can. But the gist of it is our position and that has not changed. Our government relations team in Washington says that there's no reason to think anything has changed, and they remain optimistic. So we'll see.

Operator

And our next question comes from the line of Matt Weight with Feltl and Company.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Just a question here in terms of the variability in practice mixes. Is it safe to assume as we go forward, you do more anesthesia deals, why won't we see lower margins, company-wide?

Vivian Lopez-Blanco

Well, I think that's kind of the point that we're making if you look -- like I said before in the fourth quarter we started to see some of that. So it just has to do with whether we're buying practices on the anesthesia side that the CRNAs are employed by the hospital or the practice. And then there's also a piece related to the core, obviously anesthesia was a bigger driver in the lapping [ph] effect in the fourth quarter. But depending on what's happening with the revenue growth. But yes, on the anesthesia side, it just depends on the anesthesia care team model. So we have kind of tried to drive home that point. Again, one of the things that I want to remind all of you, as I speak to you individually, I do this, the company is rather insensitive to margins as it relates to that basically included in how we price any deal because we're basically paying a multiple on the contribution of that practice. And so from our perspective, the pricing accounts for that.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Okay. And then this maybe coincidental but looking back the anesthesia deals seems like over the last couple of years have fallen in the last part of the year. As the deals are more -- are larger, more complex, probably take longer to integrate. Doesn't that just setting yourself up for a cycle kind of going forward that more often than not these are going to be back-weighted in the year?

Roger J. Medel

I wouldn't say that. I think that there are different -- there are deals that are at different stages in the pipeline. And I think that you'll see some deals here hopefully relatively soon. And so I don't think that necessarily they'll be weighted towards the end of the year. I think we are just going through this cycle here where now there's a private equity firm, and so some people are talking with them and trying to figure out what that's about. But I think once we work through that cycle, I think we'll go back to doing deals across the year. Again, I expect that we'll get our next deal done here in the very near future.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Okay. And last question, Vivian, I know you're not going to disclose how much the separation charge was, but given that this was the first quarter since 2009 you didn't have any G&A leverage, would have you achieved any without that charge?

Vivian Lopez-Blanco

I mean basically, we would have had a slight improvement. But like I said, I wanted to set the trend for the rest of the year, which we do believe will be roughly in that 10%, 9% to 11%. And I think we'll have the normal increases that we have. We're always looking at the infrastructure here as we continue to grow because we do need to make sure that we have adequate coverage in all of our areas that we look at, that Roger talked about in his speech, which is why we have core competencies and compliance and coding and all of that. But normally, it should be in the normal run rate. This one I wanted to identify as a onetime charge because -- because to your point, we didn't have any slight positive leverage.

Operator

And our next question comes from the line of Brooks O'Neil with Dougherty & Company.

Brooks G. O'Neil - Dougherty & Company LLC, Research Division

Sure. I have a couple of questions. So maybe, Vivian, just because I'm a little bit of a simpleton, and I want you to be very explicit about it, maybe you could just describe with anesthesia deals, I assume the revenue's the same either way but you have more expenses if the practice employs the nurse anesthetists. Is that what you're talking about?

Vivian Lopez-Blanco

Yes. But the revenue is not...

Karl Wagner

Yes. So, in the practices we have, we have a mix of practices where we employ the CRNAs and certain situations where the hospital employs the CRNAs. When the hospital employs the CRNAs, they get an amount of revenue for the services the CRNA provides and we bill for the physician services. That -- in that model, we have a situation where we have a higher margin on those practices. A big chunk of the expense goes to the hospital. In -- typically the CRNA themselves [indiscernible] the reimbursement split, the leverage on that, the margin on that is not the same as it is for the physician services when you look at the breakout.

Brooks G. O'Neil - Dougherty & Company LLC, Research Division

All right. That's very, very helpful. I appreciate that. Let me shift gears. As it related to the mix shift this quarter, I think you mentioned 90 basis points, I understand that it didn't change any from fourth quarter. But did it surprise you at all? Or was it very much within the scope of your expectation for the quarter?

