Paul O'Connor:

Good morning all and welcome to the Netwealth Portfolio Construction Podcast series. My name's Paul O'Connor and I'm the head of strategy and development for the investment options offered by Netwealth. Joining us for today's podcast is Andrew Hemming from Centuria Capital Group, who is the managing director of Centuria Healthcare and is based in Sydney. Good morning, Andrew, and I'm looking forward to an educative and interesting discussion on the healthcare property market this morning.

Andrew Hemming:

Thanks for having me, Paul, and hope I can deliver.

Paul O'Connor:

I'm sure you'll be more than capable of delivering. Andrew has worked across investment markets for more than two decades, including Australian and US equity derivatives, fixed-term interest markets, and commercial real estate sectors with the latter focused on healthcare property. His investment experience spans Australian, British, European, and US markets holding senior positions at investment houses, including BNP BNP Paribas, Merrill Lynch, and Folkestone. He's managing director of Centuria Healthcare. Andrew's responsible for strategic business growth, deal origination, asset transactions, and leads 17 healthcare property specialists. He's grown the business to 60 assets under management, valued at circa $1.4 billion at 30 June 2022. Andrew guides the Centuria Healthcare investment division, his instrumental in securing institutional mandates while also overseeing development funds, closed-ended unlisted funds, and an open-ended unlisted fund being the Centuria Healthcare Property Fund. In 2019, Centuria acquired Heathley Limited to form Centuria Healthcare. Andrew was appointed managing director of Heathley in 2013 and continues in this role today.

Andrew currently sits on the Centuria Healthcare Limited Board as an executive director and holds a bachelor of arts in commerce and a masters of business administration, both from Macquarie University. Centuria was established in 1999 and is an ASX-listed company with a current market capitalization of $1.6 billion. As at 30 June, the group managed $20 billion in assets. The group's property funds under management consists of $13 billion in unlisted property funds as well as $6.8 billion enlisted property trusts. Centuria operates a vertically integrated property business across both property funds management and property services, employs 400 staff, and manage asset acquisition disposal, leasing, and tenant relationships in-house. The Netwealth investment menus include three Centuria funds including the Centuria Agricultural Fund, Diversified Property Fund, and the Healthcare Property Fund. Although I note the healthcare property fund is temporarily closed to new applications. The healthcare industry is very broad and encompasses hospitals, specialist medical centres, and aged care facilities.

The industry itself has been undergoing significant change in recent years as it faces challenges due to increased demand from significant population growth and improving and advancing medical services. This has resulted in increased demand for property and a focus on using existing infrastructure more efficiently. In addition, the ageing population and growing need for aged care services has further added to demand resulting in growing opportunities for specialist healthcare property investors such as Centuria. However, healthcare is also highly regulated, which creates positives such as regulatory support and government funding, but also potential negatives such as pricing caps. When you also consider the major players in this industry include government, health insurance companies, and private hospital operators, it's clearly a specialist area, so I'll be interested to understand where Centuria's focus is and where they believe the best opportunities exist for investors. As property funds also use a mix of investor capital and gearing, I'll be interested to understand how rising interest rates are impacting on potential returns. I know that, Andrew, you've got significant experience across investment management, so can you make a few comments for the listeners how you came to specialising on healthcare property?

Andrew Hemming:

Yeah. Paul, I must admit I've got an interesting background when it comes to financial markets, economics, and real estate. The combination of those three factors led me to think through healthcare real estate being an opportunity to explore, knowing full well there were peer sets in real estate sector that were far more experienced and intelligent real estate than I was. I focused on something that I could probably have a bit more leverage on, which is my economics background. It's very well understood that healthcare is a secular theme. It's a theme that will continue on for many, many generations as a high-need, non-discretionary theme. From a real estate perspective, there hasn't actually been a lot of capital or CapEx capital investment in the real estate sector of healthcare for some decades, and you overlay that with changes in the funding models, which changes, therefore, the models of care and the built environment. We saw an opportunity to grow that space. As you said in your introduction, we've got a little over $1.4 billion in assets under management today, and it's just the beginning.

