Good morning, ladies and gentlemen. Welcome to the earnings call for the third quarter at Mater Dei. Today we have Mr. Salvador, our CEO, and Rafael Cordeiro, our CFO and Investor Relations Director. This earnings call is being recorded and will be available on our investor relations website with the company after completion. To select the translation option, please select the globe icon in the bottom part. The presentation is available on the investor relations website at the Mater Dei Network. We would like to let you know that any possible statements about future events are subject to risks and uncertainties, and they can make such expectations not be concrete or differ materially from what is expected. These are considered only on the date when they are made, and the company is not obliged to perform them.
And after this, we will begin the Q&A session. If you do have any questions, please raise your hand and we will open up your mic. If you would rather send your question by chat, please say your name and company. I will pass the floor on to José Henrique to begin the presentation.
Thank you, Operator. Good morning, everyone. Thank you for watching us today. This third quarter of 2023 was a quarter that was very special for the Mater Dei Network. We had the consolidation of many innovations we have done over time, the consolidation of other projects that we have been working on as well, and some results as well that are very important for the company when it comes to the consolidation and expansion of our operations. Initially, I would like to talk about the publication of our annual clinical reference report that gathers our main indicators for the level of care, and it also gathers a compiled result of all of the initiatives we have been working on ever since we started to be able to strengthen our clinical governance at Mater Dei Network.
Also, in an innovative way, we have launched this annual report with some indicators that are, for the first time in our industry, certified by external entities, which are Feluma, verifying all of the clinical excellence in the institution. As we expect, it really verifies the importance of these indicators and the way we collect them. So, this annual report will take place in a recurring manner. We are already performing and preparing the next annual reports so we can continue with this commitment to provide constant transparency and ongoing improvements. Also, when it comes to the level of care and performance in our care, besides this annual report we have issued, we also had an award at CONAHP this year. It is the main conference for hospitals in Brazil, and one of the mains in the health area.
Among 500 studies sent by different institutions, we received the award as the best study, performed by CONAHP, and once again, we are competing with 500 different studies in different institutions in the country. We have also received a special award. For the first time, we were positioned in the sixth position in the ranking for innovation, and it was the first time the Mater Dei Network would win this award, ahead of some other very well-known institutions in our market. This was important strengthening for our innovation initiatives and what we have been doing also to perform in a more positive way in this scenario.
Besides this, we also had the reaccreditation by JCI of two important initiatives, Santo Agostinho and Betim-Contagem, and they were recertified by JCI in addition to Contorno, which is also certified by JCI, and they are the only JCI hospitals in Minas Gerais, which make these hospitals stand out also with the quality and safety. Besides these, we also have Porto Dias as the only JCI hospital in the northern region of Brazil. From our nine units, six of these are internationally certified. We have the Santa Clara, Santa Genoveva, and we are also certifying the Salvador unit, which should take place in the end of this year.
We believe we will have seven institutions that are internationally certified, and this is really important because it is in line with the safety and security conditions and also bringing our hospital units as in line with some of the best hospitals in the world. We also launched some new services for human reproduction in Salvador. We have been working on a major effort also to make Salvador have a real complete mix of services that can service the population in its entire needs. So, we launched the human reproduction services and also hemodialysis at Porto Dias. We also worked on the opening of new outpatient centers and medical offices in a region where you have a bigger purchase power, and we can work with all of the ecosystem and all of the payers and insurances that we work with, with unique level of quality and service.
We have also opened some new units in Contorno, besides some of the different initiatives we can work with in the outpatient center as we strengthen our hemodialysis. This is also strengthening our strategy with the work to make our transplants and hemodialysis even better as we strengthen our transplants. So, these were some of the highlights when it comes to qualitative aspects, and now, we are going to talk about some of the main highlights we have when it comes to numbers. First, this was an important quarter when it comes to the growth in our gross revenue in the year, in the nine months of 2023, as well as in the growth for the quarter. When it comes to this, we can see these are some of the biggest gross revenues in our history, and so we have been talking about this also for the second time.
Every quarter, we are able to increase the level of our gross revenue and consolidate the Mater Dei Network as an important platform that is growing. We had important positive growth as well, and we were able to reach in this quarter the breakeven in the unit from an operational perspective. We know that Salvador, with the growth of the revenue that is been taking place, will affect in the short term the consolidator when it comes to profitability. On the other hand, we also bring some expectations with the unit becoming more consolidated when it comes to the growth of the revenue and also profitability. So, we have a more positive perspectives for this unit as well. We had some adjustments also in our operation in Salvador. There was a big need we had identified to have a greater knowledge from a local perspective.
