Earnings Call Transcript - DOC Q1 2021

Bradley Page, Senior Vice President, General Counsel

Thanks, Paul. Good afternoon, and welcome to the Physicians Realty Trust first quarter 2021 earnings conference call and webcast. Joining me today are John Thomas, Chief Executive Officer; Jeff Theiler, Chief Financial Officer; Deeni Taylor, Chief Investment Officer; Mark Theine, Executive Vice President, Asset Management; John Lucey, Chief Accounting and Administrative Officer; and Laurie Becker, Senior Vice President, Controller. During this call, John Thomas will provide a summary of the company’s activities and performance for the first quarter of 2021 and year-to-date as well as our strategic focus for 2021. Jeff Theiler will review our financial results for the first quarter of 2021. Then Mark Theine will provide a summary of our operations for the first quarter. Following that, we will open the call for questions. Today’s call will contain Forward-Looking Statements as defined by the Private Securities Litigation Reform Act of 1995. They are based on the current beliefs of management and information currently available to us. Our actual results will be affected by known and unknown risks, trends, uncertainties and factors that are beyond our control or ability to predict. Although we believe our assumptions are reasonable, our forward-looking statements are not guarantees of future performance. Our actual results could materially differ from our current expectations and those anticipated or implied in such forward-looking statements. For more detailed description of potential risks and other important factors that could cause actual results to differ from those contained in any forward-looking statements, please refer to our filings with the Securities and Exchange Commission.

John Thomas, Chief Executive Officer

Thank you, Brad, and thank you for joining us this afternoon. Physicians Realty Trust is off to a very good start for 2021. This begins with our pure play focus on medical office facilities, which continue to serve us and our shareholders well. While other types of healthcare real estate are just beginning to see signs of a recovery, medical office clinical visits have been and remained at pre-COVID levels and have been for a long time. We created this operational strength for our nation’s healthcare providers who adapted quickly at the onset of the pandemic to manage COVID outbreaks while continuing to provide necessary non-COVID healthcare services. They accomplished this by shifting non-COVID care to the outpatient setting, accelerating a trend that has been apparent for the past 25 years. All indications are that this is a permanent change in the delivery of healthcare that will continue to grow in the years ahead, especially for more acute orthopedics, oncology, and cardiology procedures. Beyond the pandemic, demand for medical office buildings continues to grow in line with our nation’s ongoing need for out-patient healthcare. CMS estimates $4.1 trillion were spent on healthcare services in 2020, and national healthcare spending in the United States is expected to grow at an average annual rate of 5.4% from 2019 to 2028, outpacing GDP as well. We expect that a significant portion of this spending will be directed to off-campus facilities in particular, where we continue to see health systems demanding more space. The trends in favor of medical office have proven to be very predictable and reliable. As a result, we expect our portfolio to produce a consistent and reliable rental income stream with steady growth over time for the benefit of our shareholders. Public investors in healthcare real estate can count on medical office to remain open, occupied, and busy. Medical office does not need to recover as an asset class; it was only impacted temporarily in Spring 2020, and DOC has maintained close to 96% occupancy routinely ever since. We remain focused on growing our funds available for distribution each year, and we will continue to manage our organization to achieve that result annually. On the acquisitions front, we announced the purchase of a brand-new medical office facility with an on-site outpatient surgery center on the campus of AdventHealth Hospital in Wesley Chapel, Florida. Several members of our team have long-term relationships with AdventHealth, and we hope to find future opportunities for investment with this system across their national footprint. We also finalized commitments to finance three new medical office facilities anchored by leading investment-grade healthcare systems, with two buildings being off-campus and one on campus. We continue to evaluate a number of new development projects and expect a positive uptick in development for the year and going forward. Our investment pipeline continues to grow, with visibility on nearly $200 million in prospective opportunities that we expect to close in the coming months, plus a growing number of acquisitions in negotiation that we expect to execute in the third and fourth quarters. Our growth this year may be slightly weighted to the second half of the year, but we remain very confident in our acquisition guidance of $400 million to $600 million in new investments in 2021. In June 2020, we published our inaugural ESG report, sharing our hard work on environmental management of our buildings since 2018 and progress toward ambitious goals to improve the energy utilization and waste management of all our facilities. We will publish our second annual ESG report in June 2021, and we will be proud to report great progress on all our environmental, social, and governance goals as well as the DOC culture. Under Mark Theine’s leadership, Physicians Realty Trust earned the EPA’s ENERGY STAR Partner of the Year, and we expect this to be the first of many awards recognizing our commitment and success in reducing our carbon footprint and providing a better setting for our physicians and providers through better-managed buildings. Jeff will now review our financial results and Mark Theine will share our operating results.

