Good morning, and thank you for waiting. Welcome to the earnings calls of the third quarter of 2021 of Rede D'Or São Luiz. We have here with us Mr. Paulo Moll, President. Otávio Lazcano, VP Financial and IR. Mauricio Lopes, Executive VP. Rodrigo Gavina, Operations VP, and Leandro Reis Tavares, Medical VP. This event is being recorded and will be made available at the website of Rede D'Or. After the initial presentation, we're going to do the Q&A, where we will provide you with more information. Before we continue, we would like to say that any information that is said during the earnings call in regards to the future business projections, operational goals, and financial goals are beliefs of the board of directors based on the expectations of the company's management on available information. The company is under no obligation to update these statements.
It involves uncertainties and based on circumstances that may or may not take place. Economic and industry conditions and other operational factors might also affect the performance of the company, and might lead to differences in the financial statements. Therefore, I would like to give the floor to Mr. Paulo Moll. You may continue.
Thank you. Good morning. Thank you everyone for being here. I'm going to talk about a few themes before giving the floor to Otávio. Talking about our good performance. We have a growth here. In the first nine months of 2021, we invested BRL 4.8 billion in investments, a record for Rede D'Or, BRL 3.4 billion in acquisitions and BRL 1.5 billion in organic projects.
Just in the third quarter, we invested BRL 1.7 billion, and out of these, BRL 1.1 billion was in M&As. We have 43 projects in development among our hospitals and expansions. I would also like to highlight two projects that are very close to getting ready for launch. The first is the Maternidade São Luiz Star in São Paulo, and it will occupy 33,000 sq m, 22 floors, four basements, and 170 beds. These are the operational beds. The project also replaces the current maternity building that is in Itaim Bibi, right by the side of São Luiz. In that hospital, we will have another tower, another building that is under construction, and we will have it ready by 2022. This is very important for the city of São Paulo.
Let's go back to Maternidade Star. We have the standard, which is the medical technology, which is unique in Brazil, functionality, technology, and we can offer the best treatments for our patients. The other project that I would like to mention is the expansion of the Sino Brasileiro Hospital, acquired in 2015. We have also São Luiz Osasco. An expansion that surpasses 22,000 sq m, 90 beds, reaching 296 total beds. Besides this, it's very important that we can improve the emergency and diagnostics, a new hemodynamic system, and we have a technology that is intelligent for the use of energy and water. Now, let's talk about M&A. This is the important part of growth. Since October 2020, we have acquired over 16 hospitals with 2,183 beds.
In the third quarter, we concluded 3 acquisitions that were just announced. In Paraíba, Nossa Senhora das Neves, Éclair Hospital. We have Proncor in Mato Grosso do Sul, and Santa Emília in Feira de Santana, State of Bahia. In the last 2 months, we announced 4 new acquisitions. These are still awaiting the approvals pre-closing. We have Novo Atibaia in São Paulo, the Hospital Aeroporto in Lauro de Freitas in Bahia, Santa Isabel Hospital in São Paulo. Yesterday, we just announced Líder Hospital in Alagoas. We closed the quarter with 63 hospitals, 10,098 beds. Adding to the 4, we get to 67 units and a total of 10,650 beds. Now, let's look at the ESG. We don't consider ESG as something that is a passing fad.
No, this is a long-term commitment for the sector and for the country. On the social side, we are very proud with everything that we've done, and we still do fighting COVID. We have high-level services provided to millions of patients, and we have over 1,300 beds in the public healthcare system, SUS, and donations of thousands of BRL. Our investment in research has also. Well, we have our Instituto D'Or for research and teaching. We are testing vaccines and research in different things that are important for the Brazilian society. We also provide psychological support and providing the necessary assets to fight this pandemic to our employees. We have the trust that the economy will restart. We estimate 58,000 job positions to be open at the end of our projects, just the organic ones.
Very similar number for the works that are generated, for example, in real estate and all the supporting areas to build these hospitals. Environmental. We continue to do our transition to clean energy. We have an energy efficiency and reduction of expenses. 29 hospitals, and we are implementing this in many more. We also reduce our CO2 emissions, greenhouse gases in 48 hospitals. Since the beginning of the year, we signed the Global Compact of the UN, and we will continue to contribute actually to the sustainable development of this institution. Recently, we just committed to the Race to Zero, a campaign that will zero the net emissions of greenhouse gases by 2050. Now, you can see this in our Sustainability Annual Report on our website. Now let's talk about the operational part.
