The ramp-up of Mater Dei Salvador and opening of new services and beds in some of our hospitals. We do observe a growing movement in our units. An important issue at the Mater Dei network with this movement we had was this journey of the culture that we've been discussing to be able to take to the acquired units and to those that are beginning their operations, the culture that made the Mater Dei network reach this point. We hired an external consulting company, which is involved in this in-depth movement involving all of these units, where we try to re-signify our values, and we try to discuss the role of each unit. Also bringing in a single guideline that can really mirror what Mater Dei is and would like to be in the next few years.
This movement that has really had a lot of resonance in our units at a corporate level, and that is in course with everything we need to really make this network, where the units can interact with each other and where we can really make tangible this effort and this movement that has been done in this integration.
So we can have synergy with the different aspects, not only financial synergies, but also from a care perspective, operational perspective, and also when it comes to our earnings from our core business, and that we can really bring these units in to the standards we believe in. So this journey is underway in the corporate culture, and this has been an important movement for our network.
Another important movement that we would like to highlight is this close relationship that we have tried to deliver together with the clinical teams in the hospitals and the cities where our hospitals are included. Attracting physicians that are relevant so that we can have an increase in the production level of our hospitals. I personally, and other directors as well, have a permanent agenda and contact with our medical teams and even the medical teams that are potential and that can bring an increase in our production to our institutions.
So when it comes to Mater Dei Salvador, we have this important ramp-up. We've noticed this ongoing process where we open up more hospitals, beds, more hospitalization units, and we'll be opening up more ICU beds as well with a ramp-up that is going on as expected with the entrance of the medical center.
That was really important as well with this building next door with 10,000 sq m and 73 offices. This line of care from a primary, secondary, tertiary level of care in the medical center will position Mater Dei in a way that is really unique. So that we can not only work with our patients as in line with the best evidence, but also to meet the needs of the operators so we can have more coordinated products and where we can look at the other links of this chain and have them interact among each other. So in the Mater Dei Santo Agostinho, we've also taken advantage of a wave in the city of Belo Horizonte, where we have a lack of good hospitals and maternities, and our maternity becomes a reference at a regional level.
We also opened up one more maternity as well with more beds and 36 apartments actually that allow for what we call PPP, or pre and postpartum in the same environment with a very unique level of service and a physical structure that's really unique as well. Our maternity has really been transformed more and more into an opportunity for generating relevant revenue because even patients that don't have an interaction with the Mater Dei network have been acquiring these packages to be able to use these in our installations and facilities. Another important aspect is that the National Association of Private Hospitals has been leading a document called the Anahp Observatory, which is just the opportunity for benchmarking different institutions, and from a hospital perspective in the health segment.
This was really interesting because when we compare our results with the results of the group at the ANAHP, which is the National Association of Private Hospitals, with all the hospitals that are part of the association, we've noticed some indicators for quality that are really unique, such as our permanence time, which is smaller than the average noticed.
The normal birth rates that are vaginal birth rates that are also really unique compared to other hospitals. The stimulus to have natural births, which is an important worldwide movement, searching for the correct and adequate births. Mater Dei has really been leading this in Brazil when it comes to this agenda. Also, other rates such as the Porta-Balão rate, which would be related to the American Heart Association indicators with what is defended all over the world.
As well as a match of different opportunities with some specialties where we can move along and progress. This was a very positive surprise this year. We have been guiding our results with the results of the hospitals at ANAHP, as a reference in Brazil, had presented in this document. Our agenda is firm and has been moving along with the integration of these units that were acquired, the ramp-up in Salvador, taking advantage of the opportunities with the operators in the Belo Horizonte hub and the Midwest and Northeast hubs, so that we can really start opening up more beds.
It's a moment where we can also keep our eyes open in the sector and understand which movements Mater Dei can get involved with when it comes to this expansion. It's really a dynamic movement, and generally this is what I wanted to present as an introduction. Now I'll pass the floor on to Rafael Cordeiro as he talks about the numbers a bit more and the figures in our financial lines and balance sheets. We'll be open, of course, to Q&A afterwards at the end.
Good morning, everyone. Thank you, Dr. Henrique, for this initial introduction, bringing in excellent elements to our work day to day, because that will, of course, help us to remain with these positive results and grow in these new units. Starting off with slide four, I want to talk about the amount of operational beds where we see growth from the fourth to the third quarter when it comes to the amount of beds, but also occupation rates.
