Good morning, everyone. Welcome to the Earnings Call of the Fourth Quarter of 2021 of Rede D'Or São Luiz. We have here with us Mr. Paulo Moll, President. Otávio Lazcano, VP Financial. Maurício Lopes, VP Executive. Rodrigo Gavina, VP of Operations. We have the Medical VP as well. This will be recorded and will be available at the Investor Relations website of Rede D'Or. After the presentation, we will do the Q&A, and we will continue. Before we start, we would like to clarify that anything that is said during the earnings call regarding the business perspectives of Rede D'Or São Luiz projections, operational goals, financial goals, are based on beliefs of the board of directors, based on information that is currently available.
Any future financial situations, operational results, they are involved, forward-looking statements are involved, depend on many factors and situations that might not take place. Investors have to take into consideration that many operational factors can affect the future development, performance of the company and might lead to different results. Now, I would like to give the floor to Mr. Paulo Moll, and he will start the Q&A. Mr. Paulo.
Good afternoon, everyone. It is great to be here. We have the year of 2021, a lot of growth and operational results. We have a lot of assets in the first semester. We have the first semester here. We have been growing 32%, and also we have an occupancy of 45%, and this is in line with the historical records of the company. We are getting great results.
We have 17 M&As since the IPO, and we have 2,200 beds, including the entry of four new states. The integration process. We concluded the works at the Maternidade Star in São Paulo, and the expansion of Hospital São Luiz Osasco, which should be operational soon. We also have 40 different projects under development and an entire team in that sense. We have our ESG, we have the best practices. We have the annual sustainability report, edition 2021, that will be published. We would like to highlight that we earned the Empresa Sustentável, the award of sustainable company by the Chamber of Commerce, Industry and Services of Brazil. We have invested over BRL 300 million in fighting COVID-19.
We also increased 60% the amount of intensity in the reduction of the greenhouse gases, going over 48 hospital units from 48 units in 2020 to 78 units in 2021. The association with SulAmérica. April fourteenth, the shareholders of both companies will deliberate the agreement. We have a great admiration for SulAmérica. This is a company that is over 127 years old, and it's a great process. Great historical partner of Rede D'Or. It is something, in our opinion, that adds value to both companies. We have a combined revenue of over BRL 40 billion. It improves our investment capacity. The strategy of growth of Rede D'Or does not change. We have 300 different healthcare plan operators. In the same way, SulAmérica will have their own relationship with the market.
The companies work in similar geographies. We will comment this thereafter. Also with a lot of joy, I wanted to highlight that after the approval, we are going to have new members of the board of directors of Rede D'Or. We have entrepreneurs that we admire deeply, and it would be great to have them here. Also, we will remain in the new business, and this shows the trust that we have in SulAmérica and they in us. We have a great knowledge of the healthcare sector here in Brazil. We'll be available for Q&A. Now I'll give the floor to Otávio, and he will talk.
Thank you, Paulo. Thank you once again. Good morning, everyone. Well, let's continue with the issue SulAmérica. We know the combination of business, and you understand that we are in a process that is undergoing that contemplates the approval of shareholders.
Before we have that executed and concluded, we have to go over all the stages. That's why we are adopting a very conservative communication system. We are talking qualitatively about different areas. Then we will continue with the analysis, and we can talk about data on synergy and financial values. We've seen several areas where we can generate synergies for the shareholders of this expanded company. An area that is very obvious is the use of the capital structure of the expanded company in such a way that the company can use real estate assets to you know release cash. SulAmérica has their capital requirements for their own business, of course. Another area to start these synergies is the reduction of transactional costs between the companies.
The third area is the debt reduction with the—Since Rede D'Or has a capital structure that is very conservative, has our subordinated capital costs very well worked, the indebtedness is very diluted. SulAmérica is cash positive and has generated record numbers that are very good and will contribute to the expanded company with a significant EBITDA, and this will allow us to reduce indebtedness and net leverage of the combined company, so we can capture other opportunities for investments and accelerate investments and/or distribute dividends sooner for the shareholders without any impact to the capital structure for the combined company. Well, one of the big strengths is the procurement, the negotiation with hospital and also the purchase of medications.
