Last week’s blockbuster deal in which CVS Health (NYSE: CVS) agreed to acquire Aetna Inc. (NYSE: AET) for $77 billion, including assumption of debt, has the potential not only to fundamentally alter the health plan market but also radically reshape the retail and health care real estate markets.
With about $245 billion in combined revenue and around $19 billion in combined EBITDA, CVS and Aetna are banking on the potential to redefine the way individuals access health care services in lower-cost, retail/pharmacy locations. Aisles of greeting cards and soft drinks could eventually make room for wellness treatments, clinical and pharmacy services, vision and hearing testing, as well as the expected nutrition, beauty and medical equipment offerings.
CVS Health’s current network includes more than 9,700 CVS Pharmacy locations and 1,100 MinuteClinic walk-in clinics. In addition, CVS Health has more than 4,000 nursing professionals on staff providing in-clinic and home-based care across the nation.
Aetna is a leading diversified health care benefits company, insuring 22 million people and providing services to an estimated 44.6 million people in other ways.
At the heart of the combination is a business proposition to address the growing cost of delivering health care services by reducing check-ups and other “between” doctor visits through face-to-face counseling at a store-based health hub.
“These types of interventions are things that the traditional health care system could be doing,” noted Larry J. Merlo, CVS Health president and CEO. “But the traditional health care system lacks the key elements of convenience and coordination that help to engage consumers in their health. That’s what the combination of CVS Health and Aetna will deliver.”
One of the proposed merger’s goals is to deliver more health care services in CVS stores and its retail clinics, shifting the traditional health care delivery model further away from more costly settings, including urgent care centers, doctor offices and hospital emergency rooms.
This shift has been ongoing but could accelerate following the CVS-Aetna merger. CVS has been transitioning space in its stores for the last two years, adding such things as vision and audiology centers.
“There’s no question that we have the opportunities to repurpose some of the space in our stores,” Merlo said. “You can think about this as more of a hub-and-spoke model in that there will be a core set of services that would be available broadly, and there likely would be a subset of stores that would have enhanced services. And that delta would certainly be reflected in the space allocation within the store. But, obviously, we’ll have a lot more to say about that as we get these pilots underway and go from there.”
With its deal to acquire Aetna, CVS could further sharpen its focus on making health care its core business, said Brian McDonagh, a director with CBX Brand Strategy in Minneapolis.
“For far too long, U.S. chain drugstores have suffered from a bit of an identity crisis,” McDonagh said. “Despite the coolers and front-of-the-store merchandise, CVS, for one, has realized that it isn’t primarily a food seller, nor is it a discount retailer or c-store. Increasingly, CVS has been trying to act like a health care company.”
Real Estate Industry Paying Close Attention
As CVS begins to remake its retail pharmacy stores to become a new “front door” to a fragmented health care system, real estate investors will need to pay close attention to both near- and long-term consequences of the combination, said Quinn McCarthy, an analyst with JLL Capital Markets, Net Lease.
“In the short-term, I expect the acquisition to give many risk-averse net lease investors pause regarding CVS-leased assets,” McCarthy said. “CVS will almost inevitably experience a multi-notch credit downgrade as a result of the acquisition cost, and will also see their EPS diluted significantly. The other risk that stands out to me is the future viability of current CVS locations.”
Without knowing how CVS intends to physically implement the expanding health services arm of its business, leases approaching expiration of the initial term may be approached with a significant discount until the future of CVS’s prototype is known, McCarthy said.
“If it is revealed that they intend to reduce retail floor area in existing stores to add dedicated health service space, this worry will likely be assuaged. But the risk of a fundamentally different new prototype making existing layouts obsolete will be a common investor worry,” McCarthy said.
However, over the long-term, assuming successful implementation by CVS, McCarthy said he can see the merger boosting net lease investors’ interests in CVS as a tenant.
Milt Charbonneau, a senior director at Cushman & Wakefield in Iselin, NJ, sees any growth in health care shifting to more conveniently located retail space as a downside worry for investors in medical office buildings. Charbonneau said the concern would be even more if other retailers, such as Walmart and Walgreens, expand their health care offerings in a similar fashion.
“The CVS/Aetna deal may be the start of ‘the department store of health care,’ said Mike Polachek, executive vice president at SRS Real Estate Partners. “In addition to their fleet of retail stores, I could see them opening selective stores in former large boxes and housing, in addition to their retail format adding an insurance office, urgent care (without overnight) stays, physical rehab, concierge doctors and other medical providers. They could form a hub-and-spoke distribution with the hub being these large format operations and the retail stores being the spokes.”