We also brought in an executive that had a lot of experience in the health sector, that understands the market in Salvador very well, so that she could also help lead the unit in Salvador and manage that, grow the unit even more based on the excellent work that was done so far by the management that is in the institution. We also had another important highlight, which was the ticket growth at about 6%. Last quarter, we mentioned that some of the readjustments we had projected had been completed by the end of the quarter, and here, we already see a positive impact of these adjustments that took place. On one side, from a more negative perspective, we have the non-payments, with either due to the production that was significant. The non-payment rates also were in line.
We have also seen the situation with the payers, and the situation that the payers are experiencing. On the other hand, we have been working on some excellent efforts internally to make sure that we can be more efficient and we can improve our financial cycle. We must advance in our average payment terms, and in our internal financial cycle. However, we have been working on some initiatives that have already demonstrated some important results. When it comes to debt, we have been quite comfortable with our numbers. It is a long-term debt with low costs, and when we compare it to other entities in the supply chain, it is one of the best rates, with a positive capital structure that makes us very well-positioned to perform new investments in the future and also strengthen our cash position as time goes by.
Our debt situation and our capital structure will allow us to do this. When it comes to cash generation, we have had a positive cash operation. And once again, we have this internal efficiency work to strengthen our position at a moment we are experiencing in the health sector with pressure on our supply chain. An d although we have not had a positive trend towards the average term of receipt, b ut this is one of our main update points here. Now, I want to pass the floor on to Rafael, our CFO, so that he can talk about the numbers in this quarter with greater depth.
Thank you, José Henrique. Thank you, Operator, and good morning, everyone. It is a great pleasure to share one more of our results here in our earnings call. I am going to get back to our operational items as we go over some of the financial numbers and economic numbers in the company. In the third quarter, we did have a reduction in our occupation rate, and i t is important to mention that quarter-over-quarter, we have been reaching the same kind of seasonality, working with occupation rates that are higher. So, when we compare with the same quarter last year, we had an occupation rate that was higher. Then, we considered this, highlighting with the patients per day. When we consider other networks, we can also look at what our occupation rates are considering the patients per day with 1,590 beds.
We also notice that there is some stability in the amount of beds because we have already incorporated all of the units acquired. Now, the growth comes from an organic perspective that we may have in some units, such as Betim, Salvador, and some of the acquired units as well. As we perform investments, this provides us with the possibility to grow. We had 94 beds additionally year-over-year, and 18 more when we compare with the previous quarter. When it comes to patients per day, the company has 13.6% of patients per day above when compared to the third quarter of the previous year.
It is important to mention, as José has already mentioned, we had a positive ticket, and so, t his demonstrates that we have been able to have more revenue, which demonstrates the work with a mix of hospitals and complexity, which we have been searching for to provide better profitability in the company. Now, jumping over to slide number six. José mentioned that it is the greatest gross revenue in a quarter. We mentioned that adding 222% growth upon the gross revenue of a company is not something easy, but we have major work to make the maintenance grow with profitability and keep up with the high EBITDA margins as we have been able to achieve quarter-over-quarter. Now, we want to provide greater profitability.
Of course, we have a challenge with what is going on in each hospital, the average ticket each one has, but we have been achieving this successfully. We had 222% growth compared to the first nine months of 2020, and 123% compared to 2021, and 32%, reaching BRL 1.778 billion in the first nine months of 2023. As we mentioned, we had some adjustments internally, and some of them were parameterized during the quarter. This was an important level of growth. Compared to the previous quarter, we had 6.6%. Compared to the previous period, we had 5.6. Moving on to the net revenue, we had a growth of 32% in line with the growth we had, compared to the gross revenue, which reflects this growth, and a growth of 20% in the net revenue quarter-over-quarter, and 3%, reaching BRL 568 million.
Now we move on to slide six, where we have a challenge in our company due to the moment we are experiencing in our sector and also the mix of hospitals we have. We had a growth of 2.6 percentage points. We notice a growth of 0.7 percentage points, and I think this is a point that we have been working on a lot. The items on our list that we can see that can explain these deviations are especially considering medical fees and cost of personnel. This considers the growth of our revenue, and so you have Salvador and the other units, and this is with our result. There is this mix change as well, and also the challenges in the units we have been in. When it comes to personnel, we will see this is a line that is pressured in this quarter and the next quarters.
We've been going through strong discussions on the nursing bill, with some adjustments where initially we do have an increase in the company as well as the salary adjustments in the second quarter in the metropolitan region, with an adjustment of 4% in salary prices. When you compare with the previous quarter, it's really in line with what we've seen now in the third quarter. At the controller level, here we're just showing our consolidated numbers by the controller. Besides these two items, we also had an increase in medical materials due to the profile that Salvador has with high levels of surgeries, which is also why you have higher medical materials used. About the expenses, we also see stability in our expenses in general lines, such as SG&A. There's a reduction actually compared to last year.