It is important to highlight that the 70.7% of occupancy rates, when we consider the day patient that does not sleep at the hospital, we are basically considering 75% occupancy rate. We have been noticing that even in this dynamic of always having the adequate number of beds for each hospital, we have been having new beds opening, growing the occupancy rates, and we believe that this is sustainable growth for the next quarters in the company. An important reflection of this growth has been the number of day patients. We had a growth of about 50% compared to the first quarter of 2022. This growth is really in line with the growth of the amount of beds we had and the occupancy rate remained as well, constant.
When we move on to the ticket, it is important to mention also that we had a small adjustment in our calculation and we had this per quarter, the number of days per quarter as a constant rate. Due to, well, we assessed this result in February with less days and holiday days, which was a month that really impacted our operations a lot. We noticed that it would be good to have this with the correct number. We have a small adjustment in our historical series, but we are always going to have the real number of days per quarter now.
In this quarter, in this methodology, we had BRL 2.10 million per bed per year, and this is a drop compared to the fourth quarter, which is really, well, after the Q&A session, we can clarify this more, but from a company perspective, it is part of the seasonality. We had some of our units that had some levels of service that were maybe a little less complex.
We had dengue in some units here, meningitis, dengue fever, which reduces a bit of the ticket. Now with our growth, we have also had a mix with other health plans and insurance companies, and there is a bit of a consolidation in the market, so that leads to a bit of a drop. This is not an actual detractor for this non-adjustment.
But we have been able to achieve this with our operators, but we can really have the sustainability where the ticket can be corrected. From now on, we will have this new methodology for the average ticket calculation and then a reflection in this growth of beds and the occupancy rates. We have the growth about 2% of the revenue. We reached BRL 424 million in our net revenue and a growth of 53% in the amount of beds. We had grown 50% patient day, looking at two slides backwards. This growth has been coherent, the growth of the revenue with the growth of the beds. This growth also gives us opportunities up ahead because we have some units that are a little bit more mature, others are undergoing growth. Others have room for growth, such as Goiânia.
Our unit in Salvador has been performing a ramp-up month after month, growing the amount of patients and surgeries. This is a growth that is constant, very robust, and also one of the possibilities for growth in revenue for the next quarters. When it comes to the costs, we were able to control costs a bit considering our operations.
This has been work that we have been working on with this issue of the culture, protocol, and flow. This is not work where you obtain all of the results at the first moment. It is quarter over quarter, so you have a shift in routines. You involve a lot of the clinical body. This is something that we are going to slowly but surely demonstrate, and we can demonstrate that for the hospital and for the success in each of the areas. It is important to have these protocols.
We had a drop of 0.6 percentage points. This has been impacting our net revenue. When it comes to expenses, we have also had an improvement. Part of this has been coming from a synergy where we were able to have a dilution of these expenses because our network has been bigger. For some of them, we have been sharing expenses in our shared service center that services all of our new hospitals. When we reach 13.9 in our net revenue and our operational expenses. This is for operational expenses, but also a significant improvement. This reflection in these both costs and expenses, we reach an improvement in our margins, and we got back to our levels of the third quarter of 2022.
We had some runoffs in the fourth quarter, and so we performed 25.2 in the EBITDA margin, reinforcing the fact that we do not have any other type of adjustment. We mentioned that the EBITDA and the adjusted margin for the previous quarters, but from the fourth quarter onwards and this first quarter of 2023, we have not performed any adjustments in our results due to M&A, COVID, or any other factors with stock options. This is really just the net earnings of the company. Moving on to the net income. We have this improvement that we have achieved in our EBITDA, which is partially reflected on the net income. Of course, we have had some continuity in this high interest rate, and the financial results really impact all of the organizations in Brazil.
We have low leverage and so a cost of debt that is relatively attractive, which is less harmful, but even so, it is a financial result that kind of impacts our profitability. We reached BRL 33 million in net income in the quarter without this adjustment, +BRL 18 million from the adjustment in BP and our goodwill there, and we reached BRL 51 million. We performed this adjustment once again because it is directly impacting the cash flow of the company. We stop having the payment of this amount. We think this reflects our profitability in the company better when it comes to the net income per share. The net margin also reached 9.6% with a growth of 2.6% compared to the fourth quarter.
