Perspectives in Healthcare: Third-party developers can be a vital asset to healthcare providers.

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The capital markets for
hospitals and health systems have yet to recover from the financial crisis of 2008, the Great Recession of 2008-09 and the continued weak economic recovery. From a peak of about
$61 billion in 2008, tax-exempt bond volume for healthcare projects has declined steadily. Bond issuance sank 62.3 percent during the past three years to approximately $23 billion
in 2011.1 The decline was partially due to a reduction in the number of new capital improvement projects in light of uncertainty regarding the economy and the ultimate impact of
healthcare reform. However, another major factor has been the unfavorable lending environment for hospitals and health systems with weaker credit ratings. Many of these weaker
credits have been forced to merge with or be acquired by stronger systems during the past two years. The more creditworthy systems are finding it somewhat easier to access capital,
yet they also face the prospect of reduced revenues, continued economic uncertainty and increased costs due to the mandates of healthcare reform.

As a result, most
hospitals and health systems – both the “haves” and the “have-nots” – are being forced to take a far more circumspect view of capital projects and capital allocation
decisions than they did during the easy credit era of the early 2000s.

Yet time does not stand still – and neither does the competition. A hesitancy to commit to
capital projects that satisfy real estate, equipment and technology needs can open the door to more aggressive competitors. Indeed, despite continued uncertainty, healthcare
construction edged upward in 2011. The value of construction starts for U.S. healthcare facilities during the first 11 months of last year rose 4 percent, compared with a 2 percent
decline in total construction starts during the same period.2 And even if systems didn’t face competitive pressures, many are finding that aging plants and deferred maintenance
leave them with facilities that are antiquated and ill-equipped to support the kind of integrated and accountable care required by today’s healthcare

How can providers remain competitive and continue to deliver quality care when uncertainty abounds, revenues are threatened, and there are so many
competing demands for capital? Many forward-thinking healthcare executives are taking a fresh look at third-party real estate firms.

The third-party

Third-party development, financing and ownership of non-core healthcare real estate is a proven model that has been successfully implemented by hundreds of
hospitals and health systems nationwide. Yet some providers have remained hesitant, perhaps because they felt they did not “need” outside capital, or they were concerned about
“losing control” of their real estate and facilities. Some hospital executives also believe that if the facility will be occupied more than 50 percent by hospital services or
hospital-owned medical practices, the hospital should own the building because it will be paying rent to itself rather than an investor. There might be valid concerns, but the
ongoing transformation of the industry compels pragmatic hospital and health system executives to consider the third-party alternative.

This realization appears to be
driving more providers to partner with third-party real estate firms to develop, finance and own medical office buildings and other outpatient facilities. Aside from the ability to
shift the financial burden and risk to an outside entity, many of these decisions are driven by the recognition that real estate is neither a core business nor a source of
acceptable return on investment relative to other alternatives.

Third-party firms bring real estate expertise that few providers possess in-house. They can provide an
integrated suite of development, entitlement, procurement, leasing, property management and equipment management services that allow providers to focus on their core mission of
delivering quality healthcare. At the same time, by tapping third-party firms as alternative sources of equity and debt, providers reduce risk and avoid making relatively
low-yielding investments in outpatient real estate, potentially adversely affecting their credit profile. Additionally, the “control” issue can be addressed through the use of
long-term unsubordinated ground leases, use restrictions and other agreements. These instruments allow the provider to control what happens within the building, without owning the
bricks-and-mortar. Healthcare providers can also benefit from third-party developers’ extensive expertise in the areas of regulatory approvals, architecture and engineering,
innovative space planning, benchmarking, best practices and construction management.

More than “off-balance sheet”

In the past, many hospitals and
health systems turned to third-party development, financing and ownership as strictly a financial strategy that would enable them to achieve “off-balance sheet” financing for
their outpatient facilities. Rather than owning the facilities directly, providers leased the facilities from third-party developers and owners to avoid having any related debt
appear on their balance sheets. However, proposed changes in the treatment of capital leases will likely soon require providers to recognize operating leases on their balance

Yet, this accounting change should not necessarily affect the decision

to own vs. lease space. Consider this:

  • Many investment
    bankers, healthcare executives and rating agencies recommend that hospitals achieve an unleveraged return of at least 12 percent on their investments to avoid a negative impact to
    their credit ratings, yet nearly all real estate investments fail to reach that threshold.

  • Pressure to preserve cash remains a critical need. “Days

  • on-hand” might be the most important credit metric for a hospital

  • The ability to “walk away” from space after lease

  • is an important consideration

  • There is an inherent conflict between hospital-landlord and physician-tenant to create operational value
    in a medical office project. Third-party landlords can insulate the hospital from potential conflicts with physicians over rental rates, property management

  • and
    other issues – helping to protect the all-important hospital-physician relationship

  • Options to purchase third-party facilities can be incorporated into the ground
    lease agreement between the hospital and developer, allowing the hospital to regain full control of the asset, if necessary

The time is

There has never been a better time for hospital and health system executives to leverage the benefits that can be derived from using a third-party real estate firm
to develop, finance, own, lease and manage their medical office buildings and other outpatient facilities. By availing themselves of the expertise and resources provided by
third-party developers, hospitals and health systems can reap exceptional value in the form of development expertise, execution capabilities and capital solutions. Today’s
competitive pressures, growing capital needs, and uncertainty regarding the economy and the effects of healthcare reform make it imperative to seriously consider this proven real
estate and capital strategy.

1 Cain Brothers, “Industry Insights,” Jan. 9, 2012

2 McGraw-Hill Construction, “November Construction Slides 11%,” Dec.
21, 2011

About Jones Lang LaSalle Healthcare Solutions and PMB

Through a nationwide strategic alliance, Jones Lang LaSalle and PMB offer
providers the most complete, full-service, third-party real estate solutions available in the healthcare industry.

Jones Lang LaSalle (NYSE: JLL) is a financial and
professional services firm specializing in real estate. The firm offers integrated services delivered by expert teams worldwide to clients seeking increased value by owning,
occupying or investing in real estate. With 2010 global revenue of more than $2.9 billion, Jones Lang LaSalle serves clients in 60 countries from more than 1,000 locations
worldwide, including 185 corporate offices. The firm is an industry leader in property and corporate facility management services, with a portfolio of approximately 1.8 billion
square feet worldwide. For further information, please visit

PMB specializes exclusively in the development and management of medical office
buildings, outpatient facilities and parking structures for hospitals, medical groups and universities. For nearly 40 years, PMB’s executives have led the industry in the
development and management of medical care buildings, with 77 healthcare facilities constructed to–date throughout the Western United States. The firm currently owns and manages
44 facilities totaling about 3 million square feet with more than 7,000 structured parking stalls, and has eight projects under development that will total 750,000 square feet. The
San Diego-based firm also has offices in Honolulu, Los Angeles, Phoenix, Nashville, Portland, and Vancouver, WA. For more information regarding PMB, please visit

To learn more about Healthcare, contact:

Shawn Janus

Managing Director



Barry Weinbaum

Vice President


+ 1 858-794-1900