NIC is pleased to welcome you to the new look and feel of our blog, which up until a week ago was titled NIC CARES. The old blog, which was designed and launched back in March 2015, was, according to our marketing vendor, in need of an update. We’re excited to have launched the new platform over the July 4th holiday, with no major bugs or any complaints – but, of course, will be looking for any feedback from our subscribers and readers.

Not every new feature will be visible to visitors. The new blog is operating on a platform that is easier to work with on the publishing side – and has better tools for tracking visitors and their reading habits. It is our hope that, in addition to reducing the effort required to publish each post, the new platform will help provide some insight into which posts are valuable to our readers, and which ones perhaps fail to attract attention. Over time this approach should help us fine tune the blog to suit our readers’ needs and interests. 

The update provided an opportunity to make some design changes as well. The new interface, which is easy to read on any type of device, also makes loading images easy – so we’re planning to include images in most of our posts going forward. The new layout was designed to be easy to read and to make scrolling through easier as well. 

The new blog’s search function has also been refined. We have developed a much shorter, more useful list of search categories, designed to make it easy for our various audiences to quickly find relevant material. You will find the categories in a drop-down list next to the search button at the top of the page. The entire catalogue of posts, which still dates back to 2015, can also be searched by any keyword users wish to enter. 

Another change, of course, is the name of the blog. “NIC Notes” replaces “NIC CARES” to help remove any misconceptions around our mission and brand, particularly as new readers, and those who may be new to the sector, continue to find the blog online. “NIC Cares,” for some, may imply a medical or skilled nursing focus, which would be inaccurate. While this is not a big problem, we have been aware of the possibility for confusion, and took the redesign as our opportunity to better align the blog with our overall brand. 

Please keep reading NIC Notes – and look for further updates as we continue to refine and improve what has become one of NIC’s favorite sources of insight, news, and commentary on seniors housing and care. 

The Labor Department reported that there were 224,000 jobs added in June, above the consensus estimate of 160,000. The June increase in jobs marked the 105th consecutive month of job growth. The latest six-month average increase is 172,000, less than last year’s 223,000 monthly average. Nevertheless, the pace of job gains is strong and generally stronger than the levels that have usually prompted the Federal Reserve to cut interest rates in the past. This suggests that the Fed will not be cutting rates immediately despite other concerns about a slowing economy or trade-related threats to the economy. In recent months, the Fed’s has indicated that it is paying close attention to the risks of an economic slowdown.

Revisions subtracted 11,000 to the prior two months. The change in total nonfarm payroll employment for April was revised down from 224,000 to 216,000, and the change for May was revised down from 75,000 to 72,000. Monthly revisions result from additional reports received from businesses and government agencies since the last published estimates and from the recalculation of seasonal factors. In June, employment in health care rose by 35,000. In the past year, health care has added 403,000 jobs.

The unemployment rate edged up 3.7% in June from 3.6% in May. This is still close to the lowest rate in 50 years. A broader measure of unemployment, which includes those who are working part time but would prefer full-time jobs and those that they have given up searching—the U-6 unemployment rate—rose to 7.2% from 7.1%.

Average hourly earnings for all employees on private nonfarm payrolls rose in June by six cents to $27.90. Over the past 12 months, average hourly earnings have increased by 3.1%, the same as last month. For 2018, the year over year pace was 3.0% and in 2017 it was 2.6%.

The labor force participation rate, which is a measure of the share of working age people who are employed or looking for work was unchanged at 62.9% in June, very low but up from its cyclical low of 62.3% in 2015. The low rate at least partially reflecting the effects of an aging population.

Part III—Operators Highlight Successful Approaches 

As new research shows that the number of middle-income seniors is growing quickly, forward-looking seniors housing providers are already experimenting with new and more affordable models of housing and care. Innovative ideas include smaller building footprints, private-public partnerships, and efficient designs and staffing models.

These ideas, and others, were recently showcased at an investor summit May 21 in New York City. The NIC-sponsored summit brought together industry stakeholders to share ideas to cut costs and streamline operations to improve affordability for middle-class elders.  

The investor summit followed the release of a new study, “The Forgotten Middle,” which highlights the need for more housing options for the growing number of middle-income elders. The study was recently published in the journal Health Affairs and discussed at an April 24 policy forum in Washington, D.C. 