Paul O'Connor:

I'll just make the comment there that it's niche. It is certainly I think a growing sector and area for investors to consider. I think of the thousands of managed funds we have available on our investment menu at Netwealth, we've only got a couple that come to mind that are focusing on healthcare, so I suspect we'll see a few more come to market over the next few years. You may have a bit more competition there. Maybe for starters, Andrew, can you provide some insights into the different stages of healthcare in Australia being primary, secondary, and tertiary? What are the different types of healthcare real estate required for each stage?

Andrew Hemming:

No problem, Paul. In Australia, we've got two tiers of healthcare, public and private. But across both those tiers, there's primary care, secondary care, tertiary care really that is the patient journey from a GP to a specialist to in-hospital care. Across our portfolio, we own medical centres, which is primary care where the GP-anchored tenant is delivering health promotion or early prevention and treatment through chronic conditions or out-of-hospital treatment for that patient through a GP. We also own specialist centres or medical office buildings that house consulting rooms with specialists where someone can get specialist consulting. That generally then leads onto hospital treatment, whether it'd be a day-only hospital treatment or an overnight hospital treatment where we have both overnight, but what we call short-stay hospitals and day-only hospitals. That continuum of care as you go from primary care all the way up to hospitalisation is about the level of acuity that that patient needs to have serviced. If it's a common cold, obviously, that's primary care, if it's something that's operable, it's generally hospitalisation.

Paul O'Connor:

Can you explain the new models of care in the Australian healthcare system and what are the key themes driving these models both in a hospital and out of a hospital?

Andrew Hemming:

Yeah. Paul, this really lends on my economics background. I spent a long time with some of the health insurers, largely been well-publicised. I've spent some time with Medibank understanding the payment structures and the potential changes in those payment structures. I think to understand the new models of care, my economics background would say to follow the money. It's probably good for listeners to just clarify what that means. In the private system, if there are three key stakeholders that are all either benefiting or at risk of changes in the payment systems, it's good to understand their position. You've got, for example, insurers or payoffs or health funds as they're called, and you've got Medicare and then you've got the doctor cohort. For example, the insurer understanding what they pay for is important in understanding why these changes in the funding models have come about and to change the models of care.

Insurers largely pay for prostheses. Anything you put in your body like a hip, knee, or shoulder joint replacement, you've got electronic devices for your heart or pacemakers, defibrillators, stents, cardiac stents for your heart, the insurers also pay for accommodation. That's a key change in the models of care. Then you've got Medicare and the insurers pay for doctor bills, imaging, pathology, again, that's changing how a patient is serviced through specialisation or hospitalisation. Then the doctors, controversial but interesting, doctors largely charge out of pocket, but there is actually no technical pricing structure with how a doctor charges out of pocket. We think over time that will come. The washup of all that, Paul, is that we saw two things happening. Basically, we saw lower lengths of hospitalisation stays. When a patient goes in, and I always use the example of hips because we do have an ageing demographic, there are more people proportionately getting hip surgeries or hip replacement, joint replacements done for obvious reasons because they're wear and tear, but their length of stay is reducing dramatically.

If you look five-plus years ago, the average length of stay for joint replacement, namely a hip was about 6.7 days. That was the average. Therefore, there are some at 12 to 14 days, there are some at 2 to 3 days. The average length to stay that they want for a hip replacement now... When I say they, it's largely the health funds that are requesting this and it is evidence-based to have better healthcare outcome, but certainly, it's about cost, it's about one to two days. If you play that through, that means we won't need as many beds, we won't need as many recovery beds in a hospital setting as we do today. A hospital prior to when we got Centuria and myself got into the healthcare space was typically 5 theatres, 200 to 300 beds. Today, it's about 5 theatres and about 30 to 40 beds. That's huge reduction in beds because the length of stay is reducing dramatically.

So people are encouraged now through the health funds to get out of hospital and recover at home. Obviously, that doesn't suit all patients because there are comorbidities or complications that patients may have. That is the first change, the length of stay. The second change will be... Again, I don't think it's too controversial, but it has been written up in the press as controversial as you are getting vertical integration, what that means is you've got health funds like Medibank who we do some developments for, have now vertically integrated into a hospital business. You've got an insurer that now owns part of a hospital business. For example in Kew, the Adeney Private Hospital in Melbourne, Medibank owns 49%, 42 doctors own 51% of that operating entity, the tenant. The agreement that that tenant has with Medibank is to provide zero out-of-pockets for the customer or the patient rather.