Jeffrey Theiler, Chief Financial Officer

Thank you, John. In the first quarter of 2021, the company generated normalized funds from operations of $57.7 million. Normalized FFO per share was $0.27 versus $0.26 in the same quarter of last year, an increase of 3.8%. Our normalized funds available for distribution were $54.5 million, an increase of 7.8% over the comparable quarter of last year, and our FAD per share was $0.25. We remain highly focused on this metric as it is the most direct way to measure our company’s performance versus our peers, and we will continue to focus on growing our FAD per share at an outsized rate for our shareholders. We continue to see strong operating performance from our $5 billion medical office building portfolio in the first quarter of the year; same-store NOI growth was right in line with expectations at 2.4%, and we increased the lease percentage of our portfolio by 10 basis points to 95.8%. Our portfolio continues to successfully manage the strain of the COVID pandemic, and we collected the usual 99.7% of our billings in the current quarter. The one deferment we granted last year continues to be paid back on time, and the last and final payment will be made in June. Barring an unforeseen intensification of COVID in the future, it now appears that DOC has been able to manage through the worst of the pandemic and emerge with no material negative impacts. This is a direct testament to the strength of the medical office asset class in general, and in particular, the strength of our investment-grade tenant base as well as the high quality of our buildings, credit team, and property managers. The balance sheet has been an area of focus for us and is now a positive differentiator between us and the rest of our healthcare REIT peers. With our enterprise leverage of five times debt-to-EBITDA, including our pro rata JV debt and our 62% investment-grade tenant base, we believe we offer our shareholders the best risk-adjusted investment in healthcare real estate. We raised $52.4 million of net proceeds on the ATM in the first quarter, effectively pre-funding a portion of what we anticipate to be a substantial year of growth for the company. Our revolving credit facility is only 18% drawn with $156 million outstanding, leaving $694 million of availability. We generally expect the targeted leverage of 5.25 times debt-to-EBITDA on an enterprise basis going forward. We continue to be confident in the acquisition guidance we laid out several months ago of $400 million to $600 million of new investments despite the relatively slow start in this quarter. We have been admittedly picky. However, we also have high visibility on a number of the types of medical office buildings we are seeking, those with investment-grade-rated health system tenants, performing specialized medical procedures in strong demographic areas. JT referenced the pipeline value of those deals and those types of deals in negotiations during his prepared remarks. Because these are primarily relationship deals, we feel a higher degree of certainty than if we were trying to acquire them at auction. We still expect to end the year within the total acquisition amounts we guided to at an average cap rate between 5% to 6%, subject to suitable capital market conditions. Turning to other portfolio metrics, our first quarter G&A, which usually trends higher than the rest of the year, was on track at $9.5 million, and we expect to meet our guidance range of $36 million to $38 million for the year. Our recurring capital expenditures were well under budget at $5.6 million as our team managed to create some additional efficiencies, and some TIs that were budgeted for new leases turned out better than expected. We now expect to be at the bottom of a recurring CapEx guidance range of $25 million to $27 million for 2021. I will now turn the call over to Mark to walk through some of our portfolio statistics in more detail.

