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South Florida is on the verge of a major statewide demographic shift, with impacts that will ripple through the healthcare economy in many ways. Currently home to the highest concentration of older residents in the nation, more than 3.3 million Floridians are 65 and older, with 1 in 20 now 80 years old or older.

With continuing migration into Florida and increased longevity, nearly 1 in 4 Floridians will be 65 and older in 2030, according to The Florida Legislature Office of Demographic Research.

This growing population sector will certainly increase the local demand for medical care, but will there be enough medical real estate to keep up?

Real estate development and demographics go hand-in-hand. Our aging population will require more medical care.

Medical providers will need to prepare in advance for the demographic shift. Physicians must prepare for expansion. Diagnostic and treatment centers will need additional locations. Hospitals will need to expand outpatient services, on-and-off campus offices, and possibly acquire more medical practices.

Considering these needs, the current commercial real estate market presents formidable challenges to medical providers.

Construction costs are up and vacancy rates are down, making renovating and leasing existing space more difficult and cost-prohibitive. Regarding factors limiting construction of new medical office buildings, the apartment boom has driven land prices so high that office developers cannot compete to purchase sites.

Lenders have financed many new apartment projects but shied away from speculative office development. Medical office requires more parking than many other uses, thus requiring more land for development. Will these costs be passed on to the patients or will they lower profits for medical providers?

This looming demand for property to build patient treatment facilities likely will require creative solutions such as infill development, repurposing existing properties, and utilization of nontraditional properties for medical care.

For example, there are many “big box” retail sites (think Sears, K-Mart) that could easily be converted to medical uses. The parking is there, and the structures are sound, requiring only interior renovation.

Will investors continue to bring funds to medical office REITs and other medical properties? There is lingering uncertainty about the long-term impacts of the Affordable Care Act (ACA) and the Tax Cuts & Jobs Act (TCJA), including how many people will be insured, how leases will be treated for accounting purposes and other investment considerations associated with purchasing, leasing and owning.

Another big question is how new technologies, particularly telemedicine, will reshape South Florida’s healthcare delivery system. This may upend the traditional “bricks and mortar” medical office to a degree none of us can predict.

Despite various reasons for uncertainty, the coming increase in demand for medical services should keep investment in medical properties at a high level. In fact, in 2016, 2017, and 2018 to date we have seen very healthy investment and development in healthcare real estate.

On a national scale, according to data released by Revista and Healthcare Real Estate Insights (HREI), outpatient medical real estate development projects totaling nearly

$7.7 billion in construction value and 19.4 million square feet were completed in 2016, while another 17.3 million square feet of outpatient projects with a value of almost $6.5 billion were started.

Locally, in 2018, Cleveland Clinic Florida opened its new, three-story, 73,000-square-foot Coral Springs Family Health Center. Built for about $33 million and equipped for another $20 million, the ambulatory surgical center houses 17 medical specialties, imaging and diagnostic services.

As the aging population continues to shape the future of healthcare real estate in South Florida, healthcare real estate developers will face challenges related to finding land and existing buildings at a reasonable price. End users, including hospitals, physicians and diagnostic centers, will have difficulty finding affordable space to lease and contractors who can perform at an affordable level.

Navigating this real estate landscape demands market knowledge specifically as it pertains to healthcare providers. Expect to see emphasis on creative long-term options for renewal and expansion as a hedge against diminishing supply and rising costs.

Brokers, attorneys and appraisers who are experienced in the healthcare real estate sector will be focused on guiding all players through the markets and locating “deals.”

