Mednax Inc (MD) Q1 2021 Earnings Call Transcript

Image source: The Motley Fool.

Mednax Inc (MD -1.70%)
Q1 2021 Earnings Call
May 7, 2021, 9:00 a.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Ladies and gentlemen, thank you for standing by. Welcome to the MEDNAX First Quarter 2021 Earnings Conference Call. [Operator Instructions]

I'll now turn the conference call over to your host, Charles Lynch. Please go ahead.

Charles Lynch -- Vice President, Strategy and Investor Relations

Thanks, operator, and good morning, everyone. Welcome to our first quarter earnings call. With me today are Mark Ordan, our CEO; and Mark Richards, our CFO. I'll quickly read our forward-looking statements, and then we'll get into the call. Certain statements and information during this conference call may be deemed to be forward-looking statements within the meaning of the Federal Private Securities Litigation Reform Act of 1995. These forward-looking statements are based on assumptions and assessments made by MEDNAX' management in light of their experience and assessment of historical trends, current conditions, expected future developments and other factors they believe to be appropriate.

Any forward-looking statements made during this call are made as of today, and MEDNAX undertakes no duty to update or revise any such statements, whether as a result of new information, future events or otherwise. Important factors that could cause actual results, developments and business decisions to differ materially from forward-looking statements are described in the company's most recent annual report on Form 10-K, its quarterly reports on Form 10-Q and its current reports on Form 8-K, including the sections entitled Risk Factors. In today's remarks by management, we will be discussing non-GAAP financial metrics. A reconciliation of these non-GAAP financial measures to the most comparable GAAP measures can be found in this morning's earnings press release, our quarterly reports on 10-Q and our annual report on Form 10-K.

With that, I'll turn the call over to Mark Ordan.

Mark S. Ordan -- Chief Executive Officer

Thanks, Charlie, and good morning, everyone. Along with Charlie joining me this morning are Mark Richards, Dr. Mack Hinson, Dr. Jim Swift, Dominic Andreano; and John Pepia. My comments this morning will be in three areas: the results we reported this morning, the essence of what we do as a company and how we're strengthening and reshaping MEDNAX. I'm, of course, pleased with our results for the quarter, which were ahead of what we could have foreseen when we talked to you in February. Our patient volume strengthened through the quarter, ramping up to March and into April. I'm sure most of you saw the statistics published this week by the CDC, which indicated a sharp downturn in nationwide births in the fourth quarter of 2020. As you know, we experienced the same trajectory at the end of last year, but to a significantly lesser degree.

We believe this reflects the typical profile of the hospitals where we provide neonatology services, which tend to be larger and bigger markets and with extensive labor and delivery services, including robust neonatal ICUs. It may also reflect our geographic footprint, which has a heavier weighting in faster-growing states and markets. Now through into the first quarter and the roughly 400 hospitals that make up our own births statistics, this downward trajectory on price did not continue. Adjusting for the leap year, total births at the hospitals where we provide NICU services were essentially unchanged in Q1, which is better than what we reported in late 2020. Lastly, while it's too early to make a final call, the improvement in our payer mix so far suggests that the volatility we experienced in November and December could have been more of an anomaly.

To give me one quick insight into how this rebound in trends impacted our results, our revenue for the quarter, excluding the CARES money we recorded, was over $30 million ahead of our internal expectations, which translated into meaningful year-over-year growth in adjusted EBITDA versus the expectation we shared with you in February that it could easily be down versus 2020. Looking ahead to our full year 2021 expectations, we expect that our 2021 adjusted EBITDA will be at or above $220 million. I'll explain. I said last quarter that we'll listen closely at our 2019 adjusted EBITDA of $265 million before the pandemic as the best available benchmark for how our business is recovering as well as backing out our estimate that the 2020 impact of the pandemic was roughly $40 million to $50 million. If you look at the first quarter of 2021, our adjusted EBITDA of $45 million was still below the first quarter of 2019. And when we reported -- and that's when we also reported $50 million in adjusted EBITDA.