We have had a change in the number of COVID patients in our third quarter. From the peak that we serviced in March, we had a reduction of about 85% in the number of patients that were admitted to the hospital. Lowest level since the beginning of the pandemic. Obviously, we will continue to be alert and ready to service the patients, whether they're COVID or they have other pathologies. Now that we had a decrease, we had a record number of surgeries. We are doing this transition in a very differentiated way and very quick one. We reached 105,000 surgeries in the third quarter. If you compare it to 78,000 in the second quarter and 70,000 in the third quarter of 2020. It's an increase that's very expressive.
We had a drop in the occupancy rate of COVID to 78.4%. We have a great transition. Efficient infusions, oncological infusions, we grew 14.4% in the third quarter of 2020. I would like to highlight the follow-up that is very important for us to continue to invest and offer the best treatments for our patients. Now in the digital channels, I would like to highlight the evolution that we've seen in this initiative. We want to bring new patients. We concentrate a third of all the appointments here at Rede D'Or through the digital channels. The internet portal has 20 million accesses in the first nine months of the year. If you compare it to 9 million accesses in the same period in 2020.
We also have the appointment via WhatsApp and a chatbot that really helps for the convenience of our clients, of our customers, and also keeping their adherence or compliance higher. Also, I would like to say that we continue to evolve. This is a very important theme for us, and we want to ensure safety of our hospitals, evolution in the quality of the service provided, improving the clinical outcomes for our patients. Rede D'Or, we did the third quarter, and we did the international accreditation by the commission in São Luiz, Anália Franco, and others.
Now, I'd like to congratulate the board of directors of these hospitals and the team for this work. I would also like to say that our indicators of quality, they are improving. 8.6. In Marcas Star, 9.4. NPS, 76 point. Even with a great economic growth, we have a challenge, and we could get an excellent result and stability in this year. I'm glad to finish, and I will give the floor to Otávio. Once again, thank you very much for all the employees of Rede D'Or for their dedications, for their work. I know that you are the greatest asset of our company. Also, the healthcare plans, the operators, our partners, thank you, and our shareholders for all the support. Otávio, please, the floor is yours.
Thank you, Paulo. Once again, good morning, everyone. I'm gonna start on page 4. Paulo already talked about the changes of the environment, business environment. We can affirm that there was a change in the mix of the patients for the third quarter. We have operational results and financial results that are extremely strong.
You can see the graph here, what Paulo already commented. 85% reduction in the number of COVID patients, COVID-19, of course. Since the end of the third quarter 2021, from 625 to 400. In the next page, on the left, we can see the evolution of the operational indicators, the evolution in total surgeries. As we commented, our historical record, 35% growth in comparison to the previous quarter, so 105,000 surgeries. It's important to notice that the highest complexity 11-14 surgery is also a big record.
Having this concept of high complexity surgeries, the oncologic, cardiologic, transplant, robotic surgeries, each of these categories, they had a new historical record, a new threshold that was established by the company. To give you the complete information as usual, on the right, we have the evolution of surgeries here. We have a growth of 25% in the total surgeries. On page six, the strong operational dynamic that also here we are talking about the emergency third quarter. We had a record number of services in our emergency, more than 1 million appointments in the third quarter. Next page six. Let's start as usual on the left. We can see the volume of patient stays and the occupancy rate.
Patient day volume, you can see here that it's very stable, 625,000 in comparison to the previous quarter, and about 32% above the same period of 2020. The average occupancy rate for the 63 hospitals is aligned with the threshold of the patients. Since there was a reduction in the COVID-19 patients, we deliberately decided to convert once again common areas of the hospitals that had been transformed temporarily into COVID beds. What do we do with Hospital São Lucas, for example, and Hospital Aliança? As we are changing the significant number of patients, we converted therapies into apartments, which is a process that is ongoing. You have to remember that historically, the occupancy rate of the third quarter is always a little bit lower than what is reported for the second quarter.
On the right, we can see the oncology procedures in volume. Ambulatory infusions, 54.8 thousand procedures, a growth of 14.4%, and the same in comparison to the previous period, another historical threshold. If you look at page seven, usual. We are going to start on the left. As Paulo has highlighted, we have the evolution of operational beds at the end of the third quarter, 8,761 beds, aligned with the number reported for the previous quarter. On the right, we can see over 10,000 total beds. What I would like to say that we added over 2,000 beds through 16 acquisitions announced since the IPO of the company in October of last year. We have to affirm that the company is growing faster than we imagined.
