With the senior housing and care sector at a crucial inflection point, the 2023 NIC Fall Conference convened a cross section of industry stakeholders to network, learn, and identify strategic opportunities.  

The NIC conference theme, “Accelerating Change” provided a timely framework to address the disruptions that continue to be felt throughout the U.S. economy, the healthcare services sector, the labor and capital markets, and the evolving preferences of aging consumers.  

“Transformational disruption demands a pivot,” said NIC Board Chair Susan Barlow, co-founder and managing partner at Blue Moon Capital Partners. “With the pain comes great opportunity for the industry.” 

The conference was held October 23-25 at the Sheraton Grand Chicago. Highlights included: 

• An economic keynote conversation with former Speaker of the U.S. House of Representatives Paul Ryan on the influence of policy and economics in today’s global risk environment.  
• The welcome return of “NIC Talks,” the 12-minute Ted-style talks that offer innovative insights and creative solutions to industry challenges from visionary thought leaders.  
• A skilled nursing keynote with Phil Fogg, Jr. on the headwinds and tailwinds driving the sector. 
• A multi-layered market analysis from CEO’s of the sector’s top REIT investors—Dabra Cafaro and Shankh Mirta. 
• Deep dives into the challenges facing the capital markets and what’s ahead.   
• An update from executives at the Alzheimer’s Association—Dr. Dr. Joanne Pike and Robert Egge—on encouraging medical breakthroughs that will change the course of memory care. 
• Multiple daily, formal and informal, networking opportunities.  
  

The conference drew 2,800 attendees, with 74% comprised of C-suite and executive decisions makers. Operators, developers, and capital providers represented 72% of attendees, a mix that supports conversations to promote housing access and choice for older adults.  

Networking Opens Professional Opportunities 

Attendees enjoyed multiple occasions to engage in results-oriented meetings with other industry stakeholders including several well-attended receptions, with one for first-time conference attendees. A Women’s Networking Meetup drew several hundred women who exchanged ideas and made connections.  

NIC Board Chair Barlow spoke to the women’s meetup and relayed her own story of how she and Kathryn Sweeney shared a cab ride after an industry meeting and then decided to launch their company, Blue Moon Capital Partners. “This gathering is an actionable event,” said Barlow. “Identify opportunities in your organization and ask yourself what you are doing to move forward. Get involved.” She added that her participation in NIC had prepared her to succeed throughout changing business cycles.   

NIC hosted a reception for college scholars who are currently enrolled in senior living programs and attended the conference via conference scholarships sponsored by Welltower. NIC Co-Founder and Strategic Adviser Bob Kramer spoke at the reception. He emphasized that senior living offers excellent career opportunities for those inspired to “do well by doing good.” 

Experts Discuss Relevant Topics 

The conference offered 10 stand-alone educational sessions. Many of the discussions addressed both the tailwinds and headwinds faced by the industry. (High quality videos of most educational sessions are available to attendees in the conference mobile app for conference attendees. Click here to access the app.) 

A standing-room only crowd packed the ballroom for the keynote session with former U.S. House Speaker Ryan. He held a conversation on stage with Bob Hillis, chairman, CEO and founder of Direct Supply/Aptura. 

Known for his policy expertise, Ryan expects capital to be more expensive for a longer period of time. He said that the massive amount of U.S. Treasury debt offerings coming due will need to be refinanced at attractive yields which will keep interest rates high.  

Ryan also pointed to positive tailwinds for the industry, including a healthy jobs market and an aging population. The discussion also covered the regulatory environment, technology, immigration, and the current political landscape. Ryan noted that it was never a good idea to bet against free enterprise.  

NIC Talks featured four main-stage speakers. The session was curated by NIC’s Kramer. “These speakers inspire us to think differently about senior housing and care,” he said. 

Caroline Pearson, executive director of the Peterson Center on Healthcare challenged the audience to embrace the integration of healthcare and senior housing. “Think about ways to locate healthcare services in your community,” she said, explaining that healthcare is both a need and a want of residents. 

Former Apple executive Dhaval Patel provided a roadmap on how to sort through various technology offerings and select the right ones. His advice: Ask yourself if the technology is solving the right problem.  

