MEDICAL PROPERTIES TRUST INC
For the period ended Mar 31, 2024. Filed May 29, 2024.
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Mar 31, 2024 · Filed May 29, 2024
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Notes to Condensed Consolidated Financial Statements
- Organ ization
Medical Properties Trust, Inc., a Maryland corporation, was formed on August 27, 2003, under the Maryland General Corporation Law for the purpose of engaging in the business of investing in, owning, and leasing healthcare real estate. Our operating partnership subsidiary, MPT Operating Partnership, L.P. (the “Operating Partnership”), through which we conduct substantially all of our operations, was formed in September 2003. At present, we own, directly and indirectly, all of the partnership interests in the Operating Partnership and have elected to report our required disclosures and that of the Operating Partnership on a combined basis, except where material differences exist.
We operate as a real estate investment trust (“REIT”). Accordingly, we are generally not subject to United States (“U.S.”) federal income tax on our REIT taxable income, provided that we continue to qualify as a REIT and our distributions to our stockholders equal or exceed such taxable income. Similarly, the majority of our real estate operations in the United Kingdom ("U.K.") operate as a REIT and generally are subject only to a withholding tax on earnings upon distribution out of the U.K. REIT. Certain non-real estate activities we undertake in the U.S. are conducted by entities which we elected to be treated as taxable REIT subsidiaries (“TRS”). Our TRS entities are subject to both U.S. federal and state income taxes. For our properties located outside the U.S. (excluding those assets that are in the U.K. REIT), we are subject to the local income taxes of the jurisdictions where our properties reside and/or legal entities are domiciled; however, we do not expect to incur additional taxes, of a significant nature, in the U.S. from foreign-based income as the majority of such income flows through our REIT.
Our primary business strategy is to acquire and develop healthcare facilities and lease the facilities to healthcare operating companies under long-term net leases, which require the tenant to bear most of the costs associated with the property. The majority of our leased assets are owned 100%; however, we do own some leased assets through joint ventures with other partners that share our view that healthcare facilities are part of the infrastructure of any community, which we refer to as investments in unconsolidated real estate joint ventures. We also may make mortgage loans to healthcare operators collateralized by their real estate. In addition, we may make noncontrolling investments in our tenants (which we refer to as investments in unconsolidated operating entities), from time-to-time, typically in conjunction with larger real estate transactions with the tenant, which may enhance our overall return and provide for certain minority rights and protections.
Our business model facilitates acquisitions and recapitalizations, and allows operators of healthcare facilities to unlock the value of their real estate to fund facility improvements, technology upgrades, and other investments in operations. At March 31, 2024, we have investments in 436 facilities in 31 states in the U.S., inseven countries in Europe, andone country in South America. Our properties consist of general acute care hospitals, behavioral health facilities, inpatient physical rehabilitation facilities, long-term acute care hospitals, and freestanding ER/urgent care facilities. We manage our business as a single business segment.
- Summary of Significant Accounting Policies
Unaudited Interim Condensed Consolidated Financial Statements: The accompanying unaudited interim condensed consolidated financial statements have been prepared in accordance with accounting principles generally accepted in the U.S. for interim financial information, including rules and regulations of the Securities and Exchange Commission (“SEC”). Accordingly, they do not include all of the information and footnotes required by generally accepted accounting principles (“GAAP”) for complete financial statements. In the opinion of management, all adjustments (consisting of normal recurring accruals) considered necessary for a fair statement have been included. Operating results for the three months ended March 31, 2024, are not necessarily indicative of the results that may be expected for the year ending December 31, 2024. The condensed consolidated balance sheet at December 31, 2023 has been derived from the audited financial statements at that date but does not include all of the information and footnotes required by accounting principles generally accepted in the U.S. for complete financial statements.
The preparation of our condensed consolidated financial statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the condensed consolidated financial statements and the reported amounts of revenues and expenses during the reporting period. We believe the estimates and assumptions underlying our condensed consolidated financial statements are reasonable and supportable based on the information available as of March 31, 2024, (particularly as it relates to our assessments of the recoverability of our real estate, the ability of our tenants/borrowers to make lease/loan payments in accordance with their respective agreements, the fair value of our equity and loan investments, and the adequacy of our credit loss reserves on loans and financing receivables).
For information about significant accounting policies, and how actual results could differ from estimates, refer to the consolidated financial statements and footnotes thereto included in our Annual Report on Form 10-K for the year ended December 31, 2023. There have been no material changes to these significant accounting policies.
