Good morning, ladies and gentlemen, and welcome to the presentation of our earnings call at Mater Dei, the second quarter. We have Dr. Salvador and Rafael Cordeiro, our CFO as well for investor relations. This earnings call is being recorded and will be available on our investor relations website after closure. To activate the simultaneous translation option, please select the globe icon on the bottom. The presentation. Any possible statements about future statements are subject to risks and uncertainties. These forecasts are just based on the conditions when they were made. After the presentation, we will begin the Q&A session. If you would like to submit any questions, please raise your hand and we will open up your audio. If you rather, you can also send your question through chat. Please give us your name.
Now I will pass the floor on to Dr. José Henrique, so we can start the presentation.
Thank you, Alvida. Good morning, everyone. It is a pleasure to be with you guys. It is the first time we are participating in the earnings call here representing the management at Mater Dei.
Dr. Henrique is welcoming our board members, especially the independent board members, and some visits we are organizing at our units here in the metropolitan region of Belo Horizonte. We are having a round of visits so that each of the board members can get to know in depth our hospitals and what is going on at the moment.
So we are here to talk about the second quarter of this year and the results and some advances in the second quarter in the year of 2023.
Although we do not manage the company per quarter, we do have a vision in the long term. We can see the results that give us clarity to understand if we are on the right path or not, and if the fundamentals that we consider for our business are also in the right direction. Which are the adjustments we need to perform in the short term so that we can reach this guidance. When we look at this specific quarter, it is a quarter that is really exciting for the company. We had growth that was very significant with an all-time high in revenue, 28% growth when it comes to net revenue compared to the second quarter of the year of 2022. When we analyze this semester over semester, we had significant semesters also for the company with growth of 39% when it comes to revenue.
When we try to understand what happened to be able to look at the figures that made us have this increase in revenue, we reach finally an increase in volumes through a bigger amount of procedures that we were able to implement in our hospitals. We opened up another 18% of beds in our institutions. We had growth of about 26.4% in the amount of patients per day, which demonstrates that we have the capacity to open up more beds. Our hospitals are becoming more relevant when it comes to their different cities and regions where they are in. At the same time, we have been able to operationally be more productive as well with a better turnover in our beds when we consider 26% growth of patients per day comparing to the 18% of the additional beds.
When we analyze the profitability rates, especially operational profitability and EBITDA, we had a growth semester over semester without adjustments of 48% in the total absolute EBITDA numbers, which is very significant when we look at the advances in our management. In this quarter, we also had an important milestone for the company, which was a year where we celebrated a one-year anniversary ever since the Mater Dei Salvador was open, with numbers that are also very important when it comes to the growth of the hospital. In other analysis that we shared with you guys, we demonstrated a bit of investments to consolidate our movements with these relevant operators and changes in the compensation models as well. When we look at this strategy for the greenfield in Salvador, it seems to be very precise.
If we compare some relevant numbers from July comparing with January, we can see that we have an increase of 57% in the amount of outpatient services, 79% increase in the emergency and urgency services, 71% the amount of exams, 74% in the amount of outpatient center exams, almost 54% increase in the surgery notices, which make us have the need to open up more beds in this period. We already go from over 120 beds distributed into ICUs, hospitalization units, and we have high occupation rates at this moment. More and more, this hospital has reached a potential to transform what Mater Dei is for that hub, and of course, impact positively our results globally. Taking advantage of another point in this period, we've invested a lot on the profitability of our operations and identifying some opportunities to the expansion of new services.
This is in our release, and we also disclosed our. We opened up our first private unit for burn treatments. I've also performed some occasional investments in each of these units to be able to take advantage of some gaps that exist in certain medical and hospital services so we can grow the relevance of these units. We also must say something that took place in this quarter, which was the launch of our folder with clinical excellence indicators that demonstrate our performance. That's very unique, with clear indicators for performance which are above average of what we see in Brazil and within the best international practices in a clear commitment to really proceed with the best levels of care, but also have a clear commitment from the Mater Dei network with the transparency of these indicators. We have news coming around.
In our third quarter, we're going to advance even more to be able to disclose with greater clarity the performance and place us as a reference in care when it comes to clinical performance, contributing to a practice in our sector. We must also say that we have the sustainability report. This report talks about. We also highlight our strategies with a very rich document that demonstrates a bit of the ins and outs in the Mater Dei network towards our partners, and a clear commitment to provide more transparency on the priority investments in the Mater Dei network. These were the main points here. Now I'll pass the floor to Rafael to get into more details on the numbers when it comes to our financial performance. We'll be available for all of the questions that may come afterwards.
Good morning, everyone.