Other provocative topics presented by NIC Talks speakers Hanh Brown, Founder and CEO of ThinkA16, and Gerard van Grinsven, CEO of Van Grinsven Hospitality Group, included the impact of artificial intelligence on senior living and how to delight and surprise consumers. 

Capital Markets Under Strain 

Several sessions addressed the state of the capital markets and financing challenges. However, the panelists agreed that a huge wave of new demand from aging baby boomers will change market dynamics. 

The opening panel discussion paired Ventas Chairman and CEO Debra Cafaro and Welltower CEO Shankh Mitra. The session was moderated by Randy Richardson, former CEO, president and strategic advisor at Vi Living.  

Out of control construction prices and the dramatic spike in the cost of capital will continue to dampen new development, according to Mitra. Cafaro said that a big company with staying power helps to ride out commercial real estate cycles.  

A deep dive into the debt market and a separate session on valuations illustrated the challenges faced by investors. Arick Morton, CEO at NIC MAP Vision provided some perspective on market fundamentals. Occupancy is recovering and rent growth has caught up with wage growth. Demand is strong.  

The final day of the conference kicked off with a keynote discussion titled, “Navigating the Current Skilled Nursing Environment.” Phil Fogg Jr., CEO at Marquis Companies, was interviewed by Steve Monroe, editor at large at Irving Levin Associates.  

As immediate past Board Chair of the American Health Care Association, Fogg gave a thorough analysis of the skilled nursing sector. He is concerned about proposed regulations that mandate new staffing minimums. But Fogg expects providers to have more negotiating power with payers in the next 3-5 years. 

Attendees also heard from experts on promising Alzheimer’s research, the alignment of management companies and owners, and how to establish inclusive labor practices.  

During a session on how to appeal to the new consumer, moderator Helen Foster, principal at Foster Strategy, challenged attendees to experiment. “Baby boomers will change our industry,” she said. “So many solutions are needed. True innovators are looking to outside sources for inspiration. We have to take risks.”     

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Mark your calendar! Join us March 5-7 at the 2024 NIC Spring Conference in Dallas. Registration opens November 29th!! 

NIC MAP Vision released October 2023 intra-quarterly data on November 9, 2023. The following NIC analysis highlights the ongoing occupancy recovery overall and includes market-level insights from the data.

Key Takeaways:

• Senior housing occupancy for the 68 NIC MAP Secondary Markets has fully recovered, buoyed partly by majority assisted living properties’ performance.
• Recovery trajectories and timelines continued to be uneven, resulting in notable shifts in occupancy rankings among metropolitan markets.
• Market dynamics have evolved recently; once-dominant markets now display lower occupancy rates, while others that previously ranked at the bottom have climbed.

Senior Housing Occupancy by Markets Aggregate. The all-occupancy rate for senior housing for the NIC MAP Primary Markets increased to 84.9% in the October 2023 reporting period, up 0.5 percentage points (pps) from the September 2023 reporting period on a three-month rolling basis, according to intra-quarterly NIC MAP data, released by NIC MAP Vision. From its pandemic record low of 77.8% in June 2021, senior housing all-occupancy increased by 7.1pps and remained about 2pps below pre-pandemic March 2020 levels of 87.1%.

By comparison, the all-occupancy rate for senior housing for the NIC MAP Secondary Markets was up 0.5pps from September 2023 and 8.2pps from its nadir in March 2021. At 86.7%, senior housing occupancy for the Secondary Markets bounced back quicker and had fully recovered, at only 0.1pps below the March 2020 benchmark level.

By majority property type. At 86.5%, the all-occupancy rate for majority independent living (IL) properties for the NIC MAP Primary Markets increased 0.4pps from September 2023 but remained 3.0pps below March 2020 levels. For majority assisted living properties (AL), the all-occupancy rate for the NIC MAP Primary Markets was up 0.7pps to 83.2% from September 2023 and is now 1.4pps below March 2020 levels. Occupancy for AL continued to recover relatively fast compared with IL. From June 2021 – the pandemic-related low – all-occupancy for AL increased by 9.3pps, 4.3pps more than IL (up 5.0pps since June 2021).

In the NIC MAP Secondary Markets, the all-occupancy rate for IL stood at 88.2% in October 2023, having recovered 5.8pps from its pandemic low. It is now just 1.1pps below the March 2020 level. Occupancy for AL properties was 85.1%, about 1pps above the March 2020 level.

