Despite Uncertainty Over Drive To Repeal Obamacare, Investors Banking On Demographics To Maintain Healthy Outlook For Health-Care Properties

Signs in hospital

Health-care REIT stocks definitely caught a cold in the wake of the unexpected November election results. Even as the Dow Jones Industrial Average topped 20,000 for the first time, the health care REIT sector has declined 2.7% over the past three months, with shares of leading companies like HCP, Inc. (NYSE:HCP) tumbling over 10% in the run up and weeks following the election.
To be sure, many market analysts acknowledge health-care markets face many unknowns, chiefly regarding any replacement for the Affordable Care Act (ACA) targeted for repeal by Republicans, and the effects of changes in government reimbursement of medical and seniors housing costs to providers.
According to a new report by the Congressional Budget Office, repealing portions of the ACA, also known as Obamacare, would cause 18 million people to lose their insurance during the first year of a new plan, and lead to 32 million more people becoming uninsured by 2026. Repeal would also lead to a doubling in the prices of premiums paid by those who remain covered in the individual insurance market, according to the CBO.
Not surprisingly, many health-care providers are expected to delay making major commitments until more information about impending changes to the Act becomes available, according to CBRE Group, Inc.’s 2017 Medical Office Building sector outlook.
While any repeal of the ACA without a replacement plan in place could bring a steep drop in health-care visits and demand, CBRE Americas Head of Research Spencer G. Levy, chief economist Jeffrey Havsy and senior managing economist Timothy Savage recently authored a report saying the long-term prospects of heath-care real estate will be affected more by the tens of millions of retiring baby boomers and ongoing health-care industry consolidation and technological advances, than by the vagaries of government health care policy.

“We are certainly in the midst of intense change and corresponding uncertainty in the health care world, particularly when it comes to government reform,” added Matthew Stevens, senior director with The Advisory Board, in a recent conversation with Colliers International Healthcare Services National Director Mary Beth Kuzmanovich. “The true keys to success are less dependent on political particularities. Providing accessible, reliable and affordable health care will remain top priorities,” Stevens said.

CBRE’s analysts also said a full repeal is highly improbable due to the negative impact of millions of Americans immediately losing their insurance and the potential for higher federal deficit spending if the tax revenue underpinning the law is not replaced. But they believe any short-term disruption will be trumped by major population trends.

“Over the long term, the wave of aging baby boomers will drive demand for health care services, irrespective of any regulatory changes,” the report said.

Outlook for MOBs Remains Solid
Health-care REIT stocks definitely caught a cold in the wake of the unexpected November election results. Even as the Dow Jones Industrial Average topped 20,000 for the first time, the health care REIT sector has declined 2.7% over the past three months, with shares of leading companies like HCP, Inc. (NYSE:HCP) tumbling over 10% in the run up and weeks following the election.
As of the third quarter of 2016, medical-office buildings (MOBs) continued to outperform the broader U.S. office market, achieving over 50% higher demand growth, according to CoStar Portfolio Strategy. The average U.S. medical office vacancy rate of roughly 8% is well about the overall office vacancy rate in all but a few high-construction metros such as San Francisco and Nashville, according to CoStar data.

MOBfund

Along with other income-property types, MOB sales and pricing have slowed in comparison to 2015’s historic peaks. However, MOBs, along with seniors housing, skilled-nursing facilities (SNFs) and hospital properties, continue to attract debt and equity capital, said James Seymour, senior managing director of Capital One Healthcare’s real estate financing team, which closed more than 220 transactions, half of them leveraged loans.
One of those deals was among the largest medical office transactions of the year, In December, the Capital One team served as the lead arranger and book runner for a $535 million loan to mortgage REIT Starwood Property Trust for its acquisition of 34 medical office properties.
CBRE’s U.S. Healthcare Capital Markets Group sold 109 medical facilities in 2016 totaling over 7.2 million square feet, including another of the year’s largest portfolio transactions, the $725 million purchase of 52 medical offices by Physicians Realty Trust, a self-managed health care REIT, from Englewood, CO-based based Catholic Health Initiatives (CHI).

“The market for medical office buildings was particularly robust last year. We saw strong deal flow, driven in part by hospital monetization and consolidation,” Seymour said. “Private buyers took a more active role, as private REITs moved to the sidelines and some public REITs were net sellers of assets for the first time in many years.”