Straightaway you've got people entering into hospital and leaving sooner, but they're really not paying any out-of-pocket. The cost of that service is coming down materially. Those two changes change the built form, they change how the operator performs its healthcare service. They change the ownership structure of that operator in terms of doctor co-investing, in terms of equity of the business. Quite a bit of change that means that in Australia we need to build out this new hospital environment. In the US, where a lot of this has already played out in terms of the delivery of the more efficient healthcare hospital rather system. It's got its own issues over in the US in terms of fractured costs. But in the hospital system, they have what they call ambulatory surgical centres, ASCs. We've got about 6,000 over there. If population is about 30 million, we could have 400 or so in Australia. We have about half a dozen to 10 in Australia. We've got a long runway to go to building up this more efficient hospital sector.

Paul O'Connor:

Well, I mean just judging by your comments you've made there, Andrew, it's the increasing efficiencies in the hospital system and increasing efficient use of the infrastructure certainly was coming to mind as you were making those comments there. I know I've got an elderly family friend who had a hip replacement, well, had both hips done, but I think the first hip about 15 years ago, and it was a three-week stay in hospital. Then the other hip was a two-night stay. I think that really highlights the increasing efficiency in the better level of care we're all receiving now. Healthcare real estate seems like the Cinderella of the commercial property market. Why has this alternative asset class come to the fore in your view?

Andrew Hemming:

Nothing is immune to the current forces of work, whether they be supply chain costs, increases for materials, whether it be increasing costs of capital through interest rate rises and inflation healthcare, and again, excuse me, going back to my economics, it's a low beta play. When times are good, it'll underperform those that probably are more elastic, but when times are tough, it'll outperform. It's the bellwether. If you want to use the word Cinderella, that's fine by me because of really two things. One, as I mentioned at the start of the podcast, non-discretionary demand. People must have healthcare and people will pay for it. The other thing is its specialisation. The capital investment from the tenants, the doctors, and the co-location of other businesses, other tenants to the anchor tenant such as a hospital, make it really sticky. These tenants generally sign long-term leases for 10 to 15, 20 years.

The leases are net leases or the outgoings are paid by the tenant, they're inflation-hedged. They have a CPI review on their annual rent bumps and they have alignment. As I said, it's not just the capital that they're investing, but their doctors will invest to that, into that business in that location, they are aligned with ensuring that business outperforms or performs solidly over a sustained period of time. Of course, it comes with its risks, but it'll move up and down with the vagaries of the market like everything else. But we suspect that over a long period of time, 20, 30, 40 years, it'll be the constant performer because of the things I've mentioned.

Paul O'Connor:

It resonates there that spending a lot of time with equity managers, they regard the whole healthcare industry is a more defensive sector of the listed equity market. I'm not surprised at your comments there being that you consider it a lower beta sector of the broader property market. How does healthcare real estate differ then from other real estate sectors? There's some obvious thoughts coming to mind around the regulations overriding it. The other comment you'd made earlier that it's not really correlated to the economic cycle, but can you make just a couple of high-level comments there about what really differentiates it?

Andrew Hemming:

Yeah, of course, Paul. It would be more heterogeneous than homogenous. What I mean by that is it's more specialised. I think your listeners would understand that being a hospital is not an office building, it's not a shed, right? It is highly specialised because the services that go in there need to be done according to a standard, and Australia has a better level of healthcare regulation and standards than most countries in the OECD, which is fantastic to hear, but it comes at a cost, of course. The specialisation in terms of sterilisation, in terms of air filtration, in terms of fit out, and in terms of co-location, you can't just build a hospital necessarily anywhere. There are locational drivers to why a hospital is in that location. Those factors make it somewhat different than the more homogenous factors of industrial or office or even retail.

The other thing is what a lot of people don't see in healthcare is it's just not as mature corporately. It's not as institutionalised, it's not as well understood. I spent a lot of my time dealing with doctors. Sometimes it's a joy, sometimes it's not if I'm honest. We've got two worlds combining here. We've got the godlike world of providing care for someone and we've got a business world. Sometimes we just don't see eye to eye, and it's quite challenging. When you're dealing with a tenant, and the example I gave earlier about the one in Kew in the Adeney Hospital with the Medibank owing 49% and the 42 doctors owing 51%. I deal with the 42 doctors. You're dealing with a lot of stakeholders. That I think alone is very different than dealing in a more homogenous institutionalised space such as office or retail or industrial.

