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Edited Transcript of MPW earnings conference call or presentation 31-Oct-19 3:00pm GMT

Q3 2019 Medical Properties Trust Inc Earnings Call

Birmingham Nov 6, 2019 (Thomson StreetEvents) -- Edited Transcript of Medical Properties Trust Inc earnings conference call or presentation Thursday, October 31, 2019 at 3:00:00pm GMT

TEXT version of Transcript

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Corporate Participants

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* Charles R. Lambert

Medical Properties Trust, Inc. - Treasurer & MD of Capital Markets

* Edward K. Aldag

Medical Properties Trust, Inc. - Founder, Chairman, President & CEO

* R. Steven Hamner

Medical Properties Trust, Inc. - Founder, Executive VP, CFO & Director

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Conference Call Participants

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* Andrew T. Babin

Robert W. Baird & Co. Incorporated, Research Division - Senior Research Analyst

* Connor Serge Siversky

Joh. Berenberg, Gossler & Co. KG, Research Division - Analyst

* Derek Charles Johnston

Deutsche Bank AG, Research Division - Research Analyst

* Jason R. Idoine

RBC Capital Markets, Research Division - Associate

* Kathleen Noel Morgan

KeyBanc Capital Markets Inc., Research Division - Associate

* Omotayo Tejamude Okusanya

Mizuho Americas LLC - MD & Senior Equity Research Analyst

* Seth J. Canetto

Stifel, Nicolaus & Company, Incorporated, Research Division - Associate

* Steven James Valiquette

Barclays Bank PLC, Research Division - Research Analyst

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Presentation

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Operator [1]

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Good morning, ladies and gentlemen, and welcome to the Q3 2019 Medical Properties Trust Earnings Conference Call. (Operator Instructions) As a reminder, this conference call is being recorded.

I would now like to turn the conference over to your host, Mr. Charles Lambert, the Managing Director. Please go ahead, sir.

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Charles R. Lambert, Medical Properties Trust, Inc. - Treasurer & MD of Capital Markets [2]

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Thank you and good morning. Welcome to the Medical Properties Trust conference call to discuss our third quarter 2019 financial results. With me today are Edward K. Aldag Jr., Chairman, President and Chief Executive Officer of the company; and Steven Hamner, Executive Vice President and Chief Financial Officer. Our press release was distributed this morning and furnished on Form 8-K with the Securities and Exchange Commission. If you did not receive a copy, it is available on our website at www.medicalpropertiestrust.com in the Investor Relations section. Additionally, we're hosting a live webcast of today's call, which you can access in that same section.

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

Please note that in our press release, Medical Properties Trust has reconciled all non-GAAP financial measures to the most directly comparable GAAP measures in accordance with Reg G requirements. You can also refer to our website at www.medicalpropertiestrust.com for the most directly comparable financial measures and related reconciliations.

I will now turn the call over to our Chief Executive Officer, Ed Aldag.

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [3]

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Thank you, Charles. Good morning, and thanks to all of you for joining us on today's third quarter earnings call. A year ago, we noted that we anticipated 2019 to be another record year for MPT. As we near the close of 2019, we can certainly say that it's been a fantastic year, and we may not be done yet.

Year-to-date, we have closed $3.7 billion of transactions, $1.55 billion for Prospect here in the U.S., $906 million for HealthScope in Australia, $423 million for Ramsay in the U.K., $284 million for Swiss Medical Network in Switzerland, $254 million for Vibra in the U.S., $154 million for St. Luke's in the U.S., $55 million for house in Watsonville in the U.S., $45 million for BMI Harbor Hospital in the U.K., $28 million for a development project with NeuroPsych in the U.S. and $32 million for additional projects with existing customers.

92% of 2019's investments have been with new relationships. We've expanded our investments in the U.S., Germany and the U.K., while making initial investments in Switzerland and Australia. We continue to see exciting domestic and international opportunities to grow, primarily with new operators all across the globe. Our pipeline remains robust, with more than $5 billion in potential transactions that we are actively working.