The cash flow, i n our release, we actually explained the working capital a bit, and we have an operational cash flow that is positive. But when we complete this with our investments, we have a negative free cash flow, but the acquisitions are reducing. Part of this mostly were due to these BRL 94 million, and this was due to the payment in installments of Premium. We also had bought some quotas that were foreseen in Santa Genoveva. Almost half of these investments and the other half were for investments. We had already done this in Salvador. There are some investments in Nova Lima. We have the purchases of equipment, some of our activities in the bottlenecks on these activities.
We have to purchase some equipment, which is an important investment to have better quality in our services, in our operation for patients, but also to grow our revenue with some external patients and other great opportunities ahead. We end with a cash position of BRL 328 million, which is BRL 50 million less than our cash in 2022. We also have a net debt to EBITDA index. This is basically no other significant debt. We have a bit of an exchange in the units. We have a gross debt that is constant, and our cash of BRL 328 million, which leads us to about BRL 900 million in our net debt, where you split that by the EBITDA and the LTM, and it is 1.9. We do not carry on the EBITDA from all of the units because they do not have 12 months since the consolidation.
If we already had the results multiplying the quarter, we would have a lower indicator than 1.9, which positions us in a very healthy level. If we want to have any other movement, we would have room for this in our balance sheet. Our schedule is super healthy. We have 85% of our debt expiring over four years, 49% above five. We have an average term of 5.4 years, and this debt is a long-term debt, but also has very attractive costs. We also have this swap in our BNDES debt, and that of course leads our debt cost to CDI and 0.95% per year. This is lower than the applications with the CDI, because even though we have high interest rates, our capital structure is still healthy.
Now we will finish off this presentation with the numbers, and then I will get into a Q&A that we can get into more details about from a strategic perspective, and also from the numbers. Thank you so much for your presence. Our first question here is from Yan Cesquim from BTG.
Well, good morning. Thank you. On my side here, I have two questions. The first one you already anticipated about the ticket dynamic, but I just wanted to maybe have a little more color here about which of these effects within the mix of complexity, the business days, the agreements with payers, what most reflected this sequential drop in the ticket, and what is the perspective that we should be looking at? The second question is about the CapEx for the year, which already had reflected a bit of a purchase in the new equipment. I wanted to notice what we could expect as an ideal level for CapEx this year, since we already have the operation in Salvador underway, and there's no other major developments going on this year. Thank you very much, guys.
Thank you, Yan. We're going to start off with the ticket first. When you talk about the ticket dynamic throughout time dropping, the answer to this is the consolidation. We put into our balance sheet the metropolitan region that represents 50% of our revenue approximately, and then you consider different operations that consolidate this with a lower ticket than the controller. You have this sequence of smaller tickets, which is really leveraged by the consolidation, especially from one quarter to another. Then you have other issues that you even included in your question about the complexity.
This is a quarter where people travel a lot. When it comes to elective issues, we do have a drop, and we noticed in this quarter closer that carnival in the region of Bahia is stronger than the rest of Brazil when it comes to drops in the hospital. Even with tourism strongly moving towards Bahia, we have this restructuring of the revenue due to tourism, and so we have some specific issues in the quarter. There's nothing actually structural where we have a loss in ticket. We always mention this with this growing ticket, considering the IPCA, where we know there is a discussion with the inflation and then, of course, we always want to try to transfer this inflation to our payers to be able to reestablish our costs and our profitability. When it comes to CapEx, we have this major payment.
Every quarter, we're going to have this payment for Premium. But when we remove this, we should be operating below BRL 50 million in our CapEx, in this quarter. We know about the difficulties in the brownfield, and we will also be working on this a little more care. Of course, considering the cost of capital dynamic, and we expect to be reducing this by BRL 50 million when you consider all of the joint effects. Although Salvador did drop a bit, this medical center is ready. We do have some investments where we have the new payment terms for the construction work that still remains, and also some retention fees for some of the development companies and construction companies that provide these services to us.
After you have the testing of all these services, we release some of these payments. There's a delay or a lag between the conclusion of the construction work and the actual payment. One of the points that we're going to consider in the next quarter is also Salvador, since the construction work there has already been finished.
Just to mention one of the points we were discussing with Rafael. When we received some of these units that were acquired, we noticed that with just a little bit of effort, we would be able to improve our operational structure for some hospitals that are already accredited or registered by the payers and already have their clinical teams ready to work. This is an effort we've been working on, but financially, it's not that relevant, and it's going to end up positioning these hospitals differently in the markets they're in.