Last year was 15%, today it's 12.9%, so 2 percentage points reduction due to the increase of the company size and direct dilution as well, and some work done with a lot of our medical and hospital costs being reduced. When it comes to the overall year view, it's a stability of 13.5% when we look at the operational net adjusted expenses, because the second quarter had a one-off factor, which is about 1.5 percentage points. That would, of course, bring in the second quarter to close to 13% related to a reversal that we performed from a tax perspective. That was just in the second quarter. When you compare the second quarter and the third quarter, there is a growth of 2.3 percentage points, 1.5 is due to this reversal.
Finally, we reach this amount of net operational expenses with 13.5% of the company's net revenue. Moving on to slide number eight, I'll talk about our EBITDA. We reached BRL 413 million in EBITDA, growth of BRL 107 million compared to the first nine months of 2022. The margin had a small reduction of 1 percentage point, which reflects the impact on the EBITDA, as explained before, because we've been growing and hospitals do bring in a bit of a different profile sometimes. Salvador, when compared to the first nine months in 2022 and the first nine months of 2023, it's a hospital that grew very quickly. That breakeven only happened now in the third quarter. It did hinder the consolidated margin in the company initially.
When it comes to consolidated numbers, where you have a reduction of 2 percentage points, but also at the controller level of about 4 percentage points when comparing this without Salvador. Salvador is strategic for us. It's very important, and it will be a strong cash generator for the company. We're more and more confident about our project there, and we already imagined that we would have this greenfield moment in our business plan, where you have this ramp-up process, and initially, the costs represent a lot for the unit. Quarter over quarter, we were able to reach 23.6 percentage points in margin. EBITDA margin in the company, BRL 134 million compared to BRL 147 million in the previous quarter. That's where you have an adjustment I mentioned also in expenses related to the reversal, the tax reversal, from a labor perspective.
When we compare these differences, it is about 1.4 percentage points and not 2.9, as demonstrated in the graph. This distance of 1.4 is due to those two lines I mentioned with medical fees and also costs of personnel. Due to the reasons we explained, which is kind of offset by the improvement in medical materials and OPME, this is mainly due to the strong growth, the purchase strategies for each unit. We had some important work done, and we expect this to bring in a lot of results so we can have a customized purchase for the hospital according to each ticket. We do hope this will bring important value to the company's results next year. We are still in between this work, but it is going to be very strategic.
As we acquired the units, we had this clinical team that already existed in the same units, and we need to have this work done to bring in more profitability. Moving on to the last line of the results, the net income reached a net margin of 10.1%. It is BRL 167 million of net income in the company, BRL 6 million less than the same period last year. We had a drop of 3.7 percentage points in the net margin. We have different reasons for this, and partially related to the financial results are a little higher. We are considering an interest rate that is higher. With the reduction of our interest rate, we do hope to have improvements in the next quarter. In the quarter-over-quarter, we have seen this amount compared to the previous quarter.
We were able to reach 9.4% of net margin in the company. When we move on to the right side of slide nine with our cash flow, we can see that there has been. Here it is nine months, and I am going to quickly show you the slide 10 with the quarter-over-quarter view. We can see that this amount had one of the biggest rates, and it is also a lot greater than the previous quarters. Also when it comes to the working capital, which dropped this by half of the previous quarter, but also when it comes to the CapEx control. We can move on to slide 10, and we can explain this change quarter-over-quarter. From this amount of our cash in regards to December 2022.
In the first and second quarter, we had a reduction, and this mainly comes from two lines. For the cash flow, as we were mentioning, about BRL 70 million and went to BRL 112 million. This is also related to the working capital. We had this consumption of working capital, and we have had this reduction to 32.9. This, of course, along with this operational improvement, had a reduction in the reduction of the CapEx. This is where we really performed investments in the units acquired and also some opportunities we had for the growth of some services. In the first quarter also with some requisitions. When we reduce this guidance from 58 to 46 and an improvement, we have BRL 25 million compared to the first quarter and BRL 13 million about the second quarter.
This is super important as well as it provides us with the stability at the moment where we go through a more restrictive scenario. These are mostly concentrated in the first quarter, which is where we pay the payments, and we have this installment that we have to perform every quarter for the next four years. We finish up with BRL 374 million in cash, and this is going to continue to be the focus. We were not able to improve this with a reduction of the dates for receipt, terms for receipt, but we have already improved this in many different initiatives. We had this general meeting in October where we had about 100 leaders of the Mater Dei Network gathered, and one of our main focus in 2024 is what we called zero mistakes.