Let me walk through some of the more recent transactions, one of which was an expansion of our long-standing relationship with Vibra, one of the top post-acute care operators in the country. We were able to acquire 3 very strong IRFs in Kentucky and California for approximately $200 million. All of Vibra's properties are cross-defaulted, but for illustrative purposes, the EBITDARM coverage on these 3 IRFs is 2x.

As a part of this group of properties, we acquired 7 LTACHs for approximately $54 million. These LTACHs are well-priced and have an overall coverage of approximately 5x. These profitable facilities are located throughout the U.S. in attractive markets with strong referral networks and have already exceeded our expectations for the year-to-date.

Another recently closed transaction was with Halsen Healthcare, a new operator to MPT for an acute-care hospital in Watsonville, California. The Halsen executive team is comprised of veteran healthcare executives with an average of 25-plus years of experience, including within the California market. Several of these executives were executives at previously owned MPT facilities. We are delighted to welcome them back.

Additionally, we just closed on a $28 million behavioral health opportunity with NeuroPsychiatric Hospitals for the development of a 92-bed freestanding hospital in the Houston, Texas market. NPH is a behavioral health company focused on providing best-in-class care for patients with acute, complex, medical or psychiatric conditions and is known as the largest neuropsychiatric care organization in the country. They meet an underserved need in treating the more severe comorbid cases that traditionally psych hospitals are not equipped to take. NPH currently operates 4 facilities with 187 beds in Indiana and is well positioned for near-term growth into new markets in 2020. Construction is underway, with an estimated opening in the third quarter of 2020.

During the third quarter, we also closed on the previously announced transaction to purchase 8 acute care hospitals operated by Ramsay Health Care in the U.K. Ramsay is listed among the world's largest hospital operators, and we are excited to develop this new relationship.

Finally, we completed the previously announced $1.55 billion transaction for the Prospect Medical Holdings hospital portfolio. Our Prospect Hospitals are performing as expected and tracking in accordance with our underwriting. Prospect continues to benefit from cost-reduction strategies, renegotiated payer contracts and greater focus on growth opportunities.

With the transactions discussed today as well as the previously announced transactions from the first half of the year, we have already achieved the single largest year of acquisition growth in MPT history. And we still have another quarter to go. While I can't predict with certainty when we will be able to announce and close any of the properties we are working on in our pipeline, we do expect that we'll be able to make such announcements over the next couple of quarters.

Now I'll provide a quick update on our existing portfolio. We added 22 properties to our same-store reporting, including 13 IRFs, 11 facilities in Germany, 1 in Louisiana and 1 in Ohio; 8 acute care hospitals, 3 in Florida, 2 in Pennsylvania, 1 in Ohio, 1 in Idaho and 1 in Germany and 1 LTACH in Texas. Same-store acute care EBITDARM coverage is 3.19x, which represents a slight 16 basis point decrease year-over-year, primarily driven by slight volume declines at a few of our larger general acute hospitals.

Just a note to remind you, we report 1 quarter in arrears, so this is referring to the second quarter of the year. A quick update on Steward. Steward made the decision to discontinue operations at its St. Luke's facility in Arizona. They made the strategic decision to transfer some of those operations to other Steward facilities and closed some services rather than competing with a newly renovated Banner facility 5 minutes to the West and a planned $1 billion county-owned facility 5 minutes to the East.

Steward will continue to pay the full MPT rent as required under their master lease. We expect their decision to close St. Luke's to be a positive for their bottom line, and thus an improvement to their already strong coverage. Steward continues to fine-tune its portfolio and expects to see continued improvement during the remainder of 2019 and their coverage ratios.

Steward's concentration is currently 29%. IRF EBITDARM coverage is 1.97x, which is essentially flat compared to 1.98x year-over-year. It is probably important to note that the U.S. IRFs saw a 9.9% increase in coverage from 2.55x to 2.81x. LTACH EBITDARM coverage is 1.5x, which is essentially flat year-over-year. This does not include the recently acquired Vibra portfolio, where the LTACHs have a combined coverage of approximately 5x.