It's a pleasure to highlight another bit of our results at Mater Dei. We're going through a moment where we have a real turnaround, and we hope that we'll be able to have better numbers in the second semester due to so many different initiatives that were mentioned by José Henrique, and we're really excited with the perspectives for the future. We know that we have a capacity to always operate better and have an additional delta, and we've been really sharing this culture. These integrations have been going on in a very positive way. We hope that we'll be able to do this within these points.
It's also important to mention that some adjustments and commercial negotiations with the units will be important for our results in the second quarter. Sorry, in the second semester, and these negotiations have already been implemented, but they're still not reflected in our financial statements. On page five, we have the best quarter when it comes to occupation rates with 72.8% occupation rates, and it's going to be the last quarter with a significant amount of beds. Now, the amount of growth will be more focused on the organic growth of the actual units. They have had more services, and we do hope that quarter over quarter, we can share this with you. We had 241 beds. We reached 1,572 beds. This is a growth of 18% compared to 26.4%.
As mentioned by José Henrique, this is an important index that demonstrates better turnover and use of this by our patients without mentioning the opening of these other beds, which can bring good prospects for the units. Moving on to slide six, we have begun with our financial numbers, and we have a growth of 39% of the semester of 2023 compared to 2022. We reached BRL 1.078 billion of net revenue. It's the biggest semester in the history, as well as the quarter where we had BRL 554 million in net revenue, a growth of 6% compared to the first quarter of 2023, and 28% growth compared to the second quarter of 2022. Significant growth, 18%, and of the revenue, 28%.
When we look at the average ticket, we can see that this point should be detailed a little more because sometimes we are kind of stuck to the numbers, and they're kind of cold. They're just on the screen, which is like the growth of 1% of the semester of 2022 compared to 2023, 1.4 % compared to an inflation of 3.5% in this period. But it's important to highlight that we had the incorporation of 241 beds in the second quarter of 2022- 2023, and we know that the beds we incorporated and the units that we acquired have a smaller ticket. From the administrative perspective, it's always a concern to search for improvements in this average ticket. But in the mature operations, we've been growing our average ticket above inflation in this quarter.
This is mainly due to adjustments that we have been searching for according to the inflation, but also the new compensation models that we have been able to manage very well with success in the growth with our fee for service. In our IPO, we had quite shy numbers, and today we see this trend in the market, and we really turned the key in some units with a lot of success. With this drop from the different quarters, we see that this is mainly due to the consolidation we mentioned, but there is already some adjustments in the units that we acquired, as I mentioned, for all of them, with negotiations with different operators and the main units where we expect that in the units acquired in a more normalized flow, such as in our operation originally, we will be able to have the dates preserved.
There was also consolidation and some adjustments which made this delay take place. There is a healthy ticket, and there is also growth for the second semester in the units we acquired to be able to have growth quarter-over-quarter. Moving on to page eight, we have costs and expenses, and in the costs, we had a growth of 2.5 percentage points compared to the first semester of 2023. This difference of 2.5 percentage points, 2% is mainly due to the change we had in our compensation model for physicians. In the new units, they already had a model where they operated with the medical fees and the revenue and costs. It is important to mention that we transfer 100% of our medical fees to our physicians. This is a zero margin effect in our results, which reduces our margin a bit, not in absolute numbers, but in percentage numbers.
From this growth, most of this is due to this variation. We have certain variations in the other lines, but this is mainly due to seasonality and, but all in line with what was expected. We do have perspectives that we are already looking at now with. We are just missing some of the cloud so we can have a full integration, which helps us have better purchases and monitor the entire supplies process. Moving on to expenses. We have been monitoring a semester drop of 14.7% to 12.5%. When you look at the first semester and the second, and also in the quarterly basis, we have a drop of 13.9% to 11.2%. These operational expenses are an influence of the reversal that we mentioned in the provision of about BRL 7 million, which represents 1.2% of our net revenue.
Even if we go back to this reversal, we would have a reduction in the operational net expenses as well as in the general administrative expenses. The best number in the last five quarters, and this demonstrates that we have been reducing this operational expense quarter-over-quarter, which is a fruit of unexpected by our increase with the integration of the new units. Moving on to page nine, we are going to talk about the EBITDA and margin. This reflex we just mentioned, we had a quarter-over-quarter growth of 25.2% with BRL 132 million in EBITDA to BRL 147 million in the second quarter, a growth of 1.3%. As I mentioned, even if we did not have this adjustment, we always have these provisions, and there is some of positive and negatives, and we are highlighting one specific point.
