Medical Properties Trust, Inc. (NYSE:MPW) Q4 2023 Earnings Call Transcript

Medical Properties Trust, Inc. (NYSE:MPW) Q4 2023 Earnings Call Transcript February 21, 2024

Medical Properties Trust, Inc. misses on earnings expectations. Reported EPS is $-1.11 EPS, expectations were $0.27. MPW  isn’t one of the 30 most popular stocks among hedge funds at the end of the third quarter (see the details here).

Operator: Good day and welcome to the Medical Properties Trust Inc. Fourth Quarter 2023 Conference Call. All participants will be in a listen-only mode. [Operator Instructions] After today’s presentation, there will be opportunity to ask questions, and please note that today’s presentation will only last 60 minutes. [Operator Instructions] Please note this event is being recorded. I would now like to turn the conference over to Charles Lambert, Vice President. Please go ahead.

Charles Lambert: Thank you. Good morning. Welcome to the Medical Properties Trust conference call to discuss our fourth quarter and full year 2023 financial results. With me today are Edward K. Aldag, Jr., Chairman, President and Chief Executive Officer of the company; Steven Hamner, Executive Vice President and Chief Financial Officer; Kevin Hanna, Senior Vice President, Controller and Chief Accounting Officer; and Rosa Hooper, Senior Vice President of Operations and Secretary. Our press release was distributed this morning and furnished on Form 8-K with the Securities and Exchange Commission. If you did not receive a copy, it is available on our website at medicalpropertiestrust.com in the Investor Relations section. Additionally we’re hosting a live webcast of today’s call, which you can access in that same section.

During the course of this call, we will make projections and certain other statements that may be considered forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. These forward-looking statements are subject to known and unknown risks, uncertainties and other factors that may cause our financial results and future events to differ materially from those expressed in or underlying such forward-looking statements. We refer you to the company’s reports filed with the Securities and Exchange Commission for a discussion of the factors that could cause the company’s actual results or future events to differ materially from those expressed in this call. The information being provided today is as of this date only and except as required by the Federal Securities Laws, the company does not undertake a duty to update any such information.

In addition, during the course of the conference call, we will describe certain non-GAAP financial measures, which should be considered in addition to and not in lieu of comparable GAAP financial measures. Please note that in our press release, Medical Properties Trust has reconciled all non-GAAP financial measures to the most directly comparable GAAP measures in accordance with Reg G requirements. You can also refer to our website at medicalpropertiestrust.com for the most directly comparable financial measures and related reconciliations. I will now turn the call over to our Chief Executive Officer, Ed Aldag.

Edward Aldag: Thank you, Charles, and thanks to all of you for joining us this morning on our fourth quarter 2023 earnings call. I’m pleased to be joined again today by Steve Hamner, Rosa Hooper and Kevin Hanna. You will hear from each of them shortly. As discussed in detail last quarter, our primary focus right now is executing a capital allocation strategy that will aim to generate at least $2 billion of additional liquidity in 2024 and help us satisfy our debt maturities for several years into the future. Since outlining this new capital allocation approach last year, we have made significant strides and I’d like to begin today by highlighting that progress. During the fourth quarter, we closed on the sale of our four remaining Australian facilities for approximately $305 million or a 5.7% cap rate.

And in our press release earlier this morning, we announced another $480 million of agreed upon liquidity transactions, including the sale of five hospitals to Prime, at a 7.4% economic cap rate, as well as the sale of our syndicated term loan investment in MEDIAN, the parent company of Priory Group. We believe these recent transactions and other processes we are actively engaged in, clearly demonstrate that our assets remain attractive to operators and sophistic real estate investors around the world. We are actively working on several additional cell asset sale opportunities, as well as other transactions that we believe will validate underwritten asset values. And the prices we have achieved to date are broadly consistent with initial indications of market value that we received on these other assets.