Defending Against an Amazon Incursion
Tony Miller, owner of The Miller Family Cos. in Agoura Hills, CA, said the merger is clearly a defensive play to the expected entrance into the pharmaceutical field by Amazon, offering steeply discounted prescription drugs via mail order.
“By combining forces, the newly formed entity could offer ‘in-store’ medical care, creating a one-stop shop for medical needs. I am not sure how Amazon would compete with the human interaction a medical staff offers,” Miller said.
But the potential Amazon incursion is just enough of a worry that major investors are already adjusting their pharmacy holdings. Agree Realty Corp (NYSE:ADC) said last month that it reduced its net leased pharmacy holdings from 30% to 13.2% in the last three years. Walgreens, Agree’s largest tenant, has been taken down to 8.5% from 22% in that time.
“We’re committed to taking Walgreens down to sub-5%, not because we don’t believe in the tenant or the business, but we think it’s the right thing to do to divest and redeploy on an accretive basis there, and you’ll continue to see that trajectory,” said Joey Agree, president and CEO of Agree Realty.
“While we remain believers in the pharmacy space, I will tell all investors just to [compare] what we’ve accomplished to their diversification efforts,” Agree said. “It’s one thing for Amazon if and when they do enter the pharmacy space to enter it and disrupt it. It’s another thing for them to operationally affect the Walgreens and CVS’s of the world. So we haven’t seen those rumors trickle down. What we have seen is just generally a continued flight to safety. And frankly, people have gotten in line behind the strategy, which we’ve been expounding upon since 2011 in terms of e-commerce.”
Source: CoStar
Despite the uncertainty surrounding healthcare reform and the future of the Affordable Care Act, an increased focus on improving population health and affordability is here to stay.
By making smart decisions about the right place to deliver the right care, hospitals and patients alike can benefit from reduced costs and increased convenience while also establishing new revenue sources for hospital systems. As new revenue sources and efficiencies are explored, real estate has an increasingly influential role in achieving financial stability and sustained success.
To better explain, JLL Research recently released a healthcare outlook report that explores actions healthcare systems can take to improve the quality of patient care while reducing costs.
“Focusing on making the patient experience easier, more comfortable and convenient will pay enormous dividends over the long term, no matter the uncertainty,” explains Daniel Turley, executive vice president for JLL Capital Markets. “Continued consolidation of health systems will create winners and losers in the healthcare world, which in turn will provide ample long-term opportunities for real estate expertise focused on healthcare solutions.”
Overall, the healthcare systems of tomorrow will need to be flexible to adapt to future healthcare changes; strategic in where and what to build; more accessible throughout communities; and utilize any and all data available to make the most well-informed decisions.
Regardless of the type of space health systems pursue, one common thread never changes: the need for flexibility. A building that serves as a freestanding emergency department today may need to transform into an outpatient clinic five to 10 years down the line.
That’s why Kip Edwards, vice president of development and construction at Banner Health, the state’s largest private-sector employer, says, flexibility to meet future configuration and needs is the number one must-have feature at healthcare facilities.
The right place for the right care not only offers convenience and better outcomes, but it also keeps costs down for everyone – patients, providers and the healthcare systems.
Real estate portfolios have grown increasingly complex as healthcare systems have expanded their networks in recent years. Thus, managing a complex network of various types of medical facilities requires a thoughtful strategy informed by location analysis.
Although it reflects a much different healthcare landscape than even a decade ago, healthcare experts from JLL expect the industry’s future to become even more distributed and regionalized.
This can already be seen when driving through communities today. It’s hard to not notice more ambulatory facilities, urgent care centers, retail clinics, micro-hospitals and freestanding emergency departments.
Capitalizing on these trends can reap big rewards too, like when a new urgent care center can attract new patients because of its position as an anchor tenant in a highly-trafficked shopping center.
SRS Phoenix reports, retail clinics within brand-name retailers cost $50,000 to $250,000 to build out, are usually 150 to 250 square feet and can generate revenues upwards of $500,000 per year.
In a drive to meet consumer demands for more affordable, quick and convenient access to healthcare, Banner Health purchased 32 Urgent Care Extra facilities across Arizona in August 2016 with plans to open as many as 50 Banner Urgent Care Centers in the state by the end of 2017.
Jason Wood, partner at Quarles & Brady, says, micro-hospitals are another emerging trend in healthcare that can offer emergency care, diagnostic imaging and lab services, which just recently started gaining traction in Arizona.