We will have synergy with this procurement of SulAmérica standalone. Another area is the acceleration of reduction of risk and the project of the organic growth, notably the greenfield projects. Last but not least, we imagine that we're going to have administrative savings and fiscal and tax efficiencies that invariably the combined or expanded company will capture more benefits for our shareholders. I'm on page six, the operational indicators. This page should be analyzed together, but one important message is that even though there is a seasonality in our sector with a fourth quarter that has had great results, and this company hasn't had any negative aspects here in its leverage. Let's start with the graph. On your left, we've had a record number of surgeries in 2021.
107,000 surgeries, a growth of 31.7%, and that's an increase of 31.7% in regards to the first quarter 2020. Also, year-on-year, we had an increase of 35% in total surgeries for the company. This is a second record. This is a record for the company, and this is evidence of the strength of our relationship, the quality of our collaborators, of our personnel, and the technology that has implemented in our units. On the right, you can see the same information in the concept of same hospital total surgeries. On page seven, still operational indicators. Start with the left. The company reported an average rate of occupancy of almost 76% in the fourth quarter, above the historical records for the fourth quarter over the last 5 years.
The company reported in volume, patients per day, we have 616,000 patients per day, an increase of 7.2% in the number of patient days. This is quarter-on-quarter. This is a record of the company, 590,000 patient days. Once again, patients related to COVID, also a second historical record. On the right, we have the annualized data, the occupancy rate. We can see in 2021, so 9.3%, a growth of 32.4% in the volume of patient days versus the FY 2020. Next page. We show you the update on the COVID data. The company once again has had operational competencies to fill in the gap of the COVID patients, the daily COVID patients. We have a record number of surgeries.
We have a record number of people going to our emergency rooms. Over 2.1 million services provided at the emergency in the first quarter of last year. 2021, we've had 55,000 COVID patients. In the pandemic, since the beginning, there were 80,000 hospitalized, and there is an average length of stay in our units from 6.4 days in 2020 to 7.4 days in 2021. Next page. As always, we will start with a graph on the left. The company reported at the end of the first quarter 2021 operational beds. We have 8,946. We have an increase of 29% in regards to the third quarter 2020.
This increase of operational beds, if you look at the total number of beds, yes, we had, an increase in the total number of beds for the fourth quarter with the conclusion of the acquisition of Nova Iguaçu. The deliveries of new, hospitals such as Maternidade São Luiz happened, in this year. As Paulo Moll has said before, this is consistent with our M&A strategy, but an addition of 2,200 total beds through 17 acquisitions to the portfolio since the public offering in December 2020. Let's get to the economic data. Let's start on the left with gross revenue. Fourth quarter 2021, the company reported BRL 5.7 billion, an increase of 22% when compared to the same period, fourth quarter 2020. If we exclude the M&A effect, it's a growth of 14.2%.
The ticket increased 1.7%. The number of patient days increased 20%. At the center of the page, we have annual data. The consolidated gross. We have BRL 22 billion ex M&A with an increase of 35.3% in comparison to 2020. The average ticket of 2021 increased 9.1%, and the volume increased 32.4%. The IPCA of 2020 accumulated 4.52% and the IPCA in '21 accumulated 10.9%. The evolution of the average ticket in the FY 2021 is completely aligned with the methodology of pricing that the company has implemented for the financial community since its IPO. I think our contracts are non-negotiated at the end of a fiscal year. The adjustments are negotiated all throughout the fiscal year.
We have statistical effects that we can apply to the methodology, and that's why my affirmation, as you can see, that the increase of the average ticket is 9.1%, and that is aligned with the methodology that was communicated by the company for the financial community. Also, the fourth quarter of 2021 versus the fourth quarter of 2019, the average ticket increased 11.7%. In comparison to the fourth quarter 2019, we managed to isolate substantially the effects of the pandemic. Facing the third quarter of 2021, yes, there is a drop of 1.9% in the average ticket. However, we've had the maintenance of the level of complexity within our units, the operational costs very strong. We have the complexity level because of a drop in the ventilated ICU patients, and that's stable facing the numbers of the first quarter 2021.