Source: Miami Herald

Medical office real estate has emerged as a significant and robust subclass of office real estate. (The category can be very broad and include everything from a hospital facility to a chiropractic office.) There’s been exponential growth in this market segment in recent years, and current demographic trends indicate that the growth trend will continue for decades to come. An aging population, coupled with the mass retirement of the baby boomers, will presumably spur demand for medical services required by that
population. Simply put: demand for those services creates demand for the real estate that houses them. Hence the rise of medical office space. This apparent demand has also made medical office space a preferred product type for investment buyers who anticipate consistent and certain income in the foreseeable future.
However, within this generally positive outlook for medical office space, there are some tones of unpredictability.
First, there’s the ongoing possibility that the Affordable Care Act may be altered, or completely overhauled, or completely scrapped, which would cause some unpredictability in certain medical practices’ revenue model.
Additionally, we have been in, and likely will continue to be in, a massive shift toward consolidation of larger medical practices and organizations, along with their corresponding facilities. The small one- and two-physician practices that existed for many years are being displaced by large practices with multiple physicians. As a result, medical space that is geared towards smaller practices may see greatly diminished demand if it can’t adapt to facilities able to accommodate large occupants.
Another factor impacting medical space and its location is the patient’s preferences as to where they obtain their services. Generally, medical space is located in two geographic distinctions:
On-campus space — meaning on a hospital campus, where a patient may be traveling some distance from their home or workplace but is visiting their provider on a campus with other specialties and ancillary services present, both inpatient and outpatient.
Community setting — meaning a clinic or outpatient facility that’s located in a community-based setting, amongst rooftops, and geared to be convenient for the patient. Usually, these are a short distance from a patient’s home or workplace.
The consumer trends in recent years have demanded convenience, sometimes in the form of “convenient care” clinics located in the community retail setting. The future may require services to become even more convenient to the consumer. There’s some chatter in the industry of clinicians practicing inside of grocery stores and pharmacies such as Walgreens and CVS. Should the industry respond and accommodate that consumer preference, it could redirect demand from on-campus space and other large clinical facilities into community-based medicine that blurs the line between clinical and retail space.
On a local level, the medical industry, and the corresponding real estate that serves it, has thrived. Columbia now has several hospital campuses and significant specialty facilities that have made our community a regional draw for health care services. This is among the reasons that the recession didn’t hit Columbia with the same ferocity it hit other communities, and we recognize that to the point that “medical tourism” is now being focused on as an asset that we’ll attempt to nurture in the future. If we’re successful, our community will see robust economic growth as a result. And I believe that will translate to high occupancy rates at both on-campus and community-based clinics.
Source: CBT

Elliott Management, a $34 billion hedge fund, has acquired a 7 percent stake in Mednax and intends to engage company leaders regarding “strategic options.”
In August, Bloomberg published an article called “Elliott Management head Paul Singer the ‘World’s Most Feared Investor.’” The article said Singer’s activist investor strategy led to the ousting of Arconic Inc.’s CEO and a battle with fellow billionaire Warren Buffett over the takeover of Oncor Electric. He was also in the headlines for battling Argentina’s government over its debt limits.
Now Singer has turned his attention to Sunrise-based Mednax (NYSE: MD), which owns medical practice groups across the country and several health care technology and billing firms.
On Nov. 16, New York-based Elliott Management and its affiliates disclosed that they obtained a 7 percent stake in Mednax worth about $84.9 million.

“The reporting persons believe that the securities of the issuer are undervalued and seek to engage in a constructive dialogue with the issuer’s management and board of directors regarding strategic options and operational opportunities to maximize shareholder value,” Elliott Management stated in the SEC filing. “The reporting persons believe that there is substantial upside from the issuer’s unaffected share price level of $43.37 per share, the closing price of the issuer’s shares on November 3, 2017, the last trading day prior to the reporting persons’ increased share accumulation.”

Upon disclosure of the news, Mednax shares jumped $6.11, or 13.9 percent, to $51.76 Thursday.
Mednax officials couldn’t immediately be reached for comment.
CFRA Research equity analyst Danny Yang kept a “hold” on Mednax shares and said a partial or full sale of the company appears possible and would be a positive for shareholders. However, Thursday’s gain in stock value was “purely speculative.”
Mednax is greatly impacted by the future of the Affordable Care Act, especially the Medicaid expansion that provides more coverage to the children’s health services offered at its pediatrics division.
Source: SFBJ

Healthcare real estate has been changing and evolving according to payment reimbursement changes and increasing demand for medical office space due to growing patient populations since the passage of the Affordable Care Act and the entry of baby boomers to the Medicare population.
Cushman & Wakefield Senior Director in San Diego Travis Ives asked panelists at Bisnow’s San Diego Healthcare and Life Science Summit how increased demand for healthcare services and disruptive technology are impacting healthcare real estate. He said over the past six to eight years, the healthcare sector has enjoyed increasing absorption and declining vacancy.