As such, we remain disciplined and optimistic in our ability to continue to execute transactions on attractive terms and we feel good about where we stand today relative to our $2 billion target for 2024. The Board will meet later this quarter to discuss the dividend. The Board’s policy on the dividend remains unchanged. As has always been the case, the Board will review all aspects of the company, including items such as FFO payout ratios, REIT requirements and liquidity. Before I turn it over to Rosa, Kevin and Steve, to go through our results in more detail, I wanted to provide a brief update on Steward and prospect. During our last call in October, we discussed Steward’s revenue cycle management challenges, which has resulted in a sizable accounts payable backlog.

Unfortunately, since that time, Steward’s cash collection challenges have become more pronounced and the resulting changes to vendor payment terms have put pressure on supplies constraining Steward’s ability to perform higher-margin surgeries that are a key driver of cash flow. As a result, in early January, we shared that we have been working with Steward and its advisers to develop an action plan to strengthen their balance sheet, liquidity, accelerate recovery of unpaid rent and ultimately significantly reduce our exposure to Steward. This plan contemplates a wide range of strategic transactions, including transitioning certain hospitals to new tenants and selling its managed care business called Stewardship. While it will take some time for Steward to execute these steps, we are encouraged by the early progress.

As this plan is executed, Steward needs access to liquidity to continue to operate its critical hospital facilities. As we previously disclosed in January, we funded a $60 million bridge loan, which provided sec MPT, a second lien on Stewardship’s business subordinate only to Steward’s ABL lenders. We also consented to a limited and tapering deferral of rent until the end of June, or the completion of the anticipated asset sales. In the fourth quarter, Steward paid approximately 25% of all rent and interest owed to MPT. In our press release this morning, we shared that MPT and certain lenders in the ABL Group are negotiating a new bridge facility under which each party would fund an additional — initial $37.5 million for Steward, of which MPT has already funded $20 million.

Any additional funding is entirely dependent on Steward’s achieving significant milestones, towards optimizing the amount and timing of MPT’s recoveries. Turning to Prospect. Importantly, in California, Prospect is current on all rent and interest due through January 2024. Though, they have not yet paid February’s rent. Prospect’s EBITDARM has improved year-over-year, driven by increased admission volumes, higher medical reimbursement rates and lower supplies cost. We are encouraged by their most recent December trailing 12-month rent coverage, which was above one times. While we do not have a meaningful update to share today on the sale of Prospect 3 Connecticut hospitals to Gale New Haven. As a reminder, our $2 billion of targeted liquidity transactions does not include this expected transaction or the expected recovery of our investment in PHP Holdings.

As detailed in our press release this morning, we have moved Steward in prospect to cash basis accounting and divided our portfolio into two categories. Our hope is that this split will make it easier for investors to track the performance of our stabilized portfolio, which consists of more than $11 billion of assets and is accounted for using the accrual method. As this breakdown demonstrates, the portfolio continues to perform well, reinforcing our conviction in MPT’s underlying business model. While hospital operators have spent the past several years, navigating challenges ranging from the COVID-19 pandemic to unprecedented labor shortages to insufficient reimbursement rates and some tenants has suffered more long-term impacts from those headwinds than others.

The simple fact remains, that there are no more essential services than those provided by acute care hospitals. For more than 20 years our underwriting approach is centered on these essential infrastructure-like characteristics and identifying hospitals that are integral to sustaining community health over many years. Given the highly diversified portfolio of assets we’ve assembled over that period, we are confident in our ability to find competent replacement operators as needed and continue to execute sales and achieve our objectives. I will now turn it over to Rosa to provide an update on performance of the stabilized portfolio, during the fourth quarter. Rosa?

Rosa Hooper: Thank you, Ed. It’s great to be able to participate in today’s discussion and take you through some of the highlights across our portfolio of critical hospital real estate. Beginning with Europe, broadly speaking, we are encouraged by recent market trends including increased occupancy rate, growing reimbursement revenue and the continued normalization of labor cost. As private insurance coverage expands in the UK, Circle Health continues to demonstrate steady financial performance. Circle has seen an increase in orthopedic joint procedures of more than 50% compared to pre-COVID data. Inpatient admissions also remain on an upward trajectory, as patients continue to seek high-quality care alternatives to long wait times.

