Pediatrix Medical Group, Inc. (MD) Q3 2013 Earnings Report, Transcript and Summary

Ladies and gentlemen, thank you for standing by, and welcome to the MEDNAX Third Quarter 2013 Earnings Call. [Operator Instructions] As a reminder, this conference is being recorded. I'd now like to turn the conference over to our host, with Westwicke Partners, Mr. Charles Lynch, please go ahead, sir.

Thank you, Brad. 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 the 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 report on Form 10-Q, including the sections entitled Risk Factors. At this point, I'll turn the call over to Roger Medel.

Thanks, Charlie. Good morning, and thank you for joining our call today to discuss our 2013 third quarter results. This morning, we reported strong results from operations for the third quarter, which reflect the continued successful execution of our long-term growth strategy. Our revenue for the third quarter increased by approximately 17%, with growth attributable to contributions from recently acquired practices at just over 13.5% and the remainder coming from our same-unit results. Our same-unit revenue growth was favorably impacted by increases in reimbursement-related factors, including parity payments and a positive payor mix comparison, partially offset by an overall net volume decline. We continue to see a good degree of variability in volumes. We saw increases across our anesthesia, maternal-fetal medicine, pediatric cardiology and other pediatric practices. However, soft NICU volumes, as well as soft same-unit comparisons contributed to the overall decline in volumes. So despite it being a challenging quarter for NICU volumes, we generated solid operating income and net income growth for the third quarter and continue to leverage our infrastructure as we integrated practices into our national group model. Our acquisition pipeline also remains very strong. As I mentioned on our second quarter call in late July, Sanjay Patel, a neonatal physician group practice based in Odessa, Texas, joined our Pediatrix Medical Group division. In early August, Holston Anesthesia Associates joined our American Anesthesiology division and is our third Tennessee-based anesthesiology practice. Additionally, in December, Northern West Chester Anesthesia Services based in Mount Kisco, New York, joined American Anesthesiology. This is the second New York-based anesthesiology practice we've acquired this year. Following the end of the third quarter, Dayton Newborn Care Specialist based in Ohio joined our Pediatrix Medical Group division. The physicians at this practice provide services at several area hospitals, including Dayton Children's Hospital. Pediatrix Medical Group is already an established provider of NICU services at Miami Valley Hospital, which earlier this year joined with Dayton Children's Hospital to form the Southwest Ohio Neonatal Collaborative. Overall, for the year-to-date, 9 physician practice groups have joined MEDNAX, 5 as part of American Anesthesiology and 4 as part of Pediatrix Medical Group. In terms of the volume trends we've seen so far in 2013, needless to say, we're somewhat frustrated at the lack of direction these patterns have shown. But from a broader standpoint, we believe we're positioned squarely in the face of attractive longer-term trends. Whether it be the demographics of women approaching childbearing years, baby boomers requiring more surgeries or what we see as pent-up demand from an economic standpoint, we anticipate attractive growth for both Pediatrix Medical Group and American Anesthesiology in the coming years. We also continue to invest in the operational, technological and political capabilities that we believe will maintain MEDNAX a market leader in our specialty in the future. From an operational standpoint, as I detailed last quarter, we continue