The last thing I'd say is I think healthcare is such a broad term. Our strategy is when it comes to healthcare, they're also adjacencies. You've got healthcare, which is in the hospital, out of the hospital, but you've got all these adjacencies to healthcare. You've got two really obvious ones so accommodation. I'm not talking about a medihotel, but I'm talking about in certain locations, we do a lot of regional masterplan developments for healthcare. You'll need accommodation, whether it be for workers and nurses, for security reasons to stay overnight. You'll need it for patients who travel from long distance from rural locations. Then you've got education that may for professors and other tertiary educators to stay overnight.

But also then you've got things like what people call life sciences, which is really not just about what most people would call labs, but what I would call clean rooms, which is again about sterilisation. It can be anything from designing, producing, and manufacturing and delivering a semiconductor all the way to a biological pharmaceutical product. We don't do that a lot in Australia, but I suspect that we will do more of it because it's one of the lessons that we've learned from COVID, which is we need to control more things in the country. If we are to manufacture, we've got the right mix of population to do it. But we are also to do manufacturing in the science and health landscape more than, say, produce manufacturing of cars, for example. I think at healthcare, it's all those adjacencies that I think will grow over time.

Paul O'Connor:

What is the right balance or composition of operators in a medical centre or healthcare facility, Andrew?

Andrew Hemming:

If we're talking about a hospital and a hospital in this day and age would be between 5,000 and 7,000 square metres. If the hospital itself is, let's say, 4,000 to 5,000 square metres, you've got 2,000 maybe 3,000 square metres of ancillary uses. You've got a hospital, then you've got a radiology business and Medical Centre of Pharmacy and Allied, which is generally physio. You may have a couple of other specialist consulting suites in there. I would say once you've got your anchor, you're probably dealing with another 6 to 12 tenants depending on location, size, and type. At GP, you're probably dealing with probably four to five tenants. Then at the life science combination, it's single tenant.

Paul O'Connor:

Is there much competition amongst the operators within these medical centres or healthcare facilities? Or are they all complementary really to each other?

Andrew Hemming:

Oh, no. It's a pretty fierce world out there when it comes to competition. That's why I find this very, very interesting because there's a tectonic shift in the way competition is thought about and healthcare serviced. Vertical integration of Medibank, for example, is one way. There are the incumbents like the Ramsay Health Scope, Healthe Care or now called Aurora, and some of the not-for-profits, St Vincent, St John of God, Calvary, etc. Those incumbents are now increasingly under competition from the new world order of hospital operators, whether they be Cura, Nexus, or doctor-led new joint venture businesses. Then Medibank vertical integrated businesses. The competition is fast coming, which means that these incumbents are now having to think about how they adapt. Again, the example I give is one was a listed hospital operator in the US called Tenet. I think it's listed on the New York Stock Exchange.

It was the largest long-stay private hospital operator in the country. It's now I think the third or fourth largest, but it's the largest ASC or short stay. It literally built out a business that cannibalised its own business to have something that's more sustainable. We haven't seen that in Australia yet, but I suspect that to maintain market share and to look after doctors. Because doctors rightly or wrongly are still the true customer in healthcare in hospital care, they'll be needing to adapt with those doctors to build newer facilities, more efficient facilities in locations where the doctors want them, not just where the hospital operators want them. There's quite a bit of change coming in terms of competitive landscape.

Paul O'Connor:

In general, how has the healthcare real estate sector performed over the last, I guess, 18 to 24 months? What are your longer-term thoughts about the future returns out of this asset class?

Andrew Hemming:

The last 18 to 24 months have been positive from a relative point of view, but subdued since we had first started to look into healthcare real estate back in 2013, 10 years ago. 2013, we were buying hospitals at 8.5% and 9% cap rate. I think the tightest the market got to in healthcare real estate was something like 3.5%. We didn't participate at those levels. For an institutional grade, investment grade healthcare real estate product today property, you'd be looking at, let say, 4.75% to 5.25%. I think it overshot. But I think the normalised market in this environment where the cash rate is higher than we've seen in a long time, I think the cap rates around 5% say. It's probably a softening of about 50 to 75 basis points. For the non-investment grade, sub-investment grade, not as shiny, not as institutional, you probably see that softening about 150 basis points.

