2019 was a solid year for development growth for the company.
We also increased our portfolio of outpatient rehab clinics by 78 clinics during the year and in 2019 with 1,740 clinics under our management.
Overall, our net revenue in the fourth quarter increased 8.7% to $1.37 billion.
For the full year, net revenue increased 7.3% to $5.45 billion.
Net revenue in our critical illness recovery hospital segment in the fourth quarter increased 6.7% to $455 million.
The increase was driven by both an increase in volume and rate with patient days up 5.2% compared to the same quarter last year and revenue per patient day up 1.5% to $1,742 per patient day in the fourth quarter.
Occupancy in our critical illness recovery hospital segment was 67% in the fourth quarter compared to 66% in the same quarter last year.
For the year, net revenue in our critical illness recovery hospital segment increased 4.7% to $1.84 billion.
Patient days were up 2.6% and net revenue per patient day was up 2.2% to $1,753 per patient day for the year.
Overall, occupancy in our critical illness recovery hospitals was 68% this year compared to 67% last year.
Net revenue in our rehabilitation hospital segment for the fourth quarter increased 20.9% to $380 million [Phonetic] compared to $151 million in the same quarter last year.
Patient days increased 15% and net revenue per patient day was up 8% to $1,739 per patient day in the fourth quarter.
Occupancy in our rehabilitation hospital segment was 78% in the fourth quarter compared to 75% in the same quarter last year.
For the year, net revenue in our rehabilitation hospital segment increased 14.9% to $671 million compared to $584 million last year.
Patient days increased 11.9% and net revenue per patient day was up 4.9% to $1,685 per patient day for the full year.
Occupancy in our rehabilitation hospital was 76% this year compared to 74% last year.
Net revenue in our outpatient rehab segment for the fourth quarter increased 7.7% to $272 million compared to $252 million in the same quarter last year.
Patient visits increased 7.2% to over $2.25 million -- 2.25 million visits in the fourth quarter.
Our net revenue per visit increased $104 in the fourth quarter compared to $103 per visit in the same quarter last year.
For the year, net revenue on our outpatient rehab segment increased 5% to almost $1.05 billion.
Patient visits increased 4.3% to over 8.7 million visits for the year.
Net revenue per visit was $103 per visit both this year and last year.
Net revenue in our Concentra segment for the fourth quarter increased 3.4% to $397 million.
For the fourth quarter, revenue from our centers was $354 million and the balance of approximately $43 million was generated from on-site clinics, community-based outpatient clinics and other services.
For the centers, we had patient visits of 2.9 million and net revenue per visit was $122 in the fourth quarter.
This compares to 2.8 million visits and $124 per visit in the same quarter last year.
For the year, net revenue in our Concentra segment increased 4.6% to almost $1.63 billion.
Visits in our centers increased 5.6% to almost 12.1 million visits compared to 11.4 million visits last year.
Revenue per visit was $122 this year compared to $124 per visit last year.
Total company adjusted EBITDA for the fourth quarter increased 16.9% to $171.9 million compared to $147.1 million in the same quarter last year with consolidated adjusted EBITDA margin at 12.5% for the fourth quarter compared to 11.6% for the same quarter last year.
For the year, total adjusted EBITDA increased 10.2% to $710.9 million compared to $645.2 million last year with consolidated adjusted EBITDA margin at 13% for the year compared to 12.7% last year.
For our critical illness recovery hospital segment, adjusted EBITDA was $60.5 million for the fourth quarter compared to $56 million in the same quarter last year.
Adjusted EBITDA margin for the segment was 13.3% in the fourth quarter compared to 13.1% in the same quarter last year.
For the year, critical illness recovery hospital segment adjusted EBITDA was $254.9 million compared to $243 million last year.
Adjusted EBITDA margin was 13.9% both this year and last year.
Our rehabilitation hospital segment adjusted EBITDA increased 51.4% to $43.3 million in the fourth quarter compared to $28.6 million in the same quarter last year.
Adjusted EBITDA margin for the rehab segment was 23.7% in the fourth quarter compared to 18.9% in the same quarter last year.
For the year, our rehabilitation hospital adjusted EBITDA increased 24.7% to $135.9 million compared to $108.9 million last year.
Adjusted EBITDA margin was 20.2% for the year compared to 18.7% last year.
Adjusted EBITDA losses in our start-up hospitals, $8.8 million this year compared to $4.7 million last year.
Outpatient rehab adjusted EBITDA increased 14.9% to $40.2 million in the fourth quarter this year compared to $35 million in the same quarter last year.
Adjusted EBITDA margin for the outpatient segment was 14.8% in the fourth quarter compared to 13.9% in the same quarter last year.
For the year, adjusted -- outpatient rehab adjusted EBITDA increased 6.9% to $151.8 million compared to $142 million last year.
Adjusted EBITDA margin was 14.5% compared to 14.3% last year.
Concentra adjusted EBITDA increased 6.8% to $56.8 million for the fourth quarter compared to $52.9 million in the same quarter last year.
Adjusted EBITDA margin was 14.2% in the fourth quarter compared to 13.8% in the same quarter last year.
For the year, Concentra adjusted EBITDA was $276.5 million compared to $252 million last year.
Adjusted EBITDA margin for the Concentra segment was 17% this year compared to 16.2% last year.
Earnings per fully diluted share was $0.24 for the fourth quarter compared to $0.18 for the same quarter last year.
Adjusted earnings per fully diluted share was $0.31 per diluted share for the fourth quarter compared to $0.20 in the same quarter last year.
Earnings per fully diluted share was $1.10 for the year compared to $1.02 last year.
Adjusted earnings per fully diluted share was $1.24 per diluted share for the year compared to $1.3 last year.