And when you exclude the roughly $4 million in contribution from the CARES fund we recorded this quarter, we were roughly 18% below Q1 2019. So while I'm certainly pleased with our results, it's still clear that we're not back to normal and, in fact, that our first quarter results reflect a similar run rate of COVID impact to what we experienced last year. I don't think this should be surprising, given the unique nature of the services we provide and the time led of this COVID impact and since much of our patient volume is based on pregnancies and trial birth timing. Lastly, I'll add that our operating results for the past two quarters have been unusually volatile. So we're also mindful of the still uncertain nature of how fast or consistently we'll see things recover. Now I've talked for a couple of quarters about my confidence that we can achieve a run rate of $270 million in adjusted EBITDA once we move past the impact of COVID-19 pandemic. Our results bolster our confidence that we will reach and exceed that run rate.

But I'm not confident just because we saw better trends over the past couple of months. I'm confident because we continue to push our operating plans and because we are reshaping how we do things here. Our singular focus at MEDNAX is to reinforce our position as the formal provider of women's and children's healthcare in the markets we serve and to do so efficiently and as the best partner we can be to the patients we serve as well as to the payers and health systems we work with. So let me talk about what we've been focused on and speak to you about our core Pediatrix and Obstetrix. It's all about the patient. Since MEDNAX first began caring for mothers and babies in their most challenging times about 40 years ago, the only absolute imperative that our founder and Board member, Dr. Medel, prescribed has been take great care of the patient. Much of my time is spent with our clinicians, hospital partners, prospective partners, and of course, with my team.

And I can attest to this unwavering commitment. There's an unshakable conviction at MEDNAX that we always take great care of the patients, everything else will follow. Now that's easier said than done. To take the best care of the patients, the mothers, babies and children required a lot of work and investment. First, we have to recruit and retain the finest physicians and clinicians. Second, to do this, we try to provide more support for our affiliated clinicians than anyone else in our field. Third, we have a foremost independent research organization in our field of medicine, including complex newborn screenings. one in four babies in the U.S. are patients of ours. We have more knowledge and data in these areas than anyone else. And since our care is provided, of course, at a very local level, we have to provide more support for our affiliated clinicians in each market where we are than anyone else. Finally, we must always lead in our field.

For example, one of the most critical and active parts of our organization is our clinical support group. This grew along with our full support team, make sure that we can continue to advance our skill and knowledge for the sake of our patients. In two weeks, as we did even during the depth of the pandemic last year, we will be holding our Annual Medical Directors Meeting, where over 2,000 clinicians will actively participate and will learn from research, quality and clinical experts. On top of these areas, we provide system support, recruiting support and every other kind of health to allow our clinicians to, again, take great care of the patients. This long-winded tour of what we do is what I believe makes a de-choice among our nation's hospitals. This is what makes us a lead employee, a partner to great medical brands. This is what makes us the leading referral choice of physicians who want their patients to be in our care during their most difficult minutes, days and weeks.

I've spoken about our drive to employ our practice data and dashboards to improve patient access. This has and continues to be a paramount importance to us. It's a steady drumbeat. We want to be certain that a patient who needs care from one of our affiliated physicians gets that care as soon as possible. I'm sure anyone on this call can relate to how a medical appointment process can win or lose loyalty. And we know as business leaders and owners the effect that this can have on volume. So we're working with all of our practices to help them make scheduling as driven and efficient as we can, making sure their appointments are kept and immediately rescheduling no-shows, backfilling cancellations, using our scheduling tools to open additional slots staggering staff, outreach and referral management. They're all part of this necessary equation. We've already seen improvements in many practices, particularly in terms of higher percentages of kept appointments and reductions in no-shows.

