A recent NIC Notes blog titled “Market Fundamentals Amid Challenging Time for Skilled Nursing” published by NIC Analytics, evaluated supply and demand dynamics for freestanding skilled nursing properties within the 31 NIC MAP Primary Markets (Primary Markets) aggregate since 2017, and examined property-level occupancy distribution to get a better understanding of how widespread the effects of the pandemic have been.

This analysis digs further and reviews how select individual skilled nursing markets are faring after two years of the pandemic.

Occupancy Loss and Recovery Varied by Market. During the height of the pandemic, the occupancy loss for freestanding skilled nursing properties across all the Primary Markets was mainly a function of a demand contraction. In fact, inventory across most of the Primary Markets remained somewhat stable over the period from 1Q 2020 to 1Q 2021.

Drilling down into metropolitan markets, Boston’s occupancy fell 17.8 percentage points (pps) from 88.7% in first quarter 2020 to 70.9% in third quarter 2020. As a result, occupied units in Boston fell by nearly 21% in the span of two quarters. This was the largest demand contraction and occupancy loss a market experienced in the first two quarters of the pandemic. New York also experienced a large drop in occupancy. In the early months of the pandemic, New York’s occupancy rate fell 13.4pps from 92.0% in the first quarter of 2020 to 78.6% in the third quarter of 2020.

Notably, all the Primary Markets experienced double-digit occupancy declines, except Dallas (negative 9.6pps) and Kansas City (negative 7.7pps). Additionally, none of the skilled nursing Primary Markets experienced significant inventory growth during the height of the pandemic. Therefore, the skilled nursing occupancy declines were mainly a function of demand contraction whereas the occupancy loss for the private pay senior housing sector was a function of both an increase in supply and a decrease in demand.

On the other hand, the occupancy recovery paths and timelines are also proving to be uneven across markets with select Primary Markets improving more rapidly than others. For example, Orlando is a market that experienced a relatively smaller drop in occupancy during the first year of the pandemic of 10.7pps, from 89.7% in the first quarter of 2020 to 79.0% in the first quarter of 2021. However, Orlando’s occupancy increased by 6.8pps during the second year of the pandemic and stood at 85.9% in the first quarter of 2022. This helped the market recover 64% of the occupancy loss in percentage points and pushed its occupancy ranking from thirteenth to first among the Primary Markets.

The exhibit below shows that occupancy across several markets is recovering relatively fast. These markets include Orlando, Phoenix, New York, and Boston. Notably, 17 of the 31 Primary Markets have recovered at least 30% of the occupancy loss in percentage points, although occupancy across some of these markets is still far below pre-pandemic levels.

While the occupancy improvements across most Primary Markets depict a very welcome positive trend and indicate light on the horizon, the uncertainty bands remain wide in terms of when occupancy rates for skilled nursing properties will return to pre-pandemic levels. A key question is whether obtaining a sustainable level of occupancy and revenue growth will be sufficient to grow NOI and recoup some of the losses associated with the severe downturn in occupancy rates, higher expenses associated with agency staffing, PPE and other costs, Medicare funding cuts, and underfunding of Medicaid reimbursement in many states. Other headwinds for NOI growth include staffing shortages that are effectively restricting admissions of residents into some skilled nursing properties, and broader inflationary effects associated with the pandemic.

For example, a few markets experienced prolonged occupancy pullbacks and the recovery has thus far been elusive. This is the case of Tampa where 1Q 2022 occupancy remained 14.3pps below pre-pandemic 1Q 2020 levels and shifted the market’s ranking among the Primary Markets from fifth to sixteenth. Similarly, Washington and Atlanta are markets that experienced prolonged occupancy declines and remained far below pre-pandemic levels.

We cannot yet know how pandemic-derived challenges will unfold in future months, or when they will be fully behind us, but the skilled nursing industry has weathered this extremely difficult period and begun the path to recovery.

This analysis examined approximately 4,000 freestanding skilled nursing properties within the Primary Markets. Note that combined properties offering at least two types of service and life plan communities (LPCs)/continuing care retirement communities (CCRCs) were excluded from this analysis.

—

To learn more about NIC MAP data, powered by NIC MAP Vision, an affiliate of NIC, and accessing the data featured in this article, schedule a meeting with a product expert today.