We always have this effect that is very live within our accounting processes in the company. That is where we reach 26.5% of EBITDA margin, which is the best number we have had ever since the third quarter of 2022. From a semester perspective, we have 25.8% compared to 26.7% in the first semester of 2022, where in the first semester of 2022, we had an adjustment for M&As and also stock option adjustments. So in a clean scenario in the semester, in reality, we had the best adjusted margin. So slide 10 now, and we are talking about net income and our operational cash flow. Just a moment. We had in the second semester of 2023, BRL 78 million of net income without adjustments, and the BRL 36 million that we adjust, it is the only adjustment really in our results.
It comes from the goodwill for Porto Dias, and we adjust this because it is a cash flow issue, and it keeps the controller from having to pay income tax. So that is why we adjust this to reflect this reality, which is how the company generates results. This made us reach 10.5% in the semester when it comes to net income and 11.4% in the quarter. We had a growth of BRL 12 million in the net income without the adjustment. So this is a growth that is quite interesting for the company, making us reach BRL 63 million with the adjustment and BRL 114 million in the semester, as I mentioned. The margin comes from a recovery. We had the worst result in the fourth quarter of 2022, when we had all of the units integrated already and the units we still had not operated in.
We see that quarter-over-quarter, we have been increasing this, searching for an increase in profitability. So with the trend in the drop of interest rates, we do hope to improve our financial results as well, which helps in the net income of the company. Moving on to the cash flow. I think here we have, before we move on to the numbers, there is an important point here we need to highlight, which is the working capital. So we had, once again, a working capital consumption, and this has been making us have some internal operations where we identify different opportunities that we can have a better reality in the second semester. The company is not satisfied with this working capital consumption, but we have identified these points, and we hope that this does not occur in the second semester.
This comes from many different initiatives that are already mapped out, and we hope we can improve cash generation in the second semester. When we look at the numbers, we had an operational cash flow that already discounted this consumption of BRL 140 million. We had BRL 97 million of interest and taxes. Most of them, BRL 78 million, come from interest. The taxes are low because we take advantage of the goodwill at the controller level. When it comes to investments of the BRL 142 million, BRL 38 million in the quarter were related to acquisitions. From the BRL 104 million, we have BRL 23 million that went to Salvador at the end of the construction project. We had 5% kept from our suppliers and construction workers with this project and the developers.
We performed this as we have the full completion of the services and guarantees, so that's why the construction work is already finished. But we still have some investments. We have investments also in Nova Lima, where we have a unit that we're expected to start by the end of next year. We had investments of BRL 42 million, and we had BRL 38 million CapEx. So we can increase our revenue and have greater security in the company, investments in IT and equipment. We've already now opened up some units where we have high occupation rates. For some of them, we've already reached 100% or close to 100% occupation, which demonstrates a huge opportunity to have these investments really converted in profitability. We ended the quarter with BRL 317 million compared to BRL 378 million in the end of last year. Moving on to slide 11.
I just want to highlight that we received the last installment of our loan with BNB. We received BRL 67 million at the end of the quarter, the end of June, and in the last amount, in the beginning of July, of BRL 4 million. We performed a swap in the month of July, which made us transform our IPCA debt + 1% to CDI minus 405. This made our swap, along with our other debts, would have the company below the cost of financial investments. So this demonstrates a cost and debt structure that's very robust. So there's low costs, a real extended debt with over five years average term, 51% above five years, BRL 648 million are above five years.
These numbers, when you bring them into our covenant with our debentures, we can see there's 1.8 net debt to EBITDA with a total of 1,257 and 317 cash, as I mentioned, in our cash flow. So I finish my presentation here, and I'll pass on to Q&A now. Me and José Henrique are available to clarify any doubts or questions you may have.
Thank you very much. Good morning. The first question is from Ricardo Boiati at Banco Safra.
Hi, good morning, José Henrique and Rafael and Alvida. Thank you for taking my question. To actually here on my side, we have the costs, when it comes to medical fees. That's very clear, very well explained. But my question is about other lines like MatMed and service provision as well as maintenance and preservation.
We had a bit of pressure quarter-over-quarter in the second quarter compared to the first quarter. I think an important part of this could be related to the ticket. So you have a bit of margin pressures in these lines. So if you could maybe just give us some more details on this and understand if there's something here that we need to keep our eyes open for in these lines, in these cost lines, or if there's room maybe for a dilution in these lines, from the next quarters onwards, especially when we have the adjustments that Rafa mentioned. The second question is, can you give me an update about efficiency gains and operational synergies with the integration process of all the acquired companies?
If there's something to capture still and which are the gains obtained in this process, I think that would be very interesting. Thank you, guys.
Thank you, Ricardo Boiati. I'll start off here, and then José Henrique can also contribute. As the operations director, he's really responsible for all of the integration. But I think you were very fortunate in your question, and you basically answered your own question because, I think that as a challenge here, that we have medical fees and material with the exclusion of OPME, which we don't have a breakdown to share with you. This comes through more intense work from our side. Because it's more objective, and through the protocols, we can have a quicker unification and gains. The OPME involves a bit more of the medical relationship. For our new units, there's a cultural adjustment that needs to take place.