This focus is also helping us to share best practices and create benchmarking capabilities so we can measure how effective our data has on practice scheduling in every measurable factor beyond just the post COVID recoveries we've recently seen. We also recently welcomed a new leader in telehealth to make this -- to help make that buzzword a truly active part of what we are for our patients. We all know that a physical visit is not always needed or possible. And we will make our telehealth process fluid to help our patients and attract new patients. This efficiency and effectiveness also applied to our growth plans. Our sales and business development team has reengineered a focused market-by-market approach that's driven by local intelligence and relationships. We've also added resources to this team to make sure that we're highly integrated, not just in intensifying and winning new business but providing services quickly and seamlessly to the partners who put their trust in us and in pediatrics affiliated physicians. In my view, we've lapped until now two other major ingredients to propel us forward.

First, our patient relationships have not extended path to our subspecialty practices. We need to make sure as well as we can that when a patient needs to see a physician in our network, they can do so as quickly as easily as possible. We're moving forward in pediatric urgent care to develop plans for expansion of their business in markets where we have a significant presence, and we will expand with our brand name pediatrics. We believe that providing pediatric primary and urgent care and patient-friendly dedicated clinics will allow us to give patients easier access to the exceptional specialists across our organization when they need it and will also help strengthen our relationships with the communities where we provide services and with our hospital partners. And maybe most significantly, we believe nobody knows how to care for babies, children and mothers like we do. And we want to fully extend the types of relationships we currently have. When a mother on trial want to find the best primary and urgent care practice, our answer should be and will be right here with us at Pediatrix.

Second, our brands, Pediatrix and Obstetrix, are not widely known. We do believe our hospital partners know our name very well. And more importantly, they know that they can rely on us for what we can do for their patients. But patients learn about us and count on us at their most challenging times, and then they move on. Our prospective practices and clinicians do not always think of who we are and what we provide as they cross their career paths. To address this, and all of our work, we've launched a marketing campaign and its obvious key theme is trust. Our ads are going to be widespread, and they're completely authentic. They feature only our own doctors who speak about why people should trust them and trust us. We will continue to reach out to reinforce the very unique importance of Pediatrix and Obstetrix. In hospitals, Pediatrix and Obstetrix mean trust, life saving, world-class clinicians. Our brand will be known to that. I'll finish this morning where I started.

We're working to ensure that MEDNAX can be the best possible partner to the patients we serve and to the physicians, payers and health systems we work with, all driven by our mission to take great care of the patient while, at the same time, taking great care of the business. This isn't always easy, but we have a long track record of working hard to the best solution when we need to. With that,

I'll turn the call over to Mark Richards to provide some more details.

C. Marc Richards -- Executive Vice President and Chief Financial Officer

Thanks, Mark, and good morning, everyone. I'll add some detail for our first quarter results, including some of the bench making versus 2019 that Mark mentioned and touch on some of our G&A expectations as we move through the second quarter. Lastly, I'll touch on our financial position as it stands today. Turning to the quarter. At the top line, our net revenue grew by $5.5 million or just over 1% year-over-year. We recorded about $8 million in revenue from the provided relief fund established by the CARES Act during the quarter. Overall, same unit revenue increased by 2.5% year-over-year, or 3.6% after excluding the additional calendar day in February 2020 for the 2020 leap year. Same unit volumes declined 2.5% year-over-year or 1.4% adjusted for the leap year, compared to a 6.6% year-over-year decline in the 2020 fourth quarter. The table in our press release provide some detail, breaking down our hospital base versus office-based patient volumes, and I'll add a little more color.

First, as Mark mentioned, patient volumes improved throughout the quarter, such that we saw same unit growth in March across all of our service lines with the exception of PICU and pediatric hospitalist services. Second, our NICU days for the quarter as a whole were down slightly more than total births at the hospitals where we provide NICU coverage. This reflects a modest year-over-year decline in average length of stay, partially offset by a year-over-year increase in the rate of admission. I know that the rate of admission was an area of interest for many of you following our fourth quarter release. So I'll point out that in Q1, our admit rate reverted to its historical level after being modestly lower through the latter part of 2020. Lastly, I'd like to address our 2021 volume relative to 2019. Our first quarter same unit volume was down approximately 3% as compared to the same period in 2019, with hospital-based volume down to a greater degree than office-based volume. We'll continue to look at this two year comparison throughout this year since it's likely that comparisons to 2020 will not be relevant based on the pandemic-related disruptions we experienced last year.