Mark Theine, Executive Vice President, Asset Management

Thanks, Jeff. The first quarter of 2021 represented another solid and consistent quarter for Physicians Realty Trust. I’m once again pleased to highlight the strength of our underlying assets and the value of our asset management, leasing, and property management platform. DOC’s best-in-class operations team remains dedicated to enhancing the physician-patient experience, offering healthcare providers the benefits of a national real estate owner with scale paired with a personal touch of local management. From a performance perspective, our MOB same-store NOI growth in the first quarter was 2.4%. Predictably, NOI growth was driven primarily by a year-over-year 2.4% increase in base rental revenue, in line with our weighted average annual rent escalator. Year-over-year, operating expenses were up $2 million overall, primarily driven by a $0.6 million increase in real estate taxes and a $0.6 million increase in insurance costs. However, the value of our net lease structure is once again evident in the nearly dollar-for-dollar increase in operating expense recovery revenues. Lastly, lower parking revenue had a 20 basis point impact on Q1 same-store NOI growth. Specifically, paid parking receipts have now returned to 80% of normal levels during the first quarter, which compares favorably to 48% of normal levels experienced nearly one year ago during the height of the pandemic. Turning to leasing activity, we continue to see significant opportunities to add value as we capitalize on increased demand in our larger markets. We completed 197,000 square feet of leasing activity during the period, with a 76% retention rate and positive 6,000 square feet of net absorption. While Q1 leasing volume represented 1.4% of the portfolio due to our staggered lease expiration schedule, we have had a significant increase in leasing tours and tenants looking for existing medical office space as construction prices continued to drastically increase. In fact, subsequent to the end of the quarter, we just executed a new 18-year lease for the single largest vacancy in our portfolio, a suite totaling 22,000 square feet at the MeadowView MOB in Kingsport, Tennessee. Having navigated through a year of challenges posed by the pandemic, I’m proud of our team’s uninterrupted focus and continued achievements. Similar to our asset management and leasing teams, our capital projects team also had an excellent quarter, additionally prioritizing recurring CapEx investments totaling $5.6 million or 7% of cash NOI and ahead of 2021 guidance. Embedded within all capital investments made by DOC is a solid commitment to the materials and practices that enhance the patient experience as well as our G2 sustainability philosophy. This quarter, DOC was nationally recognized as a 2021 ENERGY STAR Partner of the Year from the U.S. Environmental Protection Agency and the U.S. Department of Energy. This prestigious award is the highest level of EPA recognition, as partners must perform at a superior level of energy management and demonstrate best practices across the organization while improving portfolio-wide energy savings. We are proud to celebrate the recognition from the EPA for our ESG efforts to date but recognize that this is simply a step forward for DOC as we continue to invest in better as leaders across the real estate industry. With that, I will now turn the call back over to John Thomas.

John Thomas, Chief Executive Officer

Thank you, Mark. Epoch, we will now take questions.

Juan Sanabria, Analyst

Hi. Thank you for the time. I was just hoping, John, you could talk a little bit more about the development funding you referenced in your prepared remarks, types of yields you are expecting, if mainly that includes price to purchase the asset upon completion and if you could remind us what kind of pre-leasing you typically look for before committing that kind of capital?

John Thomas, Chief Executive Officer

Yes, happy to share, Juan. This year, we have identified several new development financing opportunities. We have initiated three projects so far. One is an on-campus building that is 75% pre-leased to the health system, showing significant potential for increased leasing as construction progresses. This involves mezzanine loan financing, where we are supplying much of the non-construction equity, while the developer covers the remainder. Additionally, we have an option to acquire the property after receiving the certificate of occupancy. Another project is an off-campus building fully leased to a credit-worthy tenant, structured more as a loan-to-own arrangement. In this case, we typically earn a yield of over 6% during construction, which then transitions into ownership. We also have a call option for ownership conversion post-occupancy. The third building is similar to the mezzanine loan financing with a partnership involving an anchor health system and a national operator, along with some pre-leasing agreements with physicians. This building is also around 75% pre-leased and structured as a mezzanine loan, giving us the option to acquire it later. We have had strong success with these financing types, balancing our risk and allowing developers to handle lease-up risks, particularly with fully leased opportunities. We are keen on the loan-to-own model, as highlighted in our annual shareholder report regarding the building at Sacred Heart. We anticipate pursuing more of these opportunities this year and being productive. All these projects are set to receive occupancy certificates in 2022, adding great value to our portfolio.