In addition to being named Private Hospital Group of the Year by Health Investor UK for the third consecutive year, Circle was also named as an outstanding company to work for by Best Companies in 2023. Let’s turn now to Priory, which is the largest independent mental health care provider in the UK by a number of beds. Priory delivered EBITDARM coverage of 2.2 times for the quarter and continues to benefit from the rapid growth of behavioral health services in the UK. It is capitalizing on this trend by driving increases to its already high utilization rate, negotiating reimbursement rate increases and ensuring efficient cost management. As a reminder, Priory is managed by one of MPT’s long-term operators MEDIAN, which is based in Germany. MEDIAN continues to steadily improve occupancy, although, at a slower ramp than originally anticipated, following government and post COVID restrictions.

Negotiated reimbursement rate increases in Germany were above expectations, and a stabilization in energy expenses have allowed MEDIAN to achieve its 2023 financial targets. Swiss Medical Network had a highly productive 2023, completing several renovation and expansion projects and executing a handful of smaller sized acquisitions that will complement their capabilities in existing markets. Earlier this year, Swiss Medical launched the first integrated care organization in Switzerland, providing a first mover advantage in an untapped market. Additionally, Swiss Medical remains focused on the development of its Genolier Innovation Hub. A state-of-the-art multi-tenant lab, training simulation platform, and office space attached to their flagship acute care hospital, which is expected to accelerate the transfer of innovative clinical solutions from bench to bedside.

The innovation hub is on track to open in the second half of 2024. Shifting to our approximately $5 billion Americas portfolio, we have been pleased to see operators largely maintain hospital volumes while making significant progress in reducing contract labor. Our Colombian hospitals continue to see high demand in their respective communities and the two Colombian operators have maintained coverage in excess of 1.5 times. CommonSpirit, which recently announced that it would take over direct management of our five Utah hospitals from Centura Health continues to deliver strong property level performance, reporting steady volumes across hospitals during the quarter. Prime delivered another quarter of strong performance with trailing 12-month EBITDARM coverage of two times after removing the impact of St. Francis, which is no longer reported in our supplemental, given the transaction announced today.

Prime has successfully reduced contract labor costs, while inpatient and ER volumes continue to increase year-over-year across our facilities. As Prime remains focused on efforts to negotiate more favorable payer contracts, we expect to see increased surgical volumes over time. Overall, our Ernest portfolio continues to deliver steady performance. While its long-term acute care hospitals continue to navigate the impacts of admission criteria waivers that were eliminated in the first half of 2023. Ernest rehab business has offset any declines associated with that. In fact, when examining the IRF portfolio exclusive of ramp-up costs associated with their new developments, same-store IRF achieved approximately three times EBITDARM coverage. Volumes at our LifePoint hospitals remain relatively flat on a year-over-year basis.

LifePoint has made significant strides in reducing contract labor by nearly half, as they execute on their recruiting and retention initiatives, particularly on the physician recruitment side, which, over time, we expect will result in improved volumes and revenue. This is particularly true at their Conemaugh Memorial Hospital in Pennsylvania, where any underperformance has an outsized impact on coverages for this portfolio. Conemaugh recently dedicated a new self-funded $77 million cardiovascular and Surgical Care Pavilion that will provide state-of-the-art care for patients. The vast majority of LifePoint’s investment over $60 million went into the real estate, while the remaining portion went towards new cutting-edge equipment. The new leadership for this market is excited about the positive clinical impact this will have for their patients.

And combining this with their physician recruitment successes, we believe this market is well-positioned for improved performance. Our LifePoint behavioral facilities continue to benefit from increased revenues resulting from increased inpatient volume. LifePoint behavioral’s ability to manage labor costs in a rising wage environment has further enabled them to maintain strong performance. We continue to make progress on the construction of our new LifePoint behavioral facility in McKinney, Texas along with multiple other expansion projects at our hospitals in Texas and Kansas. ScionHealth has produced consistent quarter-over-quarter coverage improvements in the past year by growing revenue while reducing contract labor. ScionHealth’s general acute hospitals have seen an 11% increase in year-to-date revenue over prior year, driven by increases in both admissions and surgeries.