We have the same basis of assets. It's important to mention that the company is doing several M&A operations higher than we expected, with a lot of discipline and capital and pragmatism, so we can have the best results for the board of directors and shareholders. The company has other projects aligned with the schedules, financial, budgeting. On page eight, we can see once again. On the graph on the left, we have a total gross revenue that is record, which is BRL 5.9 billion, and it's 38.9% higher than the value that was reported for the third quarter 2020. We also have BRL 17 billion in gross revenue, a growth of 54% in comparison to the same quarter over the nine months year-to-date in 2020.
Of course, we had the pandemic in 2020, and you're comparing to the year of 2020. On the right we have the revenue, gross revenue of BRL 473 million for the ambulatory oncology infusions, a value that is 6.1% and 28.9% higher than those reported for the previous quarter and the same period of the last year, respectively. Now on page nine. The graph on your left, we can see that the company has a cost of services provided of BRL 4.057 billion, an increase of 2.8% in comparison to the previous quarter and 39.6% in comparison to the same period, third quarter 2020. The expenses with the pandemic had a reduction of 18.2% if you compare it to the previous quarter.
In the comparison with the previous quarter, the biggest one is the financial services, an increase in BRL 70 million. Expenses, an increase of BRL 29 million. Materials and medications, an increase of BRL 19.7 million, as we have the change of mix of patients in our hospitals and as we add other hospitals for our portfolio. Now in the nine months, the company has reported of the provided service BRL 11.5 billion, an increase of 38.3% in regards to the nine months of 2020. A higher number of surgeries, oncology patients, and the addition of 1,800 operational beds approximately, and the expansion here of the oncology business. Now, on the graph on the right, general and administrative expenses.
BRL 229 million in the third quarter, a reduction of BRL 23.7 million or 9.4% in comparison to the second quarter, mainly due to the reduction with the staff of BRL 25 million. There was a reduction, if you remember, in the second quarter, regardless of the goals reached in 2020, the company decided to pay the profit sharing for everyone in recognition to the enormous recognition of our staff to the company all throughout the pandemic. Of course, this was not repeated in the third quarter. In the nine months, 2021, the administrative expenses, we have BRL 699 million, an increase of 15.8% in comparison to the same period, nine months, 2020. Again, we have IT services, collective bargaining agreements, systems, and the event associated that I just commented before.
The profit sharing for the second quarter and the growth of our asset base here. If you take a look at page 10. As usual, we start from the left. The company reported an EBITDA that is a record of BRL 1,256 million in the third quarter, slightly above in the second quarter of 2021, and 26.6% higher than the third quarter of 2020. The EBITDA margin of 23.7% is aligned with the previous quarters. The accumulated EBITDA in nine months, BRL 3,635 million, has a growth of a whopping 148%. Once again, the base of comparison is the nine months of 2020. On the right, we can see adjusted EBITDA and margin adjusted as well for non-recurring events.
Initially, all related to the pandemic, a highlight to the accumulated value for nine months of BRL 4.41 billion. Next page, 11. We have the net income, BRL 378 million and BRL 1.258 billion in the third quarter and the nine months respectively. Now, very important to highlight, we have BRL 74.3 million that prepayment costs. So, you know, management of liabilities, rebind the liabilities. There is a reduction in net debt of approximately BRL 200 million for the company and for the shareholders. There is a reduction there.
Such transaction had no impact in the cash flow and the average indebtedness because it was executed with the use of new credit lines with a similar debt line and a cost that is lower to the one that we had used previously. Let's look at page 12, managerial cash flow. Let's start with the graph on your left. Once again, we have the reported EBITDA accounted for the operational cash flow. We start with BRL 3.6 billion. The delta working capital, BRL 1.5 billion as the company grows strongly. Because of obvious reasons, there is here the working capital. Then there is BRL 128 million of other balance sheet items. Basically BRL 50 million with expenses, judicial expenses and also, payments. BRL 50-60 million.
In sequence, BRL 422 million for leasing, so rental costs. Here in the sequence, BRL 300 million in taxes paid by the company. It's very important to say that the threshold, the percentage of the company starts, well, remains at 27%. We have the operational cash flow accumulated BRL 1.2 billion for the nine months in 2021. Now the managerial cash flow on the right and with December to September, we started with BRL 15.7 billion at the end of the previous fiscal year. Adding the operational cash flow now reconciled and adjusted by the M&A activities, acquisitions and the financing activities. Therefore, we get to a cash and cash equivalents in September of 2020. As you can see, BRL 13.1 billion. Down below, we can see the highlights.