Okay. That's clear, Dr. Henrique. Thank you, Doctor, and thank you, Rafael.
Well, our next question is from Emerson Vieira from Goldman Sachs.
Good morning, guys. Good morning, Rafael, Dr. Henrique. Two questions here on our side also. The first is about the occupancy rate. I just want to mention two. One is considering the Hospital Mater Dei patients and the hospitalization night patients. When patients actually sleep over in the hospital and they are hospitalized, this rate and when we consider the day hospital, it goes up 4 percentage points. There is this drop and increase, right? What is the actual impact in the mix? When you compare year- over- year, you have the new hospitals with a more clinical profile, and that ends up impacting the occupation rate. Or would this maybe be an effect that is more structural, where we start seeing a bit of a reduction in the complexity of the legacy hospital?
That is the first question. Then, when you look at the occupancy rates in the legacy hospitals and the hospitals that we recently acquired. The second question is about the G&A. We noticed there is really important performance when you compare from a quarterly basis, but I wanted to understand the other expense lines, right? If they are recurrent and what were the main contributing factors for this improvement? Those are the questions. Thanks.
Okay. Thank you. Well, about the occupation rates, just to make this clear, what we mention as day patients, which is really intending to equate the concept that other hospitals use. This is just a recurring process, right? This is important. We have always considered 3%-4% in the hospitals in regards to day patients, those patients that do not sleep at the hospital, but they do help with revenue.
This needs to be accounted for. That is why we can never have the occupation rate, right? Because you have this dynamic of patients that do not sleep at the hospital, so there is not much of a concern in the mix in regards to this indicator. It is just, when you look at the historical series, you are going to have these 3%-4% in the entire historical series. There is no derivative from this number when it comes to revenue or ticket or anything else. When it comes to the second question on G&A, we have been making a big effort, and this has always been a major point for the company, to work on the dynamic here at Mater Dei. We have always been very focused on costs, and the dynamics for our market really provided this kind of legacy.
But when it comes to other expenses, we had an important shift that I could have mentioned previously in my presentation, but I forgot to, which is in our release. We also mentioned a shift in the monetary adjustments for the contingencies. Before they were listed in the other expenses and operational revenues. Now considering the correct accounting standards, we performed some internal initiatives to be able to segregate each of these processes. This is now in the financial expenses. You have about BRL 3 million that leave the operational expense line and go on to financial expenses. When you move on to the financial expenses, you have these BRL 3 million reflected there. This is just a shift in the line, but that is the actual correct practice, right?
Although we did need some controls that we are able to have now, which kind of leaves the EBITDA results at the correct level when it comes to the actual cash generation. All right?
Perfect. Super clear, guys. Thanks.
Our next question is from Ricardo Boiati from Safra.
Hi, good morning, Dr. Henrique, Rafael, and other participants. I have two questions here on my side. The first one is about the lines in costs and expenses. I think that when it comes to the SG&A, Rafael has already covered that pretty well. When we look at the cost lines, especially for medical materials, the company has been able to have pretty good results in G&A and personnel. We have been able to control these expenses really well, when you look at the evolution of these numbers.
I wanted you to maybe give us a little details on these synergies when it comes to medical materials and other main G&A lines and how you have been able to achieve these synergies with integration processes in the companies acquired. I think that would be super interesting. The second question is about the Salvador ramp-up, especially from now on with the medical center.
I want to understand where you see the greatest potential for evolution in the hospital in Salvador. I understand that you still have a lot of room to grow in the amount of beds, but when it comes to complexity, increases and an increase in tickets, what are you looking at when it comes to space for improvement since the hospital has been working for a year and you also open up the medical center in Salvador?
Well, I will start off with the first one. Well, Boiati, this is some initiatives we have in all of these cost lines. We know about the importance that these lines have. We know that medical materials, personnel are important lines in our expenses. The synergies did help a lot, especially when you have the purchases, and we have had an important reduction in the average prices we would buy at with major numbers. We had BRL 17 million in gains when it comes to purchases, and that impacts the EBITDA directly with important amounts allocated in the companies. PAR also is benefited by Mater Dei. Purchases and personnel, it is just constant work. When we look at this work and the study by the National Association for Private Hospitals, we always have this important highlight with a smaller amount of employees.