When you ask about opportunities to improve, yes, we do hope that this number can drop over the next quarters. It's a little more delicate because of this issue that I mentioned in our culture in Belo Horizonte. We already have a relationship for over 40 years with the physician, so it's something that has already been constructed, but in the new units, we need to demonstrate the results and work with a triple list of options so that we can have the maintenance of profitability. That also with the payers, we can have good margins. That's one point. But the other point is that the readjustments in these new units will help because the readjustments and costs are what they are and the best we can do when it comes to purchases to add this to stock.
What's coming up there really reflects on the EBITDA margin, and we know that the margins in the units acquired are a little less than what we could have at this moment. But we already have some initiatives that I'm going to ask José Henrique to share with you to demonstrate that we have the opportunities to improve.
Hi, Ricardo. Good morning. Thanks for the question. As Rafael mentioned, that's a great question for the moment we're experiencing. We have been working insistently to be able to, especially from a cost perspective, bring these units to the levels that we have at the headquarters, for that historical profitability level that we've always achieved at Mater Dei.
We use our headquarter units as a benchmark, and we perform some analysis in the percentages upon net revenue of each of these lines, and we establish which are the targets for each of these units. Although we know that structurally, some of these units have medical revenue within their results. We have been working on this with this line of the medical fees and transfers, so that we can reduce this fixed amount in each of these units. We've already been able to have some significant reductions. Just as we've also talked about MatMed and OPME, we've completed the standardization of the purchase planning and the joint purchases for all of the units at the end of this quarter.
All of the plan for purchases in the Mater Dei network take place jointly, and we will see important advances also in this line when we talk about the units acquired, especially. This OPME line, as Rafael mentioned, is separate, but we also see good opportunities. What we've also seen as an important advance that we saw before is the dilution of these operational expenses. Some of the advances have already been captured, and others we can still capture, especially when we talk about some hubs that must work as hubs. At the end of this last quarter, we can see this.
Most of these adjustments that were significant, they performed these at the end of last quarter with a good operation with the payers and also to promote new compensation models that can make these operators more sustainable, but also that we can transfer this as a ticket. We also hope that this will appear in the results in the next months. Last but not least, what I can say is that these results of the integration are not only on the expense and cost lines, but also on the revenue. We've had stronger production in our units acquired through this work that has been done.
Very clear. José Henrique, congratulations on this new position.
The next question is from Felipe Amancio from Itaú BBA.
Well, guys, thanks for taking my questions. The first one is that we've been observing for quite a while that the supply chain has been very pressured, and this has been repeated, especially in the working capital, among most of our providers. Could you give us an update on how these pressures have evolved and how you've been working on this? That would be great. We also see some advances in the minimum fees for nursing. If you could give us any update on how these negotiations have been taking place and what your expectations are, that would be great. Thanks.
On the working capital, I think that your question is very relevant, and thank you for that.
We have both sides, and we had a recent internal change here to keep up with the cycle better, and we've been seeing some opportunities internally to have different ways to do this and monitor this that do not have any kind of relation with this sector that's more pressured or the high claims rate of the payers. It's an issue related to improvements, as I mentioned in the cash flow moment, that's internal, and we know we can operate better. We have some homework to do. I do hope that we can reflect this in our numbers in the second semester. When it comes to the payers, I think we're also experiencing a better moment. We had a drop in the inflation. We have noticed some results in some insurance companies, which also will help.
In the history of Mater Dei, we always partnered with our payers because we understand that they need us, and we need them, and we have this long-term relationship. Now is the moment where we have these adjustments. There is also some work that needs to be done to have some improvements. When you add both of these issues, and when we consider the worst moment already having passed, and now today with a little more room for breathing, we hope that we will improve the working capital issue, which is one of the points in our results that we think we could be doing better than we are. From a working capital perspective and your question, that is basically it.
When we talk about the nursing bill, I am going to talk about José Henrique, and he is going to give us a more qualitative perspective on how this process is doing.
Just a quick overview on the first point. I think Rafa already was very clear with this answer and the work we have been doing internally and externally. When we talk about the relationship with the payers, something that has made us quite excited are the signs that the payers give us when they are in relevant markets, and they have this movement to really value the hospitals in the Mater Dei network to the detriment of other hospitals. We have seen this happen a lot more frequently, and it happens in our vision due to the fair relationship we establish with the payers within criteria that can also protect the compensation of the company.