the development of our regional infrastructure and oversight for American Anesthesiology, as that division has grown, to better support the needs of our physicians and hospitals and to enable more efficient acquisition integration. We've patterned this development off of our very successful growth of Pediatrix Medical Group and like that group, American Anesthesiology now has the capability to integrate not only larger acquisitions, but also multiple transactions simultaneously. From a technological and clinical standpoint, we believe that our proven ability to provide broad benchmarking capabilities, improve outcomes and implement CQI protocols that Pediatrix Medical Group and increasingly, American Anesthesiology, make us a valuable partner to hospitals as they prepare for the future. While the implementation of the Affordable Care Act began in earnest only a month ago, in reality, health systems have been working to adapt to the future of healthcare for quite some time. Their efforts expand many areas, including information technology, investments, participation in accountable care organization and changes in their service mix. The overriding expectation though is that these systems will be responsible not only for high quality clinical care but for providing that care in an increasingly risk-based payment environment. We are in a very favorable position to help them make this transition. Take for example our breadth of data, as a national physician group practice, Pediatrix Medical Group division sees roughly a quarter of all the NICU births in the country every year. Over the many years that we've built Pediatrix, we have also invested in broad and deep data warehousing capabilities. Today, we house the country's largest repository of data on NICU birth and in a way that can be used realtime for benchmarking, for quality improvement protocols and perhaps most importantly, for research and education towards improved outcomes, lower mortality and enhanced risk management and cost effectiveness. Under our operational and clinical leadership at Pediatrix Medical Group over the past 10 years, we've developed many quality improvement protocols, utilizing our data and focusing on the numerous areas of clinical care related to NICU birth, such as nutrition, infections, temperature and medication. The improvement in outcomes through these protocols is significant, most notably surrounding mortality and as a result, we've entered into collaborations with several academic systems, including Harvard and Duke, to help them in implementing their own protocols using our neonatal database. We will continue to expand our research and education activities, not only in Pediatrix Medical Group, but also at American Anesthesiology. With the addition of Dr. Katherine Grichnik as Director of Anesthesia Research, Education and Quality, as I discussed last quarter, and the continued expansion of our Quantum data warehousing capability for our anesthesia practices. These efforts will help to position both Pediatrix and American Anesthesiology, not only as market leaders by size, but also as thought leaders within our respective specialties. So like my discussion of our infrastructure development at American Anesthesiology last quarter, I hope this brief strategic overview gives you a sense that while we've continued to generate strong growth as we add to our existing scale in Pediatrix Medical Group and American Anesthesiology, we're also investing in the continued future success of these businesses, both through greater scalability and through the utilization of the data warehousing, analytical and clinical capabilities that we can offer. Now I want to turn the call over to our CFO, Vivian Lopez-Blanco, for a review of our financial results. And then I'll follow-up with some additional comments before we go to Q&A. Vivian?