This is an important dynamic we have already demonstrated to investors during visits, and we demonstrate how we have these exchanges and the different shifts and how the hospital works. Another line that is an important detractor for our costs, but is also part of this dynamic, is the growth of this medical services provided. In the metropolitan region, we actually had about 4.5%-5% in this line.
Now with the consolidation of these new units, where you have the medical payments transitioning in the actual earnings of the hospital from a consolidated perspective, then we have an increase. Even though we have had this increase, we have been able to have a pretty good gross margin in the activities in the network. We have different initiatives for costs and expenses, and this work is really expected, especially for the expenses to continue to have synergies and a reduction in personnel, improving technology issues with some activities, so we can have a reduction in the next quarters as well.
Well, Boiati, just to add on to this answer from Rafael, I think it would be really important to get a feel of this with some of these lines. These are so important. We do have important work being done that we've mentioned a few times with the management of people, which has been helping us as well in this journey for our corporate culture, and it's really relevant to manage the cost of personnel with a focus on certain indicators.
Indicators such as the amount of personnel or employees per bed, the indicators of costs with personnel per net revenue, the extra hours of work, and the hires. We manage this through a productivity committee we have that has production engineers participating, and they all come into the units, and they support the revision of some management processes, which actually allows us to effectively hire a necessary amount of people and not have any excessive amount of hours. When we share the human resources, we see that there are some seasonalities. The hospital's normally really full, and the receptionist needs to register the people. But about 9:00 A.M., the lab's already emptier.
But we see since the role of the receptionist is pretty much the same as the other job, we can share these resources between the units that are close, such as Santa Clara, Santa Genoveva, Contorno, Santo Agostinho. There's this logic that allows us to be able to manage human resources through processes and costs that really make us stand out. When it comes to the ramp-up in Salvador, what has happened is that we already have about 1,000 physicians registered in our clinical team in Salvador, and the hospital really is full swing. For some specialties, we've had a greater demand and search, especially for surgical specialties. In these different specialties, when you look at the year of 2022, we broadly disclosed one year of full operation in the hospital, and we had almost 200 robotic surgeries in the hospital.
In the initial year, that was quite difficult. Things were kind of warming up still to be able to get into full swing. I think we have a lot of opportunities with specialties that have greater complexity. The city really lacked a structure with technology embedded as we have in this hospital. We've noticed that we've been very welcome in the area on behalf of the patients and the physicians. The patients have a real unique experience when they're welcomed. They feel well, the environment is well lit up, big areas to wait in, cutting-edge technology. The asset's really well located in Salvador, and it's been positioning itself as a very unique value proposition in the hospital.
That was very clear. Thank you, Dr. Henrique and Rafael. Have a great day.
Great. Our next question is coming from Gustavo Chislaghi from Bank of America.
Hi. Good morning, everyone. Thank you for the presentation. Two here on our side. We wanted to explore the metropolitan region of Belo Horizonte, try to split this into two blocks, Santo Agostinho and Contorno de Belo Horizonte. We didn't have. In the last quarters, there was a stagnant operationality in the amount of beds. I want to understand if you have a shift in the beds that's dropping in Santo Agostinho and Contorno due to some local pressure, and then maybe that would be increasing in Betim, Contagem. What's this dynamic like?
Just so we can understand the ticket, if there's an exit with a high ticket or middle low ticket, or if it continues to be stable. The second issue is about the medical services provided, which is super clear in the release. When you eliminate this impact, there is a slight increase. I wanted to understand this from a structural perspective, or greater pressure on this line. Thank you very much for this opportunity.
The public hospitals are really different. The public hospitals that search for Mater Dei Contorno and Santo Agostinho, they're very different than the public hospitals that search for the Mater Dei Betim, Contagem. We haven't noticed this drop. Actually, patients that have these operators that are more premium segment, that live in Belo Horizonte and in the central regions, they continue search for our hospitals, and this has been increasing, and in Mater Dei Contorno and Santo Agostinho, including some very specific segments. In Betim, Contagem, we also have seen an increase in volumes, especially due to our decision of working with some health operators that we weren't working with before.
Such as, since this hospital, Mater Dei Betim, Contagem, is a hospital that operates with lower costs. We are able to work with operators such as IDSS and others. With this, we can also really work with patients that historically, in the past, about five or 10 years ago, we weren't working with in Belo Horizonte. Our strategy to bring Mater Dei Betim, Contagem into our network was really precise.