Reclassifications
Certain amounts in the condensed consolidated financial statements for prior periods have been reclassified to conform to the current period presentation.
Variable Interest Entities
At March 31, 2024, we had loans and/or equity investments in certain variable interest entities ("VIEs"), which are also tenants of our facilities. We have determined that we were not the primary beneficiary of these VIEs. The carrying value and classification of the related assets and maximum exposure to loss as a result of our involvement with these VIEs at March 31, 2024 are presented below (in thousands):
| VIE Type | Carrying Amount(1) | Asset TypeClassification | Maximum LossExposure(2) |
|---|---|---|---|
| Loans, net and equity investments | $498,632 | Investments in UnconsolidatedOperating Entities | $498,632 |
| Loans, net | 150,494 | Mortgage and other loans | 150,523 |
(1)
Carrying amount only reflects the net book value of our loan or equity investment in the VIE.
(2)
Our maximum loss exposure related to loans with VIEs represents our current aggregate gross carrying value of the loan plus accrued interest and any other related assets (such as rent receivables), less any liabilities. Our maximum loss exposure related to our equity investments in VIEs represents the current carrying values of such investments plus any other related assets (such as rent receivables), less any liabilities.
For the VIE types above, we do not consolidate the VIEs because we do not have the ability to control the activities (such as the day-to-day healthcare operations of our borrowers or investees) that most significantly impact the VIE's economic performance. As of March 31, 2024, we were not required to provide financial support through a liquidity arrangement or otherwise to our unconsolidated VIEs, including circumstances in which they could be exposed to further losses (e.g. cash short falls).
Recent Accounting Developments
Segment Reporting
In November 2023, the Financial Accounting Standards Board ("FASB") issued ASU 2023-07, "Segment Reporting (Topic 280): Improvements to Reportable Segment Disclosures" ("ASU 2023-07") to improve reportable segment disclosure requirements, primarily through enhanced disclosures about significant segment expenses. ASU 2023-07 is effective for fiscal years beginning after December 15, 2023, and interim periods within fiscal years beginning after December 15, 2024. We do not expect to have a significant impact from the adoption of this standard on our consolidated financial statements and disclosures, as we consider our investments in healthcare real estate, other loans, and any investments in our tenants a single reportable segment.
Income Taxes
In December 2023, the FASB issued ASU 2023-09, "Income Taxes (Topic 740): Improvements to Income Tax Disclosures" ("ASU 2023-09") which focuses on income tax disclosures regarding effective tax rates and cash income taxes paid. This standard requires public entities to disclose (1) specific categories in the rate reconciliation, (2) the income or loss from continuing operations before income tax expense or benefit, and (3) provide additional information for certain reconciling items at or above a quantitative threshold of 5% of the statutory tax. Additionally, this standard requires disclosure of income taxes paid (net of refunds), separated by international, federal, state, and local jurisdictions. ASU 2023-09 is effective for annual periods beginning after December 15, 2024. We are currently evaluating the potential impact of the adoption of this standard on our consolidated financial statements.
- Real Estate and Other Activities
New Investments
We acquired or invested in the following net assets (in thousands):
| For the Three MonthsEnded March 31, | ||
|---|---|---|
| 2024 | 2023 | |
| Land and land improvements | $— | $9,313 |
| Buildings | — | 11,652 |
| Intangible lease assets — subject to amortization (weighted-average useful life of 28.8 years for 2023) | — | 1,935 |
| Investments in unconsolidated operating entities | — | 50,000 |
| $— | $72,900 | |
| Loans repaid(1) | — | (22,900) |
| Total net assets acquired | $— | $50,000 |
(1)
The 2023 column includes a $23 million mortgage loan that was converted to fee simple ownership of one property as described under Lifepoint Transaction below.
2023 Activity
Prospect Transaction
In August 2019, we invested in a portfolio of 14 acute care hospitals in three states (California, Pennsylvania, and Connecticut) operated by and master leased to or mortgaged by Prospect Medical Holdings, Inc. ("Prospect") for a combined investment of approximately $1.5 billion. In addition, we originated a $112.9 million term loan cross-defaulted to the master lease and mortgage loan agreements and further secured by a parent guaranty. In the 2022 second quarter, we funded an additional $100 million towards the existing mortgage loan that was secured by a first lien on a California hospital. Prospect's operations were negatively impacted by the coronavirus global pandemic commencing in early 2020, but Prospect remained current with respect to contractual rent and interest payments until the fourth quarter of 2022. Accordingly, and due further to the termination of certain refinancing negotiations between Prospect and certain third parties in early 2023 that would have recapitalized Prospect and provided for payment of unpaid rent and interest, we recorded an approximate $280 million impairment charge in the 2022 fourth quarter. As part of this charge, we reduced the carrying value of the underperforming Pennsylvania properties by approximately $170 million (to approximately $250 million) and reserved all unbilled rent accruals for a total of $112 million.