The Labor Department reported that nonfarm payrolls rose by 390,000 in May 2022 and the unemployment rate held steady at 3.6%. The report confirms that the labor market remains strong, despite the war in Ukraine and on-going supply-chain pressures. Concerns about rising wage costs and inflation are also supported by this report. Average hourly earnings for all employees on private nonfarm payrolls rose by $0.10 in May to $31.95. This was a gain of 5.2% from year-earlier levels but was less than the 5.5% gain seen in April.

The data shows that the labor market continues to gain momentum and wage growth is strong. The report strengthens the Federal Reserve’s intention of continuing to raise interest rates further following the 0.75 percentage point hike in the fed funds rate that has already occurred so far this year. Another 0.50 percentage point hike is anticipated at the next FOMC meeting.

Revisions subtracted 22,000 to total payrolls in the previous two months. Nonfarm payrolls were still down by 822,000 or 0.5% from their pre-pandemic level in February 2020. The market consensus had been for a gain of 320,000.

In a separate survey conducted by the BLS, the jobless rate was 3.6% for the third month in a row. The jobless rate is only 0.1 percentage point above the pre-pandemic level of 3.5% seen in February 2020, and well below the 14.7% peak seen in April 2020. The number of persons unemployed was essentially unchanged at 6.0 million but was still above the 5.7-million-person level seen prior to the pandemic.

Among the major worker groups, the unemployment rates were 3.4% for adult women, adult men (3.4%), teenagers (10.4%), White (3.2%), Black (6.2%), Asian (2.4%), and Hispanic (4.3%).

The labor force participation rate edged up 0.1 percentage point to 62.3% in May and was below the February 2020 level of 63.4%.

The April underemployment rate or the U-6 jobless rate was 7.1%, up from 7.0% in April 2022. This figure includes those who have quit looking for a job because they are discouraged about their prospects and people working part-time but desiring a full work week.

Employment in health care rose by 28,000 in May. Employment in health care was down by 223,000, or 1.3% from its level in February 2020. Employment in nursing care facilities rose by 1,300 positions to 1.348 million but was 35,600 less than year-earlier levels.

Employment in leisure and hospitality increased by 84,000 in May and were 1.3 million positions below the pre-pandemic level.

“Demand for skilled nursing seemingly is rising as occupancy has now increased steadily since January and COVID-19 cases declined from January to March.”

– Bill Kauffman

NIC MAP^® Data, powered by NIC MAP Vision, released its latest Skilled Nursing Monthly Report on June 2, 2022. The report includes key monthly data points from January 2012 through March 2022.
Here are some key takeaways from the report.

Skilled nursing property occupancy increased 23 basis points in the month of March, ending the month at 77.1%. This was the highest occupancy level since the beginning of the pandemic in April 2020 but was still well below the pre-pandemic March 2020 level of 84.8%. After declining 30 basis points in January because of the Omicron variant challenges, including increased staffing shortages, occupancy has increased 119 basis points (1.2 percentage points) since January. In addition, it has increased 503 basis points from the low of 72.1% set in January 2021. These data points suggest that demand for skilled nursing properties is growing, although staffing shortages continue to limit the ability to admit new residents.

Medicare revenue per patient day (RPPD) decreased from February to end March 2022 at $573. The 1.0% decrease from the prior month suggests that the decline in COVID-19 cases has reduced the amount of reimbursement needed for COVID-19 positive residents. At its height, COVID-19 required additional measures of care to be implemented. The federal government implemented many initiatives to aid properties for cases of COVID-19, including increases in Medicare fee-for-service reimbursements to help care for COVID-19 positive patients who required isolation. The reduction in additional Medicare reimbursement is also evident in the revenue mix data. Medicare revenue mix declined 339 basis points from February, ending March at 21.2%.

Managed Medicare revenue mix decreased 78 basis points from February to end March at 10.6%, reversing the 83-basis point increase that occurred from January to February. Prior to the pandemic, in February 2020, it was 11.2% and then declined to a pandemic low of 8.1% in May 2020. It is now 255 basis points above the low point. The increase from the pandemic low is likely due to growth in elective surgeries from 2020, which typically creates additional referrals to skilled nursing properties.