Thanks, Roger. Good morning and thanks for joining our call. As we highlighted in our press release this morning, our results for the third quarter 2013 reflect consistent and strong revenue and earnings growth primarily driven by acquisitions over the last year. Net patient service revenue for the 3 months ended September 30, 2013, increased by 17.3% to $554.7 million from $473.1 million for the comparable prior year period. Our profit after practice expense for the 2013 third quarter was $188.4 million, up 15.2% year-over-year. Profit after practice expense margin decreased by 60 basis points, which can be primarily attributed to the variability in margins due to the mix of practices acquired since July 2012, driven by the impact from anesthesia acquisitions. Partially offsetting this impact, we continue to generate operating leverage with our G&A expenses. These grew by 13.4% year-over-year, somewhat slower than revenues, and G&A as a percent of revenues declined by 30 basis points versus last year to 9.9%. Overall, we generated operating income of $123.3 million for the 2013 third quarter, an increase of 14.8%, and net income of $77 million, up 16.8%. Our effective tax rate was 37% for the 2013 third quarter, down from 38.5% in the prior year period. Our tax rate was favorably impacted by changes in our tax-related reserves due to the expiration of certain statute of limitations, partially offset by increase in tax-related reserves from uncertain tax positions. Finally, our 2013 third quarter net income of $77 million resulted in diluted earnings per share of $1.52, which increased by 15.2% as compared to the prior year period. As you'll recall, following the second quarter, our board authorized us to repurchase shares in order to offset the dilutive impact of our equity programs. During the quarter, we used $51.9 million to buy back shares under this program. And for the quarter, weighted average diluted shares were 50.6 million, up 1.5% year-over-year. Turning to more top line detail, our revenue growth attributable to contribution from recently acquired practices was 13.6%, while same-unit revenue grew by 3.7% when compared to the prior year period. Of that 13.6% of revenue growth from recently acquired practices, American Anesthesiology practices contributed 78%, with the remaining 22% coming from acquisitions in the Pediatrix Medical Group. Same-unit revenue grew by 3.7%, with revenue attributable to net reimbursement-related factors growth of 4.1%, while volume decreased by 0.4%. On the reimbursement side, roughly 2.3% of our 4.1% growth was related to parity payments we received during the third quarter of this year. The remainder of our same-unit growth from net reimbursement-related factors was principally due to continued modest improvement in reimbursements received from third-party commercial payors, and the favorable impact of our payor mix with revenue from government programs declining by about 30 basis points compared to last year. Same-unit volumes decreased by 0.4% for the third quarter compared to 2012, driven primarily by declines in our hospital-based neonatal practices. For the quarter, same-unit neonatal intensive care and acute patient days were down 3.5% when compared to the prior year period. Recall that we faced a difficult same-store comparison this quarter with NICU volumes up 3.8% on a same-unit basis in last year's third quarter. Offsetting much of this decline was same-unit volume growth across all of our other service lines including anesthesia. To give a brief update on parity, you'll recall that during the second quarter of 2013, we started to receive parity payments from a handful of our states that are now paying at the Medicare rate for Medicaid services. This continued during the third quarter and our third quarter results include approximately $10.5 million in revenue from parity payments or approximately $0.06 per diluted share net of impact from incentive compensation and income taxes. As of the end of the third quarter, we were receiving some amount of parity payments from 23 of our 34 states in which we operate. Although the specific amounts vary widely, both across those states and relative to retro payments we should be receiving under parity, we continue to expect that our parity payments will come in a relatively slow fashion and will depend on a number of factors from state to state. It continues to be the case that there's a fair amount of uncertainty surrounding the timing and frequency of any payments, so we have included our best expectation of dollars we anticipate receiving during the fourth quarter of 2013 in our guidance. Looking at our balance sheet, we had cash and cash equivalents of $16.2 million at September 30, 2013. Accounts receivable at September 30 were $272.8 million, an increase of approximately $25 million as compared to December 31, 2012. The growth of our AR is related to recently acquired practices. Days sales outstanding improved by 3 days to approximately 45 days for the 2013 third quarter as compared to the fourth quarter of 2012, primarily as a result of improvement at existing units, as well as the continued integration of our recent acquisitions. The total amount outstanding on our $800 million revolving credit facility was $124 million at September 30. During the third quarter, we generated strong cash flow from operations of $157.9 million, a significant improvement from $134.7 million in the prior year. The increase in cash flow from operations for the 3 months ended September 30, 2013, is primarily due to improved operating results. This operating cash flow enabled us to fund both our acquisition activities for the quarter and the share repurchases I mentioned earlier. Moving on to our outlook for the 2013 fourth quarter as we announced in this morning's press release, we expect that our earnings per share for the 3 months ending December 31, 2013, will be in the range of $1.47 to $1.52. The range for our 2013 fourth quarter outlook assumes anticipated same-unit revenue growth for the period of approximately 2.5% to 4.5% higher year-over-year on a total same-unit basis. This same-unit revenue growth will be driven primarily by net reimbursement growth, including the impact of parity, the forecast estimates volume to be essentially flat for the 2013 fourth quarter. Regarding Medicaid parity payments, we are including approximately $0.06 from parity in our outlook for the 2013 fourth quarter based on growth in revenue net of incentive compensation and income taxes from the enhanced payments we expect to receive from those states that are currently paying. Finally, I want to point out that this morning we filed a universal shelf registration statement under Form-S3 with the Securities and Exchange Commission that will allow for the issuance of either equity securities or debt. Roger will discuss this in more detail, but the registration is intended to give us any flexibility that we may need related to our acquisition program. And we do not intend to issue any new securities except as part of such strategic growth. Now I'll turn the call back over to Roger.