However, Prospect continued to pursue a recapitalization plan, and, in late March 2023, Prospect received a binding commitment from several lenders to provide liquidity to pay down certain debt instruments. Along with these commitments from third-party lenders, we agreed to pursue certain transactions with Prospect as part of their recapitalization plan, including originating a $50 million convertible loan to PHP Holdings, the managed care business of Prospect, in the first quarter of 2023.
On May 23, 2023, Prospect completed its recapitalization plan, which included receiving $375 million in new financing from several lenders. Along with this new debt capital from third-party lenders, we agreed to the following restructuring of our then $1.7 billion investment in Prospect including: a) maintaining the master lease covering six California hospitals without any changes in rental rates or escalator provisions, but with cash payments starting in September 2023 for a substantial portion of the contractual monthly rent due on these California properties, b) transitioning the Pennsylvania properties back to Prospect in return for a $150 million first lien mortgage on the facilities, c) providing up to $75 million in a loan secured by a first lien on Prospect's accounts receivable and certain other assets, of which we funded in full during 2023, d) continuing to pursue the previously disclosed sale of the three Connecticut properties to Yale New Haven ("Yale"), as more fully described in Note 9 to the condensed consolidated financial statements, and e) obtaining a non-controlling ownership interest in PHP Holdings of approximately $654 million, after applying a discount for lack of marketability, consisting of an approximate $68 million equity investment and $586 million loan convertible into equity of PHP Holdings (collectively, the "Prospect Transaction"). This non-controlling ownership interest was received in exchange for unpaid rent and interest through December 2022, previously unrecorded rent and interest revenue in 2023 totaling approximately $82 million, our $151 million mortgage loan on a California property, our $112.9 million term loan, and other obligations at the time of such investment.
Lifepoint Transaction
On February 7, 2023, a subsidiary of Lifepoint Health, Inc. ("Lifepoint") acquired a majority interest in Springstone (now Lifepoint Behavioral Health, "Lifepoint Behavioral") (the "Lifepoint Transaction") based on an enterprise value of $250 million. As part of the transaction, we received approximately $205 millionin full satisfaction of our initial acquisition loan, including accrued interest, and we retained our minority equity investment in the operations of Lifepoint Behavioral. Separately, we converted a mortgage loan (as part of our initial acquisition in 2021) into the fee simple ownership of a property in Washington, which is leased, along with the other 18 behavioral health hospitals, to Lifepoint Behavioral, under a master lease agreement. In connection with the Lifepoint Transaction, Lifepoint extended its lease oneight existing general acute care hospitals byfive years to 2041.
In the first quarter of 2024, we sold our minority equity investment in Lifepoint Behavioral for approximately $12 million.
Development Activities
See table below for a status summary of our current development projects (in thousands):
| Property | Commitment | CostsIncurred as of March 31, 2024 | Estimated RentCommencementDate |
|---|---|---|---|
| IMED Hospitales ("IMED") (Spain) | $37,790 | $21,586 | 4Q 2024 |
| IMED (Spain) | 51,802 | 19,299 | 1Q 2025 |
| $89,592 | $40,885 |
We havetwo other development projects ongoing in Texas (Wadley development) and Massachusetts (Norwood redevelopment). These are not highlighted above given the ongoing restructuring of Steward Health Care System ("Steward") as discussed further in this same Note 3. However, on a combined basis, we have spent approximately $395 million through March 31, 2024.
Separately, on the Norwood redevelopment, we have approximately $150 million, net of payments received to date, due to us from a combination of recovery receivables (included in "Other assets" in the condensed consolidated balance sheets) associated with the damage to the original facility in 2020 and a $50 million advance (reflected in "Other loans" in the condensed consolidated balance sheets) made to Steward in the first half of 2023 that is secured by, among other things, proceeds from Steward's business interruption insurance claims.
2024 Activity
During the first three months of 2024, we completed construction and began recording rental income on a $35.4 million behavioral health facility located in McKinney, Texas, that is leased to Lifepoint Behavioral. We also completed construction and began recording rental income on a €45.4 million (approximately $49.0 million) general acute care facility located in Spain that is leased to IMED.