As a reminder, LTACH, including the Vibra portfolio we just acquired, currently represents 2.6% of our total portfolio. I know that all of you are well aware of the wildfires in California. At this time, none of our facilities have been affected and none have been threatened. However, many of the people working in these hospitals have had their personal homes affected. I would like to take this opportunity to let them all know that our thoughts and prayers go out to them and their families.

At this time, I will ask Steve to go over our specifics on the [provincial --] financial performance and health of Medical Properties. Steve?

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R. Steven Hamner, Medical Properties Trust, Inc. - Founder, Executive VP, CFO & Director [4]

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Thank you, Ed. This morning, we reported normalized FFO of $0.33 per diluted share for the third quarter of 2019. These results again exceeded consensus expectations. But more importantly, and as Ed has just described, MPT's growth is continuing, even following the $3.4 billion that we announced last quarter. Including the additional $282 million we invested during and after the third quarter, our year-to-date investments of $3.7 billion represents 40% growth since the beginning of 2019. Just as an aside that may only be interesting to us here at MPT, it took us 10 years to acquire our first $3.7 billion in assets, the same amount that we have invested in the last 9 months alone. In any case, I will point out a couple of items related to our quarterly results and then focus on the remainder of this year and our near-term outlook.

First, at various points during the third quarter, we completed acquisitions of the $1.5 billion prospect investment; 8 hospitals leased to Ramsay, in England, for about $423 million; a $55 million investment in a California Hospital; a $200 million portfolio of 3 inpatient rehabilitation hospitals; and a roughly $54 million acquisition of 5 long-term acute facilities. Most recently, we agreed to fund a $28 million development of a Houston acute behavioral facility for long-term lease to a specialty behavioral health operator.

Included in our third quarter FFO reconciliation are adjustments for financing fees related to the prospect transaction, straight-line rent, other miscellaneous items and the related tax effects that, in the aggregate, accounts for approximately $0.01 of normalized FFO. In addition, included in property-related expenses is about $2.9 million in certain triple net type expenses that we paid directly, primarily to ground lessors, but then recovered from our tenants, and such recovery is included in the interest and other income. Accordingly, there is no impact on FFO.

G&A expenses were approximately $23.3 million in the third quarter, at the low end of our previous estimate of between $23 million and $25 million per quarter.

This morning, we reaffirmed our current state annualized run rate of between $1.56 and $1.58 per share. This estimate retains our assumptions regarding leverage in the 5.5x range and the expected refinancing of our $451 million revolver balance with long-term funding. Our press release and Ed's comments have already made clear that we are very bullish on our near-term pipeline of actionable acquisition opportunities. We believe that MPT, in particular among health care REITs, has created a commanding position in the early stages of a rapidly expanding market for acute hospital real estate in the economically developed areas of the world where we operate. This market expansion is being driven by a growing recognition and acceptance of the benefits of long-term lease financing of core hospital real estate on the part of hospital operators, sponsors, investors and other market participants. Because only a small percentage of acute hospitals are leased, we have a high level of confidence that, as this market continues to expand, MPT will continue to grow at immediately accretive pricing for the foreseeable future.

While we are not prepared today to make any specific announcements, we believe it is not unreasonable to expect meaningful acquisition volume in the near term. As we underwrite and plan permanent financing for these target acquisitions, we expect capitalization rates and investment spreads similar to our year-to-date transactions. And we intend to remain modestly levered in accordance with our long-standing strategies.

And with that, we will be happy to take questions. Operator?

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Questions and Answers

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Operator [1]

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(Operator Instructions) Our first question comes from the line of Mr. Chad Vanacore from Stifel.