We are pleased with our portfolio’s Q3 2023 performance compared to that of public reporting hospitals. Excluding Steward, for trailing 12 months Q3 2023, MPT’s portfolio of acute care hospitals reported volume increases that were, for the most part, higher than that of the public reporting companies and income statement growth metrics that were generally in line with those of the public reporters. Over the years, MPT has carefully constructed a well-diversified portfolio in terms of care settings, operators, and geographies. We have over 50 unique tenants operating across the highest acuity care settings including rehabilitation, behavioral, and acute care hospitals. After Steward, our second largest operator, Circle Health represents 12% of our portfolio, followed by Priory at 8%, and Prospect at 6%.

Geographically, our properties are spread across nine countries with nearly 40% outside the United States. Importantly, this deliberate diversification strategy helps safeguard against any operator-specific challenges that may arise as well as geopolitical and economic disruption. With that I will turn the call over to Kevin to discuss our financial results. Kevin?

Kevin Hanna: Thank you, Rosa. This morning we reported a GAAP net loss of $1.11 per share and normalized FFO of a positive $0.36 per share for the fourth quarter of 2023. As Ed mentioned, and as described in the press release this morning, we have moved Steward to cash basis accounting effective January 1st, 2024. We want to highlight that included in fourth quarter normalized FFO is approximately $0.12 per share of Steward quarterly revenue recognized prior to this accounting change. In the press release, we also detailed approximately $770 million of charges recorded this quarter, primarily related to Steward. Importantly, these charges were recorded pursuant to U.S. GAAP accounting rules and reflect conservative assumptions regarding potential recoveries.

These charges consisted of the following; $154 million of rent reserves and $224 million of straight-line rent reserves; $81 million of reserves on unpaid PIC and other interest receivables related to Steward loans and a loan to our international joint venture. $112 million of real estate impairments with the assistance of a third-party independent appraiser we analyzed all Steward properties, and many others were possible impairment this quarter and identified less than 10 properties where our net book value exceeded the estimated fair value and we adjusted our books accordingly. We also had $171 million of non-real estate impairments, which again using a third-party independent appraiser, we adjusted our non-real estate investments in Steward to reflect the current estimated fair value of our related collateral.

Finally, we made a $30 million charge in earnings from equity interest to reflect the reserves for billed and straight-line rent on the properties included in the Massachusetts joint venture. These charges were recorded on several different line items of our income statement, and we have included additional tables in our release this morning showcasing the impact of these charges. Beyond impairment charges, we did have two other adjustments to normalized FFO that I want to highlight. As is typical, we recognized fair value adjustments in the quarter from adjusting certain marketable securities, like our Swiss investment in EBIT to market. This $8.4 million negative adjustment is net of a gain recognized on our PHP investment, as the managed care business continues to perform well.

Second and due to Steward and the significant adjustments made this quarter we recorded a $6.6 million cumulative adjustment to stock compensation expense, to reflect our updated estimate of expected payouts for certain software grants over the past years. And with that, I will turn it over to Steve for a discussion of our liquidity position and plans. Steve?

Steven Hamner: Thank you, Kevin. I will wrap-up our prepared remarks, with some perspective around our near-term recapitalization process that Ed mentioned at the start of the call. On last quarter’s call we described our plans for accessing capital through asset sales and limited secured financing. We announced an initial target of about $2 billion over the course of 2024. This morning, we announced that we have so far agreed to transactions aggregating almost 25% of that initial target. The largest of these transactions is our agreement to sell two hospitals to Prime for $350 million. Importantly, and encouragingly, the economics of the transaction imply a capitalization rate of about 7.4% that is obviously much better than what our share price implies or even what some investors believe our secured financing rate would be.