Disposals
2024 Activity
On February 19, 2024, we entered into definitive agreements to sell five properties to Prime Healthcare Services, Inc. ("Prime") for total proceeds of approximately $250 million along with a $100 million interest-bearing mortgage loan due in approximately nine months from the closing date. As such, we designated these properties as held for sale at March 31, 2024. This transaction, which closed on April 9, 2024, resulted in a gain on real estate of approximately $50 million and a non-cash straight-line rent write-off of approximately $28 million.
As part of this sale transaction, we also agreed to extend the lease maturity of four other facilities with Prime to 2044. This amended lease has inflation-based escalators, collared between 2% and 4% and a purchase option on or prior to August 26, 2028 for a value of $238 million, which is greater than our net book value for these properties at March 31, 2024. After August 26, 2028, this option price reverts to $260 million (subject to annual escalations).
During the first three months of 2024, we also completed the sale ofthree other facilities andtwo ancillary facilities for approximately $7 million, resulting in a loss on real estate of approximately $1.4 million.
Summary of Operations for Disposed (or to be Disposed) Assets in 2024
The following represents the operating results from the five properties designated as held for sale at March 31, 2024, as well as the five properties sold in April 2024 as part of the Utah Transaction (further described in Note 10 to the condensed consolidated financial statements) (in thousands):
| For the Three MonthsEnded March 31, | ||
|---|---|---|
| 2024 | 2023 | |
| Revenues | $39,007 | $43,198 |
| Real estate depreciation and amortization | (6,381) | (10,718) |
| Property-related expenses | (4) | (120) |
| Other expense | (42) | (21) |
| Income from real estate dispositions, net | $32,580 | $32,339 |
2023 Activity
On March 30, 2023, we entered into a definitive agreement to sell our 11 general acute care facilities located in Australia and operated by Healthscope Ltd. ("Healthscope") (the "Australia Transaction") to affiliates of HMC Capital for cash proceeds of approximately A$1.2 billion. As a result, we designated the Australian portfolio as held for sale in the first quarter of 2023 and recorded approximately $79 million of net impairment charges at that time, which included $37.4 million of straight-line rent receivable writeoffs and approximately $8 million in fees to sell the hospitals, partially offset by approximately $16 million of gains from our interest rate swap and foreign currency translation amounts in accumulated other comprehensive income that were reclassified to earnings in 2023 as part of the transaction. This transaction closed in two phases. The first phase closed on May 18, 2023, in which we sold seven of the 11 facilities for A$730 million, and the final phase closed on October 10, 2023, in which we sold the remaining four facilities for approximately A$470 million.
On March 8, 2023, we received notice that Prime planned to exercise its right to repurchase from us the real estate associated with one master lease for approximately $100 million. As such, we recorded an approximate $11 million non-cash impairment charge in the first quarter of 2023 related to unbilled rent on thethree facilities that were sold on July 11, 2023.
Leasing Operations (Lessor)
We acquire and develop healthcare facilities and lease the facilities to healthcare operating companies. The initial fixed lease terms of these infrastructure-type assets are typically at least 15 years, and most include renewal options at the election of our tenants, generally infive year increments. Over 99% of our leases provide annual rent escalations based on increases in the Consumer Price Index ("CPI") (or similar indices outside the U.S.) and/or fixed minimum annual rent escalations. Many of our domestic leases contain purchase options with pricing set at various terms but in no case less than our total initial investment. Our leases typically require the tenant to handle and bear most of the costs associated with our properties including repair/maintenance, property taxes, and insurance.
For all of our properties subject to lease, we are the legal owner of the property and the tenant's right to use and possess such property is guided by the terms of a lease. At March 31, 2024, we account for all of these leases as operating leases, except where GAAP requires alternative classification, including leases on 13 Ernest facilities that are accounted for as direct financing leases and leases onnine of our Prospect facilities andfive of our Ernest facilities that are accounted for as a financing. The components of our total investment in financing leases consisted of the following (in thousands):
| As of March 31, 2024 | As of December 31, 2023 | |
|---|---|---|
| Minimum lease payments receivable | $606,537 | $611,669 |
| Estimated unguaranteed residual values | 203,818 | 203,818 |
| Less: Unearned income and allowance for credit loss | (565,116) | (571,059) |
| Net investment in direct financing leases | 245,239 | 244,428 |
| Other financing leases (net of allowance for credit loss) | 987,939 | 987,202 |
| Total investment in financing leases | $1,233,178 | $1,231,630 |
Other Leasing Activities
At March 31, 2024, our vacant properties represent less than 0.3% of total assets. We are in various stages of either re-leasing or selling these vacant properties.
