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The Medical Office Sector Continues To Hold Steady

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The medical office sector couldn’t be in better shape despite fears of the impact from telemedicine and given the demand for health care, the industry should be robust over the next 12 months, according to analysts.

A segment known for its stability and resistance to recessions set record highs for asking rents in 2021 as vacancies decreased–a trend expected through the next year and beyond. Development of new medical office buildings continues after a slowdown at the start of the COVID-19 pandemic, and for quality properties on the market, investors are gobbling them up quicker than ever. That’s coming off record highs in sales volume and pricing in 2021.

None of that demand is a surprise given an aging population along with migrations and relocations that have picked up since the start of the pandemic in 2020.

Maddie Holmes, a New York-based senior research health care analyst for JLL, said medical office absorption hit a record in 2021 at 18.5 million sq. ft. on a trailing fourth-quarter basis–nearly two times the typical rate going back to 2019 and previous years. That demand continues to be strong in 2022 despite telemedicine becoming a bigger part of the health care landscape.

“Health care is a contact sport in that you have to see your physician,” said Bryan Lewitt, a managing director for healthcare in JLL’s Southern California office. “Telemedicine and Facetime and other avenues of technology aren’t enough because they’re not diagnostic. When the hospitals closed because of COVID, most people delayed their health care visits, procedures. That has created a huge demand for these next two years.”

Travis Ives, an executive director with Cushman & Wakefield who heads its U.S. Healthcare capital markets team, said telehealth has even helped the medical office segment because it connects patients with physicians.

“That makes it more likely that a serious problem will be diagnosed and require treatment,” Ives said. “That treatment is going to occur in a medical office building rather than in an emergency situation like in a hospital. There’s just so much health care that can’t be delivered over the phone. It’s become another component to the delivery care continuum, but not something that’s going to replace medical offices.”

The State Of Medical Office Occupancies

During the pandemic when there was a slowdown in construction starts, coupled with those high rates of absorption, occupancy for medical offices moved from 91.3 percent during the first quarter of 2020 to 91.7 percent at the start of the first quarter of 2022, Holmes said.

Shawn Janus, national director of Healthcare Services for Colliers, reported five of the 10 leading U.S. markets started 2022 with vacancy rates lower than the national average of 8.3. percent. Boston had the lowest vacancy rate at 6.3 percent, followed by New York, 6.8 percent. Miami, Philadelphia, and Chicago were below the national average while Los Angeles was just above it. On the other side, Dallas and Houston had the highest vacancy rates among leading markets at 10.9 percent and 12.5 percent, respectively. Atlanta and Washington, D.C. exceeded 9 percent, Janus said.

“I think you’re seeing vacancy in older medical buildings that are now picking up office tenants, while class-A and class-B (medical offices) have lower vacancy. And if they are strictly medical they do much better,” said Susan Wilson, a healthcare real estate advisor for Lee & Associates and vice president of Lee Healthcare.

Medical office rents historically grow at a steady rate of 2 percent to 3 percent year–over-year, but that pattern is being challenged by current conditions.

“There’s very little supply coming online, and we have already fallen below 10 percent vacancy, which is not a healthy market for tenants,” Lewitt said. “The landlords are going to have a lot of leverage, plus you have increased construction costs that will make it difficult for providers to relocate. I suspect that rents are going to continue to go up because 80 percent of tenants renew their lease in health care. It’s a very sticky business.”

During the BOMA International’s Medical Office Buildings + Healthcare Real Estate Conference held in May in Nashville, Ives said this was the first time that every meeting they took with medical office building owners focused on rental growth.

“They are starting to push their annual escalations and wondering how far they can push their rents,” Ives said. “Most of them have portfolios that are getting up to 90 percent to 95 percent occupied and are starting to think ‘we may as well be asking for it at this point.’ I think rent growth will run hot here for a little bit. As long as vacancy remains tight and inflation is relatively high, I think you will see rent growth running higher than it has historically. Where it used to be the norm to ask for 2.5 percent to 3 percent annual increases on a new lease, in a lot of markets now it’s 3.5 percent to 4 percent-plus. That might not be a big deal in other products but for medical offices those are big escalations.”