It's a hospital that has provided important results, and it really complements our portfolio. From the physician perspective, as mentioned, bringing in these new opportunities and new strategies really completes their agenda. We've noticed that more and more physicians have been remaining all day or week in the hospital, and that, of course, brings growth in the other plans we have.
We're super satisfied and enthusiastic about this strategy, with this growth that we want to reach in the next quarters and years. Actually, when you look at this, there's another interesting aspect, because physicians really work in teams. A junior physician, maybe that works with Mater Dei in Betim, Contagem, and then another physician that has a more regular client base, works in Santo Agostinho. To complement this medical team, I think we really had a very precise strategy.
Okay. Perfect, guys. If we could just follow up on the medical service provision line. I just wanted to understand if there's some competition, because what we hear from other players is that maybe you have more competition, and that's maybe why you have pressure on the costs for medical materials. There's an impact in the balance sheet, of course. You guys were publishing things differently before, and you always publish this in the metropolitan area of Belo Horizonte. I want to understand if now you have greater competition or not, or if that's just really the case.
No, to answer your question, no. We just see a reflection of the numbers. You have the maybe controller of 4.5% and 5% going through our balance sheet, but then you have these other units with a greater percentage. At a consolidated level, this number, which is about 10.5%, which is the current number. There's not this kind of competition. What we do see is some huge efforts from our medical team, in this relationship with the local directors and the corporate directors to manage physicians, explain our model of care, how we operate, productivity-based, to control the number.
If we're going to service all of the demands that these units had before, this number would skyrocket. We'd be paying more than the production. We would have to pay for a fixed amount or something else that is not necessarily related to the production. Actually, one of the things we highlighted a lot in Dr. Henrique's presentation at the beginning of the call, was the day-to-day work where we go to the units, demonstrate the success in the mid to long term to demonstrate that it's not just about paying something and the guy doesn't have an actual relationship with the hospital. It's a relationship where both win in this growth in the volume.
That's super clear. Thank you, guys.
The next question is from Felipe Amancio from Itaú BBA.
Hi, guys. Thank you for taking my question. We actually have two on my side. We've been observing a scenario that's quite stressed with the payers. Could you give us an update about how you're looking at the environment for negotiation with the payers and what the working capital dynamic has been in this quarter? That would be great. That's the first question. The second question is, we've noticed that there's a slightly greater debt and an operational leverage that was kind of flat. If you could share what would be the healthy level, and if you have some kind of a target, I think that would help.
Thanks. Well, let's start off with the second question. That's easier to answer. Our leverage, as I mentioned, we still don't have our EBITDA.
If you look at our EBITDA for this quarter and you multiply that by four, you already have an annual of BRL 520, and we know that the general consensus is greater than this. If you just look at this issue with being able to reach the annual expectations, we'll already have a reduction considering that since our debt is really long-term, we wouldn't reduce the gross debt but the actual cash generation in the year. We would have a reduction considering the growth of the operations and also when you consider the cash generation. This was stable with a slight marginal growth, but it was pretty stable. Our biggest debt come from debentures. At the end of the year, we had two months.
We paid this on 3rd of November , and then at the end of the year, we had almost two months of financial expenses from this debenture. In March, we had a payment on May 3rd, so we are already carrying on more time with the financial expenses. The shift in the gross debt is really just specific to this occasion, right? There is no direct connection to this. When we look at the tax rate, then, of course, we did have a working capital cash consumption, and this was very occasional. There is no specific structural reason. We increased our average terms. We did have a little bit of consumption, and there is something really specific related to the seasonality in the period with the operators being handled. Today we have a committee with a permanent cash position.
Every afternoon we meet to discuss this, and we have been really considering all of this so that we can have this recovery in the next quarter and not allow this working capital to weigh in in the next quarter. We already have some initiatives. We had a small loss, but some occasional things have already been considered, and we are working on this in the company.
In regards to your first question, Felipe, the system is stressed, of course. I do not know if you saw a survey from IPEC, that the main concerns for Brazilians are health, housing, and then jobs. Sorry, health, education, jobs, and then housing. Basically, we are providing essential services, which are health. About 24% of the Brazilians have private health insurance. I am sure that we will be able to find mechanisms to generate this kind of health system.