Micro-hospitals are usually less than 20,000 square feet and may have 8-15 beds for short-term inpatient observation.
The goal is to make healthcare more easily accessible in order to keep individuals healthy and reduce the need for long, costly hospital visits, stays or acute care treatments.
So far, it’s working to a degree.
According to the American Hospital Association, the total number of hospital beds in the United States is steadily shrinking – down from about 1.73 million beds in 2012 to 1.68 million in 2015.
While that difference may seem small, it’s a signal of larger trends that are in play.
The mix of services provided at a main hospital campus is shifting, with emphasis being placed on more critical and specialty care.
Historically, so much of healthcare delivery occurred on or near a hospital campus without a lot of significant thought to what is customer friendly, convenient and efficient service.
For many reasons, Mike Brinkley, healthcare advisor at Land Advisors Organization, predicts the trend toward providing healthcare services out into neighborhoods and communities will continue.
Thus, smaller, off-campus medical office buildings (MOBs) are the hot commodity today. In fact, during 2016, 447 new MOBs were developed off campus, averaging 63,585 square feet, while only 186 were on-campus, averaging 97,949 square feet, according to Revista.
Supporting Brinkley’s forecast, experts from JLL predict the demand for large parcels of land for new hospital developments to continue, but at a much slower pace.
Brinkley describes this as the “retail-ization of healthcare,” which has healthcare providers following the retail playbook when choosing to open new care centers in locations where patients are already spending time.
For some providers, this means partnering with retailers to open clinics within supermarkets and drug stores. Others choose locations in heavily trafficked shopping centers where its brand can receive more exposure. Both benefit from cost savings and increased visibility.
Thus, retail clinic locations have increased 38 percent in the last five years, according to Kalorama Information, and are positioned for significant growth in the future, as patients continue to seek out convenient, low-cost healthcare services.
That’s one of the trends motivating Brinkley’s work as the real estate advisor to Maricopa Integrated Health Systems (MIHS) for its Proposition 480 “Care Reimagined” program.
Proposition 480 is a nearly $1 billion bond measure approved by voters in 2014 to modernize, rebuild and revamp the MIHS hospital campus and its entire outpatient delivery system (health clinics) to become more efficient, more customer friendly and more accessible to patients.
“Ultimately, the system provides more choices by which patients can enter the provider’s care continuum,” explains Steve Brecker, executive vice president of Layton Construction Company’s healthcare division.
Layton recently completed suite remodels in a MOB for the Phoenix Children’s Hospital, which is in the process of opening a surgery center in the hospital’s east campus building, and has plans to complete three more clinics at sites around the Valley in early 2018.
For Julie Johnson, principal at Avison Young and co-leader of the company’s healthcare practice group, outpatient care has become the most prominent healthcare building trend because inpatient care has become so costly.
“We are also seeing more extensive and higher acuity surgeries being done in an outpatient setting to lower total cost of care, as well as allowing the patient recover at home,” she explains.
Like at the newly constructed Mahoney Building near the Loop 101 and 19th Avenue where a large pain management group recently signed a lease for 14,857 square feet, which will include an outpatient surgery center in addition to a clinic and lab to maximize efficiency and patient experience.
Just like traditional retailers, robust data and analytics can help healthcare executives better understand where patients are coming from, what they want and what their future needs may be.
Organizations often invest significant time and energy on identifying the right submarkets, but then fall short when it comes to analyzing the best location inside that market.
Population growth statistics and new housing starts can help identify areas where more primary care physicians may be needed in the future. Meanwhile, other demographics can point to where aging populations are creating new healthcare needs. Plus, traffic data, competitor locations and drive times can all help narrow the options.
The right real estate strategy can help hospitals ensure that it has facilities in the right places for the right care, but ultimately, these trends aim to provide better care to more people by increasing healthcare access and decreasing the cost while simultaneously improving population health.
Source: AZ Big Media
Healthcare real estate has become a more widely recognized asset class by both the domestic and international investment community. And despite uncertainty over the future of healthcare reform such as the repeal of the Affordable Care Act, value-based reimbursement and changes to healthcare delivery setting, demographics will dictate increasing for healthcare services for years to come.
A panel titled: “The “Real Deals” of 2017: Lessons Learned and Implications for What’s Next” at RealShare Healthcare, held here on Thursday, dove deeper into that discussion, noting that the increasing demand for modern, well-located space and a corresponding expansion of investor interest in the asset class and the pressures on operational efficiency and the rise in potential investors have lead many health systems and physician groups to monetize their real estate assets.