Moreover, we expect to realize an approximate $50 million GAAP gain on the transaction and the purchase price exceeds our un-depreciated initial investment by about $30 million. We expect to receive $250 million of the purchase price in cash upon expiration of a short notice period and the remaining $100 million before or on the expiration of a 9-month interest-bearing mortgage note due to MPT. In addition, we were able to consolidate our four remaining hospitals leased to Prime under a new 20-year master lease, with a lease base of $238 million. Notably, the original master lease in place for 3 of these hospitals was otherwise set to expire next year. In addition to the benefit of extending the term of this lease, our relative rent will increase by approximately $5 million.

So the economic 7.4% cap rate is based on the $350 million purchase price and $26 million of net rent. That is the $31 million of contractual rent on the two hospitals we sold offset by the $5 million rent increase that results from the increased lease base added to the new master lease. The new lease also provides Prime an option to purchase these facilities at any time for $260 million, which would represent an additional gain on sale of real estate of approximately $95 million for MPT over and above the $50 million gain I just mentioned. These are all attractive hospitals. And in our view Dr. Prem Reddy and his management team are amongst the most reliable and capable operators of acute hospitals in the country. But the geographic location of these hospitals are not necessarily the best in our portfolio and yet they traded at a 7.4% economic capitalization rate.

This speaks very strongly of continued investor interest and confidence in well underwritten hospitals that are necessary to a community’s overall healthcare infrastructure. We have proven that repeatedly over the past couple of years and Prime is just the most recent example. Other recent transactions that have validated the value of our assets include, but are certainly not limited to the sale of our Australian portfolio in October of last year at an integrated capitalization rate of less than 6%. The new lease put in place with CommonSpirit in Utah roughly one year ago, which effectively placed a mid-7% cap rate on the rental stream. Other recent hospital sales to Prime for $460 million, which generated very attractive IRRs and fully recovered our initial investment from at least 10 years earlier.

All these transactions and more have been executed in global economic and financial markets that have not necessarily been friendly to sellers of large operating facilities. And that is why we are encouraged by the progress we are making and our potential path to exceeding our initial $2 billion target, which as a reminder does not account for any proceeds from a sale of our Connecticut assets to Yale, any monetization of our interest in prospects PHP managed care business, or any possible proceeds from resolution of the previously mentioned so-called non-top 10 operator that we discussed on last quarter’s call. Although, we are not prepared to announce specifics this morning, the valuation metrics of potential transactions that are currently subject to letters of intent and in-process definitive documentation are adjusted for geography size and tenant characteristics, highly comparable to these recent transactions and in particular the Prime transaction.

As we realize capital from these transactions, we expect to immediately reduce our debt maturities. In 2024, we have only two maturing loans approximately $300 million in May and $130 million in December. In the interim, we will reduce our revolver balances, which in recent months have carried an interest rate of around 6.9% for the US dollar borrowings. In 2025, we will have roughly $900 million in bank debt and $550 million in unsecured notes maturing. And as just noted, we expect our planned sales and secured financing transactions will provide more than sufficient proceeds to satisfy these maturities. And with that, we have time for a few questions and I’ll turn the call back over to the operator.

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Q&A Session

Operator: Thank you. We will now begin the question-and-answer session. [Operator Instructions] Our first question comes from Austin Wurschmidt from KeyBanc Capital Markets. Please go ahead.

Austin Wurschmidt: Great, thanks and good afternoon. On Steward, one, have they paid you the partial rent payment that you agreed upon earlier this year February? And second, I guess just given the additional capital that you and other ABL lenders have agreed to fund, how much confidence do you have in the ramp in cash rent payments in the coming months that you laid out earlier this year?

Steven Hamner: So Steward is compliant with our previous agreement for ramping up the rent and we expect that they will remain compliant through June, when that ramp gets all the way back to 100%.

Austin Wurschmidt: Got it. And then just as far as on the $2 billion of liquidity, I believe 40% of that amount was expected to be through loans or secured debt I think more specifically, I mean how far along are you in negotiations on that front? Any sense when you could close? And I guess what are you hearing around terms for any such proceeds?