Janus said there’s a lot of discussion with tenants about sharing inflation risks since a 2 percent increase doesn’t compensate owners costs with inflation currently running at 8 percent.

“I have heard 4 percent fixed-rate increases, which I have never seen in 20-plus years in this space,” Janus said. “There has been talk about going to CPI and doing it in a risk-sharing manner.”

While leases of 10 to 15 years give owners a security of income, they are looking at shorter term leases so they can bring it back up to the market given the volatility and inflation, Janus said.

“Providers are asking if we want shorter-term leases because inflation is high right now and when it comes back down, do we want to be caught in a 10-year lease that continues to escalate,” Janus said. “And if we can reset, the market may come back down.”

With this environment, Janus said some tenants are looking at whether they should now own their buildings rather than lease them.

There are limits, however, to how much medical office rents can grow, according to Chris Jacobson, a healthcare real estate advisor for Lee & Associates and vice president of Lee Healthcare.

“It’s never going to go through the roof,” Jacobson said. “They can only afford what they can afford with reimbursement from insurance. They can only see so many patients and do so many procedures a day. It’s not like they can sell more coffee.”

Lee Asher, who leads the Healthcare & Life Sciences Capital Markets at CBRE, cited how rental rates are trending up because of rising construction costs and increased tenant improvements. Rental rates across the country have been in the low $20s on a triple net basis while new construction is in the low $30s on a triple net basis, he said.

“If you’re an existing tenant that used to be in the low $20s and your alternative is to relocate to a new building that’s going to be $30, you’re going to think hard about staying,” Asher said. “The landlords recognize that and are able to push rates at their buildings to mid-$20s on a triple-net basis.”

For those who want to relocate, a tenant improvement package to upgrade and do a full build-out for new space is about $100 a sq. ft. and $150 if it’s specialized, Asher said. The tenants can stay where they’re at, and the landlord will increase rents and give $10 a sq. ft. in tenant improvements for paint, carpet and millwork.

“If you’re an existing owner, you’re probably at 85 percent to 90 percent retention,” Asher said. “The question is if you have a vacancy in your building, how do you fill it if no one is moving. What we are seeing is there’s still a lot of consolidation and expansion among physician groups. The No. 1 reason I hear from our leasing folks as to why someone would relocate is they’ve grown out of their space and the building can’t accommodate them. It creates a vacancy in the building, but there are other tenants expanding as well that can backfill that space.”

Entering 2022, average net asking rents for medical office space increased by 1.7 percent over 2021 to $22.61 per sq. ft., which is a new high, Janus said. Rent growth in 2021 was strongest in Los Angeles at 3 percent, followed by Chicago and New York with 2.2 percent.

Los Angeles has the highest average net asking rents at $35.13 per sq. ft. Boston and New York were the next highest at $26.70 per sq. ft. and $26.11 per sq. ft., respectively. Rents in the remaining markets range from $20 to $25 per sq. ft., Janus said.

The Medical Office Investment Sales Climate

The medical office sector is building off a record year in 2021 for sales that resulted in $15.4 billion in transaction volume, according to Todd Perman, vice chairman of global healthcare services for Newmark. Perman said he doesn’t expect hospitals to use general offices as much going forward when employees can work from home.. That was a 23 percent increase over 2020 and 142 percent increase over 10 years. The price at $358 per sq. ft. reached its highest value in 20 years. Cap rates have compressed to the lowest average in more than 20 years at 5.9 percent. Private equity, strong medical office occupiers, and shifting demographics contributed to the banner year, Perman said. Because of recession resiliency, new domestic and foreign investors are seeking out acquisitions, he added.