As for health-care REITs, Peter Martin, a health care REIT analyst for JMP Securities, expects year-over-year declines in investment activity during 2017, and flat or slightly depressed capital deployments in 2018. The sector outlook is tempered by a “lack of clarity” regarding health care reimbursement changes under the Trump Administration, Martin said in a preview this week of fourth-quarter 2016 health-care REIT earnings.
Trump Policies Brings Opportunities for Seniors Housing, Challenges for Skilled Nursing
Some skilled nursing and seniors housing operators reported choppy operating performance as regulatory and market changes settle across the post-acute space, Seymour said.
While the long-term outlook for seniors housing remains very strong, operators continue to monitor flattening short-term growth in many metros as the market tries to absorb newly developed assisted-living and memory care properties, and other regulatory and cost pressures.
However, seniors housing stands to be the biggest beneficiary among health-care property sectors from Trump Administration’s policies promoting tax cuts and economic growth, which could lead to deeper demand and stronger investor appetite for seniors housing and more M&A activity this year, JMP’s Martin said.
Preliminary data from Irving Levin Associate indicates the dollar value of publicly announced seniors care M&A transactions was $14.4 billion in 2016, just edging out 2015’s $14.2 billion, though the number of deals declined by 6% to 337 in 2016.
The coming months will be a period of ‘price discovery’ in the skilled-nursing facility and long-term care hospital sectors as fundamentals weaken amid reimbursement concerns and rental rate pressure on SNFs and long-term care hospitals, Martin said. Declining cap rates will also suppress deal volume for quality MOB and senior housing assets, he added.
Source: CoStar
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How Alternative Settings Unlock Healthcare Access — And Eat Into Hospitals