Thank you, Vivian. Before I open up the call up for your questions, I want to give some more color on our acquisition activities, particularly in light of where we stand at this time of the year and the S3 that Vivian just noted. In terms of our overall acquisition goals, we remain confident in the size and strength of our pipeline. At this time, we have a number of transactions currently under letter of intent that would get us to at least our overall acquisition goal of $400 million for 2013. Of course, the issue with these acquisitions is always one of timing. You may recall last year we closed one on the last day of the year, and we may have one go down to the wire this year as well. But we remain confident that we will reach our $400 million goal even if there is some slippage into early January. Related to the S3 filing, we believe it makes sense to have one for the purposes of increased flexibility in our acquisition program. And given our business development activity, we want to be sure that we can act quickly should a transaction come about that might include equity consideration. But I want to be clear that we have no intention of merely selling stock for the sake of selling it. With that, let me open up the call for your questions. Operator?

[Operator Instructions] And our first question is going to come from Kevin Ellich with Piper Jaffray.

Roger, I guess could you start off giving us a little bit more color on the acquisition environment, has it become more competitive? And then does the shelf kind of signal that you might be looking at some larger deals? And has the market changed where you might need to provide some equity as part of the deal?

There is definitely some more competition. We have seen a number of private equity firms jump into this specific specialty. And so there definitely is increased competition for these practices. We consider that there are some practices that because of the difference in ages in the composition of the group, some of the younger physicians might be more willing to take equity as opposed to the -- our historical model of just all cash. And so we just think that it's prudent for us to be prepared to offer -- have the ability to offer some equity in MEDNAX to those younger physicians who might be more interested in going down that path. I'm not really going to comment very much on other larger potential acquisitions. We look at everything that's available. We have our business development team constantly bringing us ideas. And so we're in a position where we can consider anything that would be available at this point in time.

Got it. That's helpful. And then you commented about the soft NICU volumes and I guess kind of challenging environment with a tough comp, just wondering if you have any update on what the birth rate looks like at your host hospitals this quarter?

Yes, actually the birth rate at all of our hospitals was basically flat. It may have been up slightly in some hospitals, but I mean, basically, I don't know, less than half of a percent or something. So that -- it is frustrating. We thought that by now we would see some of the effects of the improved economy have an effect on that. But it takes 9 months for us to see any kind of result from it. So maybe that's what it is. But it is frustrating and I'm hopeful that we'll see a turnaround sometime in the near future.

And our next question will come from Ryan Daniels with William Blair. Ryan Daniels - William Blair & Company L.L.C., Research Division: A couple of quick ones, Vivian, regarding the Medicaid parity and then the outlook for Q4. I guess, first off on the tax rate, we have seen in the last few years that dipped down to the kind of mid-30% range, 35%, 36%. So I want to get your thoughts on that, kind of what your guidance is predicated on. And then number 2, in regards to parity, curious of the $10.5 million this quarter, how much of that was actually for services rendered during the quarter versus catch-up payments?

So for the tax rate first, we think that the fourth quarter tax rate will be in line with what it was last year. So basically, as you said, the tax rate last year in the fourth quarter was 35.5%. So we should roughly in that range. So for the year, our tax rate will be relatively lower than last year about 60 basis points or so based on what the run rate is. And so that's what we expect going forward. As you know there's fluctuations in our rate during the quarters because of the discrete items related to the statute of limitations, et cetera. So that's really what's going on with tax rate. On the parity side, yes, for the year really, as I even mentioned last quarter, even though we're seeing a lot more states, we still don't see any consistency in these payments. So for the year, we have had of the $13.4 million or so that we had received, a lot of that had to do is one of our larger states, which is Florida. And then basically, a lot of the retro payment came from Florida. So the other states are really a lot less catch up to them. So we're hoping that they will eventually catch up. As you know, as I said, the reason why I'm saying there is inconsistencies is because some of them are paying retro, some of them have paid retros not to January 1, some of them we're seeing the straight Medicaid being paid, some of them we're seeing managed Medicaid being paid. So there is a combination of all of the above. So I can't really figure out what the pattern is yet. So that's really what's happening with parity. But we're encouraged with the number of states that now have started to pay versus last quarter, as you saw, with 23 of our 34 states. So we continue to see progress there. Ryan Daniels - William Blair & Company L.L.C., Research Division: Okay. That's very helpful. And then Roger, a quick one for you, you mentioned that you have a number of deals under LOI. And the answer is probably it varies significantly, but I'm curious what you'd typically see from a time frame in regards to when you sign the LOI to when you have the ability to close the transaction?

Yes, as you said, it does vary, but it also has increased with a number of other private equity firms that are now in the space. Because people are just taking their time to look at other -- at the other suitors, and so it just takes longer now to get anything done.

And our next question is going to come from Kevin Fischbeck with I believe it's Bank of America Merrill Lynch.

I just want to go back to this shelf registration again. Is the desire to have flexibility and potentially doing equity related to the LOIs that you currently have under assigned or is this kind of anticipation of the 2014 potential transactions? And then I just wanted to get from you, because it doesn't feel like equity would in any way, shape or form be needed to fund any kind of reasonable-sized transaction since I guess you have almost $700 million on your revolver. Just want to make sure I'm thinking about that correctly and maybe just provide some updated thoughts on the kind of leverage that you guys would be comfortable operating at if a larger transaction did come through?