Data on oncology. Oncology had a slight without M&A, just organic growth. The gross revenue of the fourth quarter of BRL 486 million was 31.4% higher than the fourth quarter revenue for 2020. If you go to the middle of the page, annualized data, the revenue, BRL 1.8 billion in 2021 was 30.3% higher than the one for 2020. The average ticket increased 13.2%, and the volume increased 15.1%. Once again, organic growth without M&As in the oncology area. Next page, cost and expenses. As usual, let's start on the left. Costs that are higher than BRL 4 billion for the first quarter 2021, 29.4% higher than those reported for the same period of the first quarter 2020.
Year-over-year, cost of provided services, BRL 15.6 billion, 35.9% higher than those reported for FY 2020. There is the impact of COVID, higher volume of patient stay, increase in the operational beds, and the expansion, et cetera, of oncology justifying this increase. On your right, we see data on general expenses and administrative expenses. It seems that there is an increase of 88.2% in the fourth quarter of 2021 when comparing to the fourth quarter of 2020.
When we look at the necessary adjustments to compare apples and apples, oranges and oranges, and considering the provisions for the FY of 2020, they were done actually in May of that FY 2020, and the provisions for the payment of the profit sharing for the fourth quarter of 2020, we are absolutely stable with the administrative expenses of the company in the fourth quarter of 2021 when you compare it to the same period of FY 2020 year-on-year. Also, in the same way, it seems that we have an increase of 27.5%. When we do the same adjustments to allow comparison of apples and apples, we can see that the increase is just 15%, even though we presented all this growth in the company.
The EBITDA reported for the fourth quarter 2021, BRL 1,261.5 million, an increase of 24% when you compare it to the fourth quarter of 2020. A margin of EBITDA of 24.6% year-on-year. EBITDA of BRL 4.9 billion, a growth of 97% facing the accounting EBITDA on the previous FY, a margin of 24%. On your right, data on the adjusted EBITDA. The company reported in the fourth quarter of 2022, BRL 1.285 billion, a margin of 25%. In monetary values, a reduction of BRL 230 million of adjusted EBITDA if you compare it to the third quarter of 2021. This is due substantially to a reduction of expenses, extraordinary expenses with COVID patients.
BRL 173 million in the third quarter of 2021 to BRL 78 million in the fourth quarter of 2021. On your right, annualized data, adjusted EBITDA, BRL 5.7 billion, a historical record for the company. A margin of 27.9%, a growth of 79.2% if you compare it to the EBITDA adjusted for FY 2020. Net income, we have for the fourth quarter 2021, BRL 419 million, a growth of 38.5%. If you compare it to the same period last year, we have net revenue of BRL 1.7 billion, 265% higher than the one reported for FY 2020. Next page, we can see on your left the management operational cash flow reconciliation of the company.
Let's start with reported EBITDA, accounting EBITDA of BRL 4.9 billion. We have the variation delta of the working capital, BRL 2.2 billion. This is growing as the company grows at 44%. The top line grows 44%. We have the other balance sheet items, BRL 15.6 billion. We have leasing, BRL 568 million. We have the taxes, BRL 356 million. The operational cash flow, BRL 1.7 billion, a growth of 75% if you compare it to the FY 2020. I wanna bring your attention to the fact that over the last two years, the company invested in M&A, in growth, organic growth projects over BRL 7 billion, almost eight.
As we incorporate the synergies, and here I'm talking about all the M&As, and as we go through the process of ramp up of all the projects that are related to the organic growth, obviously, we are going to have an exponential growth in the operational cash flow of the company. On your right, we have the average days of receivables, days of inventory outstanding, and days payable outstanding. At the end of 2020, we had 120 ADR, 54 DIO, and 42 DPO. We can see that the system has a lot of a higher loss, and it's natural that we have these losses of cash flow. The credit risk for our counterparties.