When moderator Gino Lollio, senior director of IPA, a division of Marcus & Millichap, asked panelists about how they source their opportunities—whether it be a buy, sell or equity placement—Jason L. Signor, CEO and partner at Caddis, said that senior housing aside, while they will always pay a broker, they prefer to go direct on acquisitions. For developments, while Caddis has won its share of RFPs, they prefer to go to relationships.
“It may not be from the client, it may come from a former partner, and we try to reciprocate that.”
Darryl E. Freling, managing principal of MedProperties, said that his firm is invested in a lot of ground up development and doesn’t recall of development through an RFP process.
“We always go through direct and have developed a lot of our own provider relationships.”
In terms of acquisitions, whether value add or stabilized acquisitions, MedProperties prefers to do an off-market deal.
“As a seller, and we are often sellers, we prefer to sell through a qualified broker because you get better pricing and it is a competitive process,” said Freling. “As a buyer, we don’t mind competing, but everyone looks at assets a little different. We do a lot of post-acute assets, and a lot of buyers don’t.”
As for how that compares to the past, panelist Ann Atkinson, SVP of acquisitions at Healthcare Trust of America Inc., said that there are way more brokers now than there were five years ago. And Signor said that today’s market is much more efficient than in the past.
“The efficiency has been the biggest change and in the last three or four years, the market has tightened.”
Jim McMahon, SVP of Capital One Healthcare, said that his firm has a lot of direct relationships and are really indifferent in how a deal comes to them.
“We are looking to drive volume and provide debt to the industry.”
As for competition, Signor said that healthcare has changed from being an opportunistic investment to being a core investment.
“I think the big thing we have seen is new competitors. From a development perspective, we are competing with the core build-to-suit giants. The equity coming in is now core equity… It is overseas. It is from pension funds who have never looked our way before and now we are getting calls from them on a weekly basis.”
Atkinson said that there is a big disparity today between quality and a lack of overlap between some of the buyers that might be looking to find different assets with different risks and different yields.
“They aren’t competing for the same types of assets. There is a big difference in pricing and buyer profile.”
According to Freling, the quality assets are very competitive.
“On a risk adjusted basis, healthcare real estate is still probably less expensive than some of the other food groups but that gap is narrowing. It is very competitive on the core side.”
But Freling pointed out that there are a lot of A-type assets that can be bought, that were maybe improperly marketed, or are just a unique situation, and they can be turned into a core asset.
“There are relatively less players with the expertise or willingness to go after value-add.”
Source: GlobeSt.,Source: GlobeSt.
Innovative Industrial Properties Inc.—a leading provider of creative real estate capital solutions to the medical-use cannabis industry—will acquire an Arizona-area asset comprising more than 350,000 square feet of greenhouse and industrial space in a $15 million sale-leaseback transaction with a subsidiary of The Pharm LLC.
The firm will also enter into a long-term, triple-net lease agreement with The Pharm subsidiary, which is planning certain tenant improvements, for which Innovative Industrial has agreed to provide reimbursement of up to $3 million.
“The Pharm is pleased to enter into a long-term partnership with Innovative Industrial Properties through a real estate sale-leaseback transaction that will help capitalize our plans for national expansion. Innovative Industrial Properties’ flexible, long-term capital solutions have enabled The Pharm to unlock the equity it had invested in real estate to be redeployed back into our core business, where we expect to generate higher returns,” said Randy Smith, founder & CEO of The Pharm LLC, in prepared remarks.
LONG-TERM AGREEMENT
The initial term of the lease is 15 years, which can be extended for two additional five-year periods. The lease provides for an initial annualized aggregate base rent of $2.5 million or 14 percent of the sum of the purchase. The tenant improvements are subject to an initial partial rent abatement. The aggregate base rent is subject to 3.2 percent annual increases during the term of the lease. The Pharm subsidiary is also responsible for paying Innovative Industrial Properties a property management fee equal to 1.5 percent of the then-existing base rent.
“The Pharm’s team brings together decades of management and business execution success and we believe they are very well-positioned to continue their strong growth in the Arizona medical-use cannabis market, which as of October 2017 had nearly 150,000 registered patients being treated for numerous qualifying medical conditions, including chronic pain,” said Paul Smithers, president & CEO of Innovative Industrial Properties Inc., in a prepared statement.
Earlier this year, Innovative Industrial Propertis Inc. purchased a a 72,000-square-foot cannabis cultivation facility in Capitol Heights, Md.
The deal is expected to close by the end of the year.
Source: CPE