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Seth J. Canetto, Stifel, Nicolaus & Company, Incorporated, Research Division - Associate [2]

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This is Seth Canetto on for Chad. First question, just in terms of the strong acquisition pipeline, is that focused on acute care hospitals, IRFs or LTACHs? Can you kind of break up like the mix of those opportunities? And then are you seeing opportunities in your existing international markets or are looking to expand into new markets?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [3]

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Seth, it is almost exclusively, if not exclusively, acute care hospitals. And it is in our previously invested in and previously announced markets, not any new markets at this time.

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Seth J. Canetto, Stifel, Nicolaus & Company, Incorporated, Research Division - Associate [4]

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Okay. Great. And then just looking at the same-store pool and the impact on coverage that you mentioned in your opening remarks, how should we think about that? I know you said that some of the hospitals saw a slight decrease in volume, and that's a trailing indicator. What do the recent trends look like? And how should we think about those new assets that are in the same-store pool?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [5]

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Yes. Well, if you'll remember that the second quarter HCA's announcements on their operations showed the same slight decrease in volumes, and there was a lot of panic in the markets. But then you saw HCAs reporting this week, and it was a very nice, strong rebound. We obviously don't have reporting numbers for all of our operators yet since they're just finishing their internal numbers for the past quarter. But what we've seen to date follows what HCA has reported.

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Seth J. Canetto, Stifel, Nicolaus & Company, Incorporated, Research Division - Associate [6]

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Okay. And then you mentioned the Steward concentration at 29%. Where do you see that concentration going down once you've completed some of these deals that are in your pipeline?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [7]

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Well, obviously, it will continue to go down because the pipeline does not include any meaningful additional Steward properties. So we expect, in the not-too-distant future, that number to be down in the mid-20s.

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Operator [8]

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Our next question comes from the line of Michael Carroll from RBC Capital Markets.

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Jason R. Idoine, RBC Capital Markets, Research Division - Associate [9]

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This is Jason on for Mike. Around the LTACHs that you guys bought, just trying to get some color around what the negotiations were like for those assets, and how the team was able to achieve such good coverage?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [10]

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Jason, they were tagalongs basically for the IRFs that we wanted, and we think we got good pricing for the IRFs and we think we got great pricing for the LTACHs. The majority of those LTACHs have been through or just start -- or are in the initial stages of their final inpatient criteria numbers. We're comfortable with where all of those are, and the coverages on some of these LTACHs are double digits. So we feel very good about what we got them for on a price-per-bed basis. And obviously, with the coverage, there is a tremendous amount of room there for us in flexibility.

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Jason R. Idoine, RBC Capital Markets, Research Division - Associate [11]

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Got it. Okay. And just touching on the behavioral health opportunities that you guys are seeing in the market, is this an asset class that you guys would be interested in developing more of? And then also, if you could touch on what the underwriting is like, and what type of coverage you look for?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [12]

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Yes, it is something that we would like to see more of. We've been looking at it for a long time, but we've never had enough scale for it to make any sense to us. We think that this operator that we've just closed the transaction on, that, that won't be the last deal we do with them. So it gives us scale with that operator, and the reason why we did a $28 million transaction. From an underwriting standpoint, it's very similar to what we're seeing on an IRF coverage. It's 2.5 to 3x-type coverage.

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Jason R. Idoine, RBC Capital Markets, Research Division - Associate [13]

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Got it. Okay. And then last one for me. Any updates on the prospects of expanding that relationship with Infracore in Switzerland?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [14]

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It -- certainly, from a standpoint of our ownership in Infracore, we certainly expect that, over the medium term, that will increase. But even beyond that, even at the ownership that we have now, we expect that the size of Infracore will continue to grow so that our ownership or investments in Switzerland will continue to grow, even if our ownership doesn't immediately increase.

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Operator [15]

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Our next question comes from the line of Jordan Sadler from KeyBanc Capital Markets.

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Kathleen Noel Morgan, KeyBanc Capital Markets Inc., Research Division - Associate [16]

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This is Katie on for Jordan. Thinking about 4Q and [like a] run rate, with everything -- with all the acquisitions in place by 9/30 such that the $1.56 to $1.58 a share run rate could be achieved in 4Q '19.