On the pricing side, we had a couple of favorable items in addition to our usual rate growth, which has been typically in the 1% to 2% range based on managed care and administrative fee revenues. First, the cares revenue we recorded added little under 2% to our pricing growth. Second, as we detailed in our press release, our payer mix was 110 basis points favorable compared to 2020, which added roughly an additional $5 million in revenue, or a little more than 1% to pricing growth for the quarter. On the expense side, our practice level, salary, wage and benefit expense was up by $2.7 million or about 85 basis points year-over-year. This increase mostly reflects variable incentive compensation tied to practice level revenues, partially offset by a decrease in malpractice expense, which was higher in 2020. Our G&A expense was down nearly $1 million year-over-year, despite incurring approximately $5 million of costs related to transitional services we provided to the buyers of our anesthesia and radiology medical groups.

The reimbursement for those expenses is reflected in our investment and other income line item. So there's minimal impact to our adjusted EBITDA, but those costs do inflate our reported G&A expense. In the near term, I'll note that while the radiology PSA arrangement has concluded, we do anticipate that we'll continue providing services under our anesthesiology PSA, at least through the second quarter of this year. So you should expect a similar expense and reimbursement dynamic in the second quarter. We expect to wind down the Anesthesiology PSA services sometime after the second quarter, at which point we'll also be able to begin winding down the expenses we're incurring and move toward that future state expectation for G&A. Again, there may be some period of time when we're still incurring some of those expenses but not being reimbursed for them. Lastly, our balance sheet reflects our reduced leverage profile and strong liquidity position. We ended the quarter with $270 million in cash and net debt of $730 million, implying leverage just north of three times.

With that, now I'll turn the call back over to Mark.

Mark S. Ordan -- Chief Executive Officer

Thanks, Mark. And I think we are ready to take questions. Charlie?

Questions and Answers:

Operator

[Operator Instructions] We'll first go to the line of Kevin Fishbeck with Bank of America. Go ahead, please.

Kevin Fishbeck -- Bank of America -- Analyst

Okay. Great. Thanks. Just wanted to understand a little bit the way that you're thinking about volumes coming back for the rest of the year. I know you guys talked about COVID having an impact on volume. Just trying to see if we could tease out exactly how much you thought about that? And the fact that the volumes in the non hospital setting are coming back faster, is that a bullish time for births coming back? Or is that really -- is that more just a reflection of how quickly you're growing that business if it was underpenetrated or I understand if that's a big indicator or not?

Mark S. Ordan -- Chief Executive Officer

Well, it's -- Kevin, it's Mark. I'll start by saying that we -- I talked about volatility, and we've seen in the last quarter two quarters volatility, obviously, with an upward trend. So we're trying to see where all of this shakes out. We -- as I mentioned, because of the markets we serve and since we tend to be in larger hospitals with Level three and Level four NICUs, we think that, that helps what we do in an otherwise sluggish period. But I'm not making a bullish pronouncement here that we don't have on the basis to see. We are certainly working the operating initiatives that we talked about that are most in our ambulatory practices, we think we'll obviously increase volume and efficiency. So that would have the effect of having them take a larger part of our business. So I would say that we're doing everything we can to maximize our results in unchartered territory. I might ask Matt to comment on any thoughts about what we're sitting in our practices that could help shed some light here.