Our accounts receivable is as good as we can get here in this country. All of us have banking relationships with the paying parties. These are our historical rep partners for our company. This is actually an opportunity in the sense that COVID paved the way so that the company can have 20 days of cash flow in-house. Last page before Q&A. Let's talk about indebtedness. Here on the left, we have the gross debt to 25 billion reais, three years. We don't have a tolerance for exchange rate. We have. We always work with reais, so in the same way. The company reported the cash and cash equivalents, 12.5 billion reais. Net debt, 12.6 billion. Net debt over EBITDA 12 months, 2.6x.
In the middle, we have the indebtedness of the company. We are lengthening our horizons, and we have opportunities. Over the last year, we increased the deadline of the company, and we reduced the capital of third parties of the business. In the middle, the company hedged partial protection for this interest rate that is higher here in the country. We have over 30% of our net debt fixed. These are credit lines that are on the timeline of 2026 and 2029, and we have 7% in reais. Here is the debt amortization of the company on the right. I will close here. Obviously, it will be my pleasure to receive your questions.
Thank you. We will now start with the Q&A session.
Eugenia Cavalheiro from JP Morgan would like to ask you a question.
Hello, Paulo. Hello, Otávio. How are you doing? I have two questions, actually. The first one has to do with the average ticket. You were saying in the release that it grew around 2% if we're looking at the quarter. We wanted to know how the acquired hospitals had an impact on that number and what we're going to see in terms of the ticket and also related to the inflation. Otávio was talking about the synergy that you have with SulAmérica.
We wanted to know if you have an idea of how much the total is going to be for you to integrate that new asset.
Thank you for the question, Eugenia. Well, about the average ticket, we would say that the methodology that we communicated to the market in the IPO and after the individual interactions with the investors and after the follow-up, they're the following. The average ticket is going to grow 1% more because of the spread, and we believe that it's going to be 4%-5% more because of other services that we have in terms of diagnostics and also oncology. We capture more complex cases as well. We believe that that's going to apply for all of the hospitals as a whole, really.
That's the rule for us, for analysts, for investors or potential investors of Rede D'Or so that they can model everything the right way for the company. We know that this is a conscious decision of the company to have financial sustainability for the system as a whole and to be market leaders, and it wouldn't be possible in a different way. This pricing methodology is going to generate some good, solid financial results, as we've seen in the financial demonstrations that have been shared. This is going to be very sustainable in terms of growth. About the synergies now, Eugenia, there is an ongoing process right now that has approvals of shareholders. We already have a few shareholders meetings that are in the agenda, are programmed, so that we're going to obtain approvals. We're going to conclude the transactions.
Right now we're talking to the market about the areas where we see potential synergies. Right now we're getting ready. We're creating some analyses, and we don't want to create any frustrations. I mean, we don't want to underestimate any synergies. We don't want to communicate anything the wrong way to the market or before its time. If you allow me, about the ticket, I just wanted to say that it is very difficult for us to have a good comparison of the ticket during the pandemic. I mean, if we think about what happened in the first quarter, the second quarter of 2021, it is a very different scenario. It's not the usual.
In the fourth quarter of 2021, maybe we should start to compare it from there, against 2019, but it's still a change of around 12% in terms of the ticket. But anyway, that would be more of a comparable thing in terms of number of patients, use of intensive care units, et cetera.
Excellent, Paulo, Otávio. Thank you.
We now have a question from Yan Cesquim from BTG Pactual.
Good afternoon, Paulo. Hello, Otávio. We have two questions, actually. The first one has to do with working capital and receivables. I think what Otávio said makes it clear that we have certain deadlines for receivables. The question is: do you see things resuming in the first semester of this year, or do you think it's going to be more of a gradual process?
Also we wanted to know about the expenses reduction for 2022. I mean, how is it in terms of expenses? What is being done to compensate inflation in this sector?