We could have this supply chain that is clear and cleaner, and so that we could also have better internal work with the operators and also in the different areas that the supply chain is going through so that we can have less friction and less discussions with the payers and just discuss what is necessary with the payer at these moments for difficulty. We also see growth in the ticket with the payers. There is an important adjustment. When it comes to the claims rates, we consider this has been left behind, and so there should be an important moment with the discussion, which is also with the payers.
When we move on to slide 11, I am going to talk about our debt levels, and José Henrique has already highlighted that we had 1.7 of net debt to EBITDA, which is one of the best rates in the last few quarters. We had a reduction, which is due to the stability of our debt, plus the increase in our EBITDA as well. This debt is considered long-term and has a low cost. Most of the debt is above five years. This average term gives us the possibility to have without the short-term pressure that some companies experience at this moment, with some crises and difficulties to issue these debts. Our debt is basically 100% connected to CDI, 95%. When we consolidate this, we can transform this into CDI as well.
We have a debt that is lower, that is quite positive and healthy for the company in the next few years, and we expect that we will continue to have this cash generation with better stability and reduction of this indicator. Of course, the company will be able to perform new investments. We will move on to questions and answers.
If you have any questions, just raise your hand and we will call your name with a time for Q&A. Thank you all so much for your presence and time. We will be available for Q&A. Our first question is from Gustavo Miele from Goldman Sachs.
Good morning, José Henrique, Fábio, Roberta. I have two questions here. First one is maybe a little more strategic and more related to our supply and demand offering in Salvador, which is a market where we have strong management payers with tighter price charts. We also see you guys are increasing your complexity as well with a very relevant asset. My question is, have you had any kind of dialogue with the payers in Salvador to redesign their products or even work with creating new products that could accommodate these hospital services that are a little more complex that you're deploying in that region? Along with this, we also had a very competitive, with mentioning the loss of the accreditation by Unimed Nacional and one of the assets there.
I wanted to know if you guys have noticed any kind of change in the approach by this payer with you ever since this event. The other question's a little more specific on your earnings. If you could maybe try to break down the ticket performance in this quarter and this growth of almost 6% quarter-over-quarter. Could you give us a little more magnitude on how much of this is complexity and how much of this is actually a price adjustment? How the distribution of these adjustments in your revenue has been behaving throughout the years since your assets are ramping up. That would be great. Thank you very much.
Well, good morning, Gustavo, and once again, pleasure to be with you guys. I think you guys had been recently visiting Salvador as well to visit one of our units. Thanks for that. I'll get part of your question, the first part, so we can talk about the competitive market in Salvador, then I'll pass the second question to Rafael. Salvador is a market that has a really significant amount of lives, and actually that's one of the reasons why we chose to start our operation there. Because we knew that the hospital would have the opportunity to work with different lives in that market that were underserved. We quickly covered these numbers before, but we were able to have a volume of accreditation that's very significant.
We have over 400,000 lives insured that are covered by our hospital, split between different important insurance companies and market operators, as mentioned. About these products, as we try to support our payers in this sense, we've been doing this, and in Salvador, to give you an idea, 95% of the hospital was certified by these operators in these new compensation models that are models that kind of are distant from the traditional fee-for-service models. But we're very close to the self-management systems and the market payers and, with them, we've already been able to bring some products that are considered revolutionary to the market. One of them is Cassi Vida, which started off here in Minas as a partnership with Cassi.
We took this product to Salvador, and we're noticing some ramp-ups that have been very relevant for this product in the market when it comes to a growth in lives and also the relevant utilization in the hospital, which has been one of the products that has really helped us ramp up the hospital. Cassi Vida is a product that is very similar to the products that were launched from other payers and with restrictive networks. So they select a few suppliers which are going to work with this level of lives with a possibility of growth that's very significant. When it comes to Unimed Nacional, that was the second part of your question, we have been keeping up with a really good relationship with Unimed Nacional.
We've noticed some different measures in the overall market with losses of accreditation. Unimed also directed a significant amount of the services to our hospital. With them, we've had a pretty healthy relationship, and we've been able to have some conversation to be able to work with these lives in the market as well. It's a very significant amount of lives and a volume that's also quite interesting of companies that can hire this plan to be able to manage their lives. This has been very relevant. Unimed Nacional and other operators, and also some important tension with the self-manager.
Miele, good morning. About the tickets, there are two effects really, and there's an effect with the growth in Salvador.
Salvador has been growing month after month, and there is a ticket, as we know, that is this strong correlation with Hospital Mater Dei. We consider that there should be a higher ticket than Hospital Mater Dei because of the level of complexity. The other hospitals were already at the comparative basis and their growth levels that are a little more normalized. In this quarter, we also had announced many different initiatives or possibilities with payers where our units had the payments outdated, right? We needed to adjust these to have better profitability in these units in the next quarters. The first effect we're noticing is an improvement in this profile with these price charts with adjustments performed. We do hope that with this, we can help improve the profitability of these units in the next quarter.