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R. Steven Hamner, Medical Properties Trust, Inc. - Founder, Executive VP, CFO & Director [17]

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Not necessarily, Katie. It should be fairly close, but there's still some developments that will come online that are built into the $1.56 to $1.58 on a pro forma basis. That has an impact, as I mentioned, capital has some impact. So -- and as we -- I hope made clear this morning already, the ongoing acquisition activity could possibly have a meaningful impact also.

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Kathleen Noel Morgan, KeyBanc Capital Markets Inc., Research Division - Associate [18]

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Okay. That makes sense. And then, I think you just kind of touched upon this in like one of your previous answers, but -- that the LTACHs are kind of tagalongs for the IRFs. Can you guys just kind of touch upon your appetite for incremental exposures to LTACHs?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [19]

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Yes. Right now, we're at 2.6% of the total portfolio. We don't expect that to increase. We don't have any additional LTACHs that we're looking at. If we get an opportunity that has some tagalongs, we'll certainly look at that. But that's the appetite that is there.

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Operator [20]

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Our next question comes from the line of Derek Johnston from Deutsche Bank.

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Derek Charles Johnston, Deutsche Bank AG, Research Division - Research Analyst [21]

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So I look here and general acute EBITDARM coverage declined in the quarter. Like when you think about a cover -- a comfortable EBITDARM coverage range for general acute care, so first, what would you say that is? And then secondly, the new acquisitions not included in the same-store, how will they impact the current coverage ratios?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [22]

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Yes. If you think about it as a whole, Derek, every time we make an acquisition, the coverage is going to naturally come down. Our underwriting coverage for general acute care hospitals is in the 2.5x and above range. But obviously, when we're acquiring new hospitals at that rate, and we've been running hospitals that we've owned for 10-plus years with coverages in the 3.5 to 4x, it brings down the total average. So as I've stated on numerous earnings calls, it's a little bit confusing because we've been in such a rapid growth mode on the coverage. So when you see the coverages go down, it's not always because of just a softening. We added 22 total properties to the same-store this year. So those being new properties -- you remember, same-store means they've been in our portfolio for 24 months, so they haven't had the same seasoning that some of the older properties have had. So there's a natural decline there. But there was some softening in the volumes in the second quarter that we saw along with the rest of the nation.

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Derek Charles Johnston, Deutsche Bank AG, Research Division - Research Analyst [23]

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Okay. Great. Can we touch on the dividend and the path to growing or possibly accelerating the dividend growth rate? I mean, given the extent of the already accretive acquisitions, and we're modeling MPW to show subsector leading FAD and dividend growth, so I just wanted to get your thoughts, and maybe when you talk to the Board, what their thoughts are on the dividend trajectory?

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R. Steven Hamner, Medical Properties Trust, Inc. - Founder, Executive VP, CFO & Director [24]

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So a very, very good question and one that gets a lot of attention, especially in periods where we're growing at 40% per year. Our Board has been, in my personal view, particularly careful and conservative to grow the dividend as the cash grows, not necessarily as our pro forma outlook grows. So for example, under current dividend policy right now, the run rate guidance is about in the 80% of AFFO, cash FFO run rate. And we believe that's probably the right number. We have a fairly healthy component of straight-line rent, and so we really do look at AFFO much more focused than we do just FFO. Keeping that 80% payout ratio on an AFFO basis gives us room as these properties continue to be acquired and generate results for full quarters. And then as we continue to execute on what we've described as a $5 billion pipeline, you -- your perception that we should be able to grow it fairly rapidly, we agree with that. I'll just reiterate that we'll wait until we actually not only announced the acquisitions but actually close them and integrate the full quarter receipt of the NOI.

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Operator [25]

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Our next question comes from the line of Steven Valiquette from Barclays.