Recovery trajectories and timelines continued to be uneven, resulting in notable shifts in occupancy rankings among metropolitan markets.

The past three years have been a period of notable change for the senior housing market. The occupancy rankings tell a story of a market in flux, responding to a complex interplay of economic forces, supply and demand dynamics, and regional attractiveness. The exhibit below compares senior housing occupancy rankings from March 2020 to October 2023 across the 31 NIC MAP Primary Markets.

Notable shifts include San Jose’s fall from the top spot to seventh and Los Angeles’s steep decline from fifth to 22^nd place. These suggest a cooling in California’s once red-hot markets. Conversely, Riverside improved from 23rd to sixth, and Dallas from 25th to nineth, suggesting balanced supply and demand dynamics in these markets (relatively higher absorption-to-inventory velocity – AIV ratio).

Houston remained at the bottom of the occupancy pack (31^st position) and did not experience the volatility seen in other markets. Meanwhile, Boston, Baltimore, Portland, Minneapolis, and Tampa not only maintained their top 10 status since March 2020 but also ascended to the leading positions by October 2023.

Occupancy recovery and rankings vary notably by majority property type. All-occupancy increased or remained stable in 26 of the 31 Primary Markets for IL in the October 2023 reporting period compared with September 2023. At 85.2%, Tampa occupancy increased by 1.1pps from September 2023. However, at 85.2%, Tampa IL occupancy, ranking 21^st among the 31 NIC MAP Primary Markets, is still 6.8pps below March 2020 level, the second largest gap remaining to fully recover, following Los Angeles. Notably, Tampa was ranked seventh in March 2020.

By contrast, Pittsburgh IL occupancy edged up by 0.3pps in October 2023 to 90.8%. Pittsburgh ranked second in the pack, a significant leap from its 18^th place ranking in March 2020. Additionally, Pittsburgh IL occupancy has not only recovered the 6.8pps lost during the height of the pandemic but has also surpassed March 2020 levels by 1.6pps.

All-occupancy rose or remained stable in 28 of the 31 Primary Markets for AL in October 2023 compared with September 2023. San Jose, which was the market with highest occupancy levels in March 2020 among the 31 Primary Markets, experienced a significant drop to 27^th place by October 2023. At 79.8%, San Jose occupancy remained more than 11pps below its March 2020 level. Conversely, Kansas City occupancy stood at 87.0% in October 2023, 3.5pps above its March 2020 level. This recovery has improved Kansas City’s ranking from 18^th in March 2020 to third in October 2023.

In summary, market dynamics have shifted in recent years. Some of the markets that were dominant before the onset of the pandemic now show relatively low occupancy rates, while others that previously ranked at the bottom have climbed considerably.

Keep track of the timely review of the sector’s market fundamentals and trends. The NIC Intra-Quarterly Snapshot monthly publication, available for complimentary download on our website, continues to provide a powerful and closely watched means to stay ahead of industry trends. 

The November 2023 Intra-Quarterly Snapshot report will be released on our website on Thursday, December 7, 2023, at 4:30 pm.   

Interested in learning more about NIC MAP Intra-Quarterly data? To learn more about NIC MAP Vision data, schedule a meeting with a product expert today.  

NIC Analytics released the 2Q 2023 NIC Lending Trends Report today. The quarterly report, available complimentary to NIC constituents, includes data trends over seven years for senior housing and nursing care construction loans, mini-perm/bridge loans, and permanent loans from 3Q 2016 through 2Q 2023. 

Second Quarter 2023: Market Forces Recap

The lending environment continued to tighten through the second quarter of 2023. The Federal Reserve nudged rates higher by another 0.25 percentage points (pps) in May 2023, bringing the federal funds rate to a target range of 5.00% – 5.25%. This was the tenth rate hike since the Federal Reserve’s adoption of a hawkish stance to tame inflation in March 2022. Inflation, as measured by the consumer price index (CPI), has decelerated since June 2022. By June 2023, the rate had slowed for a twelfth consecutive month to 3.1%, marking a considerable decrease from the previous year’s high of 9.1% in June 2022.

