Health care real estate is adapting to a rapidly shifting landscape.
1/22/2018 | By Sarah Borchersen-Keto
REIT magazine: January/February 2018
(Editor’s Note: This is the first in a year-long series looking at the public’s evolving demands for space and how real estate companies are meeting their needs.)
The future of health care real estate is being shaped by a variety of forces. A growing elderly population is increasing demand for medical services. Consumer preferences for medical care are shifting. So are views on retirement living.
This is taking place amid mounting pressures to contain costs. Against that backdrop, REITs are utilizing advances in technology and pushing for innovative ways to use their space to deliver health care more efficiently and effectively. According to Welltower Inc. (NYSE: HCN) CFO John Goodey, the current environment of change in the industry means “having to think about the appropriateness of the real estate and the infrastructure around it” on a daily basis.
The REIT approach to real estate investment appears to have health care REITs in particularly strong position to adapt to changes in the market and spur innovation, according to Daniel Bernstein, a Capital One analyst.
“The advantage that the REITs have, especially those with large portfolios, is that over time they can selectively look at the portfolio and recycle assets that they believe will become obsolete,” he says. “There’s a great opportunity for the health care REITs to partner with their operators to help them find ways to be more efficient and help provide the capital for those transitions to a more technologically-advanced platform.”
Focus on Senior Housing
With the population of Americans 65 years and older expected to nearly double by 2050, senior housing owners are taking a long look at their assets. Michael Knott, managing director at Green Street Advisors, points out that REITs do have an opportunity “to continue to improve the perception of the senior living experience and the actual underlying experience” in light of the reality that the subsector is still a relative newcomer on the REIT scene.
There are the expected enhancements to senior housing facilities in terms of adding amenities. “That means providing more luxurious accommodations rather than the institutional quality of the past. It’s what patients are demanding,” says Chad Vanacore, an analyst at Stifel Nicolaus.
Yet, with the average entrance age at senior facilities on the rise, the range of health care offerings at facilities will become equally important, Vanacore says. That entails assessing and improving the technological capabilities of existing properties as well as designing new facilities to meet a growing list of requirements for care.
Research conducted by MIT’s Center for Real Estate forecasts that as the demand for senior living services increases, operators will move away from smaller, stand-alone locations in favor of larger, more complex and cost-effective facilities. Mary Beth Kuzmanovich, national director of health care services at Colliers International, observes that as baby boomers move into their seventies and eighties, senior housing supply will be repurposed to accommodate memory care, skilled nursing, assisted living and various other needs that are likely to evolve. Kuzmanovich says a continuing care model will flourish, as “it allows people to migrate” within the same facility as their needs change.
“Multiple moves are not pleasant, especially when you are older and frail,” says Bernstein of Capital One.
Medical Office on Solid Footing
Some of the latest changes to medical office buildings (MOBs) might give a preview of what is to come in senior housing real estate. Aided by advances in technology, MOB outpatient settings are ideally suited to meet the drive for improved health care delivery, according to analysts.
“It’s all about creating efficiency within the square feet that they have,” says Scott Peters, CEO and president of Healthcare Trust of America, Inc. (NYSE: HTA), when discussing the latest trends in MOBs.
Deeni Taylor, chief investment officer at Physicians Realty Trust (NYSE: DOC), says the pace of disruption and innovation has picked up significantly for MOBs in the last five years, especially for MOBs located away from hospital campuses, which he says are easier to redesign than their older, on-campus counterparts.
“It all comes back to staying current with the tenants and what their needs are,” Taylor says.
For example, the widespread move to electronic records has cut down on the amount of physical space needed for storage at medical offices. Likewise, private office space has given way to work stations for physicians. REITs also have had to reconfigure or combine smaller suites to accommodate the trend toward consolidation of physicians’ practices.
Taylor points out that as medical equipment becomes more advanced, specialists are performing increasingly sophisticated procedures in off-campus MOBs. A hip replacement used to take a week in an in-patient setting. Today, a patient returns home the same day. MOBs now require generators and more sophisticated utilities to support these types of procedures, and that need will only continue to grow as technology improves.
Welltower’s Goodey believes that newer-built and technologically enabled MOB facilities “are going to be a big winner.” The classic hospital, especially in secondary and tertiary markets, is going to come under increasing pressure, he adds.
Other Disruptors on the Radar
The rise of telemedicine—the remote delivery of health care services and clinical information using telecommunications technology— also could have a dramatic effect on health care real estate down the line.
According to Taylor, telemedicine won’t change the need to visit a doctor. Rather, it promises to “change the interaction through the sharing of information. It changes what’s needed in the office.”
Telemedicine also won’t transform the health care real estate market overnight, according to Vanacore. “Any move to telemedicine is a much longer cycle, and it doesn’t obviate the need for space,” he says.
Bernstein says he is interested to see the extent to which the health care industry uses telemedicine technology to become more efficient. For health care real estate companies, that means finding the right partners. “The best operators in the space are thinking about what technology will become prevalent in the next three, five, or 10 years that they can use—as well as what those threats are, Bernstein observes. “I believe the REITs will seek out those best operators.”
What do you expect to be the biggest game changer for health care real estate over the next five years?
President and CEO, HCP, Inc.
The dramatic rise in the population of seniors over 75 years old, which is forecasted to increase approximately 20 percent over the next five years.
This growing wave of seniors, combined with the continued shift of health care services down the continuum of care to lower-cost outpatient settings, should result in increased real estate demand in each of HCP’s three private-pay segments. Seniors will frequently visit primary-care and specialist doctors in our medical office buildings; choose to live in our senior housing communities offering recreational and social activities, daily living assistance, and coordination with outside healthcare providers; and continue utilizing new and innovative drugs, treatments and health care devices, which are created by tenants in our life science real estate.
Chairman and CEO, MedEquities Realty Trust
The continued evolution of government and commercial reimbursement together with advances in technology will be the biggest game changers in health care real estate for the next several years.
That being said, there will always be a need for facility-based delivery of health care services. We are particularly focused in our due diligence on not only the facility and its unique market, but also on the operators’ clinical, financial and technical capabilities, as well as how savvy they are at fostering relationships with referral sources and payors.
Chairman and CEO, Ventas, Inc.
We are at the early stages of incredible long-term growth based on demographic shifts in the growing population of health care consumers, as our asset classes become institutionally prized and more assets flow into public hands like Ventas. There is a long-term opportunity and value proposition offered by the real estate market for senior housing, health care and research, and high-quality property portfolios such as ours have never been more valuable than they are today as equity flows continue to accelerate for our assets.
This capital is attracted by our rapidly aging population that has immense wealth and spending power and increasing care needs with age. With more than 10,000 baby boomers turning 65 and Medicare-eligible daily and 73 percent of the U.S. health care spending coming from the 50-plus population, there is growing, powerful and sustainable demand that will provide superior risk-adjusted returns and resilience of our business.
Chairman, CEO and President of LTC Properties, Inc.
Differentiating services provided or not provided by assisted living, independent living marketing to ages 75-plus and age-restricted properties and how to underwrite them.
Current assisted living residents are becoming more frail, and independent living is marketing to the traditional new assisted living resident. The resident is not as easily defined, so the revenue stream and market are becoming more difficult to project. There is also a growing demand for affordable options which have yet to be addressed.
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