The relevant cash movements, obviously, for the period of the 9 months of 2021. I'm getting to the last page, debt profile. As you can see on the left, the company has a gross debt of BRL 24.7 billion. The average cost of this gross debt of just CDI plus 1% per year. The average term is about six years. The company has foreign currency, the percentage of debt, but the company doesn't have a tolerance for the exchange rate. So when we have derivatives dollar to dollar, well, for example, a hedge for the payment of interest rates, we pay it immediately. Also we reported the cash equivalents of BRL 13.2 billion reais, as we just talked, and a net debt of eleven point five billion reais, actually BRL 11.5 billion.
A net debt to EBITDA of 2.5 times after the payment of dividends in the third quarter. The company doesn't have covenants. Right in the middle, it's very important to highlight that we have approximately 20% of the gross debt of the company that is being changed to the fixed rate. The cash is also indexed to the CDI rate. We have 40% of the net debt of this company for prefixed rates, and it's going to be due by 2026-2029 at prefixed rates between 6.5% and 7.5%. We would like to highlight the extension 2026. Now on the right, we can see once again the debt amortization schedule of the company. Probably our cash flow would allow us to instantaneously pay any deadline until 2028-2029 including.
Our company is very well in terms of the most difficult scenarios. Now, I would like to finish my presentation of the reports, operational reports, and financial highlights, and now we open for your questions.
Thank you very much. Joseph Giordano, JP Morgan.
Hello, good morning, everyone. I have a question in regards to the trend that you can see. It's a little bit erratic because we still have the pandemic and the volume of the company. We can see that you are modulating your capacity and the expenses. I wanted to understand from you, how do you see the evolution of the average ticket?
I know that you have a very short time still in the third quarter, and then you can correct me if I'm wrong. But do you see the uptick and the trend of the occupancy rates at the units? The second question, I actually wanted to explore with you a little bit more on how should we break down these adjustments that you do of the costs related to COVID. Because with the change in the cash flows, there is a higher reduction of headcount.
Well, we don't really talk about the future. Obviously our sector has our seasonality. The second and third quarter tend to be stronger. The fourth quarter, we feel at the end of the year that there is a reduction in the number of surgeries, elective surgeries, for obvious reasons.
I mean, in regards to the surgeries and the flow of emergency services we had in October, we have the same dynamic that we shown all throughout the third quarter. Now, having said that, I cannot anticipate any changes for the dynamic of the average ticket, the complexity. It would be too soon to talk about that, in regards to your question. I know that the question is about the reconciliation between the accounting EBITDA and the adjusted EBITDA. There is a difference, BRL 775 million between BRL 3 billion of accounting EBITDA and BRL 4.4 billion of adjusted EBITDA. Now, within the BRL 775 million, we have BRL 512 million expenses in COVID that we could not invoice against the operating companies.
We still have BRL 200 million in stock options and another part of M&A. We can model, we can project the results of Rede D'Or in a more normal environment as the pandemic becomes a less critical event for everyone. Thank you.
Now thinking about the trend. These COVID costs should wind down all throughout the fourth quarter. Yes, we had a reduction in regards to the previous quarter of 18.2%, as we just mentioned. Once again, we do not like to present trends. As time goes by, the pandemic becomes an event that is less critical. Redundancies are eliminated from operational flows. Now we have a critical moment, a unit cost that is higher.
We show them in the results, in the earnings call, and the financial levers of this company. Everything helps us to have a cost structure that is healthier and eventually higher margins, that will be very close to the ones that we had reported for many years. I apologize for the way that. Well, not so direct that I'm trying to answer, but as a sign of respect for everyone, we do not like to talk about the future and uncertainties. So we don't mislead anyone. Perfect. Thank you.
Next question. Fred Mendes, Bank of America.
Good morning, everyone. Thank you for the call. Well, two points. The part of the ticket, actually, of course, in this quarter, you can see 6%, first quarter, 20. So I think that is in this quarter, we had an impact in the M&A. I imagine that these M&As have a lower ticket. I wanted to understand if this lower increase in the third quarter, of course, with a lower base, is this basically M&A or do you have a more challenging scenario for the reduction here in the average ticket of the company?
Second thing, well, the patient portal, this is very relevant, of course. Do you have any type of financial benefits? Is the patient portal, web portal gains more relevance, or do you want to improve the journey of the patient? Can you tell us a little bit more about that? Oh, just to clarify in the second part of the question, I'm going to let the first part to Otávio. The second part, you're talking about the digital channels.