“In recessionary periods, there’s always been a flight to quality and health care is one of those areas people fly to,” Perman said. “They flock to invest in health care when other areas like retail and other sectors are not performing as well, and there’s more risk in those sectors. We have seen through the pandemic that we have new investors in this space and billions of dollars invested on top of what was already here because of that flight to quality.”

Private equity interests led the way accounting for 63 percent of sales volume, according to Revista. PE investors also made up 75 percent of the sellers.

“There is a lot more money going after buildings than there are buildings for sale,” Wilson said. “If an investor wants to sell the building, it will probably never make the market if it’s fully leased. If it’s 100 percent medical and good credit tenants, it will be gone in a week.”

Janus said pricing was highest in the West and Northeast at $515 and $420 per sq. ft. The Southwest was third at $361 per sq. ft. The Midwest has the lowest average pricing of the six U.S. regions at $280 per sq. ft., he said. There have been sub-4 percent cap rates for prime medical office buildings, he said.

Jacobson said he recently saw a 2.7 cap rate in California.

Analysts said they don’t think the new cap-rate lows can sustain themselves but flatten out. There’s no shortage of capital, and there’s a lot of competition for assets and thus a positive outlook for medical office demand.

Lewitt added, however, that given inflation at 8 percent and rising interest rates, there’s some pause at the moment among investors to figure out the returns.

 

Source: Wealth Management

Medical Office Building Sales Are On A Record Pace

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Prior to 2021, the high-water mark for medical office building (MOB) sales in any given year took place in 2017, when the volume was $15.5 billion, according to information provided by healthcare real estate (HRE) data firm Revista.

During the next three years, that figure was not threatened at all, with the next highest volume during that time coming in at $12.6 billion in 2018. But then came 2021, a year in which many professionals involved in the sector say there was pent-up demand in the MOB sales sector as the country – and the world, for the matter – was doing its best to put the COVID-19 pandemic in the rearview mirror. What happened in 2021 was quite remarkable, with the MOB sales volume shattering the all-time record and totaling $18.3 billion, or 15.3 percent higher than in 2017.

This statistic was presented April 21 during Revista’s First Quarter (Q1) Subscriber Webcast, during which time two of the firm’s principals and founders, Mike Hargrave and Hilda Martin, presented a wide variety of data concerning the MOB space.

The big increase in volume in 2021 was, as noted earlier, due to pent-up demand for acquiring the product type as the pandemic continues to wane. It was also a testament to the strength of the product type, which has proven once again to be a solid investment despite the many headwinds brought on by the pandemic and a number of obstacles facing most business sectors, such as rising prices for all types of goods, materials and labor; increasing interest rates; labor shortages; supply chain difficulties; and other challenges.

Two of the ways in which MOBs have shown their strength is in the nationwide absorption and occupancy rates. According to Revista data, Q4 2021 saw the strongest MOB leasing activity since 2018, with 6.2 million square feet “absorbed across the top 50 (metropolitan areas of the country),” according to Mr. Hargrave. At the same time, the occupancy rate in the top 50 metropolitan areas rose to 91.8 percent by Q4 2021, he noted.

In addition, during the earliest days of the COVID-19 pandemic, when many industries were shut down and elective procedures and surgeries were put on hold in most states throughout the country, owners of MOBs widely reported that their rental collection rates remained in the high 90 percent range, solidifying the product type’s status as a strong investment during difficult times.

During another event March 2-4, the Revista Medical Real Estate Investment Forum 2022, which was held at the Loews Coronado Bay Resort, Mr. Hargrave said “The record-setting sales volume in 2021 is representative of the pent-up demand we all heard about coming out of the pandemic, what with all of the new interest in this space and all of the new capital coming into the MOB market. And, sure enough, that unfolded in the second half of 2021. We could see this continue in 2022, but we’ll keep our eye on that.”