Medicaid revenue per patient day (RPPD) declined from February to end March 2022 at $246. In addition, Medicaid is down 1.2% from the prior year in March 2021. However, Medicaid RPPD has increased during the pandemic as many states embraced measures to increase reimbursement related to the number of COVID-19 cases to support skilled nursing properties. Medicaid RPPD has increased 2.9% since February 2020, prior to the pandemic.

Get more trends from the latest data by downloading the Skilled Nursing Monthly Report. There is no charge for this report.

The report provides aggregate data at the national level from a sampling of skilled nursing operators with multiple properties in the United States. NIC continues to grow its database of participating operators to provide data at localized levels in the future. Operators who are interested in participating can complete a participation form. NIC and NIC MAP Vision maintain strict confidentiality of all data received.

In a new question in the Wave 41 survey, respondents were asked whether they found the acuity of new resident move-ins to have increased, decreased, or stayed the same as compared to before the pandemic. Significantly, move-in acuity has increased for 71% of the respondents with assisted living, and for more than 60% of respondents with memory care units and nursing care beds. In independent living settings, 41% of respondents report acuity having increased since before the pandemic. The shares of organizations reporting acceleration in nursing care move-ins continued to increase – from 21% in Wave 37 conducted in January 2022 to 68% in Wave 41. This marks the fourth consecutive wave where the pace of nursing care move-ins has increased from the prior wave. Over one-half of respondents to the Wave 41 survey (53%) reported lead volumes above pre-pandemic levels in May – a noteworthy increase from the Wave 38 survey reflecting results in February (33%).

-Ryan Brooks, Senior Principal, NIC

NIC’s Executive Survey of senior housing and skilled nursing operators was implemented in March 2020 to deliver real-time insights into the impact of the pandemic and the pace of recovery. In its third year, the “ESI” is transitioning away from the COVID-19 crisis to focus on timely industry topics. While some standard questions will remain for tracking purposes, in each new survey “wave,” new questions are added.

This Wave 41 survey includes responses from May 2 to May 27, 2022, from owners and executives of 60 small, medium, and large senior housing and skilled nursing operators across the nation, representing hundreds of buildings and thousands of units across respondents’ portfolios of properties. More detailed reports for each “wave” of the survey and a PDF of the report charts can be found on the NIC COVID-19 Resource Center webpage under Executive Survey Insights.

In a new question in the Wave 41 survey, respondents were asked whether they found the acuity of new resident move-ins to have increased, decreased, or stayed the same as compared to before the pandemic started. Of note, increased move-in acuity was reported by 71% of the respondents for assisted living, 61% in memory care, and 62% in nursing care. Only 41% of independent living reported increased resident acuity at move-in.

In the Wave 41 survey, three-quarters of respondents indicated the severity of their staffing shortages across their organizations was moderate (77%). This marks the second consecutive wave in which moderate staffing shortages increased. Conversely, 16% of respondents reported staffing shortages to be severe in the Wave 41 survey. This marks the second consecutive wave in which severe staffing shortages declined, compared to Wave 40 (19%) and Wave 39 (27%).

Despite fewer reports of severe staffing shortages, attracting community and caregiving staff remains to be a top challenge cited by operators (83%). Rising operating expenses (80%) and staff turnover (63%) follow as the second and third most reported challenges.

In another new question in the Wave 41 survey, respondents were asked about their utilization of the CMS nurse aide training waiver, which temporarily waived the 12-hour in-service training requirement for nursing assistants. With the waiver set to expire on June 7, 2022, 43% of respondents reported using the nurse aide training waiver to employ aides for longer than four months, even if those aides had not completed the training and certification requirements. Respondents who reported making use of the waiver were asked what impact the expiration would have on their organization’s ability to staff their properties. All respondents indicated the expiration would have an impact: 25% reported it would have a minimal impact, 58% reported it would have a moderate impact, and 17% reported it would have a strong impact.

Regarding the current share of all full-time, open positions across respondent organizations, in the Wave 41 survey, approximately one out of three respondents have between 11% and 20% of full-time positions unfilled, whereas roughly two out of five respondents have 20% or more positions currently unfilled.

The timeline below shows the share of organizations reporting an increase in the pace of move-ins during the prior 30-days. Data from the Wave 41 survey shows that the increase in pace of move-ins continues to be above the levels reported in Waves 32 through 38. This is an encouraging sign that recovery is continuing.