Juan Sanabria, Analyst

And how big is the pipeline of opportunities where you have the right of acquiring assets that you’ve already committed to? Do you have any sense of that scale?

John Thomas, Chief Executive Officer

Yes. We have got it under, I guess, various mezzanine loans. We did a large package at the end of the year. So we are pushing $500 million, $600 million of underlying asset value securing our mezzanine loans. In all of those, we have some form of option to acquire and/or right of first refusal, ROFR rights.

Juan Sanabria, Analyst

Great. And then just one last question for me, just on cap rates, and I recognize you are sticking to your 5% to 6% guidance range. Just curious, we are obviously hearing about increased competition, but how you are feeling about within that range where you are more likely to come out and where things are trending for the deals you are looking at that are under LOIs or what have you, just to give us a sense of where the deals are trending pricing wise?

John Thomas, Chief Executive Officer

Yes. We are in the low fives for Class A assets. As Jeff mentioned, we are really picky on the high-quality assets. And again, these are health system-anchored and heavily leased buildings that we have been acquiring. They are all off market, so that does help us. The auctions that have been published, cap rates that are coming through the marketed deals seem to be compressing. But we are in the low-five to mid-five on Class A acquisitions and then stretch closer to six on usually smaller assets that are off-campus and/or the development projects that again we are financing this year.

Juan Sanabria, Analyst

Thank you.

John Thomas, Chief Executive Officer

Thank you, Juan.

Jordan Sadler, Analyst

Hey, guys. So just a point of clarity on the $500 million to $600 million, you mentioned JT. You have mezz supporting presently $500 million to $600 million of assets that you have rights on or acquisition rates or options to purchase? Is that what you were saying?

John Thomas, Chief Executive Officer

Yes, that is right. So the underlying value of the buildings that are securing our mezz loans is well in excess of $500 million.

Jordan Sadler, Analyst

Okay. And in terms of the pipeline of additional mezz loans and/or development loans that you are underwriting right now in terms of additional capital you put out the door, how much is that of the $200 million plus that you flagged?

John Thomas, Chief Executive Officer

Yes. Most of the $200 million, or I must say all of the $200 million that were kind of an LOI or close are acquisitions. We have additional development financings that we are still underwriting and competing for, if you will. So that would be in addition to the $200 million.

Jordan Sadler, Analyst

Okay. And what is the nature of the $200 million? Is it sort of your bread and butter transactions, some anchor deals, affiliated deals typically?

John Thomas, Chief Executive Officer

Yes. These are newer. It is a mix of on and off-campus. Some are just finalizing construction. They are all health system anchored and heavily leased to health systems. But there are some physician groups obviously in some of those buildings, and the pipeline itself is just bread and butter buildings.

Jordan Sadler, Analyst

Okay. And then I heard the word picky, obviously Jeff mentioned, I just heard you mention it again. So what is sort of you are flagging? I’m kind of interested in maybe the lessons learned, if at all from the pandemic, if there is something that kind of has informed your underwriting. I know you guys came out pretty well, but is there anything that we have looked at some assets, and this has now filtered into your new underwriting?

Jeffrey Theiler, Chief Financial Officer

Hey, Jordan, this is Jeff. I will take a stab at that. So as you said, I mean, we came through the pandemic really well. I think a testament to the underwriting that we did and kind of the continuous monitoring of the credit team of our tenants. So I don’t know that really changed anything. For the last number of years, we have had a really strong focus on investment-grade tenants, large health system-anchored buildings. And so when we say picky, I think that is really what we are talking about. It is picky in terms of the tenants and the specialties and where they are. So nothing different than the last few years; we have been focused on these types of tenants, just kind of a continuation of the strategy, which really served us well during COVID.

Jordan Sadler, Analyst

Perfect. Maybe just one for Mark before I get off the clarity on the parking fees. Mark, you said, I think 20 basis points of the 2.4% rental revenue - sorry, 2.4% of NOI was related to the parking benefit, but I’m not sure if that was sort of a year-over-year metric because I heard the 80%, the 48%, but I was just trying to clarify what periods we were talking about there?