Thank you for those questions. Well, let's start with the working capital. As Otávio was saying, in 2021, it is true that with the increase for different suppliers, we had a few negotiations. We had a change in the number of days of accounts receivable, and we're working now to go back to the usual numbers. We know that in the beginning of 2022, there was a certain stability. Now, after the second or third quarter, we want to have effectively a reduction in the number of days. What we see is a change maybe in trends, but a certain stability still.
We'll try and have that optimization in 2022. Now, in terms of management of expenses, we've been working to standardize things. We've been working in that regard. We have an important project now that is called Compartilha. It's a project where we're trying to join different support areas. We're looking at best practices, basically, to try and make sure that we're going to have a better outcome in 2022. There is one more thing that I could share with you. In terms of supplies, medications, we did indeed have an important inflation. It is true. Some of these items, they were affected. We needed to see standardization. We had to review many processes. I believe that it's been complicated to think about those trends, and we already see a few processes or transactions that we implemented last year.
In terms of stock, we know that things are more expensive right now, and we hope we're going to have good news in 2022. Anyway, we want to go back to the usual trends. We have good perspectives that we're going to be able to do it.
Excellent. Thank you.
Now we have Gustavo Miele from Goldman Sachs. Actually, it's Fred Mendes from Bank of America.
Hello, good afternoon. Well, we understand that you cannot share a lot of information on this right now, but I wanted to know more about the integration. How do you see this strategy with the assets? I mean, are you going to change anything in terms of operations, or is it going to be more of a subtle operation focused in the short, medium, or even long term?
Also, when we think about M&A, in 2022, you were saying 500 more beds, right? Which is a third for what we have in this year. In the past few months, we haven't seen many announcements, so we wanted to understand more about that. In terms of SulAmérica, did that have a good impact or any kind of impact in that regard?
Thank you for that question. About the strategy with SulAmérica, we would say that we still have 300 operators that we work with. As for SulAmérica, we see a lot of opportunity for growth for this company. I believe that it is a very strong brand. It is both organic and inorganic growth, so we're going to see that change in the business model. We're going to try and have a better interaction. We're going to look at cooperation.
We're going to look at better payment models. SulAmérica and Rede D'Or will try to bring more responsibility to this sector. In terms of care and all that, and payment for the sector, we're going to be more sustainable. It's going to be a task of Rede D'Or to take this kind of practice to all of the operators.
This is an association that, on the long term, we are looking at sustainability and the relationship of the companies with the stakeholders. This is the way that we face this, strategic alliance. The other part of the question, could you just repeat it? Sure. The M&A part, Paulo. Well, you already talked about the 2022 in regards to the year. It's very strong. Over the last few months, we didn't have that. Well, the operation of SulAmérica had some impact in the hospital. No. There is no impact. It doesn't change our M&A strategy, the organic growth strategy. M&A, you have a pipeline. We depend on the dynamic for the negotiations. We have to be careful. When we look at the records. This is part of the dynamic and the maturing of the negotiations in the pipeline.
There is no influence of SulAmérica in our M&A strategy.
Thank you, Paulo. Very clear.
Next question comes from Gustavo Miele from Goldman Sachs.
Good afternoon, Paulo, all the directors. Thank you for your presentation. Two quick questions here. First, I wanted to hear you in terms of oncology. It's something very interesting in regards to this. Paulo already mentioned this. It's interesting that the interesting performance here is due to price. The paying parties in this beginning is doing well. How do you think that the solution of oncology that is different from the other players in the paying parties? And do you think that as the company is ever more vertical in the oncology service, can you gain some more traction here?
Do you think that verticalization and if the protocol is well-defined, it will make you get more market share as time goes by? I want to understand how this is tied with the business. Second question, I wanted to talk about two points that were already highlighted. The working capital. When we do a deep dive in the analysis, we have volatility that is lower, and you already commented on the dynamics. When we look at the working capital, the days here for paying subcontracted parties is decreased. Has this happened because of a decrease in price or the variables do not talk amongst themselves? The pressure on service providers, is it different? The strategy of oncology, verticalization protocol, and this mat-med cross dynamics . Oh, thank you.