It's a mix of complexity with different hospital mixes. We also had a significant adjustment because it's appeared in the third quarter with important readjustments. Some of them were a bit late, but they did contribute to this number, with a significant amount of 6% growth annually when it comes to this, annually and quarterly.
Very clear, José Henrique. Thank you so much. Have a great day.
Our next question is from Vinicius Figueiredo in Itaú BBA.
Good morning, everyone. Thanks for taking my question. I did want to talk about volumes a bit. You mentioned a very strong growth of patients per day, year-over-year, and I imagine this is mainly because of the ramp-up and the operations that are still under integration. If you could just talk about this in a more qualitative perspective and how this growth has been, if we notice that there's a metric here of the same hospitals, in more mature hospitals, I guess it would help a bit. I want to understand, in my second question here, about the CapEx dynamics for the future. You had some consecutive reductions in this line when we look at the last few quarters, despite the fact that you continue to make the hospital beds operational during the entire period.
If we could maybe just help us think about 2024. Do you think it makes sense to consider the CapEx will be kept at this level we've seen in this quarter? Thank you very much.
Hi, Vinicius. Good morning. Thank you for the question. About the growth of our units, we have had significant growth in our acquired units. We have significant growth considering the ramp-up in Salvador as well, which also helps a lot with this, compared to the other quarters and years. We've also had relevant growth in our matrix of the three units, Santo Agostinho, Contorno, and Betim-Contagem. With this, we've also had significant volumes of surgeries and surgical patients in these units. All of these units have growth of the surgical notices, which is very relevant, and that's super important for these units. We've also been able to have growth in our outpatient center services, such as diagnostic medicine. In the last quarter, we actually talked about new investments with some new MRI services, as well as other services related to new diagnostic medicine services we've been providing.
What we can say is that this significant growth in this quarter and this all-time high in our revenue, it comes from the growth of the units acquired, but also the strong growth in the consolidator at the headquarter level.
Well, good morning. How's it going? About this issue, I think it's really important to understand, we have these nine hospitals, and each of these are at their own life cycle. Salvador has very important growth. When we open up these beds, we don't want to have a low occupation rate, right? We want to have the best rates, so we can have the level of services, so we don't have too high occupation rates and get in the way, maybe, of the level of care and the perception of quality. When you look at Salvador, we can see significant growth in Betim as well, year-over-year. If you take a look at Santa Genoveva, we also had significant growth of patients per day from the end of last year and this year.
We're finishing some investments as well at Santa Genoveva with the opening of new beds. José has been there, and he was there in October, and we're almost opening these, so we'll have more beds soon. These are some important units. Premium is also a unit that has been growing a lot. Now with the Bradesco accreditation, we'll already be able to have a growth in the amount of patients per day. These are all initiatives that are a mix, right? The growth of units that are in greenfield ramp-ups, other units that are finding their path towards growth, like Betim. Premium, which is a unit that should grow, because it came in more with a clinical perspective, and now we're transforming into a general hospital with greater accreditation, better medical staff, and growing in all of the pairs we work with there.
Santa Genoveva, once again, is another example of beds opened that we're going to be working on in the next few months in that unit. It's really an initiative where the CapEx we achieved in the first, second, and third quarters are very important. When it comes to CapEx variations for the future, as a part of our forecast, I think the only one that would have an increase would be Nova Lima, where we are currently at a pacing of about BRL 5 million per month, but we should accelerate the last month this year, but especially next year, to complete this investment. Or either, well, another investment you will see in the fourth quarter also is a strategy for growth in Feira de Santana in Bahia.
We also had some important investments with the acquisition of some different areas, because the hospital there has limitations towards growth. We operate with high occupation rates at the moment in a city where we notice we have a big opportunity. We have medical staff that are really in line with our objectives, and this investment in the area structure, then more towards the end of 2024, 2025, after we perform the new master plan for the hospital, we will have some investments at the unit. But these are the main points or possible increases in investments currently with the company's current perspective or vision.
Just to add on to this, on this point about CapEx, our vision for the units is always really feet on the ground, and it is part of our DNA to invest CapEx, or performing investments that can bring more value or profitability to the company in the short and midterm. None of these slower pacings when it comes to the investments made will harm or hinder our units in any way. The headquarters when it comes to the level of revenue that these hospitals must have. What we have noticed, however, are opportunities to position our hospitals in a better way, whether they are acquired in each of the regions. They are also strengthening the metropolitan regions.