The higher interest rate environment since March 2022 has limited the availability of debt and driven borrowing costs significantly higher. Federal Reserve data tracking senior loan officers’ observations of credit conditions across the U.S. showed tighter lending conditions in the second quarter of 2023 in construction, multifamily, and commercial and industrial (C&I) loans. These observations align with the trends identified in the most recent NIC Lending Survey.

Additionally, the disruption to the banking system in the second quarter of 2023 following the failures of Silvergate, Silicon Valley Bank, and Signature Bank, and the sale of First Republic Bank to JP Morgan Chase raised concerns about potential contagion among regional banks.

Takeaways from the 2Q 2023 NIC Lending Trends Report

The issuance of new permanent debt for senior housing hit a new low within the time series during the second quarter. Factors adversely limiting the issuance of permanent debt include the disruption in the capital markets, limited debt availability, tightening lending standards, higher interest rates, inflationary pressures, troubles in the banking system, widening spreads (i.e., the amount charged over the risk-free rate to compensate for risk), and reduced loan proceeds. For the sample of lenders in the NIC Lending Trends Report, the volume of new permanent loans closed for nursing care surpassed that for senior housing for the first time since 2018, reflecting a 75% increase versus a decline of 8% for senior housing loan volume from the prior quarter.

The issuance of mini-perm/bridge debt for senior housing dropped further through the second quarter of 2023, and was down by 52% from the prior quarter and 76% from late 2022 levels. Concurrently, nursing care mini-perm/bridge loan closings remained relatively very low and on par with pre-pandemic levels. Borrowers are adjusting to the prevailing “higher for longer” mindset, anticipating sustained rates without a potential decline in the near future. While short-term debt options are limited, those available often come with increased costs and additional credit enhancements e.g., the need for more equity or a repayment guaranty.

New construction loan closings for senior housing remained weak in the second quarter of 2023 compared with historical patterns. Notably, senior housing construction starts remained relatively low in the second quarter of 2023, and the number of senior housing units under construction in the 31 NIC MAP Primary Markets remained near its lowest level since 2015, according to data released by NIC MAP Vision.

As for nursing care, the issuance of construction debt was virtually non-existent for the lenders sampled in the NIC Lending Trends Report. This aligns with the observed pattern of limited debt financing for new nursing care property construction since NIC began data collection in 2016. In fact, there has been limited development of new nursing care properties and overall inventory has been declining for several years.

The total balance of delinquent senior housing loans saw a notable increase, although the balance was still lower than the high levels seen in the third quarter of 2020 in the immediate aftermath of the COVID pandemic. Senior housing delinquencies rose by 36% in second quarter 2023, while nursing care delinquencies declined by 24% from the prior quarter. Delinquencies as a share of total loans rose to 2.9% for senior housing, up from 2.1% in the first quarter of 2023. For nursing care, the delinquency rate edged down to 0.9%. Note that loans in forbearance are reported in the delinquent loan data for some debt providers. Also of note, foreclosures were reported for this quarter’s sample of lenders for both senior housing and nursing care, at $14.7M and $71.4M, respectively.

From the Field: 2Q 2023 Survey Comments

For the past two quarters, NIC Analytics has reached out to our network of contributors, asking them questions about the lending environment for senior housing and nursing care. We are asking about their strategies in response to changing capital market conditions, lending patterns with respect to existing versus new clients, and any notable trends they are observing in the market.

In the face of changing capital market conditions, the responses in second quarter 2023 continued to indicate that lenders are reacting to these changing conditions by focusing on strong sponsorship and credits. This trend reflects a reaction to a jump in the SOFR and 10-year Treasury rates, leaner loan proceeds as measured by lower loan-to-value (LTV) ratios, higher equity requirements and tighter spreads. Nevertheless, there was some level of lending activity as shown in the data derived from this survey.

The second quarter of 2023 also saw a focus on long-term relationships with many lenders extending loans predominantly to existing clients. Tightened lending standards and the increase in interest rates and inflationary pressures affected the industry, resulting in fewer new clients being onboarded.

The second quarter of 2023 also witnessed a series of market-shaping events, including Fannie Mae’s revised guidelines focusing on lower leverage loans and higher DSCR requirements, respectively, posing challenges in identifying financing opportunities that fit within debt-service-constrained loans and contributing to a cautious lending environment.