The study shows that the number of middle-income seniors will double, and most will not have the savings needed to meet their housing and personal care needs.  

The investor summit included three separate panels of industry participants: equity investors, debt providers, and property operators already piloting middle-market options. Each panel discussed what is needed to make middle-market solutions work from their perspectives.  

What follow is an edited transcript of the third panel discussion, focused on building operators. (A link to transcripts of the other panels is here.) 

The operator panel was moderated by Kai Hsaio, CEO, Eclipse. Panelists included Thomas Grape, chairman and CEO, Benchmark Senior Living; Gaurie Rodman, director, development services, Direct Supply; and Judy Marczewski, CFO, Leisure Care. NIC Founder Bob Kramer wrapped up the investor summit with remarks about the next steps for the industry.  

Hsaio: The question is whether we can make this middle–market operating model work. Tell us about your companies. 

Grape: Benchmark Senior Living has 58 communities, mostly in the Northeast. We have rolled out a shared occupancy model with reduced construction costs and staffing changes.  

Rodman:  Direct Supply supports operations. So we see a wide array of concepts brought to the market. Innovations in technology can have an impact on the cost of operations.  

Marczewski: Leisure Care has 50 communities of independent living, assisted living and memory care from middle market to middle upper market. We just opened our third middle market product in Raleigh, North Carolina.  

Hsaio:  Why are you doing middle market buildings? And what were the initial steps you took? 

Grape:  We were drawn to it for the same reasons that motivated the study.  We knew there was an underserved middle to tap into as rents and costs increase. We’re pleased with our success.  We tried the first community as an experiment to see if we could make it work. Now we have a couple more ready to open.  

Marczewski: We wanted to design a product that met our philosophy for seniors housing but at an affordable price. In 2014, we designed a product based on monthly rent of $2850, which matches where middle market turned out to be. We started from scratch to design and operate this model from a customer perspective within that rent price.  

Hsaio: Where did you get financing? 

Marczewski: We just opened our third project and each one has a different equity partner. The secret is to build an efficient operating model. An efficient capital structure is what’s missing.  

Grape:  We targeted rent of $50,000 per year, an average of $3,300 a month for assisted living and memory care is higher. That’s 25% less than competitors. We reduced staffing by 15 percent compared to our other properties but without touching care levels. Instead, we reduced overall staffing by tinkering around the edges. Building size is 25% percent less than our traditional buildings. We used conventional financing. It would be great to have a financing mechanism like the low income housing tax credit to marry with this kind of operating model to help target the middle market.  

Hsaio: If I looked at a pro forma for your traditional product and for your middle– market product, how would they compare? 

Grape: We are located in a more blue collar market where land costs are less. Construction cost per unit was 25% less. We did a smaller building size and memory care is on a single floor and assisted living on two floors. We did wood frame construction in the two-story portion to keep costs down. On the operating side, we reduced staffing by 15% percent. We have no dining room manager and we reduced the activities staff by half of a full time equivalent. We nibbled around the edges without touching the care staff.  We did not market the building as lower cost, but as a high sociability option.  The vibe in the building is electric. There’s a great sense of volunteerism from residents and families. The more compact building size and common areas have created a great culture and it has worked with less staffing. The smaller building requires fewer housekeeping staffers and maintenance workers. The margins are about 5% less. The NOI per unit is $2,000 less, but we get the same unlevered returns and the same projected IRR over the whole period.  

Marczewski:  Similarly, we focused on efficiency. Thoughtful design helped us to reduce staffing levels. We offer high quality food, but fewer options. Food is prepared throughout the day rather than all at once to allow for better staffing. We spent time very thoughtfully designing the building from the inside out. We focused on operations, not on how to make it look pretty on the outside. We operate at significantly less cost.  In 2014 dollars, project cost was $26 million, or less than $200,000 per unit. Our portfolio has been built over 40 years with expensive and moderately priced buildings. For what we are doing, repurposing another building would not work. Operational efficiency is where you get returns.  

Grape:  Our cost was $440,000 per unit, but $221,000 per bed compared to $339,000 for a typical building, or 35% less. The trick was shared occupancy. We could not build today for those numbers because of the rise in construction prices.  

Hsaio:  How do you think about the middle–market product?  