We will, as we notice this more robust cash position or a level of debt that is a little more adequate, we will also start releasing a more robust level of investments to accelerate some of our growth plans. Vinicius, since you had two questions and they are pretty broad, I just want to make sure that was clear and covered everything.
No, I think your answer was super complete. Thank you so much, Rafael and José Henrique. Have a great day.
Thank you.
Our next question is from Yan Cesquim from BTG. Yan Cesquim.
Hey, good morning, José Henrique and Rafael. Two questions here. The first one is about the cost line, and we wanted to know if you could give us more details about the increases in medical fees. Also, we want to understand what the behavior was for this line and if it was impacted maybe by some of the transfers in the nursing salaries, and if we should expect this kind of level we have seen, in the third quarter as something recurring. The second point is about oncology. If you could give us some more details and if it was growing in line beyond the consolidated amount, about this volume or ticket in this vertical. Thank you so much.
Hey there, Yan. Good morning. Pleasure to speak with you again. Yan, about the cost line, starting off with the average transfer. As our revenue grows and as it grows disproportionately in some units, as we mentioned earlier, it is natural that we will have some growth in the average medical payments for some of these units. We have been also working on in-depth initiatives together with the medical board and the VP as well to see for each of our units, and the units we acquired, we had some different levels also of payments that differ from the ones we have at the headquarters.
We have been working unit by unit to understand which is the level of payments we must have in this unit to be able to make a more efficient operation with some issues related to these transfers, especially the fixed payments as well that we may have in some units. This is also some work that we must be doing when it comes to efficiency, when it comes to improving this over time, and this item will also get better in our different units. This does not have any kind of correlation with the base salary for nursing and some other structures for service and care. When it comes to the nursing bill that is being discussed in Parliament, we have had different negotiations with local unions.
We have been able to advance a lot with some of them with the same strategy we discussed in the previous quarter. We have been working on some relevant adjustments in our operation to reduce our impacts. We have been working on trying to split the impact between these different apartments to be able to perform the negotiations required. This impact will not have any kind of correlation to the issue with the medical payments. Your last question was about oncology, if I am not mistaken. Our oncology service in these regions is really a robust service. We have seen positive growth, and we are not only looking at the levels that we have, but also how the oncology patients can really bring important achievements in the entire oncology front.
We have also been advancing a lot in our acquired units to be able to make this service more relevant. The oncology services have been important catalysts for the Salvador unit, and we have also been mentioning this from a more positive perspective as well.
About the medical fee aspect, we want to mention that the objective is to try to control this, right? One of our initiatives actually that we have not been able to implement yet completely is the issue with paying the medical fees along with the receipt. It is a lot of changes in our units when we come in, change older rules, eliminate some privilege that some clinical teams had in the hospitals. With this movement, with higher non-payment rates, we have a medical fee that is a little higher than what we should be transferring at this moment because of the retention with these non-payment rates.
But in some cases, we do perform some exceptions, and we consider a higher pacing for the entrance of some of these criteria so that we do not impact our production and this movement as we reach a unit. We have different initiatives being done simultaneously as well. For some of these, we actually give up a bit of our, from a temporary perspective, it is not long term, of course, but it is more one-off in this quarter. We do hope to improve this. But another point that is really important also is that Betim represents significant growth at the controller level, and you can see this number going up, and we grew the revenue overall. It is also a hospital where some payers transitioned with their full fees, not only with images as we had done in Belo Horizonte, which also pressures numbers a bit.
Salvador is growing a bit as well, and there are many different aspects impacted. We know this is an important line. We have highlighted it because we know there is a lot of work to be done, and it is more of a short term impact, really, than thinking this is going to be perpetuated throughout our cash flow.
Okay, perfect, José Henrique. Thank you so much.
Our next question is from Gustavo Tiseo from Bank of America.
Hey, good morning, everyone. Thanks for the opportunity. Two points here on our side. The first one is a follow-up from this last one you mentioned. When you talk about the acquired companies that have improvements in the forefront, is this because something is going to change in a percentage perspective or a strategy towards what you pay to physicians after you get paid? Or do you have a Mater Dei, your core business, and you are just going to change the rules, maybe from a percentage perspective for the EBITDA? Is there an actual synergy in the long term that you can conquer? And where would the synergy come from? Is it like a smaller payment to physicians?
The second point is about receivables. Do you see some kind of improvement in this sense? I want to get a feel on the timing and how the situation has been. Have you reached your limit for worsening and you are going to get better up ahead? Or are you really stressing a lot in these operator segments, and do you have a slight batch of receivables still coming along in the next quarters? Thanks, guys.
