Sovereign Wealth Funds, Private Equity Step Up MOB Acquisitions

For the unfamiliar, MOB stands for Medical Office Building.

Obviously, MOB is a niche, and sovereign funds and private equity are BIG players … with big research budgets and smart analysts.

So watching what big players are doing is one way to identify a hot niche.  Then you look for a niche within a niche where Main Street investors can play.

But first, let’s look at why the big boys like MOB …

“ … increasingly view medical office space as a core property type with strong fundamentals.”

“ … demand for space continues to grow amid an aging population in need of more medical services …”

 “This particular sector of commercial real estate benefits from one of the largest and fastest-growing components of the U.S. economy: healthcare … ”

That “aging population” they’re referring to are the baby-boomers.  This huge demographic wave is sometimes called “the silver tsunami” because of its economic size and impact.

It’s something we’ve been following closely … including which industries and geographies stand to benefit.

But if the big boys are already in the space, is it too late?  Or is there still opportunity for Main Street investors?

We think there is.  And clues in the article support the thesis …

“ … risks facing medical office investors …  tenants are increasingly facing reimbursement pressures from insurers and government payors such as Medicare and Medicaid … ” 

“…  medical office facilities do not offer tenant diversification … tenants are exposed to the healthcare sector, unlike conventional office buildings …”

 “ … a shift of providing high-quality care … [in] alternative settings …” 

So let’s consider how these clues might fit together to spell opportunity …

First, it’s not MOBs that big money is excited about.  It’s the demographic and industry that the properties support.  It’s about elderly people and healthcare.

The properties are actually a problem because they’re specialty use.  A medical building is typically only suited to medical uses.  That can be risky.

So, even though medical buildings appear strong for the long haul, it’s still a one-trick pony.  If the sector cools, you’re trapped in a property that’s not of much use for anything else.  Yikes.

Next, the tenants of MOBs are healthcare providers whose income is largely derived from insurance and government reimbursements, which are facing downward pricing pressure.

Savvy landlords always look past the tenant to the tenant’s ultimate source of income.

In this case, “commodity” healthcare providers are getting squeezed by stingy insurance companies and social services.  Not good.

Lastly, the article reports a “shifting preference” by tenants (healthcare providers) towards “providing high quality care [in] alternative settings …”

Now THIS is interesting!

It seems those providers being squeezed are moving towards sub-niches where there’s more profit.

In fact, people we know in healthcare say a popular strategy for combating the declining margins of “commodity” healthcare …

(commodity healthcare are the kinds of services major insurers and government programs aim their cost-cutting strategies on)

… is to focus on boutique services for affluent clients who pay by cash or through private insurance.

That’s a clue.

How can Main Street real estate investors play?

Since we’ve already identified the demographic (boomers) and economic sector (healthcare), let’s focus on the property.  After all, we’re real estate guys.

We’re looking for a property well-suited to a boutique healthcare for an affluent, self-paying, or privately insured sub-demographic.

Of course, Main Street real estate investors aren’t healthcare professionals.

So we either need to find tenants who are, or find a simple healthcare service we can deliver through readily out-sourced operators.

And we’ll need to pick a property type that works well for the healthcare service … but also other things, so we don’t get trapped in a single-purpose property.

Sounds like a tall order …

Or maybe the answer is right in front of you … or next door … or down the street.

Single-family homes!

But not just ANY single-family homes … residential assisted living homes.

This is an exciting sub-niche of the healthcare real estate niche that checks a lot of boxes …

First, your tenants are the parents of boomers (today) … and will soon be the boomers themselves.  That’s a substantial long-term pipeline of tenants.

Plus, boomers are the most affluent demographic right now … and paying for Mom or Dad’s care is a TOP budgetary priority.

It’s always good to be at the front of the line for getting paid.

Also, care fees (rent) are often paid out of a combination of the parents’ estate, private long-term care insurance policies, or incomes and assets of the adult children.

So when you’re in what our residential assisted living guru Gene Guarino calls “the sweet spot” … you’re not dependent on government reimbursements.

Residential assisted living homes are boutique, high-quality, “alternative setting” healthcare … which, as the article points out, is the trend.

Another investing adage is, “The trend is your friend“.

Check.

Next, residential assisted living homes are NOT big, single-purpose commercial buildings well-suited only for use as a medical facility.

Residential assisted living homes are operated in single-family houses located in regular residential neighborhoods.

No special zoning.  No commercial location.

So if for some reason the bottom falls out of the sector … the home can be rented to a residential occupant (albeit at a much lesser rent), or simply sold on the open market to an owner-occupant.

In other words, you’ve got multiple exit strategies.  You aren’t trapped by your niche.  This mitigates one of the major risks the big boys fear.

Check.

But perhaps one of the greatest advantages in the sub-niche of residential assisted living homes is the ability to QUICKLY right-size to changing market conditions.

Big-box commercial properties are all-or-nothing propositions.  That’s another worry for the big guys.

When you have a 120-bed medical facility and profits get squeezed or things slow down, you still have 120-bed facility … and all the fixed costs which come along with it.

There’s no throttling capacity up or down based on demand.

But when you own ten 12-bed homes and things pick up a little … you simply add one more home to your collection and increase capacity to 132 beds.

Compared to a big-box, the properties are easy to find, set up, and get optimized.  You can catch an “up” wave sooner and ride longer.

Even better, if things slow down, you simply consolidate your residents into fewer homes … and sell or rent out the excess properties individually.

Again, there a multiple exit-strategies, and when it comes to real estate, single-family homes are arguably the most liquid.  A big-box?  Not so much.

This is HUGE in terms of maintaining profit margins … even in a declining market.

Think about it …

A big-box can’t cut facility overhead.  They either own the whole property or they don’t.  It’s all or nothing.

So the only way preserve margins when occupancy is down is to cut back on staffing, care, and amenities.  Not good for the resident under care, nor the staff or brand.

Meanwhile, the residential assisted living home operator has an advantage …

While the big-box cuts services, the more nimble RAL operator can right-size and maintain or even improve services … and attract an unfair share of residents in a competitive market.

Big check.  And who doesn’t like big checks?

But whether or not residential assisted living is for you … (though it probably will be some day … we all get old) …

… there are still great lessons to glean about strategic sub-niche investing to find profits under the radar (at least temporarily) of the big players.

Until next time … good investing!