C. Marc Richards -- Executive Vice President and Chief Financial Officer

Yes. I would agree with Mark. I think the volatility makes it difficult to comment on definitively on a trend. Historically, the markets we are in have -- we have been less affected by the total birth rate because we've tended to be in markets. The total national birthrate being down, we tended to be in markets that were a little more favorable to this. And certainly, on the ambulatory side, there's a whole host of work. Again, the initiatives we've discussed before and the ability to see in real-time the data about what's happening in our ambulatory practices, I think, are making us significantly more efficient. And we believe having drive our unique patient volume.

Kevin Fishbeck -- Bank of America -- Analyst

Okay. And then, I guess, as far as the TSA goes, I understand that you're kind of backing it out to the number, but you mentioned that the reimbursement will drop as the year goes on. It may not be one-for-one as how quickly you're cutting costs. Does your guidance assume it's a net zero? Or does your guidance assume that there isn't a drag from that in the back half of the year?

C. Marc Richards -- Executive Vice President and Chief Financial Officer

We really don't have guidance out there, but our ongoing assumption is that as we wind down the TSA, there will be a residual cost component that will flow through the remainder of 2021, where we're not collecting fees for some of those stranded costs. The bulk of what we have here, aside from human capital, is really IT related costs that are under various contracts. So there will be a lag. It's not one-for-one, but it's materially in that range.

Mark S. Ordan -- Chief Executive Officer

Yes. No, the only other thing I would add, looking forward is once we're past the TSA since a lot of the work that we've been doing while we're reimbursed for it, it does take a lot of our team's time and attention as it needs to. So I do think that as we move past it, we will find a lot of ways to be much more efficient than I would also say it's going to enable our team to be less distracted by outside interest to be fully focused on our needs. So I would expect that it's going to be a net positive.

Kevin Fishbeck -- Bank of America -- Analyst

Okay. And then I guess last point. You mentioned about 5% down year-over-year, was that in your view because last year was insulated? Or how do we think about what you saw this quarter?

Mark S. Ordan -- Chief Executive Officer

Yes. Kevin, it's MedMal. Yes, Kevin, we were -- our MedMal expense was a little bit above trend in the first quarter last year on a temporary basis. So what we pointed out is that for this quarter, we were generally in trends, and that's where we got the tailwind for this quarter. Nothing unusual in 2021.

Kevin Fishbeck -- Bank of America -- Analyst

Okay, perfect. Thank you.

Operator

Our next question will be from A.J. Rice with Credit Suisse. Go ahead.

A.J. Rice -- Credit Suisse -- Analyst

Hi everybody. Couple of quick questions here. The pickup in the commercial mix. Are you rationalizing that, that basically the people that made decisions to sort of postpone extending families or starting families were tended to be people that were more commercially covered and maybe, therefore, a little more sensitive to the economy? And therefore, as you see it come back, you're going to get that pickup in commercial, and that's something that will persist? Or is there something about this quarter that drove that commercial mix improvement?

Mark S. Ordan -- Chief Executive Officer

What I would say is, as I commented, A.J., that we now look at the results in the latter part of the fourth quarter and say those were more of an anomaly. So I would say that the payer -- what we see is that the payer mix is more in line with what we've expected before, not that there's a difference, a new trend. So I think that so far, it's still early in the year, if the fourth quarter was an anomaly, then we would say that we're going back to the kind of payer mix that we've experienced in the past.

A.J. Rice -- Credit Suisse -- Analyst

Okay. Any update on the deal pipeline and acquisitions? Obviously, with your leverage where it is, you've got plenty of firepower. I think you spent about $6 million in the first quarter. Is there anything to comment on what you expect for the rest of the year there?

Mark S. Ordan -- Chief Executive Officer

Yes. Actually, I'm going to ask Jim to make -- Dr. Swift to make a couple of comments. As I said, we are operating in a more organized fashion, I think, than ever before with obviously first time of the year is where all of our focus in growth is in pediatrics and obstetrics. So we do see a very strong pipeline, and I would say, a full-court press from all of us to make that happen. Jim, you might want to.