Well, hi, Gustavo . Great to speak with you. Thanks for the question. Just about these points here with costs in line with Yan's question, we do not intend to change our medical transfer model on the units we have acquired. This is not what we believe in as an improvement for our margins with the costs that are structural for the payers, and we think that this effort is not worth it. We do believe, however, that this improvement will be coming a lot more through the growth of the units and their production, and we can pay the same things physicians are used to receiving per production levels. There are some services that do not pay themselves off, but then we would not have the level of services at the unit well covered for us. That is why our strategy comes through a change in this conception.
José Henrique mentioned this. I am going to pay for a fixed fee until production does not reach the necessary volume, so they can make what they were making before or close to what they were making. We need to help physicians have higher productions, but also the hospitals having better results. The growth in this unit would make us dilute some costs from the actual unit and also dilute medical costs that we would pay per productivity. These are not the formulas we work with in the regions we are in. Well, Gustavo , just one point here about our philosophy. Ever since we started off with the Mater Dei Network, we have physicians being compensated directly by the payers.
Actually, they are incentivized to do their work well and make patients like their model of services and care and come back to be serviced by the institution and have greater loyalty in this unit. We have been encouraging this as well to all of our units so that physicians can really be entrepreneurs along with us in their different teams and can have motivation to grow in the level of services. As time goes by, what we are doing is making the medical compensation be more connected to their production levels and reducing their reliance on complementary values or fixed amounts alongside the compensation model. When you consider in the year of 2023, the numbers demonstrate this, of course. You can see a drop and an extension in the payment terms.
We reached 119 days, and there is a peak in health segment services, which are really high. Some initiatives we have in the company take a while to get back. This batch is really considering a lot of days back, in line with what happened in the cycle. We are probably talking about things in 2022. What we believe in is at the beginning of the cycle and what we have been doing now, we are a lot more mature with this better perception and different agreements done with the payers. We can improve the cycle. That does not mean that in the short term, the effects of these numbers will demonstrate this. In these 6 additional days in this quarter, we were able to notice a reduction in the pacing internally in the numbers we are looking at.
Of course, this takes a while, until you can get this work done. In between, we also noticed some changes operationally, so that we can establish better upflows with the payers, and so we can have less discussions about what actually makes these terms grow. These discussions are coming and going, and sometimes some part of this is extending the cycle as a whole. We are keeping an eye open, and we have this perception of improvement. In the short term, we were pressured in the last two quarters. Next year, we do hope to have more stability and improvements because then we would consider the cycle what we are doing today in the company.
Okay, great. Perfect, guys. Thank you. Very clear. Have a great day. Bye.
Thanks.
Our last question is from Estela Strano from JPMorgan. Estela? Estela? You may proceed with your question. Please open your mic, Estela. Estela, it seems your mic is open. Can you try speaking? Maybe she had some technical issue. Well, while we try and wait and see if Estela can make her question, if anyone else has any final remarks or questions, we can take the last question. Oh, we have Caio from Santander. Caio, please.
Hey, guys. Good morning. Can you hear me all right?
Yes, we can. Great.
We had noticed the opening of new operational beds over time, which is super positive, but I wanted to understand a bit of what we should expect of new beds operationally opened for 2024. I also want to ask you about the hemodialysis services we've seen, with some expansion in certain hospitals in the beginning of the operation, and I want to understand what the level is, and if you could also continue this expansion of the services to other hospital units as well. Thank you very much.
Well, thanks for that question. The first point is really focused on expansion, I think, with the beds and revenue. What we've been doing, Caio, is we've been working towards, as Dr. Henrique likes mentioning, we want to consider we need to balance this out, right? It wouldn't make sense to open up beds if we don't need to. We want to have more efficiency in the amount of beds. We've already done this actually with greater strength at the end of this quarter, and we should be able to have a correction or adjustment in some of the occupational indexes, so we can generate the growing revenues and the same level of resources with the same levels we have here. With this, we have extensive work. We have some work focused on high complexity as well with some specific projects.
With these different levels, so we can identify some types of cancer, for example, and other types of needs with some of our patients, making us operate beforehand to avoid diseases from getting worse and also as an opportunity to help our patients have greater loyalty and adhesion to our institutions. Once again, we're moving ahead with accelerating the ramp-up of our units. We have the opportunity to start up new beds in Contorno, Betim, Contagem, Salvador, no doubt. The opening up of new beds in these units that were acquired as a real example, at Santa Genoveva, for example, it's a hospital that's working very close to 100% occupation, and we're starting up new beds at this unit as well. We're going to continue with this significant effort for the new hospital beds.