Rodman: We look at every layer of the development and operating process from the beginning.  It might mean finding land in communities where you can have a conversation around getting real estate taxes reduced, increasing the floor area ratio (FAR), and leveraging community taxes for infrastructure improvements.  It means looking at partnerships with local home health agencies, hospitals, universities, and high schools for volunteers. Technology is providing a lot of innovation that we need to embrace.  

Hsaio: Any lessons learned? 

Marczewski:  Our first project did not fill that fast. It’s in too small a market. The second one is doing well. The building design as well as the operational efficiencies has proved out. Our margins are incredible and the third building is off to a wonderful start. We will start our fourth building depending on how quickly the third one fills.  

Grape: Our first building has done well and opened near full. It had shared occupancy units. The next two buildings have a few one bedroom units to add some variety.  

Hsaio: Looking forward, which will grow faster: middle-market or other products? 

Grape:  For us, we’ll see how the next two do before we launch more. We are feeling our way.  We want to understand the customer and operations and know we have it down. We’re not there yet but we’re encouraged.  

Marczewski: It depends on land and construction costs. It’s challenging now to build because construction costs are up. The next cycle is coming, so we’ll see.   

Rodman: Regulations have to change. We need to take a look at the required number of ADA compliant units and see if we can build for less and still meet consumer needs.  Maybe it’s the difference between building a closet vs. adding a wardrobe in the unit. Little things can add up. Maybe we can leverage the land with another user to produce different revenue streams. Our next population of residents will desire that. We need to start thinking out of the box.  

Hsaio:  Is CapEx different for these projects? 

Marczewski:  The kitchens in our moderate buildings are the most expensive kitchens we’ve built.  We put high–quality equipment in kitchen to reduce staffing. You can trim expenses through less staffing with good design and equipment. The equipment is easy to clean and maintain and the costs associated with that can add up.  We are not willing to compromise on providing great communities for residents. We don’t do shared units. There are a lot of ways to do this, but the building has to be thoughtfully designed.  

Hsaio:  What about acuity levels? 

Marczewski: Our middle market product is independent living, but with space for physical therapy, occupational therapy and home health which operate in the building. That allows us to keep pricing down. We’d like to do assisted living too and that is coming next.  

Grape:  We offer assisted living and memory care, no different from our other product.   

Audience Q: Are these places the vision of the life residents will want?  

Marczewski:  We designed a model not around what we have done in the past but what people will be looking for in the future. It’s a modern, social model with the kind of apartment future customers would want based on their psychographics.  

Grape:  We market the community as a sociability model, not as an inexpensive alternative. The building is located in a modest income community but people are drawn to the sociability and that’s what they want. The community is based on research of people who want a social setting.  We’ve done a good job in this middle market community by not having people feel like it’s a middle-market product but one that’s highly social because that’s what they wanted.  

Rodman: We shouldn’t call it seniors housing just because people are in the later stage of life. We need to think about it differently.  

NIC Founder Bob Kramer summarized the ideas presented at the investor summit and offered insights into the future of middle-market seniors housing.  

Kramer:  If you look ahead to 2029, the middle-income segment represents a huge market for seniors housing which will only grow in the following two decades. How are we going to take advantage of this opportunity and meet the need?  

We’ve touched on the need for a combined public–private approach to this challenge. And if the private sector is not part of solution, we will pay a price because there will be pressure on safety net programs such as Medicare and Medicaid. Should seniors housing only care about the wealthy? If so, tough regulations will come and there will be mandatory set asides for middle-income folks.  The reality is that this is an untapped market and a huge unmet social need. We will have more flexibility going forward as an industry if we demonstrate our commitment to this market and offer practical solutions.  

What I heard today is that the equity component presents the greatest challenge, but that the debt piece will be there to finance middle-market projects.  

Our industry has been focused to a great extent on offering the same product with different bells and whistles. But our operator panel today showed a different way of looking at things by looking at a price point and figuring out a way to deliver what the customer wants. Efficiencies can be found with technology and a better use of staff.  

It’s easier to create an independent living product that’s a fun socially engaged community where there is not as much focus on care. Real estate capital is more comfortable with that model.  

The tough challenge is solving the care piece for the 85– plus population.   Maybe real estate equity won’t be part of the solution. Instead, insurance plans might see the opportunity to wrap a managed care product around a seniors housing platform to serve a middle–income market they have risk for. Healthcare investment funds might be more interested in that kind of product than real estate funds.  