This has been happening, and we have been evolving a lot in this sense. In the second point about the bill for nursing rights, we closely monitor this, whether it is through monitoring the negotiations with the National Association, but we have also been mentioning some of the regional negotiations we have with each of the unions. We have some important operational changes to reduce the impacts within what we see, which is going to be the basis for all of these rules with this new bill for nurses. For each of these units, we have some targets established to reduce this impact, and we have been monitoring this a few months to anticipate anything is coming ahead.
We have a big concern so we do not have any kind of impact in care, and a big concern also so that we can really train these professionals, which are the professionals that are going to continue to be with us after these changes. We have been working on this side by side to negotiate and reduce this impact.
Perfect, guys. Thanks for the answers.
The next question is from Gustavo from Goldman Sachs.
Thank you, José Henrique. I have two questions. One of them is that I want to bring the discussions on how the development is for the new product developments for the payers in these new markets. That is a discussion that you guys have been discussing for quite a while in the conversations with the market.
You guys enter some markets with assets that are a little more complex, and sometimes the health plans in these regions don't have products that are adherent to your network. I wanted to understand how these conversations have been with the payers so that they can create these new products and so that the MLR for these products can be more adherent to the change in the network that they're going to have. Is there anything happening in that sense? Just so we can understand when we'll have a more recurring relationship between you guys, the health plans, and the beneficiaries, especially when we look at the hub in the Midwest and Uberlândia, which is our more recent entrance. A second question, a little more objective. If you guys could talk about some more granularity. I think 39 beds operationally.
It would be great. I think that would help us as well.
Just a pleasure to speak with you guys once again, and I think it was an event that was very rich, and you always had very good questions as well. When it comes to products in these new markets, what we have noticed is that, first of all, we had a strong advance in new products. In the Midwest region, for example, with some payers, we've been able to set up products for exclusive networks that could be used in our Hospital Santa Clara and the Hospital Santa Genoveva.
What we've noticed is that at certain moments, some payers have a difficulty with launching products that are innovative, and they prefer to work with products, especially those that have. We've been working very close to these payers so that we can work with our own compensation models and really help these products have predictability that's more precise here, and make this payer also have more efficiency when it comes to the sales. In certain markets, you mentioned, for example, the Midwest region, we've been working on some work to standardize and provide more information and consistency to other links in this chain that are very important for the sale of these products.
We have intense work with the brokers and with the companies so that we can make these entities that are very relevant also know about the differentials in our hospitals, and so that with them, we can also set up a more close relationship. This has been done in a very relevant way. The second question is when it comes to beds. I'm going to pass this on to Rafael, and he can give you some more information. Soon after, I'll also have a question.
Miele, how's it going? Good morning. About the beds in this quarter, specifically, we had most of them in the Contorno. Part in Salvador and part in some of the Vale do Aço units that have had very good performance. Premium also had a bit of beds opened, but not too much.
It is not so important from a strategic perspective. What I think, as I mentioned in the beginning, that is important to mention, and he highlighted this very well, is Salvador. In this number specifically that you guys are looking at, you do not have all of the beds that Hospital Mater Dei Salvador currently operates in. In Salvador, we opened up another floor, and we held this a bit after the São João, and we mentioned this in our release, actually, because it is a month where you have people leaving the city of Salvador, so you have a low flow, which is seasonal in the city. July is very strong. We also had a shift in CNU in the city, and so we have been able to have an increase in the beds and also services around the beds, which makes us have an increase in the average ticket.
To give you a bit of perspective, that you guys liked having for the projections, and in line with our operational movements, you have probably noticed that we grew the amount of beds in a significant way, but we also grew in the amount of day patients. We have a guidance and some targets so we can measure this and monitor this. We have been able to generate these beds in a more efficient way. This gives us a perspective of better productivity and also from a care level. That is important so that our patients can reach their activities as soon as possible. This is an important indicator, and we have been working strongly in this direction. For beds, there is no bed without employees.
Amidst this, you need to have very important intelligence, and you need to work on the increase of the occupation rates, because we know that we are going to have pressure related to the nursing bill. These are different factors that we bring in here internally. Maybe the bed is the last measure that we have so that we can be more productive.
Okay, very clear. Thank you, Henrique. Rafael. Good morning, everyone.
The next question is from BTG. Yan Cesquim.
Hi, good morning, guys. Can you hear me?
Yes, we can hear you, Yan.
Okay, great. I have three questions here that are very objective here on my side. The first one is about the evolution in the ticket.
It has been very clear how it has been behaving compared to the mix of the mature operations and the acquired operations in this last one year and a half. I wanted to understand if you guys could give us a little more color separately about the evolution of the ticket and the operations acquired, and to understand if, specifically looking at the operations, you guys have been able to transfer the prices, or if this has been evolving in the mix. I want to understand this. The second question is very objective, is with the current capacity you guys mentioned with Hospital Mater Dei Salvador, what is the size of the operational capacity currently? We know that there was an expansion of 39 beds, and I want to understand how this operation has been working specifically.