James D. Swift -- Chief Development Officer

Yes, I think both on the acquisitive side and on the organic growth side, we've seen in the first quarter, especially on the organic growth side an acceleration in terms of contract signings with our hospital partners. On the acquisitive side, I think we'll see -- the pipeline is very full right now. In the second quarter, we'll have some execution on some of the current priorities, and that will accelerate into the third and fourth quarter.

Mark S. Ordan -- Chief Executive Officer

We're not calling the numbers on this right now, but -- and growth in Pediatrix and Obstetrix was relatively small in 2019 and 2020 so we do think that's going to become a more meaningful part of our story going forward.

A.J. Rice -- Credit Suisse -- Analyst

Okay. And then just last question. I know in the prepared remarks, you're saying you expect 2021 adjusted EBITDA to be at or above $220 million. We look back, and it looks like in a normal year, who knows what a normal year is, but you get about 15% to 20% of your earnings in the business in Q1. And you were to apply the midpoint of that, you'd probably end up with an EBITDA range, given what you reported in Q1, more in the $245 million range. I know you said something about the -- you're just -- given the volatility being conservative. But is there anything specific that you know now that suggest the trend in the quarters over the course of this year might be different than the normal seasonality is there in the factory?

Mark S. Ordan -- Chief Executive Officer

Well, A.J., you hit the nail on the head. We've looked at this every way we can with very different shade of light. It's not a normal time, and 2020 wasn't normal. So we can only go by our current trends and say -- and look and compare that to 2019 and say, not that we're trying to be conservative but to say that we don't have a basis to project that what we saw in Q1 of 2021 is the start of a normal pattern. But as we've gone a month into '20 -- into Q2, we see that we would expect -- I see that for Q2, the consensus seems to be around $50 million, $55 million of EBITDA. And we think that's looking like that's about right. So $220 million seems like without providing guidance, seems like not a conservative number but a justifiable outlook. We don't have a reason to think that -- yet that the quarters will follow a traditional pattern where we've had the volatility we've had, and were coming off of what we have. So that's why it wouldn't be throwing out numbers in the $240 million to $250 million. That seems a bit robust.

A.J. Rice -- Credit Suisse -- Analyst

Okay. All right. Thanks a lot.

Operator

We'll go next to Brian Tanquilut with Jefferies. Go ahead please.

Jack Slevin -- Jefferies -- Analyst

Hi. Thanks, Jack Slevin on for Brian. Congrats on a good quarter. I think I just want to piggyback on A.J.'s. M&A question here but more looking at it from a strategy perspective. Seeing what you did with NightLight do you think -- I guess trying to understand how you're thinking about balancing tuck-ins and smaller acquisitions that you can then kind of take the blueprint and push it over to the organic growth side of the equation versus maybe slightly more sizable deals, given the flexibility you have in the balance sheet now.

Mark S. Ordan -- Chief Executive Officer

Well, we're all open to more sizable deals. We think that this -- the key to our -- the key to MEDNAX is to be the best partner in our markets that we possibly can be. And we think that starts with tuck-ins and being able to do things that make our relationships with our hospitals really deeper and more lasting. So that's why our focus is absolutely on that, to make sure that our core business is as strong as we can be and we're being the best possible partner. And then we have a position in each of these markets so that a clinician and physician who is looking for a place to land wants it to be -- but wants it to be with one of our affiliated practices. So that's what's for us there. Now as we've spoken about for the last few quarters, we -- it's sort of a frustration that we take care of mothers and babies and then we wish them well. And we know that there's an enormous opportunities into many of our markets we leaded in Pediatrix and Obstetrix to be able to build that part of our business.

So strategically, we think it's a major plus to be able to be in a combination of primary and urgent care. We think it's a natural extension of what we do. We think we have more local knowledge about that than anybody else, and we have the best relationships with local hospitals than anybody else. So we think that's a major strategic advantage. Certainly, we could do that in a combination of organic growth and acquisitions. The most important thing is to get it right, is to get the combination of primary urgent care right so that we are in great locations in facilities that are really welcoming, that are very patient-friendly where we're backed by systems and apps that enable you to make appointments and do the things that we all know have been vesting before the pandemic and certainly heightened by the pandemic. It's unscripted. So Jim, do you have anything to leave out here?