Our tenants’ financial performance and resulting ability to satisfy their lease and loan obligations to us are material to our financial results and our ability to service our debt and make distributions to our stockholders. Our tenants operate in the healthcare industry, which is highly regulated, and changes in regulation (or delays in enacting regulation) may temporarily impact our tenants’
operations until they are able to make the appropriate adjustments to their business. In addition, our tenants may experience operational challenges from time-to-time as a result of many factors, including those external to them, such as cybersecurity attacks or public health crises (like the COVID-19 pandemic), economic issues resulting in high inflation and spikes in labor costs, extreme or severe weather and climate-related events, and adverse market and political conditions. We monitor our tenants' operating results and the potential impact from these challenges. We may elect to provide support to our tenants from time-to-time in the form of short-term rent deferrals to be paid back in full (like as described below under Pipeline Health System), or in the form of temporary loans (like as described previously in the Prospect Transaction). See below for an update on some of our tenants:
Steward Health Care System
Due to the uncertainty concerning the sale of Steward's managed care business, ongoing operational and liquidity challenges, and the bankruptcy filing as more fully described in "Significant Tenant Update" under the section captioned "Management's Discussion and Analysis of Financial Condition and Results of Operations" of this Form 10-Q, we have recorded approximately $470 million of additional impairment charges in the quarter ending March 31, 2024, that fully reserves for the remaining value of our 9.9% equity investment in Steward and the $362 million loan due from affiliates of Steward along with the accrual for property taxes and other obligations not paid by Steward under its master leases. The equity investment and loan to Steward affiliates are included in “Investments in unconsolidated operating entities” on our condensed consolidated balance sheets and were adjusted for after comparing our carrying value of these investments to an updated fair value analysis of the underlying collateral, with assistance from a third-party, independent valuation firm.
At March 31, 2024, we have approximately $346 million of non-real estate investments in Steward, consisting of the working capital loan and other secured loans advanced in 2024. Based on the analysis discussed above, we believe these investments are fully recoverable at this time. However, no assurances can be given that we will not have any additional impairments in future periods.
In the three months ending March 31, 2024, we received approximately $11 million of rent and interest, which we recorded as revenue. In addition, approximately $38 million of rent ($9 million relating to December 2023) was received in our Massachusetts partnership during the 2024 first quarter, of which approximately $19 million represents our share.
Prospect
Starting January 1, 2023, we began accounting for our leases and loans to Prospect on a cash basis versus our normal accrual method. In the first quarter of 2024, we recognized approximately $7 million of revenue representing cash received for rents on our California properties.
In regard to PHP Holdings, we account for our investment (both the equity investment and convertible loan) using the fair value option method. On May 23, 2024, Prospect's investment bankers informed us that they had received updated indications of interest from prospective bidders for PHP Holdings. Based on our consideration of information in the updated indications, along with consultations with our third party appraisers, we recorded as of March 31, 2024, a $201 million unfavorable fair value adjustment, resulting in a total investment in PHP Holdings of approximately $500 million at March 31, 2024. Each quarter, we mark such investment to fair value as more fully described in Note 7 to the condensed consolidated financial statements.
Pipeline Health System
On October 2, 2022, Pipeline Health System ("Pipeline") filed for reorganization relief under Chapter 11 protection of the United States Bankruptcy Code in the Southern District of Texas, while keeping its hospitals open to continue providing care to the communities served. On February 6, 2023, Pipeline emerged from bankruptcy. Per the bankruptcy settlement, Pipeline's lease of our California assets remained in place, and we were repaid on February 7, 2023, for all rent that was outstanding at December 31, 2022, along with what was due for the first quarter of 2023. As part of the settlement, we deferred approximately $6 million, or approximately 30%, of rent in 2023 to be paid in 2024 with interest. As of March 31, 2024, Pipeline is current on their monthly rent obligations per the terms of the lease, and we hold a rent deposit that more than covers all rent previously deferred.