The ongoing rise in interest rates prompted a stronger focus on stabilized senior housing and nursing care properties in proven markets with limited new construction and with proven stability and strong sponsors, as opposed to “riskier” or non-stabilized properties in tertiary markets. Considering these factors, the lending environment is expected to continue tightening throughout the latter half of 2023.

Looking Ahead. As we look beyond the second quarter of 2023, though inflation has decreased significantly from its peak of over 9% last year, the recent months have seen a halt in progress, with inflation still remaining more than a percentage point above the central bank’s 2% targeted rate. The Federal Reserve implemented a 0.25 percentage point increase to 5.25% – 5.50% in July 2023, maintaining stability since then and at its most recent meeting on October 31-November 1. However, the Fed has left open the possibility of another hike, potentially in December 2023.

Download the complimentary 2Q 2023 NIC Lending Trends Report for full details on these and other trends in senior housing and skilled nursing lending. 

Note: These data are not to be interpreted as a census of all senior housing and skilled nursing lending activity in the U.S., but rather reflect lending activity from participants included in the survey sample only. 

The 3Q2023 NIC Lending Trends Report is scheduled for release in mid-February 2024.

Interested in participating? The NIC Lending Trends Report helps NIC Analytics to deliver on NIC’s mission to enable access and choice by further enhancing transparency of capital market trends in the senior housing and care sectors. We very much appreciate our data contributors. This report would not be possible without them. 

If you would like to participate and contribute your data, please contact us at analytics@nic.org. As a courtesy for providing data, data contributors receive this report early before publication on the website. The information provided as part of the survey will be kept strictly confidential. Individual answers will be combined with the answers of all other respondents. Data acquired from this survey will only be reported in the aggregate, and therefore, the resulting aggregated data will not be attributed to you or your company upon distribution. 

NIC MAP Vision released its latest Skilled Nursing Monthly Report on November 2, 2023.  The report includes key monthly data points from January 2012 through August 2023.   

Here are some key takeaways from the report:

Occupancy 

Skilled nursing property occupancy increased 59 basis points from July to end August at 82.3%. Occupancy is up 142 basis points from one year ago in August 2022 as it continues to recover since the pandemic low of 75.0% set in January 2021. Occupancy hovered around 81% from January 2023 through July 2023. August 2023 represents the first-time occupancy was over 82% since April 2020. However, challenges do persist with staffing shortages that continue to create difficulties within skilled nursing properties limiting the ability to admit new residents in some markets. The current occupancy trend over the past year does suggest that demand for skilled nursing properties is recovering. Occupancy remains low compared to February 2020 pre-pandemic levels of 89.1% (6.9 percentage points). 

Managed Care 

Managed Medicare revenue mix increased 19 basis points from July to end August at 11.8%. It has declined 68 basis points since its recent high of 12.5% in February 2022, but it is up by 262 basis points from the pandemic low set in May 2020 of 9.2%. Expectations are that it will continue to increase over time with the continued growth of managed Medicare. Meanwhile, Managed Medicare revenue per patient day (RPPD) declined 0.6% ending August at $487 and it is down 0.1% from last year in August 2022.  It has decreased $122 (20.1%) since January 2012 and continues to pressure some operators’ revenue as managed Medicare enrollment grows around the country. However, some operators see managed Medicare as an opportunity for growth in patient volume. 

Medicaid 

Medicaid patient day mix decreased 13 basis points to 67.0% in August. It has increased 397 basis points from the pandemic low of 63.1% set in February 2022. In addition, Medicaid revenue mix decreased in August, but still represented over half of property revenue at 53.8%. It has increased 472 basis points from the pandemic low of 49.1% set in February 2022. Meanwhile, Medicaid revenue per patient day (RPPD) decreased to $277 in August. It increased 2.6% from $270 one year ago in August 2022. 

Medicare 

Medicare revenue per patient day (RPPD) increased from July to end August 2023 at $592. It has increased 2.9% since September 2022. Most of this increase in reimbursement is likely a result of the increase in Medicare rates to skilled nursing properties for fiscal year 2023 and potentially higher acuity patients, which also increases RPPD to care for more complex patients. Meanwhile, Medicare revenue increased slightly from July to end August at 17.3%. However, it is down from one year ago, decreasing 419 basis points from August 2022.  