In the Wave 41 survey (reflecting operator experiences in May), 36% of respondents with independent living, 53% of respondents with assisted living, 51% of respondents with memory care, and 78% of respondents with nursing care reported an acceleration in the pace of move-ins. The portion of respondents reporting an acceleration of move-ins declined for independent living and assisted living, compared to 50% of independent living and 61% of assisted living in Wave 40. The pace of move-ins did increase for the memory care and nursing care segments, compared to 43% of memory care and 63% of nursing care in Wave 40. Since January, the shares of organizations that reported acceleration in nursing care move-ins increased significantly — from 21% in Wave 37 to 68% in Wave 41.

Despite the positive trend in the accelerated pace of nursing care move-ins, it is important to balance this with the corresponding pace of move-outs, which also showed an accelerated pace since Wave 39 in March.

In Wave 41, 54% of respondents indicated lead volumes above pre-pandemic levels, compared to 52% in Wave 40 and 33% in Wave 38 reflecting results in February. In Wave 41, large operators (26+ properties) had the greatest portion of respondents indicating lead volumes above pre-pandemic levels (60%). Mid-sized operators (10-25 properties) reported 57% with lead volume above pre-pandemic levels, followed by single-site operators (53%) and small-sized (2-9 properties) operators (46%). While this is an encouraging sign, this may be reflecting pent-up demand from earlier in the pandemic.

Wave 41 Survey Demographics

• Responses were collected between May 2 and May 27, 2022, from owners and executives of 60 senior housing and skilled nursing operators across the nation. Owner/operators with 1 to 10 properties comprise roughly one-half (51%) of the sample. Operators with 11 to 25 and 26 properties or more make up the rest of the sample (24% and 25%, respectively).
• More than one-half of respondents are exclusively for-profit providers (58%), approximately one-third operate not-for-profit senior housing and care organizations (29%), and 14% operate both.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 74% of the organizations operate senior housing properties (IL, AL, MC), 31% operate nursing care properties, and 28% operate CCRCs (aka life plan communities).

Owners and C-suite executives of senior housing and care properties, please help us tell an accurate story about our industry’s performance. If you are an owner or C-suite executive of senior housing and care and have not received an email invitation to take the survey, please contact Ryan Brooks at rbrooks@nic.org to be added to the list of recipients.

NIC wishes to thank respondents for their valuable input and continuing support for this effort to provide the broader market with a sense of the evolving landscape as we recover from the pandemic. This is your survey! Please take the Wave 42 survey and suggest new questions for Wave 43.

NIC’s 2022 Leadership Huddle series continued May 25 with a deep dive into real estate market trends and an outlook on economic forces. Beth Mace, chief economist and director of outreach at NIC, was joined by Mike Acton, managing director of AEW Capital Management, and Mary Ludgin, head of Global Investment Research at Heitman, to discuss navigating federal monetary policy shifts, investment strategies amid record inflation, and opportunities in senior housing segmentation.

With the Federal Reserve raising the federal funds rate, Acton explained that now is the time to remember that these cycles happen, and experience should inform investment. “There’s a playbook – we know what we’re supposed to do as these events unfold,” he said. Ludgin added that experience with these cycles suggests investment is still possible: “In that environment, you can invest through debt as opposed to equity.”

Join the Next Complimentary NIC Leadership Huddle
Evolution of Market Segmentation
June 8, 2022 at 1:00 PM ET

{{cta(’70ff9344-7c68-45f6-adf1-606d38de09a4′)}}

To combat the strongest inflation rate in 40 years, Ludgin explained that real estate is in a much better position than stocks and bonds. As supply and demand balance out, senior housing should prove to be an effective inflation hedge, according to Ludgin. Acton agreed, explaining that real assets are key to making smart investments and fighting future inflation.

Discussing the future of senior housing, Mace explained that diversification and segmentation in the industry present a number of opportunities for investors and developers. “It’s an exciting time in senior housing because you’re seeing a lot of change,” Mace said.

“There’s a lot of good opportunities for debt providers, equity providers, as well as operators.”

NIC Leadership Huddles reconvene June 8 with a timely discussion on market segmentation. Join us as “in the know” experts Melissa Andrews, Tom Gaston, and Ashley Fitzgerald discuss the continued evolution of the senior housing sector. Register today. And, watch all past leadership huddles in the NIC Leadership Huddle Archives.