Other Matters
As discussed in our Annual Report on Form 10-K for the year ending December 31, 2023, we placed our loan to the international joint venture on the cash basis of accounting, as we determined that it was no longer probable that the borrower would pay its future interest in full. This loan, accounted for under the fair value option method, was collateralized by the equity of Steward held by an investor in both Steward and the international joint venture. Consistent with the discussion above on non-real estate investments in Steward, we have recorded a $220 million unfavorable fair value adjustment in the 2024 first quarter to fully reserve for the loan. The loan, which is included in “Investments in unconsolidated operating entities” on our condensed consolidated balance sheets, was adjusted for after comparing our carrying value of the loan to an updated fair value analysis of the underlying collateral, with assistance from a third-party, independent valuation firm.
Investments in Unconsolidated Entities
Investments in Unconsolidated Real Estate Joint Ventures
Our primary business strategy is to acquire real estate and lease to providers of healthcare services. Typically, we directly own 100% of such investments. However, from time-to-time, we will co-invest with other investors that share a similar view that hospital real estate is a necessary infrastructure-type asset in communities. In these types of investments, we will own undivided interests of less than 100% of the real estate and share control over the assets through unconsolidated real estate joint ventures. The underlying real estate and leases in these unconsolidated real estate joint ventures are generally structured similarly and carry a similar risk profile to the rest of our real estate portfolio.
The following is a summary of our investments in unconsolidated real estate joint ventures by operator (amounts in thousands):
| Operator | Ownership Percentage | As of March 31, 2024 | As of December 31, 2023 |
|---|---|---|---|
| MEDIAN | 50% | $471,303 | $471,336 |
| Swiss Medical Network | 70% | 441,636 | 472,434 |
| Steward (Macquarie partnership) | 50% | 405,781 | 394,052 |
| Policlinico di Monza | 50% | 78,752 | 80,562 |
| HM Hospitales | 45% | 53,010 | 56,071 |
| Total | $1,450,482 | $1,474,455 |
Investments in Unconsolidated Operating Entities
Our investments in unconsolidated operating entities are noncontrolling investments that are typically made in conjunction with larger real estate transactions in which the operators are vetted as part of our overall underwriting process. In many cases, we would not be able to acquire the larger real estate portfolio without such investments in operators. These investments also offer the opportunity to enhance our overall return and provide for certain minority rights and protections.
The following is a summary of our investments in unconsolidated operating entities (amounts in thousands):
| Operator | As of March 31, 2024 | As of December 31, 2023 |
|---|---|---|
| PHP Holdings | $498,632 | $699,535 |
| Swiss Medical Network | 173,647 | 186,113 |
| Aevis Victoria SA ("Aevis") | 65,120 | 77,345 |
| Priory Group ("Priory") | 40,394 | 163,837 |
| Aspris Children's Services ("Aspris") | 15,977 | 15,986 |
| Caremax | 368 | 1,148 |
| Steward (loan investment) | — | 361,591 |
| International joint venture | — | 225,960 |
| Steward (equity investment) | — | 35,696 |
| Lifepoint Behavioral | — | 11,429 |
| Total | $794,138 | $1,778,640 |
See "Leasing Operations (Lessor)" under this same Note 3 for details on the change in the quarter related to Steward and the international joint venture.
For our other investments marked to fair value (including our investment in PHP Holdings), we recorded approximately $216 million in unfavorable non-cash fair value adjustments during the first three months of 2024 as shown in the "Other (including fair value adjustments on securities)" line of the condensed consolidated statements of net income; whereas, this was a $4 million favorable non-cash fair value adjustment for the same period of 2023. The amount recorded in 2024 includes an approximate $201 million unfavorable fair market value adjustment to our investment in PHP Holdings, as further described in the "Prospect" subheading of this Note 3.
In the first quarter of 2024, we sold our interest in the Priory syndicated term loan for £90 million (approximately $115 million), resulting in an approximate £6 million ($7.8 million) economic loss. In addition, we sold our remaining minority equity investment in Lifepoint Behavioral in the 2024 first quarter.
Credit Loss Reserves
We apply a forward-looking "expected loss" model to all of our financing receivables, including financing leases and loans, based on historical credit losses of similar instruments.
The following table summarizes the activity in our credit loss reserves (in thousands):
| For the Three MonthsEnded March 31, | |||
|---|---|---|---|
| 2024 · 2023 | |||
| Balance at beginning of the year | $96,001 | $121,146 | |
| Provision for credit loss, net | 362,187 | (1) | 986 |
| Expected credit loss reserve related to financial instruments sold, repaid, or satisfied | (1,596) | (160) | |
| Balance at end of the period | $456,592 | $121,972 | |
(1)
Reflects the charge related to the $362 million loan to Steward, as further described under "Steward Health Care System" subheading of this Note 3.