Other ideas might be prefab, modular units with lots of technology. Labor will continue to be an issue and regulations will have to change to find creative solutions, such as volunteer family caregivers or allowing the less frail to care for the more frail. Middle-income seniors represent a huge market and a great opportunity, but we have to be more flexible.   

It’s critically important as we talk about 2029 to understand how customers are changing. They are not going to accept a condescending model of senior care. They are looking for social connection and purpose. It has to go deeper than care or a real estate product. Maybe it’s the village model or co-op housing—a college-style place where you can reinvent yourself in your 70s.  Activity directors could become purpose matchmakers with the care component running in the background. Today’s image of assisted living is a place where you need care. But people don’t want to move there.  Selling a lifestyle and the human connection is different.  

Go back with your team and discuss this. We want to bring a spotlight to ideas in four areas:  development, capital, operations and regulations. NIC hopes to highlight our need to come together to provide more and different types of housing and care options for middle-income seniors. They’re hoping not just to age, but to age well, in other words, to thrive. 

Part II—Debt Providers Offer Possible Solutions 

Innovative ideas of how to provide housing for the growing number of middle-income seniors were discussed by industry stakeholders at a recent investor summit in New York City. Convened by NIC, the summit also spotlighted new research on middle–market seniors.  

Results of the research were initially detailed at an April policy forum in Washington, D.C. (link to research results). The ground-breaking study, “The Forgotten Middle,” forecasts a shortage of affordable seniors housing and care options for middle–income seniors in the next decade.  

The investor summit included three separate panels of industry participants: equity investors, debt providers, and property operators already piloting middle-market options. Each panel discussed what is needed to make middle–market solutions work from their perspectives. 

What follows is an edited transcript of the second panel discussion which focused on debt providers. (A link to the other discussions is here.)  

The debt panel was moderated by NIC Chief Economist and Director of Outreach Beth Mace. Participants included: Robert M. White, Jr., founder and president, Real Capital Analytics; Michael Patterson, vice president, Underwriting and Credit, Freddie Mac; Christopher Callaghan, group vice president, head of healthcare banking, M&T Bank; and Heidi Brunet, managing director, Newmark Knight Frank. 

Mace: I’d like to introduce Bob White, founder and president of Real Capital Analytics, who will set the discussion in context by providing a profile of debt providers to the seniors housing market. 

White: A transition in the composition of lenders for seniors housing has occurred since mid–2005 through today. Before the financial crisis of 2007-08, the sector relied on the CMBS marketplace; in contrast CMBS is not a source of financing for seniors housing today.  The government agencies have carried lending for the multifamily and seniors housing markets since the crash. At its peak in 2009, the government agencies were 82% of conventional acquisitions and refinancings for seniors housing. The agencies were half of originations in 2011 and 40% in 2018. The highest proportion of bank lending took place in 2018. Regional banks accounted for 20% of the loans and national banks made 17% of the loans. Financial funds accounted for another 12%.  Institutional debt funds will be an interesting component of the capital stack going forward.  

Seniors housing relies on national and regional banks for new construction loans. There are 6,000 banks, but relatively few are active in seniors housing. We need to educate the regional banks about seniors housing. The government agencies and local and regional authorities are generally not active in construction financing which should change if we’re talking about increasing middle–market seniors housing availability   It’s an important factor to meet the upcoming middle–market demand.  

There are differences by market. The major metros—Boston, New York, Chicago, San Francisco, Los Angeles—have the greatest competition among capital providers. The agencies are more active in smaller markets but there are fewer options for financing.   

The seniors housing market has low default rates. By 2011, we had tracked about $300 billion of distressed commercial mortgages nationwide. Seniors housing was less than $3 billion of that.  Default rates in seniors housing were minimal. Losses upon default have averaged 20-25%, comparable to multifamily losses but lower than other property types, especially compared to hotels which had the highest default and loss rates. Some people attribute that to the operating component. It’s   important to track default and loss rates because of new regulations around capital withholding requirements for banking organizations. We could get cheaper debt for seniors housing if we show default and loss rates are lower than industry standards.  

Mace:   What is your viewpoint of lending to the seniors housing sector? 

Patterson: Freddie Mac purchases seniors housing mortgages for independent living, assisted living, memory care and apartments.  We purchased over 200 mortgages last year which were sold to investors as securities. Seniors housing is a good business line for Freddie Mac. The industry is growing, profitable and stable, and it provides a durable income stream.  