Compare that to other sectors, not that I want to speak ill of other sectors, but I think it'll outperform other sectors. Whilst, the returns over the last 18, 24 months have come back a little bit. I don't expect it to continue to come back. I expect through stabilisation of the cost of capital through hopefully inflation becoming controlled somewhat through immigration, as we see more nurses, more GPs, more doctors, the landscape for healthcare real estate is strong and will continue to grow even when the vagaries in market are volatile.

Paul O'Connor:

I guess that sounds like a fairly attractive return outlook when consider the lower beta nature of the sector as well there that you've obviously got to take into consideration as well. In terms of investor appetite, who is investing in healthcare real estate and is there a preference for a particular sub-sector?

Andrew Hemming:

It's a good question on investor landscape. We started out with retail investors, which is how Heathly had cut its teeth. We then introduced two institutional investors being the Grosvenor Group, which was the Duke of Westminster's money, and AXA Investment Managers, which is insurer. We now also manage money for Morgan Stanley. What I'm saying is there are more institutional, both local and offshore investors wanting to gain access to increasing the allocation into healthcare real estate. It's still hard to grow scale, but the ability of scale is coming. It's largely because of your second question because of the sub-sectors. Whilst, two-thirds of our portfolio is in hospitals, which I still maintain the hardest area of healthcare to understand and to deliver.

If you can do that, I think you can do other things. It's almost the rite of passage for us. I think the accommodation piece, not really saying build to rent at all. I'm saying the accommodation piece that is strategically, tactically located next to infrastructure, whether it be universities and/or health is the next growth phase. As well as I mentioned earlier, Paul, clean rooms, so life sciences where you've got large multinational companies wanting to research, develop, manufacture, distribute microbiological pharmaceutical products in Australia, but also export. I see that as a massive growth area, both from a public sector point of view and a private sector point of view.

Paul O'Connor:

Centuria Healthcare has a development pipeline of close to a billion dollars. Can you talk us through the pros and cons of developing rather than acquiring an existing asset and what additional risks are associated with healthcare property development?

Andrew Hemming:

It's a good question, Paul. At the moment, there are property factors that relate to any real estate development, whether it be healthcare or otherwise. Then there are healthcare-related specific factors to consider. The normal property factors would be cost control basically. Ensuring that we are buying the land, that the valuation is maintainable over a sustained period of time whilst we achieve a planning outcome. Then to deliver either that building or a multitude of buildings if it's a master plan, for example, cost sustainably to ensure that not only the tenant is able to be viable over a 10, 20-year period, but we can make a return for our investors. In this environment, it's particularly difficult given that we've got inflation and material costs increase throughout the supply chain for materials, building materials. We've got the benefit of time with some of these that we just have to sit and wait and be patient.

But then we're dealing with doctors and hospital tenants that may not in circumstances have that period of time and the luxury of time to wait because for a variety of reasons, they need to leave their existing building because it's over 100 years old and the regulations have changed and they need to go into a more regulated environment or they need to, as I mentioned earlier, look after their doctors to ensure that they don't leave and join a competitor. I think overall, this is a sector where development is at the core because these models of care don't really exist. You have to build it out and it will take some time to do, and it will relate to better investment performance for investors as we don't leak as much stamp duty and ingoing costs as we can be patient if your manager knows what they're doing, and to deliver higher yields on costs or development margin to investors that are looking not just for the low beta play, but for a little bit more alpha.

It's not for the faint-hearted. We do deal with emotional stakeholders such as doctors and hospital operators. I guess that's why I don't have any hair, but it's good now that we've done it a number of times we understand and we're building a bit of a pedigree and a bit of supporter base from these hospital operators and doctors. Hopefully, that means it'll gather momentum.

Paul O'Connor:

Yeah. Well, I guess your comments there tied together some of the other comments you previously made there, Andrew, in that we've got a growing population. Growing population has a greater demand for hospitals, hence a key part of your focus in your portfolio is hospitals, but therein also comes the need for property development and why that's a key area of your business as well. Since the pandemic, has there been a change in operator expectations for landlords?

