An Overview of Long-Term Care, Skilled Nursing, and Investing in the Industry
Thinking of investing in the skilled nursing industry? This article outlines the state of the industry in 2023 from an investment perspective and reviews some key statistics that make skilled nursing facilities (SNFs) an attractive investment opportunity for the right individual or organization.
Table of Contents
Industry Overview
A vast majority of revenue for skilled nursing comes from government agencies and programs, mostly Medicare and Medicaid. As a result, price competition is generally difficult due to this funding source and significant regulation. On the other hand, this also makes skilled nursing attractive as a stable, long-term investment as demand for skilled nursing care will continue to grow as the aging population grows.
There are approximately 15,000 SNFs in the United States. While demand is expected to increase, many states require a certificate of need before a new facility can be built. Also impacting the ability to fund or build new facilities are moratoria in place that cap the number of long-term care facilities or licensed beds in a given state. There are approximately 20 states that have a moratorium of new beds.
Both certificates of need and moratoria on beds and/or facilities make ownership of existing facilities an ongoing, attractive proposition.
When ownership of an existing facility changes hands, it is called a ‘change of ownership’ (CHOW). This process is particularly complex due to the high level of regulation in the industry and variability between states’ requirements, but there are a number of established experts in CHOWs available that provide services that make the process as seamless as possible.
Key Figures
Skilled nursing care in the United States generated $140.5 billion in revenue in 2020, prior to the COVID-19 pandemic. In 2022, the market size was $151 billion.
Between 2015 and 2020, industry revenue growth was around 1.6% but is expected to surge toward 5.1% in the next 5 years as the population ages and the number of people living with complex health issues and chronic care conditions increases.
Cap Rates Decreasing in Skilled Nursing
Explained: Capitalization rates are the expected return rate on a real estate investment property. It is calculated by dividing a property’s net income by its current market value, so a decreasing cap rate means a better valuation and prospects of returns with a lower risk.
According to an industry report from CBRE, cap rates are decreasing in skilled nursing care. Compared to 2021 values, there was a 17 bps decrease in Class A skilled nursing facility assets. Assisted living decreased by 10 bps and independent living facilities decreased by just 5 bps. Skilled nursing in 2022 saw the greatest improvement in the senior housing and care sector.
Recovery from the Public Health Emergency
Despite taking a hit to its reputation during the worst of the COVID-19 pandemic, skilled nursing is experiencing a revival of its importance. It has been shown, despite some attention-grabbing headlines caused by underperformers, that SNFs serve a vital role in the healthcare system.
In some studies, it has even outperformed home health care for complex patients—an option that was lauded during the COVID-19 pandemic, but may become untenable as a larger population of aging individuals combines with rising rates of comorbidities.
Occupancy rates are steadily returning to 2019 figures. In general, the market a SNF serves, staffing rates, and its quality scores impact an individual facility’s occupancy. As with other medical and hospitality businesses, occupancy is a core performance metric that drives profits.
Skilled Nursing in the Facility vs. Home Health
For payers and government agencies, home health has beenis associated with lower costs, but in the long term has been associated with higher hospital readmission rates. Owners should understand that readmissions to hospitals of long-term care or skilled nursing residents can negatively impact a facility’s quality scores. In value-based care models like Medicare Advantage plans, that can impact your facility’s ability to participate in payer networks (also referred to as getting ‘in-network’ with payers). This can fundamentally impact occupancy rates as referrals from certain health plans can’t be accepted.
The nature of SNFs having 24/7 staff and skilled clinicians physically present to treat more complex patient conditions enables them to provide higher quality oversight and care versus the dependency on traveling nurses and caregivers.
An Investment to Feel Good About?
Investing in SNFs that provide quality care supports high-performing operators, ensuring communities in need have access to quality skilled nursing care, which is vital to proper recovery from operative procedures and support for those living with chronic or terminal illnesses. Even operators with a great track record require investors in order to secure the equity needed to purchase a facility and grow their organization.
Whether through real estate investment trusts (REITs) or other investment methods, SNFs benefit from investment, especially after a particularly tumultuous few years.
Investing in SNFs provides a material way to give back to communities in need of quality skilled nursing care. Within the industry, there are a number of opportunities where investment can help turn around struggling facilities and keep them from shuttering their doors, leaving many in-need patients without local options for post-acute or long-term care.
There are a number of ways to invest in skilled nursing, including REITs. Recently, private equity in skilled nursing has come under regulatory scrutiny. Some studies have correlated lower performance metrics in PE-owned facilities, although the difference is normally only a single digit difference. On the contrary, other studies have shown that REIT-owned facilities are associated with higher staffing time with patients.
A Complete Solution for Informed Investing in Long-Term Care and Skilled Nursing
LTC Ally is a proven partner for owners and operators of long-term care and skilled nursing facilities. We offer a full suite of back office and growth advisory services, enabling operators to outsource their revenue cycle management (RCM) and financial reporting duties. We also help facilities get in-network with highly sought-after payers to maximize their occupancy and a complete solution for CHOWs, including underwriting services.
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