TAHFM Interlink Continuing Changes in an Era of Healthcare Reform and Oil Industry Concerns. April 1, 2015

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1 TAHFM Interlink Continuing Changes in an Era of Healthcare Reform and Oil Industry Concerns. April 1, 2015

2 Memorial Hermann Overview Greatest market share in Houston area market Largest provider of uncompensated care and community service 4,350 beds Only Air Ambulance Service in Houston Life Flight Only Burn Center in Houston Only Hemophilia Center in Houston Only non-county based Level One Trauma Center 25,000 employees Three National Quality Awards Winner Only System in Texas 215 retail locations vs 2008 $6 billion in physical medical facilities ($2B in progress) $1 billion in medical office buildings $2.3 billion current capital program 2

3 Houston - Forbes #1 America s Fastest Growing Cities When oil prices are low, Houston s economy grows. When oil prices are high, Houston s economy booms MSA: Houston-Sugar Land-Baytown, TX 2014 Population growth rate: 1.81% 2015 (Projected) pop. growth rate: 1.74% 2014 Gross metro product growth rate: 3.52% Job growth rate: 4.5% Unemployment: 4.8% Median pay: $71, Population: 6. 4M 2019 Population: 7.0M (est.) 2

4 Integration Health System 4

5 Recent Accolades 15 Top Health Systems; Top 5 Large Health Systems (2012 & 2013) John M. Eisenberg National Patient Safety & Quality Award (2012) National Quality Forum National Quality Healthcare Award (2009) TIRR Memorial Hermann - - No. 3 in rehabilitation hospitals Texas Hospital Association Bill Aston Quality Award (2011) Healthcare s 100 Most Wired 8 th consecutive year America s #1 Quality Hospital for Overall Care (2011 & 2012) America s 50 Best Hospitals ( ) The Joint Commission Top Performer (2012), Heart Attack, Heart Failure, Pneumonia, Surgical Care 2011 Texas Healthcare Foundation Quality Improvement Awards (9 Memorial Hermann Campuses) 2014 Houston Business Journal (HBJ) No. 3 Best Places to Work 5

6 High Reliability Organization 6

7 Awareness Q: When you think of hospital systems in the area, which one comes to mind first? 100% % 69% 60% 58% 43% 40% 31% 28% 26% 20% 8% 15% 13% 6% 0% Memorial Hermann Methodist St. Luke's MD Anderson Don't Know/No Others * 2013 & 2014 data reflects phone and online survey 7

8 Preference 100% Q: Which hospital system would you prefer to use if you or someone in your household needed medical care? % 60% 40% 20% 0% 45% 36% 38% 15% 17% 22% 13% 12% 11% 15% 8% 9% 3.0% 2.0% 1.0% Memorial Hermann Methodist St. Luke's MD Anderson Don't Know/No Others * 2013 & 2014 data reflects phone and online survey 8

9 Balance Or Close Enough.Be Reasonable (Critical Timing/Need) (Real Estate Projects Needed x Many Clinical Projects) Hospitals Many MHHS Worthy Projects MOBs Retail CCCs Developer Funding/Benefit (Profit) Balance Sheet REMEMBER: HEALTH CARE SYSTEMS HAVE CASH, CREDIT, FINANCING, EXPERTISE DESIRE TO BE REAL ESTATE DEVELOPERS/OWNERS.. 3

10 To Own..Or Not To Own.That, Is the Question. Balance sheet impact Days cash on hand Debt capacity Wall Street Financial Ratios Spectacular patient care programs that should be funded Funding sources In order of preference Cash flow Debt tax exempt vs. taxable Partners (a lengthy discussion) Developer owners (for-profit projects) Asset Types Hospital Tax exempt financing available vs. MHHS/Northeast Hospital MOBs Taxable Not strategic/core assets (lengthy discussion on MOB asset management philosophies) Retail locations (CCC example of pure retail) 4

11 Convenient Care Centers The tale of a Convenient Care Center (CCC) project funding discussion What is a CCC? Owned by Memorial Hermann? Developed and leased by MHHS and then monetized? RFP for developer turn-key lease? Who owns the key piece of land? Expansion opportunities? Developer covenants vs. leasing? 5

12 The healthcare industry along with its associated medical real estate and facilities management industry is changing and your organization needs to continuously be educated, informed and active to add value and be successful in the future. 12

13 Facility Services Overview Facility Services Departments Architecture and Construction Capital Planning & Asset Management Clinical Engineering Biomedical Engineering Electronic Engineering Imaging Support Services Environmental Services Laundry Services (MH & TMC Laundries) Medical Equipment Investment Council Medical Plaza Leasing and Property Management Physician Medical Plaza Joint Venture Operations Sterile Processing System Engineering System Parking System Security Food Service Materials Management and Supply Chain SIGNIFICANT DIVERSITY OF RESPONSIBILITIES Every department is becoming more efficient and effective through standardization and centralization. 13

14 Bundling Facility Services Facility Services Philosophy (Personal Philosophy) Design Construct Occupy/Lease Maintain Supply All one team All one vision Single Point of Responsibility New entities into this bundled services model Standardization..current initiative.. Henry Ford quote.. 14

15 Recent Events Exchange sign-up still very low State of the Union/Rebuttal January 2015 (no mention) Future government shutdowns for Texas and Medicaid? Healthcare reform delay January 1, 2016 Employers shedding healthcare coverage = savings to them Benefit plans dropping healthcare coverage or large deductibles added Actual cost of new healthcare coverage vs. value Employer fines Individual fines Lacking: Sign up of the young and healthy (SS Program Example) 15