Well, I'm not going to answer most of that. We -- the deals that are under current LOI are not equity deals. Beyond that, like I said earlier, we're looking at everything and we feel that we're progressed enough in our experience with these acquisitions and the integration of these acquisitions that if a larger deal were to come along we would be interested in looking at it. But beyond that, I really don't want to comment.

And our next question will come from Ralph Giacobbe with Credit Suisse. Ralph Giacobbe - Crédit Suisse AG, Research Division: I had 2 questions. First, I guess, just on the acquisitions side, just staying with that theme. You mentioned more competition, you mentioned sort of private equity involved. I guess, just wanted to understand what you're seeing in terms of the multiples and what you'd have pay if that's changed from historical? And then I had a second question.

Okay. We remain disciplined in the multiples that we pay. We're not going to going to go out and pay any increase. We're not going to compete on the basis of price. I think we think that we offer a very unique 30-year experience. We think there's no risk in coming with us of being flipped or sold at some point a few years from now. We think that people know who we are. We have built a company that does research, that provides value for our physicians, that provides medical malpractice. That we think we have a track record and we compete on the basis of our track record and not on the basis of price. We have seen crazy multiples being paid or offered for some of these practices and we just step out when that happens. We're not interested in that. I'm sorry, what was the second question? Ralph Giacobbe - Crédit Suisse AG, Research Division: Yes, the second question. I just want to go back to the volume a little bit. Down 40 basis points, you talked about pressure in the hospital base, neonatal. I'm just hoping you can give us a better idea of the volume trends more broadly for neonatal versus anesthesiology, what those rates look like? And then just how you're thinking about healthcare reform? Would you expect to see more volume particularly, obviously, on the anesthesiology side?

Yes, well we do continue to see a lot of variability on a region-to-region basis and even state-to-state basis. And so some are up and some are down, which has been our frustration all along because it doesn't allow us to really make any kind of a trend statement that we're seeing in different parts of the country. It's not related to immigration. It doesn't seem to be related to anything like that. So we did see volume down. I think Vivian has the numbers there.

Yes, so volumes for the other specialties -- and service lines as we talked about, Ralph, are good. Anesthesia is up over 2% and cardi is up 3% and MFM is up. So I mean they're all up. So really the driver of volume was related to the NICU -- the NICU days. But we have seen some variability in the other service lines, but we really are encouraged with them at the moment.

And our next question will come from Gary Taylor with Citigroup.

Just a couple of quick ones. Vivian, on the third quarter, tax rate was a little lower than we had expected and obviously, 4Q tax rate, as you've already discussed, is often lower than what you see the first 3. When we think about heading into 2014, is there a reason to think that the 3Q tax rate can also be trending lower? It think it was just slightly lower last year, but how would you characterize that?

Yes, I mean -- first of all, for the year, I think Ryan was asking me that, you guys should just use the run rate, which is about 60 basis points better than what we ended '12 at. I mean, as you know, there is fluctuations between our quarterly rates. So in the first and the second quarter, it's higher than the third and the fourth, but about 60 basis points better for '14, is what -- which is where we anticipate ending up '13 is what you should use going forward at the moment. That's what -- the best estimate I have.

And then just going back to volumes, I guess, I was sort of back-of-the-envelope calculating that the non-NICU volumes must have been up at least mid-single digit on a same-store basis to kind of tie back to the overall same-store volume. But it sounded like some of the numbers you were just calling out weren't quite as high as that. Is my math off on how much same-store volume growth you had in the non-NICU volume?

Yes, I mean, I don't -- like I said, our volumes in anesthesia were over 2%, cardi, MFM was over 3%. So you have other NICU services. Remember that we've talked before that we have well-baby care and delivery room services and that was positive as well. And so maybe that's the piece that sometimes isn't quite obvious to folks on the volume side.

And our next question will come from Darren Lehrich with Deutsche Bank.

Just 2 things here. Back to the volume topic. I just wanted to hear an update whether you saw any other changes in terms of the drivers of NICU days, length of stay, preterm rates. Can you just shed some light on that? And what kind of impact that may have had relative to what sounds like a flattish birth trend at your host hospitals?

Yes, as you know, the 2 things we -- the 2 variables we look at are length of stay and percentage of births submitted to the NICU, and both of those are well within our historical ranges. So we don't see any trends there.