Indeed that strong velocity has continued into the early part of 2022, according to Revista. During its most recent subscriber webcast providing Q1 statistics, Revista presented data showing that Q1 2022 saw sales of $3.8 billion, which is a preliminary figure that is likely to increase as more transactions are discovered and recorded by Revista.

That Q1 volume is the second highest volume for an opening quarter of any year on record since Q1 2017 and it represents a 90 percent increase from the sales volume recorded in Q1 2021, which, of course, turned out to be a record-setting year.

“This is preliminary data,” Mr. Hargrave said during the webcast. “So, that figure will increase, as we’re still cataloguing transactions that occurred within the first quarter.”

With such a strong volume to kick off 2022, Revista’s data indicates that MOB sales have topped $20 billion in the past 12 months (April 1, 2021 to March 31, 2022), the largest volume for such a time frame “we’ve seen since we’ve been tracking transaction activity.”

Could 2022 Set Another Record?

Even after a record-setting volume in 2021, some predict that 2022 could see another record for MOB sales. The HREI™ Editorial Advisory Board (EAB), which represents many of the sector’s top firms, met March 29 in Nashville, Tenn. One of the board members is Christopher R. Bodnar, vice chairman of the U.S. Healthcare and Life Sciences Capital Markets team with CBRE Group Inc.

“I think it’s definitely possible (that MOB sales in 2022 could top that of 2021),” Mr. Bodnar said. “The first quarter of 2021 was pretty slow for us and then we ramped up quickly with most of our activity in the second half of the year. For the first quarter of this year, (CBRE) has already transacted on $4.2 billion in deals. This has been a record quarter for us, personally, but if this activity continues, (the sector should) be able to eclipse the numbers achieved in 2021.”

Erik Tellefson, a managing director with Capital One Healthcare in Chicago, agreed with Mr. Bodnar.

“At this point, I would expect medical office transactions to exceed even the volume in 2021,” Mr. Tellefson said. “That was a high-water mark… But borrowing costs remain relatively low, and I think the industry still orients to the private buyer, developer, private equity firm, balance sheet, bank debt. So that bodes relatively well for the industry.”

John R. Smelter, senior managing director of White Oak Healthcare MOB REIT, said he, too, remains bullish on the MOB and HRE sector.

“There are certainly a lot of reasons why so many investors are getting into this space,” Mr. Smelter said, “because of the stability of our sector as compared to other sectors that have certainly not fared so well, especially during COVID-19.”

Indeed, a wide variety of deep-pocketed investors, including institutional investors, continue to enter the space by acquiring MOBs. Many are doing so through the formation of joint venture (JV) partnerships with long-standing HRE firms that own portfolios of MOBs. In many cases, a JV is often launched with the recapitalization of a portfolio of MOBs owned by the HRE firm in which the new investor acquires a large portion of the ownership. The HRE firm typically retains a smaller percentage of the ownership.

Pricing Remains High, Too

With demand continuing to increase for MOBs from a wide variety of investors, it should come as no surprise that pricing remained high and capitalization (cap) rates, or expected first-year returns, remained low during the year.

For 2021, according to Revista’s data, the median cap rate was an all-time low of 5.7 percent on a trailing 12-month (TTM) basis. Of course, many deals involving the highest-quality properties with credit-rated tenants saw cap rates significantly lower than that, as transactions with cap rates in the lowest 75th percentile of all deals averaged 5 percent. MOB transactions in the highest 25 percent of deals, or those considered value-add transactions, averaged 6.7 percent in 2021 on a TTM basis.

“With increased transaction activity or increased volumes comes more competition for assets, obviously, and increases in prices and resulting compression in cap rates,” Mr. Hargrave said.

However, with 2022’s economic outlook quite different than in recent years – what with inflation on the rise and the U.S. Federal Reserve Bank indicating that it plans to increase borrowing rates multiple times in coming months – Mr. Hargrave said the folks at Revista often get asked where they think cap rates are heading.