Andrew Hemming:

Yeah, not just the operator expectations for landlord working more collaboratively with tenants, but the design and what goes in the hospital will increasingly change. Things like both public now and private want smaller hospitals. If there is another pandemic, they can contain that risk. They're able to ensure isolation for patients, for example, with COVID, and those without, right? They can maintain operating theatres. What we saw during the pandemic with Scott Morrison in closing elective surgery was because we couldn't have those theatres open when those patients may be at risk of catching COVID because there are other wards in that hospital with patients with COVID, so improved sterilisation and quite technically improving the airflow. The positive and negative pressures in operating theatres and procedure rooms is a big focus at the moment.

So that goes through not just smaller hospitals, but better compartmentalised and managed hospitals through having the separation of wards and operating theatres and then patients that don't stay overnight. So just what they call outpatients. There's a lot of thinking that goes into how to keep the system running if there is another pandemic.

Paul O'Connor:

Maybe turning to interest rates. How have the rises in interest rates impacted on future investments and potential returns from this sector?

Andrew Hemming:

I mean, as I mentioned earlier, Paul, we're not immune from the cost of capital. Interest rates and every asset class worldwide. We are somewhat protected from it because, as I mentioned earlier, the non-discretionary nature of the demand, the ability for our leases to have inflation hedges. I think it's something like 73% of our leases across the 60-odd properties that we have inflation rent bumps factored into those leases. From the revenue point of view, it's quite good. From a cost point of view, certainly, as I mentioned, to deliver a hospital, it becomes more difficult. The washup of that is the cap rates have softened somewhat, but I don't expect them to continue to soften and haven't softened as much as other sectors.

The cost of capital that we have for whether it be a development opportunity or a passive opportunity has affected price. But as I mentioned very early on, we are early in the runway of healthcare. The $1.4 billion or $1.5 billion that we've got under management today is just the start. When I first came into the sector, we had something like $3 billion securitized. Today, we have something like $15 billion over the 10 years. We could very easily have over $100, 150 billion securitized relatively quickly in the healthcare and adjacent healthcare space. We're a long way. If we think through that, then we'll be buying and developing through the business cycles of interest rates.

Paul O'Connor:

Maybe just to finish any notable or emerging healthcare subsectors or themes that Centuria is exploring, aside from your short-stay hospitals and medical centres?

Andrew Hemming:

We're currently fitting out a clean room for a company that's listed called Paragon Care in Mount Waverley, East Melbourne. We suspect... That's for in vitro diagnostics, basically, blood reagents. To test what type of blood type that you have for various reasons, great for pregnancy tests, for example. We expect that theme to grow quite quickly, both as I mentioned in the public and the private sector. We are currently exploring these opportunities with universities, both from a metro-locational point of view and a regional point of view. When you do start to explore those conversations as well as with hospitals in the same conversation, suddenly, you've got a precinct that's almost a health and life science precinct.

When you've got those two anchors being a delivery and testing and manufacturing of health products, biological or pharmaceutical, and a hospital that treats humans, you've then all got these flow-on opportunities for accommodation, food, and tertiary education opportunities where your development suddenly goes from two buildings to five or six buildings. I think the precinct idea, particularly in regional Australia where there has literally been no development is something that we're very focused on. We continue to grow for some time.

Paul O'Connor:

Well, Andrew, thank you very much for joining us today on the Netwealth Portfolio Construction Podcast series. From my perspective, it's certainly been a very educative discussion. I've learned a hell of a lot on, I guess, the broader healthcare sector, but healthcare property and why Centuria have a specialist focused on this sector. Thank you very much for joining us. I guess my takeouts too are the longer-term growth opportunities in healthcare property, and potential for sound returns with lower beta or potential lower risk compared to the other property sectors. Really appreciated you joining us. Thank you, Andrew.

Andrew Hemming:

Thank you, Paul. Thanks for having me.

Paul O'Connor:

To the listener, thank you again for joining us on another instalment of the podcast series. I hope you have a fantastic day. I hope you've enjoyed the discussion this morning, and I look forward to you joining us on the next instalment of the Netwealth Portfolio Construction Podcast.