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Steven James Valiquette, Barclays Bank PLC, Research Division - Research Analyst [26]

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I guess, I was kind of curious about that comment you made about the roughly 9%, 10% improvement in the U.S. IRF coverage. I was curious to hear more about whether you think that's related to operator-specific initiatives, or are there maybe some industry-wide tailwinds for the IRF sector that you think is driving more of that better performance in mid-2019?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [27]

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Yes, that's industry wide. That's across the board on all of our IRF operators. Ernest has been doing very well in their IRF portfolio for a long time. Encompass, as you saw in their recent announcements, they've been performing very well. So it's been all across the board.

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Steven James Valiquette, Barclays Bank PLC, Research Division - Research Analyst [28]

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Okay. The other quick one, just around the $5 billion pipeline, I think there's been some -- a little bit of discussion around whether additional deals could still be announced maybe in calendar '19, or might more of that happen in the calendar '20? So I'm just curious if you have any additional updated thoughts around the timing, near term of any potential stuff coming out of the $5 million pipeline?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [29]

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Yes. After doing this for 30-plus years, I've learned never to count my chickens before they hatch. But we're very optimistic about the pipeline that we're working on.

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Operator [30]

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Our next question comes from the line of Tayo Okusanya from Mizuho.

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Omotayo Tejamude Okusanya, Mizuho Americas LLC - MD & Senior Equity Research Analyst [31]

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I just want to talk about 2 particular things. The first one is the Vibra transaction. I appreciate the color on the LTACH piece of it. I'm just curious if you could talk a little bit about, one, the cap rate on the transaction, specifically (inaudible) kind of think about it of cap rate on the IRFs versus cap rates on the LTACH. And then on top of that, just wondering -- and Vibra was a very large tenant of yours years ago. They kind of moved away because they kind of thought they could get better cost of capital. And that's kind of interesting that they're working with you again. So I'm just kind of trying to understand whether it's -- what kind of changed, whether it's their cost of capital, whether it's you guys are now offering more competitive cost of capital versus alternatives. Just kind of curious what's kind of happening there.

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [32]

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Tayo, you remember that Brad Hollinger and I have been working together since 1986. So we have a very, very long and healthy relationship. You'll remember that Brad was offered -- we were offered from one of our competitors to acquire most of his portfolio from us at very nice gains for us. It was at a time that we were trying to have some examples to the market of just how valuable our properties were. So it was literally just opportunistic for both of us, for us and for Brad. We have maintained our relationship. As you know, he and one equity bought the operations for the Ernest transaction. So we've been working with Brad continuously, literally since the start of MPT. It's just fluctuated in the total amount that we've had with them. I think that our cap rates have been on par with everybody else's cap rates at different times. Obviously, when we did those original transactions with Brad, they were in the early days when interest rates were much higher than they were. And so when interest rates came down and he had the opportunity to reprice it with a competitor and we had the opportunity to take some gains, it just made sense. From the standpoint of what the cap rates are on this particular portfolio, it's all under a master lease. So it's kind of hard to look at it on an individual basis. But from our underwriting standpoint, we underwrote the IRFs at good market rate -- cap rates. We think we got above market cap rates for the small LTACH portion of it. We think that these particular LTACHs are performing exceptionally well and are well positioned in the new payment require -- I mean, patient pay payment requirements. And I think that we're well protected for them.

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Omotayo Tejamude Okusanya, Mizuho Americas LLC - MD & Senior Equity Research Analyst [33]

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Got you. Okay. That's helpful. And then just second of all, the $5 billion pipeline in front of you, again, whether it's $2 billion you put in the bag, $4 billion, what have you. I'm just kind of thinking how you kind of think about funding that on a going-forward basis in regards to trying to get nice spreads versus, again, the idea of staying leverage-neutral, or if you're okay going up a little bit higher on the leverage stack, just kind of curious how you're thinking about that, Steve?