Brunet:  At Newmark Knight Frank, we originate the loans and service them on behalf of our clients. Freddie Mac has financed $20 billion of seniors housing with us and the losses are insignificant. 

Mace: Can that same model work for middle–income seniors housing? 

Patterson:  Yes, we make mortgages on durable cash flow and that would continue as long as the properties are stable and have a steady cash flow. We have been able to securitize mortgages and we think that will continue. I have been lending for 35 years and the best thing about securitization is that we can see how the mortgages perform on a monthly basis which informs investors. Education is a big part of what we bring to the process. 

Brunet:   We have green investors and a middle-market product might attract a certain type of investor with a social mission.  

Callaghan:  We can underwrite to a lower margin for permanent debt and get comfortable with the sustainable cash flows.  The challenge is finding the equity for construction. How do you develop a brand new facility? Or find the equity to convert a building into seniors housing? If you look at the ability to take cash out at low margins, it’s a challenge for the institutional markets to get their returns over a five year period.   

Mace:  Would you provide debt for a middle-market product? 

Callaghan: Yes, we’ve done low–income properties and high–end properties in tax exempt scenarios where 20% of the units are for those below the area’s median income. There are a lot of ways to finance a middle-income project. 

Mace: We talked about the number of units needed going forward to house the growing numbers of middle-income seniors. Is there a vehicle that would provide that kind of scale? 

Brunet: If it’s a good sponsor and good operator, the capital will be there though it might be different than the capital we have today. We’re lucky that there’s more liquidity in this space—both debt and equity—and it’s better than it has ever been and it will continue to get better.   

Mace: You sound optimistic. So what is the biggest challenge?  

Brunet:  The industry’s biggest challenge is labor and staffing. As a lender, if you have good operators and good product, whether it’s a new building or repurposing of an older one, the debt piece will be easy. 

Mace: Freddie Mac does affordable multifamily lending, any lessons learned there? 

Patterson: We do affordable and workforce housing and we spent time to learn and understand those markets. We would like to have the opportunity to learn what works whether it’s the shared units we’ve talked about or other ways to operate properties. We need to understand the property to provide financing.  

Mace: Do you think the alignment of interests will change in terms of debt service coverage ratios or loan-to-value ratios? 

Brunet:  It’s important to partner with sponsors or operators who are experienced in the space and have good track records. As a lender, I am not interested in working with a multifamily developer without experience in seniors housing. But if they are experienced seniors housing folks committed to the space, then that’s a different conversation.   

Callaghan:  Lenders will be there as long as cash flow looks strong and sustainable. We may assign a higher cap rate to that kind of project so the loan–to–value ratio is appropriate. But we should think about leveraging community– based services such as Meals on Wheels or tapping into Medicare-funded services.  

Patterson:  When reviewing a deal, we look at the potential tenant pool in the area that can fill the building. One thing this study has shown is that the tenant pool is going to be huge at a certain price point. The ability to understand that allows us and our lending partners to get comfortable with those properties.   

Mace: Why does seniors housing have low default rates?  And do you think that would be the case for the middle–market as well? 

Patterson: Our book of business has a good collection of people who understand the business and run their businesses well.   

Callaghan: Risk models differ geographically. We see strong performance in downtown areas and in places like Massachusetts, New Jersey and northern Virginia. They have the demographics that work to keep those markets strong and losses minimal.  

Mace: What are some innovative or practical ideas about how to spur more options for middle-market seniors today? 

White:  NIC has been great educating investors and making it a major property type on the institutional side. Debt markets are farther behind. The more they hear about the experiences of the banks and lending platforms, the better it will be. Only a few of the 6,000 banks are in seniors housing. Banking specialty groups could be formed to meet the coming demand.   

Brunet:  New purpose–built properties with shared units and repurposing vacant office or malls are two ideas.  The debt will be specific to the project but it will be there. Fannie Mae and Freddie Mac have pre-stabilized programs that allow the borrower to lock in low permanent rates prior to full lease-up.    

Callaghan:  Maybe some of the care can be reimbursed. How do we manage reimbursement avenues to bring in more revenue? The real innovation is on employee and staffing side because costs are going up and the labor pool is tight. Maybe regional training initiatives among multiple providers could help fill the void in workers.   