Gustavo, I will start with oncology and the second part of working capital, and I want you to comment this. We can see that there is an important growth in oncology. We will have an organic integration here. We will have the services in our. This is the big differential. We have the oncology services and chemotherapy, surgery, interventional radiology. This is the big differential that we offered. Under the leadership, we attracted in all the states where we acquired hospitals, we assembled services. We have reference services. There are reference services in, their cities and their hospital services. There is a great differential in the quality provided. In the context of oncology, and it also differentiates a hospital because we can do complex surgeries.
There is an expressive organic growth, and we understand that we want to explore this better. We can grow our services connected to hospitals, adding more oncology professionals. This has been the best strategy. About the average ticket. This is a dynamic of oncology, in and on itself, and this is the area of medicine that we have the most launches and investments in the industry. This has impacted in the fact that the tickets for the new medications, they still are higher, the prices, than the previous drugs. In the context of oncology, we are working with the operators to have standardized protocols. We have Paulo Hoff, where we discuss all the cases with all the units in Brazil, and we have the capacity to offer well-defined protocols. Obviously, looking at the indicators.
Well, let me go to the second part of the service providers. Wonderful. Gustavo, Paulo. Well, Gustavo. The company has a capital cost of subcontracted parties that is very low, and certainly this is due to how we work with our service providers. We have a shorter payment deadline because it's convenient for us. Obviously we use those commercial levers to have a reduction of price per item or product or that is provided to the company. For example, at this moment, the company has an average indebtedness rate of 6 years of CDI plus 7. My cash flow 0.7%.
My cash investment has investments in the fourth biggest country's banks in the country, and I don't have negative carry in the cash that I have invested in the company. It's convenient to us to use a shorter deadline, therefore, because certainly we have subcontracted third-party capital cost that is lower because of the way that we work with our service providers. Year-over-year, this is dropping.
Clear. Otávio and Paulo, thank you.
Well, the next question will come from Vinicius Figueiredo from Itaú BBA.
Well, thank you, everyone. Now working with a few colleagues at the beginning of the call, with the tickets of the acquired companies. Well, how should we imagine the strategy of taking more complexity and adjusting this to the hospital?
How is this done in the hospitals that you acquired recently? Another point that I wanted to talk about is about normalization. When you look at occupancy rates and emergency, 2022, do you think that it will be easy to work with a year that is more like what we observed pre-pandemic? If I may, also in the part of costs, specific costs. I wanted to actually better understand the dynamic for the subcontracted parties, because we've seen that this number is in a higher standard in the results of the third quarter. I wanted just to understand what is the base number that you're using looking ahead, so we can model this better.
I am going to start with the first part of the question, Vinicius, about the integrations. We know that things are gradual, and that's going to depend on the profile of the hospital. There are a few hospitals we really have to invest a lot in infrastructure in some of them. In some others, we already have a very modern infrastructure. We don't really have to worry about, I don't know, electricity and some other types of infrastructure. In that case, we can have a different cost of investment. In every hospital, we also look at NPS, we look at other indicators. We really try to have good indicators, good outcomes. We have a certain average that we want to achieve for NPS.
For every opportunity of cost reduction, we really want to look at the right integration of our shared services center. We want to also implement the right systems, the HIS, as we call them. There are a few things that we can do, and in approximately two years, we're able to implement all that usually. We have a good improvement in terms of EBITDA usually. We have a six- or sevenfold increase in that regard usually. We are observing good trends in terms of margins in all these hospitals. Because of course, when you improve the NPS, you're going to have some additional advantages as well. The idea is to have all those negotiations with the hospitals. Usually these things are established or pre-established by Rede D'Or, and we follow that profile. It's a specific process that we have that involves technology.