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R. Steven Hamner, Medical Properties Trust, Inc. - Founder, Executive VP, CFO & Director [34]

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Yes. So we don't really see a need to plan to go up on our leverage. Now obviously, with, again, 40%-type growth and these big numbers, there will be temporary spikes up and spikes down. But we absolutely feel confident in being able to continue to manage the balance sheet the way we've been doing. So far, we've been very successful with accessing capital in the traditional forms. You saw the great success we had with the equity offering back in July after we announced the Prospect and other transactions, record-setting low rates on long-term U.S. dollar debt. Subsequent to that, we issued another $250 million under the ATM at even better pricing than we got on the underwritten offering. So not that it is without -- not without challenge when you're growing so rapidly, but we don't see an issue with continuing to fund in our traditional ways and maintain the leverage discipline that we've demonstrated.

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Operator [35]

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Our next question comes from the line of Drew Babin from Baird.

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Andrew T. Babin, Robert W. Baird & Co. Incorporated, Research Division - Senior Research Analyst [36]

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I was hoping to ask about the neuropsychiatric development that you announced. If you could talk about maybe the economics on that, as far as the cap rate as well as whether this sort of subtype within behavioral health might be a growth opportunity or whether this is sort of a segment that we can expect to kind of grow within the context of U.S. healthcare going forward?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [37]

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So the last part of that question first, Drew. I'm not sure how big it will be. I think there's a real opportunity for it. There aren't that many operators that do this specific type of care in the behavioral section. This is for the severe psychiatric patients, a lot of criminally insane patients, and obviously needs a specialized operator to handle that type of activity. From a cap rate standpoint, it's probably in the upper range of our market cap rates. It's a product line that we think is well received in the market. It's needed from the standpoint that acute care hospitals generally aren't able to handle this type of patient, so they're very supportive. Their court systems are very supportive, and the payers have been very supportive of it. So we'll see. We'll see how big it gets. This is a very small, small investment at this point, but we have high hopes for this particular operator and some other operators that we're looking at.

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Andrew T. Babin, Robert W. Baird & Co. Incorporated, Research Division - Senior Research Analyst [38]

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Thanks for the color there. And then knowing how the master leases work and how the economics sort of protect MPW at the end of the day, it -- was it a surprise that Steward is closing this hospital in Arizona? And might we see kind of more of these announcements going forward about individual facilities?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [39]

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So it wasn't a total surprise for us. We knew that with Banners' additional newly built tower and renovated ER and some other issues -- I mean, some other additions that they've done at their particular hospital, that there was going to be added competition. What we weren't prepared for was the $1 billion new hospital that the county is planning for. As you know, Steward has other hospitals in the area, it just made a lot more strategic sense for them to take the services that they were providing there at St. Luke's and move them out to some of their other facilities. And the cost savings there will be really dramatic for them. You may recall that there was at least 1 other hospital that, when they made their original acquisitions from CHS, that they had planned on selling. That particular sale fell through. They haven't made strategic decisions about what they're going to do with that particular hospital long term. I don't think you'll see a large number of these, but I think that things like that particular hospital, that we had expected from the very beginning that they would sell, you may see something like that. But overall, the Steward hospitals are doing very well. We're very happy with where they are from a total coverage standpoint and very happy with where the company is on a total integration of all the new hospitals.

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Andrew T. Babin, Robert W. Baird & Co. Incorporated, Research Division - Senior Research Analyst [40]

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Great. And just one more for me. Looking at the slight drop in coverage ratio on the general acute master leases in the quarter, which you mentioned the -- kind of the seasonal weakness that HCA talked about and same-store pool composition changes, things like that. I guess, in a more general sense, does MPW receive enough transparency from the operators to go in and really kind of make your own calculations and adjustments to kind of get to an EBITDARM number that you're very comfortable with as far as calculating these coverages? Or is there sort of an opportunity sometimes for tenants to make adjustments based on onetime items or things that may be lumpy from their perspective from one year to another? Just kind of a general question about transparency and how comfortable you feel?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [41]