Mark Theine, Executive Vice President, Asset Management

Yes, Jordan, happy to clarify. So the same-store impact from lower parking revenue was 20 basis points in the quarter. So our 2.4% would have been a 2.6% same-store NOI growth if parking was at pre-pandemic levels. So we -

Jordan Sadler, Analyst

Q1?

Mark Theine, Executive Vice President, Asset Management

I’m sorry, Q1.

Jordan Sadler, Analyst

Q1 it would have been 2.6%, right? Yes, okay.

Mark Theine, Executive Vice President, Asset Management

Yes, yes. Q1.

Jordan Sadler, Analyst

And then the 80% versus the 48%, what were those two periods?

Mark Theine, Executive Vice President, Asset Management

Yes. So the first quarter was we have returned to 80% of the pre-pandemic levels compared to 48% and we were at our lowest point last year kind of in that March-April time period. So we have got about $130,000 of parking revenue kind of upside to return to normal levels as what the dollar figure is.

Jordan Sadler, Analyst

Perfect. Thank you very much.

Mark Theine, Executive Vice President, Asset Management

Yes.

John Thomas, Chief Executive Officer

Thanks, Jordan.

Nick Joseph, Analyst

Thanks. We have talked a lot about the acquisition pipeline, but JT, you mentioned kind of beyond what is under LOI right now in negotiations. Can you try to put a size of that pipeline that is kind of the next step beyond the near-term?

John Thomas, Chief Executive Officer

Yes, Nick, it is, like I said, we are very confident in the $400 million to $600 million number, and I think that is probably the best way to say it. I think the next two quarters we will hopefully get more in the third quarter and accelerate a little bit of delay from the first quarter. But again, $200 million is in near-term visibility, another $100 million kind of in active negotiation, if you will, and then we do have good confidence in the balance.

Nick Joseph, Analyst

Thanks. And then you talked about the ATM issuance to pre-fund. How do you think about funding the remainder of this expected acquisition growth kind of going forward over the next few quarters?

Jeffrey Theiler, Chief Financial Officer

Hey, Nick, this is Jeff. Yes. So certainly, we have been using the ATM opportunistically, we will continue to do that. Like we said, we feel very confident in the overall volume of acquisitions for the year. So we are going to try to use the ATM when it is appropriate. If we pre-fund some of that, that is fine. We just want to make sure we are in a good capital position to kind of run through our guidance. So it is likely to be the ATM. If there happens to be a big portfolio deal or something like that, we would look at maybe a follow-on offering to complement that as well.

Nick Joseph, Analyst

Thank you.

Vikram Malhotra, Analyst

Thanks for taking the questions. Good afternoon. Maybe just first one, you alluded to backfilling the largest vacancy in the portfolio. Maybe just give us some more details about that lease and if that were in place, sort of what does that do to total NOI?

John Thomas, Chief Executive Officer

Yes, Vikram. Thanks for the question. Really excited about this new lease. As I mentioned, we are seeing a significant increase in our leasing tours and interest in the buildings across the portfolio, and I think this is a perfect example this quarter of what we just signed after the quarter ended here, the 22,000 square foot lease at our MeadowView building. The tenant is the existing anchor in that building. They occupy the first two floors of this building and now are expanding to the third floor and will occupy 100% of the building. Last year they invested over $3 million of their own money into a surgery center on the second floor. So this group is growing quickly; the largest multi-specialty group in the area needed this for their future growth. From an NOI perspective and same-store perspective, it is going to have a nice bump for our future growth, and it is going to have a year of ramping up as they do construction and build-out. But once we get to a run-rate basis, it should help with that 28 to 25 basis point increase in our same-store.

Vikram Malhotra, Analyst

Got it. And then you also referenced that post-quarter, again the tour activity picking up quite dramatically and the governor on supply being construction costs, etc. So I’m just wondering, give us a color maybe some of the larger systems or tenants that you are talking to. How are they thinking about sort of expansion space and maybe more granular - the type of space on off-campus? What are these tenants specifically looking for?