Got it. Okay. That's helpful. And then just the other follow-up I had relating to parity. And I guess the question, Vivian, I have is, are there any notable states here? You're just simply not getting paid. I think, there's been some discussion that Texas has pushed this out. I'm just curious if you got any updated timelines in some of your really key states and whether you think there's any hope that you'll be able to get retro in some of those bigger states?

Good morning, Darren. So yes, so we do have some -- I think I've mentioned this before. With Texas, there is no new news other than they have said they will pay but they will pay in '14. First quarter, some payments, but then really second quarter for some of the managed Medicaid. And so -- but Texas, even though it's a large state for us, from a differential and parity payment, it isn't one of the largest states. And then you have California, I believe, I just got word from our government relations last night that I think their summary document was finally approved, but I think they're not going to start paying until '14 either. And then really, those are the only ones that we have some definitives on, the rest of them is just slow to come. And I think, like I said, there's been a just a hodgepodge of how they pay, and some of them pay quarterly, some of them pay monthly, some of them pay retros going back to the full year, some of them are paying straight Medicaid, some of them are paying some straight Medicaid and managed Medicaid. So it's just the combination of all the above.

And your next question is going to come from Brooks O'Neil with Dougherty & Company. Brooks G. O'Neil - Dougherty & Company LLC, Research Division: Just following on that, Vivian, I'm curious if, as you interpret the law, do you see variability related to the various states in terms of what the law is requiring them to pay?

I try not to interpret the law too much, but -- our General Counsel isn't here this morning. But in any event, no, I don't think that there's really any differences in interpretation of the law. I really do think that this whole parity and how it was rolled out and really the practicalities that I talked about before related to states updating their systems and making sure that they're paying the right amounts and then managed Medicaid getting on board with that, I really think it's more of that than everything else. So I don't believe that there's an interpretation of the law at this point as it relates to most of the states. There could be certain programs maybe that they're debating. But for the most part, they're really -- I haven't really heard a lot of that. It's primarily timing and frequency. Brooks G. O'Neil - Dougherty & Company LLC, Research Division: That's what I thought. And so I'm kind of expecting sooner or later, they'll get around to paying you.

Well, I would hope so. Yes. Brooks G. O'Neil - Dougherty & Company LLC, Research Division: Okay. So one other question. You mentioned I think in the published remarks that there was a little bit of a mix shift towards the commercial payors. And it's been my recollection that historically went the other way in the summer months and I'm just curious if you, a, had any explanation for that? And b, if you were scratching your head a little bit like I am?

Well, you have a good memory because you're absolutely correct. The third quarter typically is the one where we see it go up. So -- but I'm happy to take it because, as you know, the payor mix has been another metric for us that has been very volatile. And so we're just happy that it went positive. As you guys know, I haven't been able to explain one way or another why there has been a shift. Again, you would think that it's the overall economy but then that doesn't translate to the volume on the NICU side although there's a delayed effect, as Roger mentioned. So we're happy to take that one.

And our next question will come from Matt Weight with Feltl and Company.

Roger, just going back to the NICU volumes, was there any trend geographically that you saw during the quarter that you could call out?

No, like I said, our frustration all along has been just the variability on a state-to-state and region-to-region basis, where 1 month, a state will be up and another one will be flat. And next month, the one that was flat will be up and the one that was up will be down. And so we really are not and haven't for the last 4 years been able to see any trends. We get a lot of questions about infertility treatments. We get a lot of questions about the illegal population coming across the borders. Some of the border states really happen to have our best rates as far as same-unit growth is concerned. So it doesn't seem to be any of those things and it's just frustrating.

Okay. And Vivian, I understand it sounds like, in terms of parity, states are kind of paying all across the board, all different metrics. But are you able to identify up to $10.5 million how much of that was of retroactive payment even if it wasn't back to the full first of the year?

Yes, it was mostly, like I mentioned to Ryan earlier, it was mostly, on the retroactive side, mostly one state and mostly Florida that was paying. I don't remember the exact amount but there was a big piece of it that was Florida.

And our next question comes from Rob Mains with Stifel. Robert M. Mains - Stifel, Nicolaus & Co., Inc., Research Division: Yes, Vivian, a follow-up to that question. When you talk about what the guidance that's embedded for the fourth quarter, is that -- you said 23 of 34 states are paying. Does your guidance for the fourth quarter for Medicaid parity assume that you're going to get most states onboard or is this kind of like taking basically -- adjusting for retroactive payments in the third quarter run rate and applying them to the fourth quarter?