Audience Q: Could we bring down the cost of development and the unit price by using modular construction? 

Callaghan: My biggest worry is the cost of land in urban areas. It’s a tough challenge.   

Audience Q: Could we look at the hotel industry and its debt sources as a model? 

White:  The CMBS market is interesting. It’s bigger in the hotel market.  Collateralized loan obligations are growing. Lenders need to be educated about the difference between hotels and seniors housing since hotels have higher default rates. Foreign capital—debt and equity—is promising. They like any kind of multifamily development. Aging economies like Japan, Korea and even China are interested in seniors housing in the U.S. as an investment and to get experience to bring the model home.  

### 

May 27, 2019 

janekadler@gmail.com 

• First year-over-year occupancy increase since January 2015
• Managed Medicare revenue mix reaches time-series high of 12.1%, higher in urban areas

NIC released its first quarter 2019 Skilled Nursing Data Report last week, which includes key monthly data points from January 2012 through March 2019.

Here are some key takeaways from the report:

1. Occupancy has been on an upward trend since June of last year (2018). Overall occupancy increased 77 basis points from the fourth quarter of 2018 to 83.7% in the first quarter of 2019, the highest rate since the first quarter of 2018. An increase in occupancy is typically expected from the fourth to the first quarter, given the flu season and higher admissions in the winter months. However, as occupancy has shown strength over the past several months, it suggests that seasonality is not the only factor in the recent uptrend in occupancy. In fact, year-over-year occupancy was also positive as it increased 28 basis points from March of 2018. This is the first yearly increase in occupancy since January 2015. The occupancy trend was the same in both rural and urban areas as it increased on both a quarterly and yearly basis. The quarterly occupancy increase was more pronounced in urban areas, however, as it increased 100 basis points from the fourth quarter to 84.9% at the end the first quarter 2019.
2. First quarter skilled mix increased from the fourth quarter. The gain was mostly driven by the increase in managed Medicare, although Medicare mix rose as well. This suggests that higher acuity patients were a driver in the first quarter as they are often admitted during the winter/flu season which in turn often drives an increase in overall occupancy. Skilled mix increased 84 basis points from the fourth quarter 2018 to end the first quarter 2019 at 26.0%. However, skilled mix was down 103 basis points compared to the first quarter of 2018 when it was at 27.0%. Skilled mix increased in urban and rural areas as well compared to the fourth quarter 2018 ending at 27.0% and 22.2%, respectively. Urban and rural both declined in terms of skilled mix compared to March 2018.
3. Overall managed Medicare revenue mix reached a time-series high in the first quarter 2019, ending March 2019 at 12.1%. This revenue mix increased 106 basis points from the fourth quarter of 2018 and 169 basis points from the first quarter of 2018 when it was 10.4%. This continued growing influence on operator revenue further demonstrates the importance of the managed Medicare payor within the skilled nursing sector. This trend is evident across both the urban and rural areas. The revenue mix is highest in the urban areas, where penetration is higher due to the density and managed care opportunity, as it ended the first quarter 2019 at 14.0%. Interestingly, the rural areas now register over 5% in terms of managed Medicare revenue mix ending the first quarter 2019 at 5.4%.
4. Managed Medicare revenue per patient day (RPPD) pressures became evident again in the latest data as it decreased from $439 in the fourth quarter 2018 to $432 as of March 2019. It was down $14, or 3.2%, compared to a year ago when the RPPD was $446. This trend is evident in both urban and rural areas as the RPPD decreased on a quarterly basis and yearly basis in both geographies. It ended the first quarter 2019 at $436 in urban areas and $408 in rural areas. The RPPD decrease in the rural areas likely has less of an impact on the business as the managed Medicare penetration is smaller than in urban areas. The managed Medicare patient day mix in rural areas is only 3.4% compared to the 8.6% in urban areas.
5. Medicaid patient day mix decreased to 65.8% in the first quarter 2019 compared to the 66.4% in the fourth quarter 2018. The decrease in patient day mix is likely due to the increase in other payer sources, e.g. Medicare and managed Medicare, rather than a decrease in patient admissions, as occupancy increased overall in the first quarter 2019. The decrease in Medicaid patient day mix from the fourth quarter 2018 to the first quarter 2019 was driven by the urban areas as it decreased 80 basis points to 66.5%. Rural area Medicaid patient day mix increased 22 basis points to 61.9%.

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