John Thomas, Chief Executive Officer

Yes. Well, as you know, our portfolio is 96% leased, so we are starting from a great position of strength there and working hard to fill up those vacancies, both on-campus and off-campus. We are definitely seeing growth in the off-campus space as groups are looking to expand just existing services. When we do lose a tenant, it is primarily due to the fact that they can’t grow within our buildings. So we do have a little bit of repurposing to do there. But again, an increase in volume and activity from our hospital partners especially.

Vikram Malhotra, Analyst

And then maybe just last one. Any update or anything that has come up on the watch list? I mean, we are still seeing the effects of the pandemic and a lot of different health systems or health operators are still getting funding from the government. So just wondering if there is anything cropped up from a watch list perspective?

Mark Theine, Executive Vice President, Asset Management

Vikram, not really. Our accounts receivable is in better shape than it has ever been. I think this is a testament, as Jeff mentioned, to our credit team and our asset management team, as well as the close relationship we have with our tenants. A significant portion, 62%, of our tenant base consists of investment-grade health systems. Many of these health systems have accessed approximately $9 billion in funds through various structures of the CARES Act funding. However, our primary focus is on the activity in our buildings, which has been robust since last May, with everything operating and busy. Our volumes have returned to pre-COVID levels, supporting the rent payments from those buildings. Therefore, we don't have any concerns. Ideally, some of that CARES Act funding will transition from loans to grants, alleviating strain on the health system overall.

Vikram Malhotra, Analyst

Fair enough. Thanks so much.

Mark Theine, Executive Vice President, Asset Management

Yes. Thank you.

John Thomas, Chief Executive Officer

Thanks, Vikram.

Amanda Sweitzer, Analyst

Thanks. Following a bit more on the stronger leasing activity that you are seeing, have you seen an acceleration in rent above your prior expectations or have you been able to pull back on TIs or other leasing concessions as a result of that strength you are seeing?

Mark Theine, Executive Vice President, Asset Management

Good question, Amanda. This is Mark. The answer is yes to both. As a result of some of the increases in construction pricing, rental rates have been rising around the country. So we have been able to push on rate as it just gets more expensive for providers to move from building to building or construct new. So we have been pushing on rate quite a bit there. And then on TIs, I mean, just because it is harder to move, our leasing team did a good job this quarter of offering less tenant improvement allowances from the landlord. So our CapEx was actually a little bit lower than we originally projected from some TI savings there.

Amanda Sweitzer, Analyst

That is great to hear. And then higher level on capital allocation, can you talk more about how you are thinking about your cost of equity today just relative to the decline in cap rates that you are seeing for medical office broadly? Has that caused you to change your hurdle price for equity issuances at all?

Jeffrey Theiler, Chief Financial Officer

Yes. Hey, Amanda, it is Jeff. So as we look at our cost of equity today, clearly the stock has done better through this year than a lot of last year. So the cost of equity for us has been pretty steady, I would say. I mean, certainly cap rates have gone down and become a little bit more competitive; luckily, the cost of our debt has gone down as well. So that makes an overall cost of capital hurdle easier to achieve with the acquisitions that we are looking at. So as we look at the stock price where it has been lately, I think it is at levels where we can achieve the full volume of our acquisition guidance and still provide accretive returns to the shareholders.

Amanda Sweitzer, Analyst

That is helpful. Thanks for the time.

John Thomas, Chief Executive Officer

Thank you, Amanda.

Michael Carroll, Analyst

Yes, thanks. So I guess, I noticed in the press release that you guys trademarked a phrase, invest in better. Can you talk a little bit about that phrase and I guess how should we think about that?

John Thomas, Chief Executive Officer

Yes, Mike. We did that I think three years ago, maybe. But... Yes, I’m glad you recognized it. It was really a combination of the culture of our organization. It goes across the board; invest in better people, invest in better health systems, invest in better buildings. It is something that came out of our internal strategy discussions, and as we try to message to investors, prospective clients, health systems, and to people that we recruit. We have had almost no turnover in our organization. The team performed extremely well during work from home and is still mostly working from home, and we take a lot of pride in that. Everything we do, we try to do it with excellence, and as we say, invest in better.