Vivian Lopez-Blanco

Well, I mean really this is one of the variables that we talk about. I mean p mix over the last couple of years as well as the volume has been volatile. So what I tried to frame up here for you guys, Brooks, was like so this year we had an increase of 90 basis points in the first quarter. Last year we had a favorable impact of roughly 1.2. And then the year before that, we had 300 basis points deterioration again. And so it's been volatile. And so we're not surprised. Obviously we would love to have it be more stable. But the other thing there is that it has been less acute as far as the movement goes, which we're happy to see too, in other words, the shift. And so, like I said, there's better seasonality in the second quarter historically speaking as the shift in payor mix goes. And so hopefully, we'll see what happens the rest of the year.

Brooks G. O'Neil - Dougherty & Company LLC, Research Division

Sure. So I understand all that, it makes total sense to me. As it relates to price increases, I was just detecting a little bit -- perhaps you weren't seeing the same level of commercial price increases that you've historically been able to negotiate. I was just hoping for a little color on that.

Vivian Lopez-Blanco

Yes. No -- I don't know what I said that gave you that impression because that's not -- I mean we've been saying in these calls that we're still pretty happy with what we've been able to negotiate with our payors. So I don't know what specifically I said that led you to believe that.

Brooks G. O'Neil - Dougherty & Company LLC, Research Division

I don't know, I think it was some word in the press release that I detected. I think it said something like slight price increase or something.

Vivian Lopez-Blanco

I think we say modest, but I think we've used that in the past. I mean...

Brooks G. O'Neil - Dougherty & Company LLC, Research Division

It's possible, I was just checking.

Vivian Lopez-Blanco

Yes.

Brooks G. O'Neil - Dougherty & Company LLC, Research Division

I appreciate it. So last question, I guess maybe you could just tell us a little bit more about what we should expect, in a broad sense related to anesthesia, in terms of some kind of -- anticipating this year we might see a broadening of the geographic dispersion of the practices? And then maybe Roger, obviously these anesthesia practices are -- the ones you're talking about bigger, more complicated would suggest they're quite sophisticated and yet they clearly see enormous value in joining your company and your group. So just share with us a little bit more about what you think is driving them to see that value even though they're big and sophisticated and have a pretty good infrastructure going in?

Roger J. Medel

Well, first of all, we will see geographic diversity. I think that there's enough interest from the Far West to the Southeast that we'll see practices in -- throughout the country. So we're not thinking to any specific geographic area. The practices that are joining us are, in my opinion, the unique practices across the country. When you look at the kinds of practices that we have attracted, starting in Virginia and moving to the Carolinas and Texas, et cetera, and here in Florida, what you see are practices that have been established for a long period of time that have great relationships with their hospital administrators, that are in growing areas, that have multispecialty physicians within their groups, meaning pediatric anesthesiologists, [indiscernible] cardiac anesthesia and OB anesthesia. So these are very, very solid practices. Again, the reason they're joining us -- one of the reasons, I think they're joining us is because they see the advantages of joining this national group practice that we're establishing. And so I've already addressed some of those things. But the basic problem there -- the basic issue here is that we're not interfering with their practice of medicine. I absolutely respect people's medical experience and their training. And so we're not going to tell anybody how to practice medicine. We measure outcomes and if there are deviations from standards, we'll figure out why they are, et cetera. But what we do is we remove all of those back-office functions and provide an infrastructure of compliance and government relations that most small practices or even large practices just can't afford to make the investment because it just erodes their profitability. And so, we bring our [ph] 5 or 6 to the table, you want to have physicians as your partners and we just have a long track record of bringing these practices together. And I'm thrilled. And really, I can't even begin to express my satisfaction with the quality of the practices that we have been able to attract. It's really flattering, actually, that we have been able to attract these practices.

Operator

And our next question comes from the line of Kevin Ellich from Piper Jaffray.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Just a couple of questions here. So first of all, I was wondering, did you guys have any acquisition-related expenses in the quarter that were related to transactions that weren't completed in the quarter?

Vivian Lopez-Blanco

Yes. I mean typically, we have that all the time. We have, as you know, with the accounting rules you expense those as you go along. So we have those all the time.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Is that one of the reasons why G&A was also higher outside of that separation charge, Vivian?

Vivian Lopez-Blanco

No. Because we have them all the time and it's not significantly different from any other quarter. From the quarter that we're comparing to either.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Okay. And then based on your comments about G&A should go back to the -- it should have been 10% and 10.9% to maybe 11%. If we look -- use that going forward, that implies gross margins should be down in Q2. I guess just curious as to what's behind that.