For hemodialysis, I think, well, before I move on to hemodialysis, I think it's important to highlight Uberlândia, because we also have, strategically, some work being done to separate some medical services between these two hospitals. Santa Clara and Santa Genoveva are two general hospitals in Uberlândia. They are the oldest and with the best conceptions, and both of them were considering different clinical teams, and they were occupying the same specialties, with each one had a part of the services. Now we have this local strategy where we would like to distribute these services a bit so we can be more efficient, and this actually helps with medical fees. It's really important to highlight that we always keep an eye open, and so we have these strategies to improve these numbers indirectly with the production and better distribution in the services.
To summarize this, we are not searching for uncontrolled bed openings, but we do want to expand and grow. The increase in the number of beds actually reflects a bigger amount of patients. We also consider that there are other vectors for growth in the unit that are very important, such as outpatient services and also the strategy for hemodialysis. For example, when we perform analysis considering the patients that have dialysis needs, we are going to see that this is a number that is going to grow a lot over the next few years with the aging of the population, but also increase of some chronic diseases and other internal needs as well, supporting our patients more and more with intensive care, with new technologies that are incorporated by the institution.
The hemodialysis services, as I mentioned, are also strategic to us because they bring us closer to our main project related to our transplants unit, which has also advanced a lot, and it brings in more complexity, of course, to our units. It is a winner when we can prove to our peers that we can improve the lives of our users a lot when they are undergoing transplants. We can reduce the cost of our supply chain in the mid to long term. Now we have been operating to be able to service this entire supply chain from the patients in hemodialysis, chronic patients, et cetera, and also contribute to these new services that we have been opening at the institution.
Perfect, guys. Thank you so much. Very clear.
Okay, thanks, Caio. Estela decided she was able to figure out her microphone issue. Estela, now can you submit your question, please? Estela? Estela, hi. Okay, now we can.
Great. Sorry, guys, I had some technical issues here with my mic. Getting back here, thanks for taking my question. Actually, it is a little bit about the strategy in the company, and considering the scenario in the industry, it is a little less pressured. Interest rates have this smaller trend. Do you see this scenario as maybe a little more favorable to M&A, and maybe if the company would maybe consider M&As out of this core area, moving on to orthopedic clinics or other services, or even think about things that are out of the box, such as other health operators or insurance companies. How has the company been looking at these opportunities for M&As? Thank you.
Hey, Estela. Good morning. I am happy we are able to take your question. First of all, about the strategy for M&As. In the short and midterm, we continue to be very focused on unleashing value in our units more and more, especially the units that we acquired, and also in Salvador. There is still some homework that we need to do. As we mentioned previously, we have already worked on the hard part for the integration. We have all the systems integrated. We can already have some pretty strong control over numbers. We have teams that are more stable as well, and these can understand the operation model as well at Mater Dei, and we can talk about this at a better moment.
The routines are all implemented, and this gives us a lot of comfort as we can see that these different buttons we have tried pushing will achieve the necessary and expected results for each of these units. We are really focused on this. But obviously, we always keep an eye open to any M&A opportunities. When we talk about M&A opportunities out of our core businesses, some of the items you mentioned we consider. But as general hospitals and a full health solution, many of these possibilities are already part of the organic revenue at the Mater Dei Network. If we understand that inorganically it will be interesting or more strategic to have growth, then if we do this organically at our units, then we are going to be ready to pursue this strategy.
We continue to keep our eyes open to M&A opportunities, whether we are talking about these M&As or transformation M&As in the company.
When it comes to verticalization, which was the point you mentioned at the end, we have no plans for verticalization at this point in time. We have no intention to perform an acquisition of a payer. But we understand that we can strengthen our relationships with the main payers and partners, and we are ready to have these innovative products and establish partnerships in a win-win scenario for these payers and the Mater Dei Network as well. Meanwhile, we need to be prepared for the future, but that does not mean. Well, actually, our focus is really internal and focused on cash generation and improvement of the working capital, as well as PME. This gets in the way a lot, so we are keeping an eye open on controlling CapEx.
These are aspects that are super important for the company and so that we can win in this scenario with so many challenges in the sector and industry. But we are sure we will be stronger, and we believe we will come out as champions. And this is in a short-term situation, but this does not in any way change our perspectives in the long run for our sector.
Okay. Thank you, guys. Have a great day.
Thank you.
We are going to end our call, and we want to thank you all for your presence as you were with us during this entire call, participating here. Our investor relations team is also available for any additional questions you may have. We are excited with the sector we are in, experiencing the moment we are in, but we are also very optimistic about the results we were able to achieve in the last quarter. And we are certain that more and more we will be working towards integrating the units, strengthening these units, and really making all of our hospitals be effectively well-positioned as Mater Dei, supporting the health needs of our population in each region. Thank you so much, everyone.
Okay, thank you. Have a great day.