“We tell people that MOB cap rates, historically, have not moved with changes in interest rates, instead they typically move with transaction volumes,” Mr. Hargave said. “In recent years, the lowest cap rates (were) in 2021, which had the largest sales volume ever recorded, and in 2017, which, oh by the way, had the second largest volume ever. This could mean that for cap rates to rise materially, we’d probably need to see the total MOB sales volume come down.”

During the HREI board meeting in March, several board members said they believe that with all of the headwinds facing the economy and rising interest rates, cap rates could level off, if not increase ever so slightly.

Devereaux A. “Dev” Gregg, executive VP of development with Charlotte, N.C.-based Flagship Healthcare Properties, said he believes cap rates will “stabilize” in the next year or so. Flagship is both a developer and, through its private REIT, Flagship Healthcare Trust, a buyer of HRE facilities.

“What I don’t see cap rates doing is going down,” Mr. Gregg said. “I don’t necessarily see them ‘jumping up’ either, but at the least trend of having cap rates continue to compress, in my estimation, is at least going to slow down.”

Richard M. “Rich” Rendina, chairman and CEO of long-time HRE development firm Rendina Healthcare Real Estate, which is based in Jupiter, Fla., said he agrees that cap rates for MOBs will stabilize in the next year or so. In addition to developing HRE properties, Rendina has become more focused on acquiring assets since forming a programmatic JV partnership with Chevy Chase, Md.-based Artemis Real Estate Partners in 2021.

“I feel like cap rates — we mentioned that 5.7 percent average – and I’m guessing that will stabilize somewhere between that and maybe 5.5 percent,” Mr. Rendina said. “Even so, there is still the potential for more compression of cap rates when it comes to core assets. I’m hopeful that assets will be priced according to what asset class they fall into, be they value add, core-plus or core, instead of seeing all of them being priced as core. And I do think that will start to happen.”

 

Source: HREI

Investors Target Medical Office In Defensive Play

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Demand for medical office space has mostly normalized, with investors pouring capital into the asset class in what some experts are calling a defensive strategy.

“While some people continue to practice caution amid the emergence of new COVID-19 variants, ultimately many of these appointments must be fulfilled,” Marcus & Millichap’s Alan Pontius writes in a new report. “All the while, the population is aging, which brings along certain medical realities. These factors together underpin the current strong tenant demand for medical offices.”

While traditional offices saw a major rise in vacancy at the onset of the pandemic, medical office vacancy rose just 80 basis points to 9.5% in 2020.  Availability tightened at the tail end of 2020, which drove the average asking rental rate up to $22 per square foot, an increase of nearly 4% from the end of 2019.  Asking rents were highest in San Francisco, followed by New York City, Los Angeles, San Jose, Miami-Dade, Oakland, San Diego, Orange County, Seattle-Tacoma, and Washington, D.C. Meanwhile, vacancy was lowest in 2021 in San Jose, Portland, Louisville, Seattle-Tacoma, and Salt Lake City.

Supply additions expected this year are on par with 2020 figures, with an estimated 9 million square feet of space projected to open this year. Marcus & Millichap predicts that vacancy will decrease to 9.2%, down 20 basis points and 40 basis points above pre-COVID levels.  Meanwhile, the firm predicts rent growth in the neighborhood of 2.5% to an average of $22.61 per square foot, with six markets predicted to hit levels above $30 per square foot led by the Bay Area, New York, Miami-Dad, and Los Angeles.

Staffing shortages remain a headwind for the sector in the short term, as the health crisis continues to hit healthcare worker payrolls. Stated simply, healthcare workers are burned out, and “medical practices are aware of this dilemma,” according to Marcus & Millichap, adding that 73% of those surveyed in a recent national poll ranked staffing as their largest pandemic-related challenge at the start of this year.

“The inability to onboard staff may keep medical practices from expanding this year, combating what are otherwise strong demand tailwinds,” Pontius says.

 

Source: GlobeSt.