Steven Hamner: So to clarify I’m not sure – I don’t remember in fact saying that 40% would be secured debt. I think all we’ve done is – all we said is there’ll be limited secured debt. We’re not in a position this morning to give the details. But I did mention by the way that a significant amount of the remaining $2 billion is under either LOI or being negotiated through definitive documents. And further, we tried to mention that the pricing that you saw not only with the most recent Prime transaction but with transactions last year, it’s generally consistent with the valuation metrics and that means pricing or interest rates that we’re seeing in those transactions that are in progress.

Austin Wurschmidt: Understood. I’ll hop back in queue. Thank you.

Operator: Next question comes from Joshua Dennerlein from Bank of America. Please go ahead.

Joshua Dennerlein: Yes. Hey, guys. Thanks for the time. Just a follow-up on that. What kind of gives you the confidence that Steward will be able to ramp up and start paying full rent starting in June?

Steven Hamner: So it’s driven by two key strategies that we mentioned early last month. One of those is the aggressive efforts at repositioning, re-tenanting or otherwise selling facilities that are now occupied and operated by Steward. Secondly, it’s dependent upon a satisfactory monetization of its own stewardship managed care business.

Edward Aldag: And Josh, in addition to that, we’ve been getting weekly cash flow reports from Steward’s advisers to which they’ve exceeded every one of them thus far.

Joshua Dennerlein: Okay. And maybe a follow-up to that answer. Just how easy is it to re-tenant a facility? And how do you guys think about just like the transition period, if you were to re-tenant a Steward property?

Edward Aldag: So the answer to that varies from state. Some states it’s really easy. It can be done overnight. Some states take a little bit longer. The real answer to that question I think for us is that we’ve been extremely pleased with the amount of interest we’ve gotten in almost all of the facilities. And in almost all the facilities we’ve got more than one party who is interested in the facilities.

Joshua Dennerlein: Okay. Thanks, guys.

Operator: The next question comes from Michael Carroll from RBC. Please go ahead.

Michael Carroll : Yes. Thanks. I wanted to circle back on the Steward bridge loan. I just want to get this straight. So MPW has already funded an additional $20 million, but the other certain ABL lender that was going to match that they haven’t yet provided those funds?

Steven Hamner: That transaction is not closed yet.

Michael Carroll : And then what is — what are you waiting for on now? I guess, what milestones need to be achieved for that money to be paid out? And what other milestones need to be achieved for you to pay out the other $17.5 million that you agreed to do?

Steven Hamner: Well, so those milestones have been reached. So in other words, the $37.5 million each that MPT and the ABL lenders are expected to fund. Those milestones have been reached. And in order to fund anything further than that, then additional milestones, which are directly related to those two key strategies that I just mentioned re-tenanting and selling the non-core stewardship assets. There are some very specific relatively stringent milestones that have to be met in order to fund anything else. But again, just to clarify, the first $37.5 million a piece of which we have funded $20 million is expected to close soon, depending on having already met the early milestones.

Michael Carroll : So why hasn’t the other ABL lender provided their initial funding yet?

Steven Hamner: The documentation is not complete.

Michael Carroll : Okay. And then just if I can squeeze one more in there. I guess for the potential buyers of the Steward assets, is there concerns of fraudulent conveyance at all related to them potentially selling off parts of their business? And do those buyers have that concern?

Steven Hamner: I wouldn’t know how to answer that for any particular buyer. But clearly, Steward is in a distressed situation, and there are multiple advisers, including legal advisers and no transaction would happen under any type of fraudulent conveyance. So that — one of the keys to our underwriting over the years has been we own hospitals that nobody wants to see closed. And so there’s a great deal of cooperation particularly in some of the eastern states that typically have heavier regulatory hand for the regulators, for the state, or others to help facilitate these transactions. So I don’t think there’s going to be an issue with fraudulent conveyance.

Edward Aldag : And Mike, obviously, we’ve done this before and there are plenty of advisers working on these transactions.

Michael Carroll : Okay. Thank you.

Operator: The next question comes from Mike Mueller from JPMorgan. Please go ahead.