“There’s more demand space, but type of space is the focus,” said Scott Mackey, a principal at local design and engineering firm Lionakis.

The ACA was intended to create value, so it allows patients to make informed decisions about where they want to receive care based on preferences like location, convenience, facility efficiency and timing, he said. So delivery of care became more patient-focused, with providers placing medical office buildings and clinics in neighborhoods close to the patients they serve.
Providers are motivated by cost containment, Mackey said. So when construction costs shot up, they began looking for ways to deliver care more cost-effectively. Providers began putting healthcare facilities in all types of spaces people frequent or congregate, beginning by backfilling retail space vacated by brick-and-mortar retailers as e-commerce gained market share and in grocery stores and big-box retail stores like Walmart.
Healthcare providers are beginning to take advantage of the drive to add outdoor spaces and other amenities in the workplace, according to Swinerton Project Executive Elizabeth Hawkins.

“Healthcare is sidling-up next to that,” she said, noting providers are adding on-site outpatient services as workplace amenities.

Mackey cited Scripps Health’s new clinic on Qualcomm’s office campus as an example, and said Hoag Health recently opened a clinic at a 24-Hour Fitness center, which also provides the flexibility to offer other programs like weight loss.
Mackey said in building out spaces, providers are looking for value and are moving to modular wall systems that provide the flexibility to change the use quickly and cost effectively. He said even complex uses like surgery centers and imaging facilities are moving in this direction and cited a mobile surgery suite created by Cedars Sinai for battlefield use. Mackey said this prototype could be adapted to civilian use and is the ultimate in flexibility, because it can easily be moved to different locations as needed.
Nationally there is a trend toward the merger of healthcare systems. Mackey said doctors once wanted to own their own buildings, but now work for health systems, which are buying out physician groups and other independent providers. As a result, big hospital systems own the majority of healthcare real estate and control delivery of care in their markets, which is impacting the build environment and providing them leverage for negotiating reimbursement deals with insurers.
Hawkins said San Diego is unique in that the huge life science/biotech sector is converging with hospital systems to create the biggest system of healthcare in the nation.

“The future is about tailoring care to a patient’s specific DNA makeup,” she said. “We’re in a better position to do that than any other place in the nation, because we have all the key pieces needed in San Diego.”

With value and volume the top priorities for providers, sustainability continues to be an important aspect of designing healthcare facilities, Hawkins said. She said it is commonplace and integral to the building process.
Mackey said inclusion of sustainable features comes down to cash flow — it has to make sense and provide a return.

“Utility bills at healthcare facilities are enormous, and anything you can to do lower costs is important,” he said.

This is why infrastructure in old buildings is being replaced with more efficient systems, he said, noting that as providers pursue ownership, they anticipate a 30-year horizon for new buildings, so LEED makes good sense.
Disruptive technology like Skype, which allows patients to have a video appointment with a doctor anytime via mobile devices, will eventually impact the medical office building footprint, Mackey said. Hawkins said providers are already pulling back on space commitments. But due to low MOB vacancy and changes in reimbursements by the Centers for Medicare and Medicaid Services, her company is still building ground-up MOBs and refurbishing or repositioning existing buildings in the community as MOBs.
She said legislation made reimbursement site-specific by requiring the CMS to reimburse providers based on type of license, with higher payments for services provided at hospital facilities. This legislation is driving hospital systems to expand MOBs on hospital campuses, rather than off-site, she said.
Disruptive technology, such as the Skype appointments, is making healthcare more accessible, consumer-friendly and cost-efficient, as well as improving price transparency. Hawkins said patients can take a picture of a rash, send it to a physician service via a mobile device and get a diagnosis for $9, or perform an EEG that would cost hundreds of dollars at a hospital inexpensively on an electronic tablet. She said technology will increasingly dictate where people get care and lower costs. Providers cannot ignore this trend and will shift to accommodate it, she said.
Transitioning to electronic medical records is also about adding value, but EMRs are not attaining their full potential for data generation, which could improve outcomes across populations, because paper copies are being scanned into the system rather than entered as data, Mackey said. He said EMR data could also provide greater price transparency and help providers determine where to locate facilities.
Mackey also noted rumors that Amazon may plan to enter the healthcare arena, partnering with patients to provide access to medical records and access to low-cost healthcare services. Amazon’s involvement could provide a big data resource for medical researchers with collection of medical records data, if patient privacy issues regulated by the Health Insurance Portability and Accountability Act can be resolved, he said.
Source: Bisnow