Yes, we're taking pretty much a run rate on states that are currently paying and we do have a little bit of an estimate on anything that could come in new, but we are adjusting for what I just said earlier, which is that a big retro in Florida, but we expect still some other large retro dollars as well. But yes, we look at the run rate, and the majority is related to the run rate. Robert M. Mains - Stifel, Nicolaus & Co., Inc., Research Division: Great. Okay. And then a question for Roger kind of related to the shelf. There's a few of us on this call who hear about using the stock to buy physician practices and we start getting shakes or whatever. You've seen the pitfalls of that in the past, kind of could you describe how you see avoiding them?

Well, we're not a -- we have been around for a long them as you know and we have seen it. And I think one of the major reasons for our success has always been that we only utilize our cash as a currency and we don't use our stock. The only time we ever used our stock as currency was when we bought Magellan, which was a private equity-backed company that was put together by Welsh Carson to compete with us. So we do see some groups, as I said earlier, where there may be larger groups where a small percentage of the population is a younger population and they're willing to take some stock and kind of roll the dice. We try very hard to talk them out of that, but we do want to have the ability, if there is something out there like that, that becomes attractive to us and that we're willing to -- with certain parameters and I just don't want to give our strategy away right now, within certain -- let's say, with certain protections, et cetera, we might be willing to utilize our stock as a currency.

And our next question comes from Brian Tanquilut with Jefferies.

Roger, just -- as we do channel checks with a lot of these hospitals, especially the nonprofits and the other hospitals that are out there, we're hearing more and more about pressures on inpatient pediatrics and how some hospital CEOs are having to decide whether or not to shut that down. I mean, is that something that concerns you as it relates to where you guys are with your footprint?

Well, as you know, we're not really big in general pediatrics. We've always elected not to compete with our clients, which happen to be general pediatricians. So we're not really big into that. We think that hospitals do like their newborn services because it does attract mothers to the hospital and there are a number of studies that show that within the family structure, it is the mother that chooses which hospital they will utilize not only to give birth, but when somebody breaks an arm or one of the kids has appendicitis or whatever. So I think that -- I don't see any pressure across the country in any of our regions to shut down the newborn services. We're not seeing that at all.

Got it. And then second question for, as you think about some of these anesthesiology groups, especially the publicly-traded guys who are more vertically integrated, who got ER and hospitalist, getting more aggressive, offering hospitals better pricing, if they sign up for more vertically-integrated contract. I mean how do you think about that strategically given that in these hospitals, your presence is NICU and anesthesiology?

Well, we do see some of that going on. We do offer to our hospitals our ability to help them with whatever their needs are. And so for example, we now own 3 groups of pediatric surgeons, different hospitals in Texas, and those were all requests that we got from our hospital partners to help them recruit these pediatric surgeons, and so a total of 16 pediatric surgery programs -- a total of 16 pediatric surgeons in our pediatric surgery programs in 3 different hospitals. We have had hospitals ask us to assume some responsibility for some pediatric cardiologists that they had brought on board that they weren't able to manage efficiently. We've developed some pediatric hospitals programs and some pediatric ER practices in other hospitals, et cetera. So we see that. We're seeing hospitals ask for help. But remember, our strategy always was -- we had a double strategy that we wanted to take great care patients and we wanted to not cost the hospital anything. And we pretty much figured if we're taking good care of our patients and we're not costing you anything, we ought to be able to keep the contracts forever because those are the 2 reasons why you would lose a hospital contract. You're not taking good care of patients or somebody else is willing to offer to do the job $0.30 cheaper than you are. And if you look at our subsidies, our hospital subsidies make up less than 5% of our revenue or around 5% of the revenue. So -- and particularly coming from the neonatal side of the business, it's probably even less in that. So we don't think that we are a danger because as opposed to emergency room and some of the other larger services that do require significantly higher subsidies from the hospitals, that's never been our strategy.

And our next question will come from Gary Lieberman with Wells Fargo.

This is Ryan Halsted on for Gary. I guess following up with a question about your payor mix. If I look at your net reimbursement growth, x the parity, it looks to be consistent with past quarters. So I guess is there any -- was there anything as far as your business mix or any other types of net reimbursement pressures that might offset the favorable payor mix?