Vivian Lopez-Blanco

Well, it's basically what I've been saying. If you go back to -- and I know I keep saying this but I want you guys to look at that as -- the fourth quarter we had about a 63 basis points decrease in the gross margin. And then this quarter is one that I really don't compare to for the rest of the year because as you know, Q1 has seasonality in it that we don't have in the other quarters for us. But basically, yes, I mean the gross margins are impacted by what we were talking about, which is all the mix of practices. And specifically, the anesthesia care team models as well as some of the PDX practices, depending on what's happening with revenue growth. So, yes. But like I said, we basically price it in the deals because the contribution specifically for those anesthesia practices is less, and we pay the multiple, the same multiple. So we're not really impacted from a return perspective.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Okay. I appreciate the color on that. And then, Roger, same-store NICU growth was good. I know there's lot of variability in the business. It was down last quarter, it was up 1.3% in Q3. Just wondering, in general, what are you seeing in the environment on the pediatric side of the business?

Roger J. Medel

Well, as far as volume is concerned, unfortunately, we continue to see that variability that is hard to identify where one quarter, one month, a certain region will be up and that same region will be flat or down the following -- there's no real trend forming anywhere that we can point to. We get hopeful when we start to see things going in a certain way, and then it turns out that it's not a real trend. So I really cannot yet point to anything that would make me feel this month-to-month and quarter-to-quarter variability is coming to an end. Hopefully, as the economy improves and the people start feeling better about their potential and their future, that will change. But right now, there's nothing I can point to.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Got it. And then I might have missed this, but did you say in general that your hospitals, that berths [ph] Were actually up?

Roger J. Medel

Yes. Our same-store berths [ph] were up about 1% year-over-year.

Vivian Lopez-Blanco

Yes.

Operator

And our next question comes from the line of Nicholas Jansen with Raymond James & Associates.

Nicholas Jansen - Raymond James & Associates, Inc., Research Division

Oh, yes. Both of my questions have been answered. But first on the payor mix issue where we're still a little bit weaker, was there any kind of select geographies about payor mix? And I know a lot of publicly traded hospitals talked about having a weaker mix in the first quarter as well. So I was just wondering if there's anything, any markets that you saw more deterioration?

Vivian Lopez-Blanco

Nick, no. Like Roger said with volumes, I mean with our mixes, it's similar. We basically see ups and downs in all of our regions. I'll be honest with you, I don't look at them on a practice-by-practice but on a region-by-region basis. We see variability within it and there's not one that I can tell you oh, this was -- this region was what drove the payor mix, that we don't see.

Nicholas Jansen - Raymond James & Associates, Inc., Research Division

Okay. And then secondly, not a lot of comments on the Burlington acquisition maybe just -- I know it's small but perspective there on what they can bring to the table. And how many more kind of tuck-ins in that market can you look at? And I know you're looking to do some more larger acquisitions in other geographies. But just kind of the tuck-in opportunity with anesthesia?

Roger J. Medel

Yes. We're really excited about Burlington. While it is a smaller group than we've seen other places, I think there's a lot of things that work well with that. One, that hospital has joined the Moses Cone system, which is based in Greensboro where we also provide services and have a good relationship. So that's kind of a -- works real well with our relationship with the Moses Cone system there. So we're seeing the opportunity to work with this group and get them interacting with other physicians throughout North Carolina that we've -- as we've built our different practices in that market. And that's an area where I think we have opportunity as we continue to grow. It's -- we're going to look at some large groups that have well established infrastructure with them but also some smaller groups where I think we can bring some of the infrastructure that we have in place and continue to add value to those along with the hospitals there. Ultimately, our long-term growth is really based upon adding value and keeping those hospital partners really engaged and working with us and us being a key part in the whole peri-operative process that's going on there. And we think we can add value to the practices that have had a long standing quest to do that, we can add value [ph] in a lot of ways. But to the smaller practices that haven't had the resources to do that, we think there's even more that we can do there. So we're excited about the opportunity and we see more of them.

Nicholas Jansen - Raymond James & Associates, Inc., Research Division

Okay. Then lastly, just -- if you do end up benefiting from the Medicaid, the Medicare rate shift, would you -- if you do find out, would you quantify that on the next conference call? Or is that's something you're just going to maybe talk about once the 2013 approaches?

Vivian Lopez-Blanco

Yes. Nick, hi, yes. No, I think we'll be cautious about it. And the reason we'll be because we'll have to look at that and figure out the codes, the volume and all of that. So we'll have to -- first of all I'd like to see it and then maybe we can talk about that.