I wanted to know, I do not know how much you guys could share with us, of course, but I wanted to understand how this oncology operation. I do not know if you guys have some numbers to share with us, but there is a significant part of oncology that I think has been captured as well with the maturity of the actual Mater Dei Salvador, and I wanted to understand if you guys could maybe share some information with us. Thank you.
Well, Yan, thank you. Good morning. Thanks for the questions. I am going to try to mention a bit more of the average ticket issue with you guys. It really is difficult to see this in the average ticket due to the size that the operations have, right? The size of the operations acquired, excluding Hospital Porto Dias, represent in our results.
When we look at the Contorno plus Hospital Porto Dias, we see most of our results concentrated in these units, and these are units that have had good performance, all of them. Salvador, in line with what is proposed for a ramp-up process. These units, as I mentioned earlier, they really are not reflected in this ticket with these commercial improvements we mentioned. When you see we were able to achieve this in some of our main. About the Unimeds, we were also able to have a very firm negotiation, and we are going to see these results in the second semester. We do hope to have better tickets in the second semester than what is already in-house.
These values will not change too much of the average ticket because of the weight that the revenue has in the total of our revenue, but when you look at how they weigh out these units. We are excited because when you reach a market, you see there are new people that do not know us yet, and we are going to be sharing our results and reliance also that the beneficiaries are going to have in regards to our hospitals, and this is due to the deliveries we have had, and this is how we have been working all our life. We had these adjustments that were a little delayed, but we hope to have an improvement. I hope that gave you more color on your questions. About the beds in Salvador that you guys mentioned, we are currently having 123 beds open in Salvador.
Just to help you with your projections, you can see this, and this number is more than 20% above what we had in the second quarter. It is an operation that we hope will have results that are very strong in the third quarter. Also want to remind you that when you open up beds, you do not have a storm of patients from one day to another. You have this high occupancy rate, and then it drops. 72.8%, which is over 75% at the metric of the other networks, which is out of what the Associação Nacional de Hospitais Privados suggests, we would be operating at 76.4%. We would be at a number that is a lot higher, and the occupancy rates were quite interesting in the second quarter, and this disclosure brings us a little bit lower when the units were reopen up beds.
But we do have a perspective with the news you saw in Salvador and all of the work we've been doing with our clinical team, Dr. Márcia Salvador Geo, Dr. Henrique Salvador, and they've been doing excellent work. So all of our board has been working on an agenda. We're not mentioning this year because we've been talking about this in a recurring manner. But besides a board that's very strong locally, we have, every 15 days, we've had meetings in Salvador with very important physicians and people that are coming to work with us and have a service, and we hope to have growth. If you look at the hospital, you see the difference in quality of the product we have. So the hospital is no doubt the best and within the possibilities for ramp-up. We're very excited.
I hope I answered your question on the tickets and the issue of the bed. To contribute to this, Salvador is a reality, and in this quarter, we were able to prove how Salvador is going to lead to an impact that's very relevant in that market. So a significant growth and month after month, we've been reaching all-time highs when it comes to surgeries, exams, levels of services in the emergency room, and also in diagnostic services. So these numbers of beds opened, especially in Salvador. Salvador has been really pushing this, but in the metropolitan region of Belo Horizonte, we've also seen other hubs and occasional movements despite knowing about our need to have an occupation that's even higher, profitablizing these beds that are already open. You also asked about oncology.
Our oncology also has had excellent performance in the units where we have these oncologists established with growth in all of our units. The oncology process starts off through the movement of other services, and this is really connected to the hospital services. So, within equipment like Salvador, they have a high complexity, start creating these networks, and most of the accreditation in oncology also came in this last quarter. You can already see that in Salvador, there's a big change when it comes to the cycles and oncology surgeries and exams related to. So for this, it's going to be an important factor for growth.
Thank you, José Henrique, and thank you, Rafael .
The next question is from Gustavo, from Bank of America.
Hi, good morning, everyone. José Henrique and Rafael, we have two points here on our side.
I wanted to understand if the readjustments are closer to 3% inflation, or if it's more of the historical inflation, just we can understand the impacts we can consider up ahead. Also when we look at the EBITDA, and we consider the impacts of other revenue expenses, you see a slight drop in the quarter compared to the previous quarter in the EBITDA. I just wanted to understand because we have a strong occupation, and we were maybe expecting an EBITDA that was higher. So I wanted to understand if the impact is on the ticket or if there's an exchange in the beds being a little more profitable, or maybe leaving Contorno and Santo Agostinho. So I want to understand what the logic is for the negative impact in margins. Okay, thanks, guys.