Concentrations of Credit Risk
We monitor concentration risk in several ways due to the nature of our real estate assets that are vital to the communities in which they are located and given our history of being able to replace inefficient operators of our facilities, if needed, with more effective operators. See below for our concentration details (dollars in thousands):
Total Assets by Operator
| As of March 31, 2024 · As of December 31, 2023 | |||||
|---|---|---|---|---|---|
| Operators · Total Assets (1) · Percentage ofTotal Assets · Total Assets (1) · Percentage ofTotal Assets | |||||
| Steward | $3,218,969 | 18.6% | $3,518,537 | 19.2% | |
| Circle Health Ltd ("Circle") | 2,088,232 | 12.1% | 2,119,392 | 11.6% | |
| Priory | 1,250,626 | 7.2% | 1,391,005 | 7.6% | |
| Prospect | 1,093,094 | 6.3% | 1,092,974 | 6.0% | |
| Lifepoint Behavioral | 813,498 | 4.7% | 813,527 | 4.4% | |
| Other operators | 7,018,904 | 40.6% | 7,352,012 | 40.2% | |
| Other assets | 1,817,633 | (2) | 10.5% | 2,017,397 | 11.0% |
| Total | $17,300,956 | 100.0% | $18,304,844 | 100.0% | |
(1)
Total assets by operator are generally comprised of real estate assets, mortgage loans, investments in unconsolidated real estate joint ventures, investments in unconsolidated operating entities, and other loans.
(2)
Includes our investment in PHP Holdings of approximately $500 million as part of the Prospect Transaction as further described above in this same Note 3.
Total Assets by U.S. State and Country (1)
| As of March 31, 2024 | As of December 31, 2023 | |||
|---|---|---|---|---|
| U.S. States and Other Countries | Total Assets | Percentage ofTotal Assets | Total Assets | Percentage ofTotal Assets |
| Texas | $1,434,667 | 8.3% | $1,891,482 | 10.3% |
| Florida | 1,271,192 | 7.3% | 1,348,210 | 7.4% |
| California | 1,248,995 | 7.2% | 1,252,674 | 6.8% |
| Utah | 818,704 | 4.7% | 824,048 | 4.5% |
| Massachusetts | 759,268 | 4.4% | 732,550 | 4.0% |
| All other states | 3,695,029 | 21.4% | 3,726,145 | 20.4% |
| Other domestic assets | 1,229,695 | 7.1% | 1,397,170 | 7.6% |
| Total U.S. | $10,457,550 | 60.4% | $11,172,279 | 61.0% |
| United Kingdom | $4,079,869 | 23.6% | $4,261,944 | 23.3% |
| Germany | 726,940 | 4.2% | 734,630 | 4.0% |
| Switzerland | 680,403 | 3.9% | 735,891 | 4.0% |
| Spain | 250,043 | 1.5% | 252,529 | 1.4% |
| All other countries | 518,213 | 3.0% | 527,344 | 2.9% |
| Other international assets | 587,938 | 3.4% | 620,227 | 3.4% |
| Total international | $6,843,406 | 39.6% | $7,132,565 | 39.0% |
| Grand total | $17,300,956 | 100.0% | $18,304,844 | 100.0% |
Total Assets by Facility Type (1)
| As of March 31, 2024 | As of December 31, 2023 | |||
|---|---|---|---|---|
| Facility Types | Total Assets | Percentage ofTotal Assets | Total Assets | Percentage ofTotal Assets |
| General acute care hospitals | $11,115,957 | 64.3% | $11,764,151 | 64.3% |
| Behavioral health facilities | 2,432,850 | 14.1% | 2,576,983 | 14.1% |
| Inpatient rehabilitation hospitals | 1,436,694 | 8.3% | 1,445,399 | 7.9% |
| Long-term acute care hospitals | 269,235 | 1.5% | 270,849 | 1.5% |
| Freestanding ER/urgent care facilities | 228,587 | 1.3% | 230,065 | 1.2% |
| Other assets | 1,817,633 | 10.5% | 2,017,397 | 11.0% |
| Total | $17,300,956 | 100.0% | $18,304,844 | 100.0% |
(1)
For geographic and facility type concentration metrics in the tables above, we allocate our investments in operating entities pro rata based on the gross book value of the real estate. Such pro rata allocations are subject to change from period to period.