No. I mean, when -- we had somebody else ask us about that, when you look at the parity, it will impact positively the reimbursement. And when you look at payor mix, we're looking at it from a gross billing perspective. So it doesn't have to do with the reimbursement. I mean, I'm sorry, it doesn't have to do with the billing, pardon me.

Okay. But I mean, so as far as the growth in the other service lines, would they have boosted, I guess, your net reimbursement growth or was it more of a -- would it have offset, I guess, the weakness in the NICU?

No. I mean I think the net reimbursement, we have seen it just be impacted slightly positive because of the uptick in the reimbursement that we're getting from the government reimbursement rate being better because of parity. So the other ones haven't really moved much the regular reimbursement rate. But I think there, what I was trying to explain to somebody else today was that they were trying to make a translation on the payor mix to reimbursement and I was saying that they payor mix, really, we calculate it based on gross charges, okay? And the reimbursement is obviously what you're getting paid, which that's what parity impacts. It doesn't impact what we bill.

Okay. And then one more, if I could. On next quarter's guidance, again, excluding the parity, it looked like -- I'm sorry. It looked like sequentially, you guys were guiding to better same-store revenue growth than last quarter. Anything that we should read into there? I guess, just as in terms of your organic business.

No, what it has to do with that -- last quarter, when we put out the forecast, we did have a better parity payments that came in from what we had in the forecast, roughly from about $3.5 million or so. And so we are factoring in, as Rob asked me, we're factoring in the parity payments to the third quarter run rate, so that's the big impact of it. So we're still, as I said, in the press release, our -- primarily, the increase is coming from all the net reimbursement factors because we're still going to have a volume be flat, even though we have a less higher comp in the fourth quarter, but NICU was still -- volume during the fourth quarter of last year was still 3% versus 3.8% in the third quarter, so it's still a high hurdle.

[Operator Instructions] We have another -- a follow-up from Kevin Ellich from Piper Jaffray.

Just 2 quick follow-ups. First of all, Roger, you talked a lot about your data warehouse, your kind of IT capabilities. Was there any meaningful use payments this quarter?

No.

Okay. And then just kind of, Roger, even though the quarter you said you're host hospital's births were flat. We've heard from some other companies, kind of more diagnostic-related, indicate they think the U.S. birth rate is growing the low-single digits. Do you think that's pretty good information?

That birth rates are growing in the low-single digits?

Yes.

No, we haven't seen that.

You haven't seen that. Okay.

And we have a follow-up from Brian Zimmerman with Goldman Sachs.

In looking at the quarter, you bought back about $52 million in stock. How should we be thinking about buyback going forward? Is $52 million a good benchmark? And then are you including any buyback in your EPS guidance for Q4?

So, no. So how you should look at the buybacks is basically as -- we announced last quarter, we're really looking to just buyback enough to offset the dilutive impact of our shares. Unless we see a very good opportunity out there, and hopefully not, because that would mean our stock went down a lot. And so fourth quarter, typically, we wouldn't need to buy any because what's happened is that from a weighted-average perspective, I really didn't get the full benefit of the buyback in Q3 because I started buying back in August. So we'll see the full benefit in Q4, like I said, barring anything that we feel is a good opportunity for us to go buy back shares. The idea of the program was to buyback the dilutive impact of the equity programs, which I think as we talked about before was roughly in the 2% to 2.5%. So that's really what we're looking at doing.

Okay. That's helpful. And then my follow-up is how should we be thinking about potential equity offerings. I know you've answered several questions on this, but how about these equity offerings compared to drawing on debt. Do you have a priority in that sense? Would an equity offering only be something you explore after you've drawn debt? Just any update there would help.

Yes, I mean, we always want use to cash. We -- equity, as I've said before, is a cause for failure of some physician-practice management companies in the past when they used equity as their only currency. And interest rates are pretty low right now and it's not dilutive. So there are a number of reasons why cash makes a lot more sense, so we'll continue to use our line of credit whenever possible.

[Operator Instructions]

Okay. If there are no further questions, I thank everyone for participating this morning and we'll look forward to speaking with you next quarter. Thank you.

That does conclude our call for today. Thanks for your participation and for using AT&T TeleConference. You may now disconnect.