James D. Swift -- Chief Development Officer

No, just -- and we see that primarily care piece fitting nicely into our subspecialties forts and the other subspecialty areas where, again, we -- that's more of an intermittent road in terms of care -- the primary care and subspecialty care, we'll tie that in with urgent care.

Jack Slevin -- Jefferies -- Analyst

Okay. Great. No, that's super helpful. I think next one I wanted to touch on just on that delta between births and NICU days. I appreciate all the color on admission rates and length of stay. I guess maybe just looking back to the last quarter, I know you talked about no changes in clinical protocols. I guess, with three more months to look back and reflect, any color you can give on that delta normalizing and perhaps what exactly the anomaly was Q4?

Mark S. Ordan -- Chief Executive Officer

Let me just give a quick point of clarity on that because I know this is a question last quarter. Our rate of admission, the percent of deliveries in the hospital that are admitted into the NICU is in the low to mid-teens. And when we discussed rate of admission being down a little bit to the back half of last year -- to put that in perspective, in the fourth quarter, our rate admission was down by 30 basis points. So it was not an exorbitant difference or any kind of significant portrait of trend, but it did, nonetheless, depress our NICU days births. So I just want to put that into context. And on a pure percent basis, it has begun trending upward from the second quarter of third, third quarter to fourth, but was still below year-over-year.

And as we get into the first quarter here, it appears to be right back on the trend line, a longer-term multi-year trend line and was up year-over-year. So I hope that's a little bit helpful. I might turn it to Mack to talk about protocols and the like, but just from the statistical side, that's what we saw. P id="671282267" name="Roger Hinson" type="E" /> Yes. I don't think that we can point to any substantive differences on how babies are evaluated and admitted to the NICU. It's a case-by-case basis based on best available evidence-based medicine that our clinicians are making in bid time. So there's certainly nothing we would point to systemically that would be different than our normal course of business.

Jack Slevin -- Jefferies -- Analyst

Okay, great. Thanks.

Operator

We'll next go to the line of Pito Chickering with Deutsche Bank. Go ahead, please.

Pito Chickering -- Deutsche Bank -- Analyst

Good morning, guys. A nice quarter on a very challenging quarter. A couple of questions here. The first one is it seems a lot of aspects of this business are to fairly hard to manage, whether it's payer mix or acuity or to your point, paced admission in the NICU or like to stay in the NICU. Looking at your first quarter guidance you gave us in mid-February versus you guys just posted, obviously, huge reflections there, on, I think mostly driven by the payer mix you're talking about. So I just wanted to see if you can give us some color on how much visibility and control you guys have on EBITDA? Or is it more sort of macro-driven or who shows up into the hospital?

Mark S. Ordan -- Chief Executive Officer

Well, I think it's not different than in the past. I think we can look at our core business and trends in our core business. And normally, payer mix has are a more linear pattern than we've seen. So I think, again, that the last several months, somewhat more volatility than we're accustomed to. As far as being a difficult business to manage, I don't want to Mack me up for a rate. But again, it's -- there are a lot of components to what we do. And -- but I do think it tends to be especially in the major markets that we're in, I think it tends to be relatively predictable. Unless we use different tactics, different tactics in both growth and in managing the business with the analytics that we have are the real changes. So I don't think it's -- it's not that it's so unpredictable.

We obviously are subject to the birth rate in the hospitals that we serve. But beyond that, I think other than what it looks like, again, the anomaly in the fourth quarter, it's generally predictable. Now obviously, the wild card is growth. And we have aspects of our business. We are like in pediatric intensive care and other areas where children haven't been getting as they traditionally do, which is a good thing overall, but not robust for our business. So we'll see how that comes back. So certainly, pandemic has a lot of barrier effects on the healthcare company. But beyond that, we're trying to just run as steady as we can. And with very close contact with our NICUs, our ambulatory practices to see how things are shaping up.