We look at complex surgeries. We try to improve the ticket. I know, I mean, it is all part of our strategy. We try to renegotiate everything the best way possible, and we can also invest in things that are more complex when we do that. Now looking at patient profile, I would say that we start to see a specific profile for the ER. We also have that for intensive care units, complex surgeries. It's probably more similar to what we had before the pandemic right now. We're already controlling that, just like what we did in 2019. We have a good follow-up on the EBITDA as well. There is nothing that indicates any changes in the trends or in the profiles right now.
It's true that we had a change in the number of cases with Omicron, but we didn't have a huge increase in hospitalized cases. Now, I'm going to turn it over to Otávio to continue to respond to your question.
Well, yes, I just wanted to complement a little bit. When it comes to complex surgeries, within the total of surgeries, we know that it is a very similar level to what we had before the pandemic. So when we think about people with ventilation in ICUs or people hospitalized in an ICU, we know that the indicators and the numbers are really similar to what we had before the pandemic. Anyway, I just wanted to say that. Also on third-party services, well, that's important.
It's important to think about the honorarium, I mean, the fees that are paid to professionals, to HCPs. We have a huge number of surgeries, and we also have to think about the maintenance and the complexity that we have in our facilities. Here I'm thinking about the third and the fourth quarter and the seasonality. The idea is that that line and the cost structure is going to present fewer opportunities for cost reduction.
Excellent. Thank you very much for the answers, Paulo and Otávio.
You're welcome.
Now we have a question from Vinicius Ribeiro from UBS. Hello.
Good morning. Good afternoon. I think my question is also connected to the previous question and also gross margins. I was thinking about the number of surgeries, maybe if you have observed a change also in the number of HCPs.
I mean, you were saying that the gross margin also changed because of COVID-19, the number of beds, and also the projects with oncology. Maybe if you could detail a little bit on what variables are the most important here and what we can expect as well, so that we can understand what the level should be for 2022. Also another question here has to do with SulAmérica. Two questions I would say. That might be simple. The first one would be. What motivated that in this specific moment? Did you see any kind of opportunities or anything that's part of the strategy?
What is happening to the strategy here, to the rationale of maintaining this, if it's going to be reassessed or not?
Let me answer about the gross margin and then I'll leave Paulo with the second question. In terms of gross margin, we see two opportunities to improve the results of the company in 2022. We had a few comments on costs, on supplies, equipment. It's really difficult to say. I mean, with the number of hours, the dedication of HCPs, of other professionals looking at this issue from the beginning of the third quarter last year until now. There were a few changes in percentage points for the margin. We were successful with the negotiations. We're looking at thousands of suppliers or service providers as well implied in all this.
I think it catches our attention because we have a certain redundancy to our operations because of the pandemic. Let me give you maybe an extreme example, but I just wanted to make this clear. If we look at the number of patients who were COVID-19 and non-COVID-19 patients, the frequency of use of certain items for, I mean, individual protection equipment and all that, since this is more endemic and not so much a pandemic anymore, this is changing broadly and going back to the historical levels that we had before the pandemic. About the second part of that question about SulAmérica. We are very excited to be working with this very important brand when it comes to insurance, to healthcare insurance. We know that SulAmérica is one of the strongest brands right now. It is focused on health.
I think it's a very good transaction, very attractive thing. Yes, extremely interesting to have this connection with SulAmérica. It's a great synergy, and I'm sure that we'll be able to share more details with you soon. We were saying that we are focused on sustainability for this sector, and I believe that this acquisition is in line with this long-term strategy. We want to have more people accessing good quality healthcare services. Since we have this operation now within the group, within our network, this is going to represent great evolution in the way we are adding value for our patients and also adding prevention, because in terms of our mission and our vision, that is going to help fulfill our goals with SulAmérica. I think we're going to be able to, you know, take this to the market and address those concerns that we had.
We want to evolve our connection with other operators as well, with other suppliers as well. We want to have more sustainability and better access, as we were saying. As for the investment, we are not controlling the company. I mean, there are some other different situations of investors that already have an investment in healthcare companies. We understand that we're going to continue in the shareholders board, I would say. Okay, excellent. Thank you for that.