Michael Carroll, Analyst

No, it makes sense. I guess, JT, can you talk a little bit about the type of patients that are flowing to out-patient settings now, I guess, due to the pandemic that were previously going to in-patient settings? Does that change the type of buildings that they are going to? I mean, is it more surgery centers or on or off-campus? I guess, how is that kind of evolving?

John Thomas, Chief Executive Officer

Yes. So Jeff spoke to this earlier as well, what we learned from last year was that just reaffirmed the strategy that we have seen and believed in for years, and again, investing in better, looking into the future, which is where healthcare services are best performed and can be clinically performed. The buildings with surgery centers last year away from hospitals that were the busiest during the - once things settled down last May and people learned how to isolate COVID patients in the hospital, literally all other care that was in trauma was being directed to out-patient settings. We commissioned consumer surveys in five of our largest markets, which found if you didn’t have COVID, you wanted to go a healthcare service at least a mile away from the hospital. We didn’t pick the mile; that was just feedback from the market, from the communities. Certain buildings we are investing in; we mentioned the Wesley Chapel building, which is on-campus but has a surgery center. Orthopedics and total joints are just moving out of the hospitals rapidly. Hospitals that didn’t have or were trying to keep orthopedic surgery in the in-patient setting or in the in-patient facilities last year lost all that volume to out-patient facilities and other providers. We think we see an uptick in new development. We are financing at least one project and think some others this year in which hospitals are investing in surgery centers away from the hospital campus to provide care for orthopedics in particular. We believe there will be a significant move of procedural cardiology out of in-patient facilities into out-patient settings. These buildings will typically be closer to a hospital but don’t necessarily have to be on campus. Again, we have been seeing this trend for years, and it is one of our development projects this year as well.

Michael Carroll, Analyst

Okay. And then is there - I guess what has driven this change? I mean, is it just - obviously, it is consumers’ preference given the pandemic of staying away from hospitals. But what is going to keep that from reverting back? I mean, have there been any changes to regulations or advancements of technology that are going to help drive that shift to out-patient or maybe accelerate that shift to out-patient that we have seen over the past few decades?

John Thomas, Chief Executive Officer

Yes. I think what we saw last year was an acceleration, again, just because people didn’t want to go to the hospital. Many sadly avoided essential care and lost their lives as a result. But I think it is here to stay as consumers are now more comfortable with it in the out-patient setting. CMS is phasing out the so-called in-patient-only rule, which is Medicare for years has put out a list of procedures that they would only pay for if performed at a hospital, so in the in-patient setting. They have shifted more and more or paying for more and more procedures to be done in the out-patient setting. This shift helped drive the move of total joint replacements from in-patient facilities to out-patient facilities. Last year there was a dramatic shift of procedures and volume as CMS declared that by 2023, they will not have an in-patient rule at all. They will just pay for procedures and let the clinicians pick the best clinical setting, which will tend to be more efficient, lower-cost out-patient care facilities that are more convenient to patients and the physicians themselves.

Connor Siversky, Analyst

Good afternoon, everybody. Thanks for having me on the call. Just really one for me, quick follow-up to Mike right there. So we have seen this chart from time to time comparing out-patient visits, in-patient procedures, and I’m wondering if you could provide any color as to what inning we are in, in that trend? And by that, I mean, how much is left to really take out of the in-patient environment?

John Thomas, Chief Executive Officer

There is a lot. I mean, there is a lot of volume. I think last year or maybe 2019 was the first year the number of procedures done in the out-patient setting was greater than the number of admissions in the in-patient setting. But that number accelerated in 2020 and will continue that shift. You are talking basis points on basically a trillion dollars a year of healthcare services. Each year, basis points would be billions of dollars moving out of the hospital and into the out-patient setting. In cardiology, we are just getting started. It will be a slow evolution but will ramp up dramatically about how much cardiology will move out of the hospital.