alternative healthcare settings

Given the choice between waiting hours or weeks to see a primary care physician, which would you choose? Near instantaneous service is just one reason that retail clinics are on the rise. Large health systems and startups alike are expanding on a primary care model geared toward consumers.
Trends behind the numbers
Retail clinics are not new to healthcare. They have been around for more than a decade, but their numbers have grown over the past several years. There are more than 3,000 retail clinics currently in operation with one in three consumers having visited one, according to a December 2016 report from PricewaterhouseCoopers’ Health Research Institute (PwC). For perspective, only 90 or so retail clinics were in operation and about one in 10 consumers had been to one in 2006. The number of families who reported utilization of a retail clinic nearly tripled from 1.2% in 2007 to 2.9% in 2010, according to research published November 2013 by the Center for Studying Health System Change. Last March, a study published in Health Affairs showed 58% of retail clinic visits from 2010 to 2012 represented new utilization.
“We believe at its core, all of the alternative care settings are going to continue to grow for the foreseeable future,” Jon Porter, senior vice-president of network services at athenahealth, told Healthcare Dive. Athena recently partnered with health clinics company OurHealth to implement its software throughout OurHealth’s 40 employer-sponsored clinics.
The news was the latest in a string of announcements of companies entering the alternative care setting space. In December, health insurance company Oscar cut the ribbon on a full-service primary care center for members in Brooklyn, NY. Last week, futuristic medical office startup Forward came out of stealth mode to unveil its flagship clinic in San Francisco. Helmed by Google alums, Forward twists the concept of concierge care boasting services such as basic screening, blood tests, wellness services, wearable monitoring as well as access to an artificial intelligence system.
Whether retail clinics and other alternative care settings eat at each other on a macro level, “they’re certainly going to eat at the hospital space,” Porter said. “We already have too many hospital beds in the country and we do too many things in the hospital that can be done elsewhere.”
“Healthcare is not a repair shop but an ongoing relationship,” Forward CEO Adrian Aoun was quoted in USA Today. The growing importance of the physician-patient relationship underscores the uptick in preventative care delivered over a long period of time. While retail clinics still account for a small share of all patient visits with a provider, it seems clear that this share will grow. Some early adopters of the retail clinic primary care model seem to be counting on it.
Tweaking the primary care model
As retail clinics become a more prominent feature of the healthcare system and more patients turn to them for routine preventative care, provider organizations who began exploring the retail clinic early on are now making changes to their model based on their early experiences.
Sutter Health started its experiment with retail clinics in 2006. The large nonprofit health system with operations throughout Northern California set up one-room clinics staffed with nurse practitioners or physician assistants in several Rite Aid stores. Open seven days per week with extended weekday hours, the Sutter Express Care clinics offered quick service for common conditions like strep throat, ear aches and the flu.
Sutter has since entered “Phase Two” of its experiment with retail clinics, as Ted Matson, vice president of strategy, told Healthcare Dive in an interview. The Sutter Express Care clinics were popular among patients, but the health system eventually found itself in a position with “more consumers wanting to use the service than we could provide in a one-room model.”
In April 2016, Sutter announced it would open three Sutter Walk-In Care clinics in the great Sacramento, California area. The decision to shift to standalone clinics from in-store clinics was driven by demand for more services in convenient locations, according to Matson. These new retail clinics are typically located in shopping centers that patients frequent for many types of services. They also offer more extensive longitudinal care. For instance, a patient diagnosed with hypertension at a Sutter Walk-In Care clinic could return to see the same provider for follow-up appointments.
“We decided to embark on more extensive design and to be more associated with more convenient locations for today’s consumers,” Matson said.
All about the consumer
There is a lot of talk about consumerization of healthcare and retail clinics demonstrate the shift to more consumer-friendly models. Rather than waiting days for an appointment with a traditional primary care practice, patients can go online to schedule an appointment or simply walk in and wait for a short time as if they were receiving service at the Genius Bar in an Apple Store.
Patients have to wait an average of about 20 days to see a primary care tradition, according to a 2014 survey published by Merritt Hawkins. One way to skirt this wait time is to situate doctors around workers for ease of access. OurHealth, the clinics company that aligned with athenahealth, partners with mid- to large-size employer groups and offers on-site or a network of near-site clinics for employees. The clinics focus on health and wellness services such as nutrition, stress management and fitness. The model is beneficial both for employees who want to actively engage with their health and for employer groups who want a happy, healthy workforce, Dr. Jeff Wells, co-founder and president of OurHealth, told Healthcare Dive. “Healthcare costs are growing and employers are focusing on the strategic value of human capital. The importance of employee engagement – the ability to recruit and retain employees – is more important than ever for growing organizations,” Wells said.
OurHealth currently operates in five states and is looking to expand. Nearly 70% of its network engage in an annual physical or meet with a health coach while the company’s Net Promoter Score exceeds 85, according to Wells. “We are undoubtedly in a wave of consumerism but we’re still in the early innings,” Wells said, adding patients will begin to expect more consumer-centric products out of healthcare as such services grow.
One Medical, which operates primary care clinics in eight cities, offers patients same- and next-day services. “The reality is, when people get sick, they don’t want to have to wait,” Sandeep Acharya, vice president of growth for One Medical, told Healthcare Dive. “There is a tremendous amount of anxiety they are dealing with.”
The consumer-facing model adopted by One Medical offers more than just quick turnaround. Its patients typically spend more face-to-face time with providers than at other practices. One Medical relies heavily on digital tools to streamline administrative tasks, which saves time for patients and providers, according to Acharya. Patients can also use the One Medical website or a mobile app to email providers, share photographs with providers, and video chat with providers, as well as to refill prescriptions and access personal health records.
The One Medical model is more than just a gimmick intended to make a quick buck. It could improve outcomes and reduce costs. It hopes to address patients’ healthcare needs before they require more costly care at an urgent care center or hospitals. “If we really want to manage people’s health and move to a more preventative basis of care, we have got to establish relationships with patients earlier and do it in a way not typical to the way healthcare industry has done it,” Acharya said.
So far, it seems to be working. One Medical primary care clinics typically score in the top 15% of providers on the Healthcare Effectiveness Data and Information Set, according to Acharya. Additionally, Acharya said that internal research conducted with payers shows that costs for One Medical patients are around 5% to 8% lower than for patients at other provider organizations.