Next question will be from Mauricio Cepeda from Credit Suisse.
Hello, everyone. Good afternoon. Thank you for the opportunity. I have a few questions. I am going to go back to the receivables, but as Otávio mentioned, part of the increase of the receivables is to decrease the liabilities, and this is a point that there might be a trade-off in tickets and the negotiation of the rates. I want to know if this is true and if there is an opposite risk. As you remove the shortened deadlines, the healthcare plan operators, they might also have cheaper tickets, I should say. The second question, I think that Otávio said that there is an opportunity, the medical honorarium is low. I wanted to talk about a point.
We have more complexity in the procedures, not only to increase the ticket, but we can also increase the margin of the procedure. I wanna know if this is true and if the margin occurs at a higher level to the point that you can open spread. Whether if it's medical honorarium or other items of this, of the purchase. Another question here is, how are you working with the statistics of the patient day in the day hospital? Strategically, how do you want to face the opportunities for the procedures and compliance?
Let me start here, Cepeda. After, and then thereafter, Otávio can complement. There is no negotiation, no correlation with the deadline because of the COVID audit issues. We have it involved in a few discussions, but as we commented all throughout 2022, we have this normalization, but there isn't a trade-off.
This involves tables, commercial discussions for the receivables. About the point that you were mentioning about the medical honorarium. We have a fixed installment and a variable installment. The honorarium surgery, we have the pass-through for the charging of the operators. For example, the surgeries, we are doing the variable. For the medical honorarium, we have the teams, emergency teams, intensive care units. Here for COVID, specifically in our emergency rooms, we have the structure, and we have a loss of efficiency that is completely separated. We are going back to our pre-pandemic reality, before the pandemic, and we hope to continue here. We have the patients that are working with a series of hospitals for this type of patients.
We have less complex surgeries, given that our hospitals offer that type of structure, and we have our numbers. I will let Otávio continue with the answer. I believe that we have 115% being transparent.
Thank you. Now, with the increase of complexity in these, we could have a larger margin even with the variable component. The variable component tends to follow up on the revenue and the fixed part, we have an operational leverage.
Thank you very much.
Our next question is from Ricardo Boiati from Banco Safra.
Hello, everyone. Another follow-up in regards to the association with SulAmérica. Let me actually do very direct questions. Do you have a predictability on the approval, regulatory approval that the companies depend on the timing in regards to this M&A?
The second question in regards to the long-term strategy of the company in that segment of insurance. SulAmérica has a position that is very good, very differentiated, but when we do a parallel with Rede D'Or in follow-up with the hospitals, SulAmérica is very far away to have a dominant position in the sector. My question is the strategy long term of the company of seeking that leadership and costs and organic growth movements, what is the ambition here in this new area of work of the company? Last but not least, also associated to this issue, we are seeing the consolidation that is accelerating in service providers for the medical and for the hospital sector and insurance. What is your opinion in regards to the future of the sector, healthcare sector? Less players, they are ever bigger.
How can that change and impact the competitive environment of the healthcare sector looking ahead to the future.
Let's do the following. We can work with other operations that are similar. It's very difficult to get a specific date. It depends on each regulator. But we imagine we hope to have these approvals within this year. About the strategy of growth. SulAmérica has had a lot of success in acquisitions, M&As. We also have several players that we admire. Once we approve, we hope that we can strengthen the dynamic for the growth of the company and its efficiencies. Well, about the sector becoming larger, I mean, with populated with larger groups, it's easy for you to have scalability, bringing efficiencies. If you spend more time, we are going to see a reduction in the number of operators in Brazil.
There might be some delays, but we have the same dynamic. Brazil is still a country of small hospitals. The average in Brazil is 60 beds. We understand that these are processes that will continue and that will be repeated. As you have larger players and with more scalability, you're gonna have more efficiency in the healthcare sector. We have costs and capacity of having protocols for the control of quality indicators. Once again, we are following up on the path of what is happening in the world. Brazil is also moving along this path.