On an individual property basis, our largest investment in any single property was approximately 2% of our total assets as of March 31, 2024.
From a revenue concentration perspective, Circle and CommonSpirit individually represented more than 10% of our total revenues for the three months ended March 31, 2024, and Steward and Circle represented more than 10% for the same period of 2023.
- Debt
The following is a summary of debt (dollar amounts in thousands):
| As of March 31, 2024 | As of December 31, 2023 | |
|---|---|---|
| Revolving credit facility(A) | $1,614,791 | $1,514,420 |
| Term loan | 200,000 | 200,000 |
| British pound sterling secured term loan due 2024(B) | 132,352 | 133,484 |
| British pound sterling term loan due 2025(B) | 883,610 | 891,170 |
| Australian term loan facility(B) | 306,487 | 320,164 |
| 3.325% Senior Unsecured Notes due 2025(B) | 539,500 | 551,950 |
| 0.993% Senior Unsecured Notes due 2026(B) | 539,500 | 551,950 |
| 2.500% Senior Unsecured Notes due 2026(B) | 631,150 | 636,550 |
| 5.250% Senior Unsecured Notes due 2026 | 500,000 | 500,000 |
| 5.000% Senior Unsecured Notes due 2027 | 1,400,000 | 1,400,000 |
| 3.692% Senior Unsecured Notes due 2028(B) | 757,380 | 763,860 |
| 4.625% Senior Unsecured Notes due 2029 | 900,000 | 900,000 |
| 3.375% Senior Unsecured Notes due 2030(B) | 441,805 | 445,585 |
| 3.500% Senior Unsecured Notes due 2031 | 1,300,000 | 1,300,000 |
| $10,146,575 | $10,109,133 | |
| Debt issue costs and discount, net | (47,852) | (44,897) |
| $10,098,723 | $10,064,236 |
(A)
Includes £232 million and£322 millionof GBP-denominated borrowings and €303 million and €303 million of Euro-denominated borrowings that reflect the applicable exchange rates at March 31, 2024 and December 31, 2023, respectively.
(B)
Non-U.S. dollar denominated debt reflects the exchange rates at March 31, 2024 and December 31, 2023.
As of March 31, 2024, principal payments due on our debt (which exclude the effects of any discounts, premiums, or debt issue costs recorded) are as follows (amounts in thousands):
| 2024 | $438,839 |
| 2025 | 1,423,110 |
| 2026 | 3,285,441 |
| 2027 | 1,600,000 |
| 2028 | 757,380 |
| Thereafter | 2,641,805 |
| Total | $10,146,575 |
Covenants
Our debt facilities impose certain restrictions on us, including restrictions on our ability to: incur debts; create or incur liens; provide guarantees in respect of obligations of any other entity; make redemptions and repurchases of our capital stock; prepay, redeem, or repurchase debt; engage in mergers or consolidations; enter into affiliated transactions; dispose of real estate or other assets; and change our business. In addition, the credit agreements governing our unsecured credit facility ("Credit Facility") limit the amount of dividends we can pay as a percentage of normalized adjusted funds from operations (“NAFFO”), as defined in the agreements, on a rolling four quarter basis. At March 31, 2024, the dividend restriction was 95% of NAFFO. The indentures governing our senior unsecured notes also limit the amount of dividends we can pay based on the sum of 95% of NAFFO, proceeds of equity issuances, and certain other net cash proceeds. Finally, our senior unsecured notes require us to maintain total unencumbered assets (as defined in the related indenture) of not less than 150% of our unsecured indebtedness.
In addition to these restrictions, the Credit Facility contains customary financial and operating covenants, including covenants relating to our total leverage ratio, fixed charge coverage ratio, secured leverage ratio, consolidated adjusted net worth, unsecured leverage ratio, and unsecured interest coverage ratio. The Credit Facility also contains customary events of default, including among others, nonpayment of principal or interest, material inaccuracy of representations, and failure to comply with our covenants. If an event of default occurs and is continuing under the Credit Facility, the entire outstanding balance may become immediately due and payable. At March 31, 2024, we were in compliance with all such financial and operating covenants.
See Note 10 to the condensed consolidated financial statements for subsequent event information related to debt.
- Income Taxes
As a result of the Australia Transaction described in Note 3 to the condensed consolidated financial statements, we recorded a $5 million tax benefit in the first quarter of 2023.
The text of this filing, as the company filed it with the SEC, without its images or exhibits. This is not investment advice.