For the fourth quarter, our operating expenses, which include our cost of services and general and administrative expense were $1.2 billion.
This compares to $1.1 billion in the same quarter last year.
As a percentage of our net revenue, operating expenses for the fourth quarter were 88%.
This compares to 88.9% in the same quarter last year.
For the year, our operating expenses were $4.77 billion.
This compares to $4.46 billion last year.
As a percentage of our net revenue, operating expenses for the year were 87.5%.
This compares to 87.8% last year.
Cost of services were $1.18 billion for the fourth quarter.
This compares to $1.09 billion in the same quarter last year.
As a percent of net revenue, cost of services were 85.5% in the fourth quarter.
This compares to 86.5% in the same quarter last year.
For the year, cost of services were $4.6 billion.
This compares to $4.3 billion last year.
As a percent of our net revenue, cost of services were 85.1% for the year.
This compares to 85.4% last year.
G&A expense was $34.1 million in the fourth quarter.
This compares to $30.3 million in the same quarter last year.
G&A as a percent of net revenue was 2.5% in the fourth quarter.
This compares to 2.4% of net revenue for the same quarter last year.
For the year, G&A expense was $128.5 million.
This compares to $121.3 million last year.
G&A as a percent of revenue was 2.4% both this year and last year.
As Bob mentioned, total adjusted EBITDA was $171.9 million and the adjusted EBITDA margin was 12.5% for the fourth quarter.
This compares to the adjusted EBITDA of $147.1 million in adjusted EBITDA margin of 11.6% in the same quarter last year.
Total adjusted EBITDA for the year was $710.9 million.
This compares to $645.2 million last year.
Adjusted EBITDA margin was 13% this year.
That compares to 12.7% last year.
Depreciation and amortization was $52.5 million in the fourth quarter.
This compares to $52.6 million in the same quarter last year.
For the year, depreciation and amortization expense was $212.6 million compared to $201.7 million last year.
We generated $6.3 million in equity in earnings of unconsolidated subsidiaries during the fourth quarter.
This compares to $7 million in the same quarter last year.
For the year, we generated $25 million in equity and earnings of unconsolidated subsidiaries.
This compares to $21.9 million last year.
We did recognize a loss on early retirement of debt in the fourth quarter this year of $19.4 million.
We recognized a loss on early retirement of debt in the fourth quarter of last year of $3.9 million.
For the year, we recognized $38.1 million of losses on early retirement of debt.
We also recognized non-operating gains of $6.5 million during the year.
Last year we recognized $14.2 million of losses on early retirement of debt and $9 million of non-operating gains.
Interest expense was $44 million in the fourth quarter.
This compares to $50.5 million in the same quarter last year.
Interest expense for the year was $206.6 million.
This compares to $198.5 million last year.
We recorded income tax expense of $63.7 million this year.
That compares to income tax expense of $58.6 million last year.
Net income attributable to Select Medical Holdings was $148.4 million for the year and fully diluted earnings per share in $1.10.
Excluding the pre-tax losses on early retirement of debt and non-operating gains and the related tax effects this year, our adjusted earnings per share was $1.24.
On December 10, Select issued $675 million in incremental 6.25% senior notes due 2026 at a price of $1.06 [Phonetic] and entered into an incremental $615 million term loan.
A portion of the net proceeds from the incremental senior notes and incremental term loan were used by Select to loan $1.24 billion to Concentra who then used the proceeds from the intercompany loan to repay in full its $1.24 billion in syndicated term loans outstanding.
At the end of the year, we had $3.4 billion of debt outstanding and $335.9 million of cash on the balance sheet.
Our debt balance at the end of the year included $2.143 billion in term loans, $1.225 million and 6.25% senior notes and $78.5 million of other miscellaneous debt.
Operating activities provided $178.5 million of cash flow in the fourth quarter.
This compares to $113.2 million in the same quarter last year.
For the year, operating activities provided $445.2 million of cash flow compared to $494.2 million last year.
Our days sales outstanding or DSO was 51 days at December 31, 2019.
This compares to 53 days at September 30, 2019 and 51 days at December 31, 2018.
Investing activities used $46 million of cash in the fourth quarter.
The use of cash was primarily related to $33.2 million in purchases of property and equipment and $12.8 million for acquisition and investment activities during the quarter.
Investing activities used $316.7 million for the year.
The use of cash was primarily related to $157.1 million in purchases of property and equipment and $159.6 million in net acquisition and investment activities during the year.
Financing activities provided $67.4 million of cash in the fourth quarter.
Provision of cash including $77.1 million in net proceeds from the refinancing in December.
For the year, financing activities provided $32.3 million of cash.
The provision of cash included $104.6 million in net proceeds from the refinancing activities during the year.
We expect net revenue to be in the range of $5.575 billion $5.675 billion.
Adjusted EBITDA is expected to be in the range of $725 million to $760 million.
And fully diluted earnings per share is expected to be in the range of $1.27 to $1.46.
As many of you are probably aware, after the end of the year, we entered into agreements with our Concentra joint venture partners to purchase a total of 18.7% of the voting interest in Concentra for a total consideration of approximately $352.7 million.
After the purchase, Select now owns approximately 68.8% of the voting interest of Concentra.

Summary:
2019 was a solid year for development growth for the company.
Earnings per fully diluted share was $0.24 for the fourth quarter compared to $0.18 for the same quarter last year.
Adjusted earnings per fully diluted share was $0.31 per diluted share for the fourth quarter compared to $0.20 in the same quarter last year.
We expect net revenue to be in the range of $5.575 billion $5.675 billion.
And fully diluted earnings per share is expected to be in the range of $1.27 to $1.46.