Different settings will appeal to different populations
One of the main questions over many healthcare innovations, from retail clinics to wearables and other digital health initiatives, is “Who is this for?” It’s a good question. Take Forward for example. The service is $149/month and so far only operates in San Francisco, one of the most expensive cities in the U.S. Taken at face value, this service would seem to appeal to affluent urbanites, a generally healthy group of individuals. Cost and geographic realities can seem to block access to sick populations that may benefit the most from these wellness services.
Athena’s Jon Porter believes as telehealth services ramp up, that can help to serve the access gap. “Different settings will appeal to different demographic populations,” Porter said noting access can be an issue for the Medicaid population. Telehealth “is pretty nascent right now,” he said. As more insurers get comfortable with the idea of telehealth, the Medicaid population, which has a high smartphone adoption rate according to Porter, could benefit from healthcare services delivered via mobile devices.
Voting with feet
It remains to be seen how large a role retail clinics will play in addressing issues with access to healthcare services and particularly primary care services. However, provider organizations like Sutter Health, OurHealth and One Medical are optimistic based on their early experiences and there is clearly a demand for these services. “The whole notion of retail and consumerism is here to stay,” Matson said. “And we’ll see lots of innovative and creative approaches to help fill that gap for folks.”
Last October, PwC found higher deductibles and other cost-sharing measures are causing consumers/patients to shop around for services, forcing hospitals to think like retailers. Consumerism will force hospitals to “think differently about who their customers are,” Wells stated. “Today, in the walls of most large health systems, there’s still a debate about exactly who their customer is and it might depend on who’s in the meeting or the topic of discussion.”
For those systems to be successful going forward, more importance needs to be centered on how they deliver value to the patient, according to Wells. “Health systems, depending on the service, will need to be much more intentional about where they’re going to play and I think there will more expectation on transparency and accountability. This is all great for patients.”

 

Source:  Health Care Dive
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2017 A Busy Year For Health-Care Construction In Central Florida

Oviedo Medical Center

January isn’t over yet and Oviedo Medical Center has unveiled its brand new 64-bed hospital, South Lake Hospital has broken ground on a free-standing emergency department in Leesburg, and Orlando Health has begun the first phase of its hospital campus at Horizon West in West Orange County.
And there’s more to come.
Local hospital systems have a full schedule of ground breakings and ribbon cuttings for facilities this year, ranging from new hospitals to free-standing emergency departments and medical office buildings.
In a highly competitive market, Orlando Health, Florida Hospital and the national chain HCA are grabbing different corners of Central Florida to build inpatient and outpatient facilities that can capture the business of the area’s steadily growing population.

“Most other areas in the country are trying to figure out how to get rid of [hospitals] and they’re talking about creative re-use. But in Florida we’re building and expanding,” said Anne Spencer, director of health-care practice group at Cushman & Wakefield, a real estate firm.

A major trend this year is construction of free-standing emergency departments, which are the front door to the hospital and make up for a large percentage of hospital admissions.

“But we need a mix,” said John Moore, president of South Lake Hospital. “We try to support development of additional primary-care offices because we don’t want people to use ER for primary care.”

Orange, Osceola, Lake and Seminole — the four counties that make up Central Florida — are home to nearly 2.4 million residents. This number is expected to grow to 2.6 million in 2020 and 3.7 million by 2045, according to projections by University of Florida’s Bureau of Economic and Business Research.
The population in Osceola County is projected to have the highest growth among the four counties, with the potential for nearly doubling to about 600,000 residents in the next three decades.
Osceola Regional Medical Center, an HCA hospital, is investing $50 million in several construction projects this year, said CEO Davide Carbone.
The hospital is adding new floors to an existing patient tower, and bringing new services online, including an eight-bed Level 3 neonatal intensive care unit (NICU), and a 28-bed inpatient physical rehabilitation unit.
It’s also expanding its free-standing satellite emergency department in Hunter’s Creek by adding 9 beds.

“It’s a great place to be with all this growth,” said Carbone, whose main nearby competitor is Florida Hospital with campuses in Celebration and Kissimmee.

Not too far away stands Lake Nona Medical City, home to UCF College of Medicine. The school partnered with HCA last year to build a 103-bed teaching hospital there. If the project gets the final approval from the state, that construction could begin soon.
Meanwhile, Orlando Health and Florida Hospital have several projects in the works in Orange County, the most populous county in Central Florida and home to 1.3 million residents. That number is projected to grow to 2 million by 2045.
Florida Hospital is adding a seven-story inpatient tower and breaking ground on a three-story medical office building at Florida Hospital Winter Garden, turning the existing free-standing emergency department to a full-service hospital.
Its new 120-bed Florida Hospital Apopka campus is opening later this year, which will be an upgrade to the health system’s older hospital that will shut down.
And in the next few months, the health system will start building a stand-alone 24-bed emergency department in Waterford Lakes. It will also begin the construction of Project Wellness in Winter Park — a partnership with Winter Park Health Foundation.
The health system’s Winter Park Memorial Hospital is beginning construction on a five-story patient pavilion on the east side of the facility.

“I see us continuing to grow in multiple locations throughout the community,” said Tim Burill, vice president of facilities management for the health system. “It’s diverse in the offerings and goes back to getting closer to patients and where they live. And that means new facilities in places we’ve not been before.”