Connor Siversky, Analyst

That is helpful. I’m wondering then as these higher acuity procedures are moved out of the hospital, do you expect any change in the design philosophy at medical office buildings in order to facilitate some of these procedures?

John Thomas, Chief Executive Officer

Yes. I mean, with out-patient surgery you’ll have to have separate ingress and egress points for surgical patients. Again, we are thinking differently about lobbies and dedicated elevators, really kind of lessons learned from, if you will, from the pandemic or preventing the next pandemic or anticipating another pandemic in the future. Cardiology buildings are - I mean, the whole idea there is moving cardiology into an out-patient surgical facility. The types of rooms that are available will be unique for that service. The move of total joints out of the hospital into the out-patient setting involves a lot of technology and procedures. The robots require more room than a typical OR fit. You are getting a little bit more space, and again, oncology continues to move to the out-patient setting, necessitating a different design for those buildings that deal with patients and their families.

Daniel Bernstein, Analyst

I will say, I concur that was just an interesting question and answer just now. So maybe I’m reading too much into the parking volume, but it seems to me the hospital volume has come back a little bit more like 90% or so and parking volume here is staying 80%. Am I reading too much into this that maybe telehealth has impacted the amount of car volume coming in? I’m just trying to assess whether you are going to come back to pre-pandemic levels in terms of parking receipts? I know it is not a huge portion of your rents, but trying to...

John Thomas, Chief Executive Officer

Yes. It is one of our elastic revenues. Dan, the issue is valet parking. It is not the volume of patients; it is valet parking. So with COVID, valets are still restricted in a lot of states. People’s comfort level getting in and out of the car is still a concern. That will come back. I think it would even be stronger once we get more vaccines out and more herd immunity.

Joshua Dennerlein, Analyst

Yes. Hey JT. Hope all is well. I’m curious about the in-patient rule. Do you typically see an increase in many MOB developments or RFPs once something comes off that in-patient list?

John Thomas, Chief Executive Officer

Yes. There is usually a time lag. Like cardiology has been - I think it was two years ago, there were 13 procedures moved off the in-patient-only rule, and last year there was another 20. It takes some time for the clinicians to organize around a different setting, which then affects design, as we talked about before. Total joints took - I mean, accelerated pretty quickly. Forgive me for that computer message. Total joints took time, but moved rapidly to the out-patient setting in pretty dramatic fashion. I think the prediction is on total joints that will be at about 90% done in an out-patient setting by 2025. What would be left would be patients with comorbidities that just require more intensive services other than the orthopedic procedure. Cardiology is slower moving but will pick up dramatically this year. We are already starting to see cardiology dedicated ASCs, and there is a lot of planning going on with physician groups we are talking to.

Omotayo Okusanya, Analyst

Yes. Good afternoon, everyone. I just wanted to follow up on that kind of last line of questioning, and I agree, definitely with the model of everything shifting out-patient. How should we be thinking about how that translates into future demand? I ask that question from the perspective that we haven’t really seen your development pipeline or development pipelines of any of your peers really ramp up. Occupancy is steady; we haven’t seen this huge kind of ramp in occupancy. How do we match that kind of what we are seeing at that level vs how it is going to translate to operating metrics in dollars and cents for DOC?

John Thomas, Chief Executive Officer

Tayo, it is a big question. I mentioned in my prepared remarks, again, the CMS actuary predicts medical spending is going to grow 5%, 5.5% every year between now and 2028. The 2028 endpoint is the back end of the baby boom population; this statistic will top out, and then the aging part of the population starts catching up to the younger population. The vast majority of spend is going to continue to shift to the out-patient setting. We talk about the hospital of the future, whether existing physical plans or those that feature rooms designed to convert for intensified care will provide necessary services like COVID, transplant, and trauma. Everything else is moving to out-patient. Thank you for joining us today. Again, we are off to a great start and we have got some fantastic things to share with you in the upcoming quarters. Look forward to seeing many of you during the NAREIT Zooms and hopefully in-person soon, and we just encourage all to get vaccinated. If you can’t find a vaccine, give us a call; we will help you find one. Thank you.