16 Community Charity Care MHHS budgeting $800 million in uncompensated care! Not sustainable! (Fair) Who will support our community? MHHS investing $2.3 billion in our community with new projects 16

17 Capital Construction Strategies Reduce the initial capital construction and ongoing operational cost of medical facilities and real estate without impacting the quality of care (use of different types of construction) Developing new medical real estate (non-hospital) strategies (own vs. master lease vs. JV) Declining reimbursements continue Changing physician-hospital-payer relationships - MHHS now offers a payor and MD employment is increasing Be alert for future healthcare consolidations 17

18 Healthcare Reform Impact (MHHS) 1. Continued, significant reimbursement declines per procedure MHHS is at capacity at almost every campus Medicare/Medicaid payment reductions hospitals and physicians negatively impacted Disproportionate Share Hospital (DSH) reductions Increase in volume of Medicaid patients Increase in volume of Medicare patients - 10K per day celebrate 65! Next 22 years! Rise in uninsured patients due to corporate cost considerations and deletion of private medical insurance as a benefit Wall Street will encourage transition Employer/employee options example provide/pay fines New elections changes profile 2. Houston & Texas economy still envy of most cities! 3. Oil and jobs! 4. Shifts focus from solely growth of patient volumes to wellness, efficiency & quality to be successful with new payer government programs Accountable Care Organizations (ACO s) Low cost provider High Quality patient safety and satisfaction Guaranteed costs = at risk provider coverage 5. Scarcity of capital for all healthcare providers and impact on development 18

19 What Does All of This Mean to a Medical Tenant/Developer/Manager? Continued consolidation No one s future is totally clear..patient, physician, hospital, real estate industry, etc. Be cautious Effective forecasting distance is probably less than months Physician reluctance to invest in new medical real estate ventures Physician reluctance to execute long-term leases Physician reluctance to align with organizations due to the unknown.or relief.. Frustration over compensation/reimbursements Increased downward pressure on operating expenses 19

20 Management Models/ Cultural Change Outsourcing Experience Environmental Services Food and Nutrition Services Clinical Engineering Laundry Property Management & Leasing Centralizing Security Supply Chain Management Clinical Engineering Sterile Processing (New 2014) Medical Equipment Investment Council (New 2014) 20

21 Facility Services Facility Services Strategy and Philosophy All Facility Services Departments have input on capital projects and we enforce Best Practices previously local campuses dominant One Team + One Vision + One Point of Accountability = Success/Efficiency (Better be Correct!) SLOW AND DIFFICULT TRANSITION FROM FULL CAMPUS AUTONOMY TO CENTRALIZED CORPORATE DIRECTION Hotel example Top executive support Performance usually = acceptance Aggregate spending 21

22 MHHS Reorganization Discussion: Purpose Succession Planning Standardization Service Lines 22

23 75 vs 50 vs 25 Year Facilities Recent focus on First cost capital Less expenditures on architectural interiors No longer building 50-year or 75-year facilities Focus on energy efficiency not green if costs more $$$ Make it a rectangle Every Team Starts Fresh Unfortunately limit! Depreciation impact to financials Competitive pricing model impact Joint ventures - OPM leasing of assets Ex: Convenient Care Centers 23

24 Further Areas for Exploration Medical Real Estate and Facilities Managers must understand the industry and have experienced personnel! Implementation of Environmentally Friendly programs Waste stream Utilities LEED Certifications Energy Star Ratings Recycling Reprocessed supplies Cost neutral mandate for all green programs! 24

25 Memorial Hermann Pearland CCC/Hospital MOB 2 Site Plan 25 25

26 Katy Hospital Site Plan New MOB 2 New Tower 26

27 Sugar Land Hospital Expansion Rendering 27

28 Texas Medical Center Campus MFP Site Logistics Parking Infrastructure Building (PIB) HPII HPI (Existing) Digital Scan Conducted by Contractor for Site Logistics Planning Life Flight to Continue Operations During All Construction 28

29 MH-TMC Master Facility Plan Partial Robertson Demo Phase I of PIB - Generator Building Robertson Pavilion Demo line Central Plant Bridge from G4 Note: All structures in Red will be demolished Dock 29

30 MHHS TMC Campus Master Plan Preliminary Rendering Park View North Campus Elevation 30

31 MHHS TMC Campus Master Plan Preliminary Rendering Park View North Campus Elevation - Night 31

32 Memorial Hermann Cypress Hospital View From Highway 290 Hospital MOB 1 CCC Preliminary Rendering 32

33 MH Convenient Care Center South Katy Architectural Night Rendering 33

34 MHHS Medical Office Building Development (Six MOBs) Memorial Hermann engaged Powers Brown Architects to design a new proto-typical medical office building for Memorial Hermann, utilizing tilt-wall construction vs. traditional pre-cast construction. Several months were devoted to designing a rectangular, energy-efficient and efficiently designed floor plan, that could easily be replicated at multiple sites, saving significant design fees and schedule time. This new tilt-wall design is less expensive, delivers occupancy more quickly, keeps physician lease rates affordable, and still provides a high-quality, long-term asset Design is complete for TWH MOB 4, Katy Hospital MOB 2, Sugar Land Hospital MOB 2, Pearland Hospital MOB 2, NE MOB 2 and Cypress MOB 1 TWH MOB 4 (On Hold) PLH MOB 2 SLH MOB 2 KH MOB 2 Standardization It Pays.. NEH MOB 2 34

35 Questions 35

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