It’s a “fair assumption,” he added, that the hospital will be building more urgent-care centers too.

Orlando Health, the region’s other major health system, is focusing this year on developing what it dubs “Health Pavilions” — a flexible design of services and buildings tailored to meet each particular market’s demands, said CEO David Strong.
The first of those, the Spring Lake Health Pavilion in the Dr. Phillips area, is expected to open in the coming days. Another pavilion is slated to open in spring in Summerport on Winter Garden Vineland Road. Both will offer primary care, specialty care, imaging, laboratory services.

“Globally, you see a movement toward ambulatory and outpatient care, which are easier and cheaper for consumers,” said Strong. “And that [trend] will continue.”

A few weeks ago, Orlando Health began the construction of a free-standing emergency department at its Horizon West medical campus near State Road 429. It will start building an accompanying 103-bed hospital tower next year.
South Lake Hospital, which is part-owned by Orlando Health, is building two health pavilions with free-standing emergency departments. The Health Pavilion at Blue Cedar in Leesburg near U.S. Highway 27 and Florida’s Turnpike broke ground earlier this month, and another one at Four Corners at the junction of U.S. 27 and U.S. Highway 192 in Lake County, is expected to open later this year.

“As more people come to Central Florida, more hospitals will come online and come out of the ground,” said Spencer of Cushman & Wakefield. “I can’t tell you how many, but it’ll be interesting to see where each hospital system will stake their claim and where everyone’s territory going to be.”

 

Source: Orlando Sentinel
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Is This Apple Store-Inspired Setup The Future Of Healthcare?

rendering of apple store-inspired health care office by forward

When it comes down to it, none of us really want to be spending time in a doctor’s office. So really, there’s no point in making them feel all that homey, right? That certainly seems to be the approach taken by Forward, a new healthcare company that is doing away with the waiting rooms of today’s overstuffed armchairs and toys, and replacing it with a setup that seems to prioritize efficiency above all else.
Indeed, the aesthetic of Forward is inspired more by an Apple Store than your at-home sofa, and according to serial entrepreneur and Forward founder Adrian Aoun, his new venture is like “an Apple Store that learns so it gets better with more data.”
On Tuesday, January 18, the modern healthcare provider opened its doors for the first time, inviting patients (who are “members”) in for everything from a pap smear to a vaccine to a physical. It’s the ultimate in modernity — the facility is practically littered with tech gadgets (including some that you’re meant to take home). Members complete their check-in process on an iPad, then make their way to a full-body scanner that sends their vitals to Forward’s AI algorithms. New members also get their blood work and genetic tests done, all of which is ultimately sent to a doctor so he or she has a comprehensive idea of a patient’s health before they ever meet.
Indeed, by the time doctor and patient meet for the first time, just about all the work is already done. At that point, the healthcare professional simply walks members through their data on a giant touchscreen (it’s make-believe participatory, you see). Then, once a diagnosis has been made and a treatment plan agreed upon, members are sent home with a wearable, which tracks and submits health data to their doctors in real-time so progress can be closely monitored.
Think of the service almost as that of an Equinox health club — for $149 a month, you get unlimited access to the facility, including doctor’s visits, continuous monitoring, and some prescriptions. Insurance isn’t accepted and you can’t pay month-to-month — for now, this is a year-long commitment. The $149 doesn’t include the cost of insurance, which members should still keep should they need to be hospitalized or to undergo surgery. That said, Forward is currently giving away some free memberships to those who need it.
Ultimately, Aoun told Forbes, the goal of Forward is to change how healthcare is perceived. Whereas most healthcare today is seen as a “once-and-done” process, there ought to be a continual relationship between patient and doctor. “The things that kill us are not the sore throats and rashes, but rather chronic conditions,” he said.

And doctors like Aaliya Yaqub, who went to UCLA then Stanford, agrees. “Your visit with your doctor is not the end of your physical for the year — it’s a continual process,” he said in an interview with Forbes.

The project includes build out of the space and the transition from their current facility, also located on Commerce Park Drive. A specialty conveyor system used to sort, package, and distribute pharmaceutical supplies for patients are part of the plans.
In addition to filling prescriptions, the facility will house front-office capabilities, which will allow DaVita to expand its pharmacy and customer service operations. Completion and occupancy of the new space is slated for March, 2014.
Along with Main-Baillie, CBRE’s Rick Wilson, will manage the build out and Davita Rx’s relocation.
Source:  Digital Trends
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