Operator

And our last question comes from the line of Ralph Giacobbe with Credit Suisse.

Ralph Giacobbe - Crédit Suisse AG, Research Division

And I hopped on a little bit late so apologies if this was asked already. I know you guys don't give annual guidance but just given where 1Q shook out and the guidance for 2Q, if I use kind of the midpoint, first half looks like it's $2.16. You guys always have sort of a stronger second half and when I just looked at the model over the last several years, looks like 45% of earnings on average came in the first half, 55% in the second half. Is that kind of a rough range of the way to think about things? Or is there something different in the second half that would cause that historical distribution to be meaningfully different this year?

Vivian Lopez-Blanco

Well, the biggest difference there is going to be the acquisitions. Because as we've said here and as you saw last year, if you'll look at our annual numbers, 77% of our revenue came from acquisitions this quarter. And last year we had like 75% or 74% came from acquisitions. So basically, other than the seasonality, Ralph, that I did talk about, I wasn't sure if you were here when we talked about that, Q1 is always different for us than the rest of the quarters because of the Challenger Day difference. Basically, it will be impacted by how many acquisitions we do in the second half of the year.

Ralph Giacobbe - Crédit Suisse AG, Research Division

Okay. And then just like -- I guess taking a step back and just looking at the last couple of quarters, the overall earnings growth number has slowed a bit. And I don't know if you're willing to do this or not, but if we were to think about the business, taking a step back and assume that you don't do anymore acquisitions, which I know is not the case, but I'm just trying to get a sense of what you think the outlook is in terms of the base business growth from the top line to EBITDA and ultimately EPS perspective?

Vivian Lopez-Blanco

Yes. Well, I mean we are definitely not going to talk about EPS perspective. But we've generally talked about where we believe that our same-unit growth will be. And we typically talk about anywhere in the range of 2% to 5%. And so that's as much as we're going to say about it. As you know, there's variability with that for everything that we've been talking about today, which is the main drivers of that being volume and net pricing with the variability and the p mix especially, that does have a significant impact in any given quarter. And so that's about all as -- I think it's prudent for me to say because again the last 2 years have been very variable on that. I mean last year, we ended same-unit at 3.5%, the year before that was 1.35%, year before was 5% and so again, I think that's a relatively good range to talk about. But other than that, I don't think I can mention anything else.

Ralph Giacobbe - Crédit Suisse AG, Research Division

Okay. And then just my last one. Can you talk about what you see as sort of an ideal capital structure? And if you'd be willing to take leverage up to what you'd be able -- what you'd like to -- or could take leverage up to if larger deals presented themselves?

Vivian Lopez-Blanco

Yes. Well, I know that MEDNAX has a history of people thinking that we don't want to be levered up. But the truth is, is that, that's not really the philosophy of the company other than the acquisitions are all accretive day one. Because that's why it takes us sometimes longer to get these deals done because we do get our physicians' credentials and we're building day one. And so basically we expanded our credit facility last year because we do believe that there's anesthesia deals in the pipeline that could certainly make us use that. And so, we're not going to be a highly leveraged company, but we'll take on some leverage. I'm not going to speculate what that would be, but if Karl comes to us and says he's got 3 big deals, we're happy to go out and get more capital. Banks are willing to give us money. As you know we were very successful in our deal last year. We have very favorable pricing in right now. I do have people knocking at our door to basically give us capital at pretty respectable rates. But we're not going to do it unless we absolutely need it. So that's my position.

Roger J. Medel

That's right. And these deals, I also like to point out, it's not just that they're accretive, it's that they come with a lot of cash flow. And so when we're completing a deal, we are not just counting on the profitability of the deal. We're also counting on the cash flow that comes with the deal. And we just have not felt the need to leverage up the company. I'm perfectly willing to do it for the right reasons. I'm not willing to do it for some financial game. I get bankers in here every once in a while who want to do a double convert with a flying saucer and we're just not going to do that. But for the right reasons with the -- to acquire the right kinds of practices, we'll absolutely leverage up as we need to.

Operator

And thank you, ladies and gentlemen. That does conclude your conference for today. Thank you very much for your participation and for using the AT&T Executive teleconference. You may now disconnect.

Roger J. Medel

Thank you.

Vivian Lopez-Blanco

Thank you.

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