This is for cost reduction and also for the compliance adherence of the clients. Well, we're looking at this more as a way to capture and to get, well, more clients. Even though the cost is lower, there is a benefit for the cost reduction. If you look at our appointments in the call center, they're still growing. In reality, there is a presence in the digital channel. That increases our loyalty from our clients. All of this is a way to capture and to get more well, the loyalty through the content that we make available, through the relevance that the company has in the digital media. This ends up being a way to retain new clients. Now I'm going to let the part of the tickets to Otávio.
Fred, as we have a dramatic change in the mix and the patients here in the hospitals and, well, the number of surgeries and even a higher number of elective surgeries, and we also have the emergency, of course, the KPI, the average ticket, the pros and cons, they present themselves. If I was in your position, in the position of a shareholder of the company, I would always have in mind our model of pricing, long-term pricing for the company that shares this with our partners, that we share a lot of the synergies, economic benefits of scalability, and we have adjusted our prices 1% above inflation, official inflation.
Here we show the competency opening of attracting a higher volume of more complex cases into our unit and other services that we invoice as we advance with the concept. Of course, I am mentioning diagnostics and ambulatory oncology. Now, tell me if I just answered your question.
Sure. Thank you. Thank you for that question, and thank you for those comments. Oh, just wanted to confirm, by the way, when I see the average ticket here, when we were talking about COVID-19, was it similar or was it different? Well, the comparison of COVID-19 ticket and the non-COVID-19 ticket is going to depend really on the complexity of the non-COVID-19 patient. I believe that wouldn't be the best comparison, Fred. Okay. Okay, Otávio. Thank you. We have a question now from Samuel Alves, BTG Pactual. Good morning. Good morning, everyone. Just have a few questions here, mostly focused on the past, not so much the future. I think you'll be able to tell us more about that. Well, first of all, we have noticed a bit of a difference in the working capital.
I wanted to understand, was there a special condition or was there a special scenario in that regard, something that will go back to normal in the future? Also, we know that now there will be more synergies, but we see that there is a different inflation rate right now. We wanted to understand if that would cause a difference in the figures that we might see from now on. I wanted you to tell us more about that, if you could. Hello, Samuel. Well, in terms of margins, we do have an impact since there was a difference in price, in everything that we need and the resources that we need and the materials, all the supplies, basically. But we do believe that those prices are going to go back to normal, to the traditional prices, so to speak.
I mean, for a while there, it was very important to have all supplies and make sure that we had all operations running safely, and that is why we had to still purchase all those supplies. Even though there was a different inflation rate, it was more expensive. I think it will go back to normal. Again, as I said before, it will go back to the usual prices and usual income. Let me turn it over to Otávio. Oh, hello, Samuel. I was thinking here about the turnover in the third quarter. There is a change. There is a variation, the third quarter against the previous quarter. We are quite sure about the EBITDA and the cash flow and the invoicing. We actually have a difference. Now it is 4.4%.
For sure, when it comes to working capital, there isn't anything that is different that is happening here at the company. Okay, thank you very much. You are welcome. Now we have a question from Rafael Barros from XP. Hello, everyone. Congrats on the results. I just wanted to ask about the Selic rate. Is there going to be an impact on your growth plan due to that? Should we see maybe an impact in that regard? Well, the change in interest rate will always have an impact on any kind of business, of course. But here we have 80% of the debt of the company that has been changed to pre-fixed rates already. That is due 2026 until 2029, and they would be 7% approximately per year.
We are well protected, I would say, in terms of the interest rates since we're working with those pre-fixed rates now. Now, in terms of the growth plan of the company, I believe that it is a very good investment plan. We see that in terms of demographics, in terms of the market, in terms of the population, there's also aging of the population. There are many hospitals closing or different assets in the hands of the same owners. We do see that kind of trend, and many units are closing the past few years. There is a deficit of beds, especially hospital beds, that have a better outcome for patients. We see that already.
I would say this is not the format of the interest rate curve that is going to really have an impact on what the company is going to do. Actually, this is well explained in the public documents. Okay, thank you. Now we have a question from Vinícius Figueiredo from Itaú. Well, my first question has to do with the occupancy rate. We still have a level that is sustained, that is quite high. Higher levels than back in 2019. Do you think we might have beds for COVID-19 patients and any other hospital stays not related to the pandemic? Also, in terms of oncology, basically, we see an exponential growth here. Do you feel like that growth is coming from that demand that was ignored in a way, so to speak, during the pandemic?