Healthcare commercial real-estate is a unique, subspecialized segment of the entire commercial real-estate industry. According to NAIOP Research Foundation, U.S. nonresidential construction spending in 2016 totaled $455.3 billion. Of this, approximately $41.4 billion (~9%) was spend on healthcare construction.
Strong demand from an aging population in setting of industry consolidation continues to propel the construction of large, consumer-friendly patient care facilities. Colliers International states that in 2016, over 22 million square feet of new healthcare commercial space was delivered, following 14.6 million square feet of deliveries in 2015. Despite a robust supply of new healthcare commercial office space, national vacancy rates, according to Colliers, continue to hit all time lows (7.4% at year-end 2016) with full service gross rents rising by almost 8%.
To better understand these trends, Clineeds, a free online platform designed to connect commercial brokers with healthcare professionals looking for office space, conducted a survey of its users consisting of healthcare professionals, hospital executives, and commercial brokers specializing in healthcare real estate. Over 79 commercial brokers along with 85 healthcare professionals/executives responded either partially or fully to the survey request and provided commentary on several questions.

“As a healthcare real estate tech platform, it’s important for us to understand the trends in the industry,” said Clineed co-founder Rishi Garg. “How are these trends impacting future decisions to construct, purchase or lease commercial office space?”

Here are the results, summarized below:
Retail clinics are on the rise. Cost-effective, convenient care provided at retail clinics has struck a chord with millennials. In an effort to capture this market, healthcare organizations have begun to partner and lease space within traditional retail outlets in lieu of purchasing offices. These leases, unlike traditional commercial leases, are faced with regulations regarding proper use, zoning, biohazard and medical waste. Also at play are issues regarding Starks Law and other anti-kickback regulations, often requiring the additional expertise of a healthcare lawyer.
Commercial office space close to hospitals retain value. Healthcare professionals continue to face declining reimbursement from insurers and government healthcare programs. This has indirectly impacted rent rates of commercial offices near hospitals.
To make up for lost income, physicians have substantially increased their productivity by adding new patients and extending office hours. Medical providers, especially surgeons, overwhelmingly stated they would prefer to rent an office near a hospital and not waste time commuting. As a result, commercial office space near hospitals continue to retain significant value. According to some brokers, in certain areas of New York City and San Francisco, rent may even exceed that of Class A commercial office space. For this reason, hospital executives continue to show a strong willingness to construct commercial space near their facilities with the added benefit of making making millions from services ordered by an affiliate physician. Large healthcare real estate investment trusts (REITs) have also shown a willingness to purchase large offices near medical campuses and hospitals given above market rent rates. Unfortunately, given the size of most transactions, small investors remain outmatched in this market.
Conversions costs remain significant barrier to supply. Transitioning a commercial real estate office to healthcare space are fraught with challenges. This has limited supply of these offices in certain markets. Aside from the myriad of regulations, the build out costs for many physician and dental offices remain significant. Owners and operators of large commercial buildings are hesitant to invest in such projects given the everchanging healthcare landscape.

What’s In Store For 2018?

Recently in an article titled The U.S. Medical Office Market Could Be Heading For A Bubble, David Park, senior SVP of Construction Novant Health, raises the concern of a potential bubble in healthcare commercial market due to a “population lull and changing technology.” Although most respondents failed to agree or disagree with that statement, a resounding concern exist about the impact changes to the ACA (Affordable Care Act) may have on yearly budgets. Short term, many hospital executives stated they may have to re-evaluate FY 2018-2019 capital expenditures, depending upon the costs of implementing new regulations and potentially lost revenue from changes to the ACA.
Although this may disrupt upcoming projects, long-term healthcare executives and commercial brokers continue to remain optimistic and bullish.

“Healthcare real estate is a unique subset of the commercial real estate market, influenced by factors beyond supply and demand. It’s essential that medical professionals partner with brokers knowledgeable in this field, and use specialized data to help them make smart leasing and construction decisions,” added Garg.

Source: cre.tech