NIC MAP Vision clients with access to NIC MAP data can access the Skilled Nursing Monthly Report. The report provides aggregate data at the national level from a sampling of skilled nursing operators with multiple properties in the United States. Talk to a product expert to learn more about NIC MAP Vision.

NIC is continuously seeking operators to contribute data featured in the NIC MAP Vision report on a monthly basis. Operators who are interested in participating can complete a participation form here. NIC maintains strict confidentiality of all data it receives. 

NIC MAP Vision clients, with access to NIC MAP® data, attended a webinar in mid-October on key senior housing data trends during the third quarter of 2023. Findings were presented by the NIC Analytics research team. Key takeaways included the following: 

Takeaway #1: Market Fundamentals on Track for Occupancy Recovery 

• The occupancy rate for senior housing—where senior housing is defined as the combination of the majority independent living and assisted living property types—rose 0.8 percentage points to 84.4% from the second quarter of 2023 to the third quarter for the 31 NIC MAP Primary Markets. This marked the ninth consecutive quarter of occupancy increases.  
• At 84.4%, occupancy is 6.6 percentage points above its pandemic-related low of 77.8% recorded in mid-2021 and 2.7 percentage points below its pre-pandemic level of 87.1% of the first quarter of 2020.   
• Demand in the third quarter as measured by the change in occupied inventory, or net absorption, totaled 7,853 units in the 31 Primary Markets, which was nearly three times the 2,806 units that arrived online during that same period. Demand has been positive over the past 10 quarters, which has helped occupancy to improve.    

Takeaway #2: Majority Independent Living Occupancy Gains Accelerated in Third Quarter 

• In the third quarter of 2023, the occupancy rate for assisted living increased by 0.9 percentage points to 82.6%. Meanwhile, after hovering around the 85% range for three consecutive quarters, the occupancy rate for independent living in the third quarter jumped by 0.7 percentage points to 86.1%.  
• Despite this jump, this was still the ninth consecutive quarter (i.e., the entirety of the pandemic recovery thus far) in which occupancy gains were stronger for assisted living than for independent living. As a result, the occupancy gap between the two stood at only 3.5 percentage points in the third quarter, which was smaller than the 4.9 percentage point gap recorded before the onset of the pandemic.  

Takeaway #3: Annual Inventory Growth Remained Low 

• In the chart below, we show annual inventory growth as a percentage of existing inventory.  
• By property type, annual inventory growth in the third quarter for independent living was 1.2%, below its pre-pandemic average of 1.6%. 
• Assisted living in the third quarter grew by a slightly higher amount at 1.5% year-over-year, which was a slight uptick from the prior quarter. Still, this year-over-year growth was less than half the typical growth recorded for assisted living before the onset of the pandemic, which was 3.2% annually. 
• This slower inventory growth stems from the slowdown in construction starts that we experienced during the height of the pandemic, a trend that occurred for both independent living and assisted living.

Takeaway #4: A Growing Share of Inventory is 25 Years or Older 

• With inventory growth slowing, it is interesting to evaluate how senior housing inventory has aged in recent years. In the chart below, we illustrate the distribution of stabilized properties in the first quarter of 2020 and the third quarter of 2023. 
• As shown at the bottom of the chart, the share of properties that are 25 years or older has grown from 34% to 41% in the past three and a half years. This older cohort has one of the largest shares of properties with occupancies that are 80% or lower, which may be driven by several factors, e.g., older floor plans that no longer meet consumer needs in terms of the size of units or the unit mix. 
• Meanwhile, the share of properties that are 10 to 17 years old has shrunk slightly from 13% to less than 11%. This younger cohort has the highest share of occupancy rates at 90% or higher, which could be indicative of having an established team in place and perhaps some brand recognition. 

Interested in learning more?

The data featured in this article derives from NIC’s analysis of NIC MAP Vision’s Senior Housing Market Fundamentals Data Release. NIC MAP Vision clients with access to NIC MAP data also receive an exclusive invitation to a market fundamentals webinar led by NIC’s Research team where they review each quarter’s trends in context with historical data and current events. To get a better idea of what’s covered, watch an abridged version of the webinar. To learn more about NIC MAP data, powered by NIC MAP Vision, and accessing the data featured in this article, schedule a meeting with a product expert today.