I mean, patients that are now being diagnosed and that weren't diagnosed, who weren't diagnosed during that pandemic time. Or do you think it is related to something else? If you could explain more about that. Hello, Vinícius. Thank you for your question. In terms of occupancy, in the past few months, we have been looking at 200 patients, 200-300 patients, COVID-19 patients in the entire network, and we compare that to 3,000, which we had in March. That would be around 2,000 patients still in April and May. There was a reduction, a gradual reduction for COVID-19. Let me turn it over to Otávio now for the other part of the question. Well, in terms of occupancy rate, we're talking about the average here, 78.4% in a portfolio of 63 hospitals.
In this window of one week, there are variations. It's common in our business. Physicians usually like to operate on Tuesday, Wednesday, Thursday. I mean, not on Friday night or on Sunday at lunchtime. If we're talking about 78.4% for the average on a portfolio of 63 hospitals, 8,800 hospital beds, I mean, this is an excellent reference. If you want to compare that with a lower number of hospitals in our portfolio, we have some that actually have more than 90% of operation rate, and this is quite elevated, quite high.
The reduction in number of COVID-19 patients led us to decide that we were going to alleviate the operation a little bit, and we reduced the occupancy rate of the one that was reported in the second semester, which was very high, and 78.4% for the third quarter. If I were in your position, as we have said many times, this would be an important figure of the company. If we're thinking about the future, I would say around 78%-81% for the average occupancy rate on this huge portfolio of hospitals, which is growing by the way. Now, if I may add to that, we've seen. I mean, we saw in the beginning of the year a few patients that had delayed some of their exams, some of their appointments.
Some people went to the ER in a more severe condition in certain pathologies. I think that in the past few months we have noticed this normalcy, so to say. Now, yeah, sure, there are still a few surgeries that were delayed that were supposed to happen last year. In oncology, I think that delayed diagnosis that was noticed, that was observed in the previous months. I mean, we received those patients at the end of last year, the beginning of this year. What we see now in this third quarter is quite similar to normal, basically. Okay. Thank you. We have a question now from Vinicius Ribeiro from UBS. Hello. Thank you for the opportunity to ask a question here. I just wanted to talk about occupancy. I remember you were saying that COVID-19 would be positive for the margins.
Is there like a net figure that you could give us in terms of hospital beds? What is the impact in terms of operational costs? Was there an impact, actually? I wanted to know more about the diagnosis. These past quarters there have been changes, I believe, in that. What's the plan? What's the strategy here? How do you think that you're going to improve the diagnostics capacity? Well, as we said, COVID-19 patients, they would have a ticket due to their hospital stay, which was longer. I mean, the number of days they would be at the hospital. But also we have to think about the complexity. You may have better margins with other patients. I mean, COVID-19 patients, they also would require more medical supplies to be treated, so you wouldn't have the same kind of a ticket.
It's not just the number of days of hospital stay, but also other factors. Now, because of seasonality as well, in the second and the third quarters, we've had a very good occupancy rate, and that was a little bit below what we had in the third quarter. Also due to the fact that we closed some of the units for ICU care for those patients. For other pathologies, I think now what we see is positive. But of course, we're always very careful. We were very careful, and we were able to do that very quick transition, you know, from one type of patient to the other type of patient. We noticed that some units were not that quick in that transition, and they suffered more of an impact.
I believe that we were able to do that in a very efficient manner because of the great team that we're working with. Now in terms of diagnosis, your second question, I think we have a great opportunity for organic growth. We're improving the resources that we have for diagnosis right now. We're looking at the number of requests of physicians that we have in that regard, and we're trying to expand, of course, as necessary. We'll be discussing more M&As, more acquisitions. You have noticed already what kind of movement we're trying to seek. Very carefully, we'll be still looking at other opportunities to do that, to have that growth. Okay. Thank you. We have a question now from Leandro Bastos from Citi. Hello, good morning.
I wanted to ask about the ramp-up of the hospital beds, if you could tell us a little bit more about that. Also, since we're talking about the leveraging of the capital of the company, what kind of levels should we expect? Hi, Leandro. I couldn't hear you really well. I think your phone, your mic is not so great. Yeah, I understood something about leveraging the capital of the company. I would say that obviously, during an investment cycle, we have tolerance to have some flexibility up to 3 times more than before. I would say 2 or threefold, that would be the increase. That would be what we would be working with. I think you should maybe repeat the first part of the question because your microphone was not so great. I. You said something about hospital beds? Yeah.