There is some work that has been implemented with ANAHP, the National Association of Private Hospitals. We have an agenda where we discuss fraud in the system, technological incorporation, so that we can find mechanisms and pathways to bring important balance in the system. It is a system that is really regulated by the health insurance side, and there are also some other assets that could help bring stability in the system if we have major stress going on.
What we have tried to search for in our initial strategy for expansion was really moving into the markets where we have hospitals that are really relevant to the health insurance companies and the overall system. When we sit down with the health insurance companies to negotiate prices or adjustments, we are basically considering clients that are very relevant, but they are also considering hospitals that are very important to them.
It ends up that we can move along in these agendas. I think this is a temporary crisis. It is occasional. It is not something that is going to last for many decades because we are considering an essential service. Of course, the fundamentals should change. We are talking about new compensation models. We are talking about a control on losses. We are also talking about a more propositional agenda than what we had in the past. We have noticed an important respect towards the Mater Dei network, especially because of the relevance we have in the markets where we are positioned.
Perfect, guys. Thank you for the answers.
Our next question is from Stella from JP Morgan.
Hi, guys. Thank you for taking my question. Could you maybe talk about the synergies coming from the incorporation of the assets that have been recently acquired? Could we expect more synergies impacting our G&A and our EBITDA, or theoretically, would most of it already have been finished?
Well, good morning, Stella, and thank you for the question. As I mentioned previously, some lines will have more maintenance in these gains. For Procurement, we could have maybe some gains marginally, but we're already consolidating this and performing joint purchases. When it comes to general management expenses, we do still have some opportunities to reduce this. Not everything will be reflected in the balance sheet of the controller. Some could be reflected in the balance sheet of the actual company. So in Uberlândia, we still haven't performed full integration. We do have opportunities for the growth in Premium and Goiânia. We also have an opportunity to be more robust and dilute some costs.
But we do continue to move along in our major operation, which was November 2021. When it comes to Porto de Galinhas, this is an important result in our balance sheet. We've already reached most of our synergies, and now it's just about doing maintenance on what we've been able to achieve and also some other gaps or points where we have some occasional issues that we could have in the units I mentioned. AMAC did change the system this year, and so we can notice certain things we haven't noticed before. These are things that consider the significance in the overall results of the company, and it's not just a number that will make such a difference. What will change is our day-to-day work with improving our processes and everything Dr. Henrique had mentioned.
It's really small day-to-day work, but the biggest challenge is in the revenue, the growth, the ticket, and the registration so that we can have a greater robustness in the units that were acquired.
Perfect, guys. Thank you so much. That was very clear.
The next question is from Caio Moscardini from Santander.
Hi, guys. I wanted to have your guys' vision on the performance of the revenue from private hospitals. You had said 71% year-over-year. I want to understand if this performance is due to a different mix in the hospitals you acquired over time and/or if this has been maybe a greater search for patients that had health plans before and then now, due to the super high adjustments, had to cancel and had to perform the payments out of pocket. I just wanted to get a bit of this dynamic. That would help a lot. Thank you.
Thanks for that question, Caio. It's actually interesting because in this report that Dr. Henrique brought from ANAHP, the National Association of Private Hospitals, we can look at the pages. But there is an analysis of the profile that has changed a lot in the big hospital groups, especially in the sample we have. We've seen growth in the private front. Maybe this is one of the points you're mentioning. But in our case specifically, although there was nominal growth from a strategic perspective where you have a change or a shift that is perceivable, we don't consider that to exist. But we've been handling that very well. We do have some hospitals that still rely on private services a lot with Goiânia, for example, due to the structures in the health plans.
But we haven't had a big change in the company's core. But it is an important customer. We've had revenues related to this. So if this person is not covered by a certain service, we charge private fees for that. So this kind of service is something that we are very careful about to be able to give them an answer when their health plans don't cover everything, right? So your point, of course, we've seen a small variation in a negative way in the amount of health insurance companies with some downgrades, and this could reflect in some way. But we're going to keep our eyes open to this point. In the next quarters, if we do notice a shift in behaviors, then we can highlight this better in the presentation.