Pito Chickering -- Deutsche Bank -- Analyst

Okay. And then as a follow up on, as you think about sort of revenues and costs relative to 2019 levels, can you remind us how much salaries in practices increase each year, the contracts you have with doctors. What is the mix of the pay to doctors on fixed versus variable? That would be great.

C. Marc Richards -- Executive Vice President and Chief Financial Officer

Yes. When you look at that practice level, [Indecipherable] has a number of components in it. And probably the largest is the underlying salaries for the clinicians and all the practices that are part of MEDNAX. There's necessarily going to be some inflationary pressure on that. Clinicians move up within the practice. There is greater seniority and the like, somewhat offset by physician turnover on retirements and the like. But it does have an upper track, and I would call that comfortably in the low single digits. The other component is variable incentive compensation. And for Pediatrix, for MEDNAX, as a whole today, and we can follow-up in somewhat greater specifics, but that level of compensation expense in that line is significantly above $100 million.

And it moves and is tied to practice level financial results. So that's where you see us call out pretty consistently in the fourth quarter as we saw revenue constraints and declines that they were buffered quite a bit by the variable compensation expense. Here in the first quarter, when we did see some return to growth and a specific callout is the provider of lead funds that we received that are practice specific those will also flow through that variable compensation expenses. So there is a layer of variability in there, and we can try to call that out.

Pito Chickering -- Deutsche Bank -- Analyst

Okay. And the last question for me. I believe you guys are blessing second quarter consensus EBITDA numbers. Is it fair to think about 2Q Street revenues also directionally in the right way. Just want to make sure that the models are probably prepped with a lot of moving parts here.

C. Marc Richards -- Executive Vice President and Chief Financial Officer

I think what we were looking at is on any kind of preliminary basis, without being specific. It just so happens that we're looking at consensus for Q2 and it looks basically appropriate. We haven't typically guided to revenue. So I don't think I'm going be in a position to comment on the top line right now.

Mark S. Ordan -- Chief Executive Officer

Yes. I think more than anything, what we're trying to do is to be as transparent as we can be. And we're -- we just don't want things to run ahead of themselves without an analytical basis for it. So we look at -- we have a better-than-expected quarter and the natural tendency would be for people to say, "well, why don't we just see how -- why don't we annualize that and look at what you get?" And we just don't see the analytical underpinning for that. As we started into the second quarter, we see that we think we'd be right around that low to mid-50s number, which happens to be, as Charlie said, where the consensus is falling out. And again, I would still say that it's way too early to think that we're out of the woods. And I'm not saying that to be cute. I'm saying that because it's way too early to say we're out of the woods. So I think that projecting anything meaningfully above 220-ish area, to us, we don't see the underpinning for it in that area. I can't rule it out, but we don't see it. So I don't want to get people ahead of themselves from the results of one quarter in a volatile period.

Operator

[Operator Instructions] And speakers, we have no one else queuing up at this time. You may proceed.

Mark S. Ordan -- Chief Executive Officer

Great. Well, thank you, everybody, for your support, tuning in this morning. We will keep you posted, and stay safe.

Operator

[Operator Closing Remarks]

Duration: 44 minutes

Call participants:

Charles Lynch -- Vice President, Strategy and Investor Relations

Mark S. Ordan -- Chief Executive Officer

C. Marc Richards -- Executive Vice President and Chief Financial Officer

James D. Swift -- Chief Development Officer

Kevin Fishbeck -- Bank of America -- Analyst

A.J. Rice -- Credit Suisse -- Analyst

Jack Slevin -- Jefferies -- Analyst

Pito Chickering -- Deutsche Bank -- Analyst

More MD analysis

All earnings call transcripts