Thank you, Gustavo, and I think both questions are very connected.
First of all, I want to make it clear that the metropolitan region of Belo Horizonte is super healthy. We haven't had a migration. The ticket has been keeping up and been above inflation due to this issue with the new models. Not that we consider as an assumption that we should transfer more than inflation, but with the operational evolution, we can actually capture part of our new models. We don't have much of a connection. About the new units, it's not because we're searching for more than the inflation, but when it comes to the units, we had a delay in these adjustments, and they were a bit below what we operate with certain payers. The adjustments we implemented are above the inflation in the last 12 -months, which was 3.5%.
It's not a policy in the company to transfer more than the inflation. We think that the inflation is a way to rebalance what we buy and how we buy it, but we always had cost control work to be able to serve through gains above inflation in the margin. This is what we expect. When it comes to your analysis, if you remove this one-off in regards to the provisions, we didn't drop. We're flat in the second quarter with these perspectives. Why are we optimistic? Well, because we're already seeing in the company the revenue is coming from these adjustments and the costs are what were already operated, and we have future improvements at these integrations. We're confident that we have room up ahead, and I hope that gave you a little more vision.
Just a quick point here, Gustavo, in regards to the adjustments, just so we can give you a little more color with the work that Renata and Dr. Maria Norma have been doing in the integration of the units. Most of them have contracts that were outdated with clauses that were also outdated that bring some kind of a lack of security in the adjustments and revenue for these units. This was a period where we had to get into details of each of these contracts and really place the clauses that guarantee future adjustments. That's why we sometimes take a little longer. But most of these contracts in these units that are more relevant have already been done, especially in the hubs we mentioned. We hope that this will come, as Rafael mentioned, and the trend is that this will reach a higher value.
When we talk about the average ticket, we can't only look at the unit value. We have mix issues, but we have no main changes when it comes to the mixes for the next month. This is, of course, something that we can't guarantee in this format. But what we can say about the metropolitan region is that our hospitals have never had performance that's so good in the metropolitan region with surgery growth and exams. It's really an all-time high and such a stability in the growth in the overall market. We're going to take advantage of this moment to invest more and more on differentiating these hospitals, compared to our competitors, either through new services, as we mentioned in the beginning with the unit for treating burns, but also other kinds of services. Like we opened up an MRI service here at Contorno.
We're doing the same thing in Betim- Contagem. We've been investing in new hemodynamics as well in Hospital Mater Dei Contorno. We just finished the construction project for another floor in Santo Agostinho, making it the most unique maternity in the region. The investments in this region also haven't stopped so that we can really consolidate the operations as more and more relevant.
Thank you, guys. Very clear. Thank you for the answers.
Thank you. Our next question is from Estela Serrano from JP Morgan.
Hi, guys. Good morning. Just a quick question. If you could talk about the initiatives to increase complexity in the hospital. If you can also explore if these initiatives differ in regards to the hospitals that are more mature or the hospitals that are ramping up. And also if these initiatives, of course, going beyond oncology.
That's what I have to say on my side.
Thanks. Estela, great question, because it allows us to explore a bit of our day-to-day activities. Ever since Hospital Mater Dei started off in 1980, sorry, we were always very concerned with relationships with our physicians and understanding the talents in each specialty. We developed this over a few years with the work with Dr. Henrique and Márcia Salvador, and having greater proficiency as we attract each of these teams to reach formats where we can develop our medical entrepreneurship, especially for the specialties that have more complexity. With some strategic projects where we can identify patients that need some kind of a treatment with greater complexity and interfere with this so that the patients have the adequate treatment, and also so that we can have these patients having these treatments with us.
As I mentioned previously, we've been investing to increase this complexity with this one here in this metropolitan region as well. Salvador is a big example. We have a list of relevant physicians that we are capturing, and more and more of these physicians have been coming to our services, and we've been adding some relevant services for these patients. In these hospitals, we also have an integration through strategic services. This, of course, helps the units have opportunities to grow when it comes to tickets and complexity. We have a national strategy when it comes to oncology. In some units, our corporate team reaches this and sets up this type of service and monitors this to make sure the strategies have traction or not. This starts off in oncology, but also in cardiology, neurology, orthopedics, and so on.
For each of these specialties that are relevant when it comes to complexity, we have this package of activities and an action plan that will help us to attract the best medical networks, but also develop the skills necessary so that these specialties can flourish in these units.
Perfect. Thank you. Very clear.
Our next question is from Thiago Cassa.
Hi. Good morning. Can you guys hear me? Yes, we can hear you. We have two questions here. The first one is about your perspective for margins for the second semester, because I understand that you have certain levers in this part with the readjustments and also dilution of costs due to the ramp-up in Salvador. But at the same time, you have this issue with the nursing bill that's in parliament. When you see this, you can see an average EBITDA margin about 25%.