Well, Caio, I think the idea from a strategic perspective is that you want to differentiate the level or standards of services at Mater Dei in the markets where we are, so that eventually, when you look at mid to low risk or complexity patients, even though they don't have the actual health insurance company registration that gives them the right to use Mater Dei, they'll end up using the out-of-pocket services. So we've noticed this, for example, in maternities here in Belo Horizonte. So a lot of patients actually ask for an upgrade in their bed or service. So it's like a whole other niche of patients or business niche. A business inside a business that's greater. We've been keeping our eyes open in the different markets where we are.
Okay, perfect. Thank you, guys. Very clear. Thank you.
Our last question is from Marcio, from Bradesco.
The first observation about the receivables is if you could mention the increase in the non-payment rates that considers the ticket. What would be the level you expect for improvements when you consider this number in the first quarter, normalizing the payment terms? What do you think would be the level you expect up ahead? When it comes to complexity, you did mention there was a seasonal aspect from January and February. Could you maybe let us know if in 2023 these effects were worse than what they were last year? If you take a look at the metropolitan region, would you be able to compare the fourth quarter maybe with the first quarter this year?
If you could share what would be the increase of the ticket when it comes to complexity, especially when you consider the March versus January and February, so that we can get a feel of how we would recover the ticket, just to consider the complexity in the second quarter. Last, I don't know if you guys mentioned, but how many beds did you guys open in Salvador? Do you already have a perspective considering the opening of the hospital center?
So these are the last questions for the second semester in Salvador. Maybe you can start with a question about Salvador that's more objective. Okay. So I'll start off with your question. We are reaching 100 beds in Salvador that are operational.
There is an expectation to open up in the next quarter, more beds, that we have noticed some occupation in some of our areas that are close to 100%, which is not good, and that really makes us need to keep our eyes open as we open up more beds. We have another structure also of nurses that are registered and pre-interviewed physicians as well, to take on more beds in the neonatal ICUs, pediatrics. In Salvador, we notice an increase in production. When we consider the interest of the patient and some agreements also with health plans that have allowed us to increase this production in the hospital. Now, when it comes to receivables, in your report, you do highlight this in the cash cycle, where we can notice the receivables about 120 days, according to your calculations, and now we have 114.
This assessment between 105, 125 days, is a variation between when you are closer to the lower hundreds, we are at a really good trend controlling our accounts and the speed in the cycle. When it gets closer to 120, then it is already like a yellow light in the company. We are kind of in between this. We have some internal work. There are some points that are more internal, and we are kind of keeping an eye open so that we can extend this to this revenue aspect.
About the complexity, which was this question. It was really broad to answer so specifically. There are so many different effects. It is not so direct. Even in a metropolitan region, if you go a year back, we have seen that we have already experienced some COVID crises. This year we have dengue as well in Uberlândia.
They also made our hospitals really full. We have been experiencing a moment where trying to compare things simply, we would have to include a whole conversational session to include what is working on in the hospital, to understand what the trend is. From a strategic perspective, we have the internal objective of increasing complexity.
We have been going after clinical teams, improving the structures of the hospitals and our surgical plans, so that we could bring in this increase in the average ticket that could come through the value for the operator, which procedures we have been working on. We believe this is really our objective as we acquire the new hospital. When it comes to Belo Horizonte , this is constant work we have been doing, and we have been able to attract new physicians. We have been able to see how Contorno is really a leading player in this.
Another point I want to highlight is that in this call, one point we discussed was the issue with private patients. I did mention also the medium and low complexity patients. Our hospitals are general and multi-specialties. There are opportunities to attract new clients and in different segments. We are not really losing this potential or this opportunity. There is some work with the users. The third is the clinical team, to be able to attract different segments and really increase our revenue base in our hospitals.
Got that. Well, just about the non-payment rates. Maybe in the increase of the receivables, did you also notice an increase in the non-payments in the first quarter compared to the fourth quarter?
Well, the non-payment is basically what we already mentioned in the other earnings release. The payers have been more careful in the contractor aspects, and we've performed some necessary adjustments to keep this. We haven't noticed these additional charges, and this scrutiny has already been a trend in the last few months. We've been keeping this up and we've been adjusting this in our operations so that we can have a really good structure, not lose any working capital.
Okay. Thank you.
No other questions? I just wanted to thank you all for your presence and say that we are available in our channels, by email, video calls, and in our conferences to talk to you and clarify additional questions. We want to thank you all for your presence, and we'll meet in our next quarter. Okay? Dr. Henrique, thank you so much for your presence. Thanks, guys.