I wanted to know about the ramp up of the hospital beds. Okay. Let me turn it over to Otávio. Otávio, about the ramp up. Yes. I couldn't hear his question, but he was asking about operational beds. Is that right? Your microphone is breaking. Yeah. Basically about the ramp up. In the future. Well, if I were in your position, I mean, I would work with this average occupancy rate, which is 78%-81%. We have this business model of the company that is well-described in the form, in the reference form. Here I am talking about 10.4, article 10.4, if I'm not wrong, in that article, in that document, which details all of the 43 projects that we have for organic growth. The budget, the location, the dates, number of beds, et cetera, et cetera.
You also have that rule of thumb, I would say, that we used for the IPO, which is 100, actually 1,000 additional beds through the M&A activities. That way we would model the growth of beds of the company until the end of this fiscal year, until actually this plan, which goes until 2025, and that occupancy rate of 78%-81%. Is that what you were asking? Yeah. I just wanted to know a little bit more about the operational beds, about the ramp up that you're looking at. Thank you for explaining more details about that. Let me just add to that about the difference of total beds and operational beds. The operational beds are the ones that are already equipped. I mean, they may already be used to serve patients, if necessary, of course.
The reason for that difference between total beds and operational beds would be around 80%, that difference. We have a rule of thumb here for some projects. No matter what the size of the hospital is, we usually have 80 beds per year. If we have 240 beds, for instance, 80 will be open every year. At the end of the ramp up, we're going to have the third fiscal year ending with that increase. Okay. Thank you. If you have a question, please press star one. We have a question from Mauricio Cepeda from Credit Suisse. Hello. Hello, everyone. Good morning. I have a few questions here. First of all, I just wanted to say thank you for disclosing all this information. It's important to see these indicators.
You were saying that you don't have that delayed demand, but we do see a change in the structure and the demands in terms of surgical needs. I was wondering if there is a volume that we can consider as normalcy in the structure. What kind of bottlenecks can we expect in that regard? That would be the first question. The second one is the following: We noticed that you have more expenses now, especially in terms of staff versus Q2 and the net income. I wanted to know what have you been doing to have a better productivity rate and also working capital. I know that somebody asked about that before, Samuel, I think. We do know that maybe operators are taking longer to pay. I wanted to know more about receivables.
Finally, we know that you have a gross debt that is high, and now we see that the interest rates are going up. Do you think it would be interesting to reduce availability and reduce the debt? Or if you're not going to do that, until when do you think it would be okay to use all that non-operational cash for expansion? Thank you. Well, I will start and then turn it over to Otávio. When you're looking at a high volume of COVID-19 patients, obviously there were times where we had to also delay some elective surgeries. I mean, we needed more beds, more people in the hospital for COVID-19 patients, especially when the surgery was not urgent, you know, we were able to leave it for later. Even though the occupancy rates were high, this had an impact on the number of surgeries.
In fact, in the third quarter, due to the high reduction that we had in COVID-19 patients, we were able to also let the hospital work with the surgeries and work with other types of procedures. If you see the growth now against the same quarter last year, there was an impact of the M&As, also an impact of the growth of the company, which is interesting, important, and also because we had those areas also available for other types of patients. Now, in terms of expenses, I think your second question was about expenses. We have quite intense work with Rodrigo Gavina working with us in operations, and Leandro Reis, we have weekly meetings where we see the main costs and we discuss the main expenses. All the corporate team has been controlling that. We've been carefully looking at our costs, our expenses.
I think that right now, I mean, we have great opportunities in many areas. We have an interesting project here to compare indicators from different areas of the hospital. If we see that, we notice that there is still an interesting opportunity in terms of productivity, especially in support areas. There are a few things that we can improve, a few points that we can increase. We have, like, this consulting team that is internal, working on all that, working to see how we can improve overall.
In terms of bottlenecks, since you asked, I think that the fact that we're buying with lower prices at the end of the third quarter, that doesn't mean necessarily that there is going to be an impact already in the third quarter because we have also the consumption of the stock right now, so we haven't felt that benefit of that reduction in the third quarter. I believe that we're going to go back to the levels that we had back in 2019 in terms of income and also expenses. Last but not least, I will turn it over to Otávio, so he talks about working capital with more details. I don't think there's anything that would be remarkable here. Maybe something in terms of accounts, but I think that is very variable.