I wanted to understand if in this second semester, you think that this margin will be able to grow compared to this? The second one is more midterm. When you see this level of EBITDA margin, we can see that it is close to about 10 percentage points below. Of course, you brought in a lot of new beds, a lot of M&As. Maybe you are not comfortable yet with these 10 gap points. I do not know where you think this stabilizes and how long. How long should we see Mater Dei at a stabilized level, and which level would this be, 30%, 28%, 32%? These are the two questions.
Okay, thank you, Thiago, for your question. Starting off with the second one. We cannot make forecasts for the future in the company. If you break down our results, you will see that this is way behind any margins.
Not only the margins we were operating before, but also the margins that the other hospitals operate with. We are way behind, so this is work we have opportunities with, as we mentioned in the entire call, to work on during the next six or 12 months. We have part in the revenue, part in the cost, part in the medical relationships, and there are many opportunities. But when you look at the margins of 35% in the metropolitan region, you can see that there are certain specific issues related to that moment. But if you separate the Contorno and eliminate Salvador, you are going to see that the gap is completely different from what we operate in the consolidated results.
We need to separate this so that you can understand how healthy our operation has been when compared to the operation in the past and bringing in new hospitals, raising a hospital in Salvador with the perspective and also bringing in units in regions where we have been working with the payers locally. There are a lot of challenges, actually. We are not satisfied with this margin of 26.5%. We have been growing compared to the first quarter. I do not think we are flat or below the first quarter. I think that these perspectives that we mentioned during the call demonstrate that we have these future perspectives as well. This work we have been doing is something you guys can break down and adjust unit by unit so that we can do this.
One point that must be considered is that the units, if you remove the metropolitan region of Salvador and the Contorno, the medical fees are transitioning in the results. If you have a medical fee, and you also have numbers there that you monitor of how much the medical fees in the units have been. If you remove this from the revenue and the costs, you also have an increase in their margins without changing the EBITDA. Absolutely. There are many different issues that we need to consider because we have good perspectives, in our opinion, for the future.
A lot of work, of course, things that are in our hands and things that we're going to have to struggle for so that we can reach the results that we think a hospital at the level of our hospitals with the best margins in the sector can reach.
Perfect, Thiago. Just to contribute to this answer, one thing we can also say is that the fundamentals for these regions and hospitals remain, ever since the M&A period. The fundamentals of the relevance that these hospitals have in the regions where they're in, the fundamentals for the relationship with physicians that these hospitals have been able to achieve, the fundamentals related to the capacity for improvements and the mix of each of these hospitals, as well as the fundamentals related to the payers and insurance companies in these regions, which are regions that are relevant.
These are regions that grow. Despite the fact that sometimes there's some economic failures in the country, they're all regions that have economic boom potential. We're going to make these units more and more relevant in these markets. This has not changed, actually. We've seen these hospitals stronger and stronger in these regions.
Our last question is from Guilherme from Santander.
Good morning, everyone. Thank you for taking my question. I want to understand what your guys' mindset is about the new M&As. We see that the interest rates are dropping now, and you have a profile for debt that's more extended with more than half of your debt expiring after five years only.
I want to understand what you guys think about this and if you think there could be new opportunities for the future as well, and how you're looking at this. Thank you.
Guilherme, thank you for the question. We really consider this to be a question that comes back to our plans and discussions when we see this shift in the interest curves and when we start seeing perspectives for us to not harm, negatively, our sustainability in the company in regards to debt. We have an expansionist perspective. This is not a secret to you. We placed ourselves and keep our strategy to be a consolidating platform. We believe in the sector. What we've noticed is that once again, you have opportunities that come up for M&A, for studying new projects, for greenfields in relevant markets.
We've been analyzing these opportunities in a very close way, but also we're very conscious about this to understand how these opportunities really connect to the Mater Dei network points. We have a very interesting shareholding control, which makes us have some interesting movement without giving up on controls. There are some opportunities on the radar, and we're going to assess them in the next months.
Thank you.
Guys, we have finished the list of Q&A, and we want to thank you all for your presence and your interest in our call and our earnings and all of the questions that are always very relevant and make us reflect on our performance and our strategy. We hope to have you guys in the next quarter with better results in Mater Dei. Thank you very much, guys.
Thanks for this opportunity to be with you guys for the first time. On our side, we continue to strongly move along in the results that are more relevant to the company, whether they are financial or also those related to the level of care, the purpose of Mater Dei, the patient's experience and really making our hospitals and the Mater Dei network become more relevant. Thank you all very much for your interest. Thank you for your questions. We will always be available. Thank you.
Bye. Have a nice day.