It can go up and down depending on the month. As Otávio was saying, there wasn't a huge change in the number of days. I think, again, it will go back to the normal levels that we had back in the day in the next few quarters because there hasn't been any change in our negotiations that would explain that variation. Otávio, do you want to add to that? Yes, sure. In terms of days for receivables, we had an alteration. We had a change of 104 to 107 days in the second to the third quarter in terms of the M&As and the assets. We see that they're integrated in a broad manner to our portfolio. Invoicing or receiving practices had a substantial improvement.
As we said before, we are very comfortable with the numbers that we have right now. We also reduced what we had previewed for denials, for disallowance. It was 5%, that went to 4.4%. We were able to reduce that. M&As also have that statistical effect, that figure effect, because when we bring a hospital to Rede D'Or, we have 100% of accounts receivable and one-twelfth of invoicing. Every time we have to do the right adjustment, otherwise this is not going to work. The analysts are going to have the impression that we have a significant variation of working capital of the company, which is not the case.
About the indebtedness here. Cepeda, if you think about the cash flow position of the company, it actually has an origin in the tranche, primary tranche of our IPO. We raised BRL 8.3 billion in the IPO, and then later we raised another BRL 1.4 billion of primary capital. This is financial muscle so that the company can continue with its investment plan, consolidation of the sector in what we believe is one of the best investments available. To do an investment without any impact to our capital structure, we do not want to use the cash to pay for the debt. This is very well what we're talking about BRL 24 billion in gross debt with a deadline of 6 years.
This CDI, plus 1% cost, and then we have every single asset of the company free of any, collateral, guarantee, and we don't have any financial covenant that is in our documents. In that sense, we have all the financial flexibility to work with the investments.
Perfect. Thank you, Paulo. Thank you, Fabio. Thank you, Otávio. Next question. Caio Moscardini, Banco Santander.
Hello, everyone. Thank you for the question. We've seen you buying assets even quicker than what was expected, and then the prices, they're a little bit higher than the historical average. I wanted to know how the sellers have behaved since the discount rates have increased. In theory, the price of these assets should have been, decreased. The salesmen, the ones that are selling understands this or the composition of the pricing, is it on the same levels that we've seen?
Hi, Caio. Well, obviously, when you are discussing the purchasing of an asset, I would like to say that every situation has their own idiosyncrasies. I mean, you are discussing with a group that has a financial sophistication that is higher. For example, they have an advisor that is working in the end-to-end. Then we have technicalities, as you say, that weigh down more. Sometimes we're talking to the average, you know, average-sized groups. In this situation, you have, you know, the investments. We are raising the bar. Sometimes that has a lot more weight, let's just say.
In a lot of the talks that we had with the M&As that we just announced, we started without any competition, even in cases where it was, you know, the sale in a partnership, and this facilitates things a lot. We did some transactions in that sense, keeping the local partners, and this adds throughout the operation. In many other cases, because of the relationship that we created with the account, that is what was the selling party, we could negotiate in an exclusive way, and this obviously is a benefit. When we are sitting down at the negotiation table, we are very objective, and we try to get a negotiation that is attractive for everyone, and we get a price that is right for the selling party as well, and for us.
Since the first M&A that we did in 2004 and 2005, and the fact that we have this track record, and the fact that the selling party knows that we are going to take care of the hospital, we'll invest, and sometimes many of the physicians will continue working there. This is very important for us, and I would say that this is even more important than just having a discussion of a discount rate, even though this is a theme also in the negotiation table. For the price composition. Well, thank you.
Paulo, if you allow me. If you remember the roadshow of the IPO, another rule of thumb that we communicated to the market that we helped them model the Rede D'Or. We talk about over BRL 3 billion per bed being acquired all throughout Rede D'Or.
None of the transactions since the first filing of the IPO, 16 hospitals, we have that rule of thumb that we established, and we have the acquisition of a new hospital, a new geography that we're just entering, and the cost per bed is BRL 2.1 million with a lot of discipline and investment really present in our decision-making process and a lot of pragmatism to do good transactions for the company. Excellent. Thank you. Since we do not have any more questions, we're gonna close the Q&A session.
I'd like to give the floor to Mr. Paulo Moll for the final or the closing of this call. Thank you very much.
Thank you to the executives and collaborators of Rede D'Or, to our partners as well, the healthcare plan operators, the suppliers that have been great partners in this very difficult part of the supply chain disorganization. I would like to thank our shareholders that have supported us in this almost one year of the experience of an open capital or a listed company. We would like to thank you all. Well, the earnings call of Rede D'Or São Luiz is closed. Thank you for your participation. Have a wonderful day.