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Yes, Drew. We get a tremendous amount of transparency. Not only do we get statistical operational information on a daily, weekly, monthly basis, but obviously we get financial information on a monthly and quarterly basis. So I think that our insight into our operators is -- makes us probably have one of the best databases for hospital operators in the world. Obviously, HCA and other big operators have a tremendous database, but they only have their own data to analyze. We have 8 of the top 10 hospital operators in the United States. So we have data from a big, diverse group of hospitals in a real diverse geographic and operator standpoint. So I think the transparency that we have is exceptionally strong. We all know that, generally speaking, the third quarter is the weakest quarter for hospital operations and volumes. So the decline in the second quarter and then the positive rebound in the third quarter for HCA and even the community health systems announcement these last couple of weeks has really been a little bit surprising. So we'll see when our -- when we get the full transparency in the next couple of weeks from our operators on the third quarter, but the initial trends are -- as I said earlier, are essentially the same thing that we saw more in line with the community volumes, maybe not necessarily with the HCA volumes.

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R. Steven Hamner, Medical Properties Trust, Inc. - Founder, Executive VP, CFO & Director [42]

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Drew, I would just very briefly add that, with respect to an operator's ability to kind of, for lack of a better term, game the system, our definition of EBITDAR is contractual in the lease, and it is highly detailed and highly constrained as to what can go in and come out of net income in calculating that EBITDAR amount. So I don't think, generally, that has been or could be an issue for us either.

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Operator [43]

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Our next question comes from the line of Connor Siversky from Berenberg.

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Connor Serge Siversky, Joh. Berenberg, Gossler & Co. KG, Research Division - Analyst [44]

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You mentioned that a lot of your investments this year involve some new relationships. Do you see this trend continuing as you address your acquisition pipeline? And then is there a level of tenant diversification that you'd be comfortable with in the long run?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [45]

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We do expect that you're going to see even new -- many new operators in this next tranche of the pipeline that we're working on. We do think that the trend will continue. It obviously is a purposeful trend on our part because it is the way that we reduce Steward's exposure. We have always said that, on a go-forward basis, if we could have a fixed point in time, that we were comfortable with an operator representing roughly 25% of our overall portfolio. But let me back up just a second and remind everyone that right now, our largest property represents less than 3% of our total portfolio, and we underwrite on an individual-property basis. So even though Steward at this particular point represents 29% of our total overall portfolio, we still look at it on an individual-property basis. And as I said, I believe this time last year, I talked about Steward in particular, and how you divide Steward up into really 7 different regions, and if something were to ever happen to the parent company, you would have many different operators looking at those individual regions. So yes, we understand that the concern that people get with an exposure of any 1 tenant being a large number, we think that the comfort zone there should be in the mid-20s. But we also think that everyone should get comfort on our individual property underwriting basis and the diverse geographic standpoint of somebody like Stewart.

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Connor Serge Siversky, Joh. Berenberg, Gossler & Co. KG, Research Division - Analyst [46]

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All right. Great. And then one small one from me as well. Do you see any significant cap rate movement for your target assets in any of your current markets? Or then do you see any new budding competition in maybe Europe or the U.S.?

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [47]

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So I think in the U.S., the cap rates have been fairly stable for the last 12 months, maybe a slight tick upward, but that would only be slight. In Europe, I think that there's been a fairly significant tick upward. I think that people have realized, while there's a lot more money-chasing properties in Europe than there is here in the U.S., that nobody can move as fast as we can, and the sovereign wealth fund to some of the other pension funds that are chasing the same properties that we are literally can take up to a year to finish their underwriting. So while they may have a cheaper cost of capital, the opportunity costs do away with any of that potential economic benefit.

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Operator [48]

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I am showing no further questions at this time. I would now like to turn the conference over back to the CEO, Ed Aldag.

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Edward K. Aldag, Medical Properties Trust, Inc. - Founder, Chairman, President & CEO [49]

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Jason, thank you very much. And as always, thank all of you for your interest and your time today. If you have any additional questions that develop after the call, please don't hesitate to reach out to us.

Thank you very much.

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Operator [50]

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Ladies and gentlemen, this concludes today's conference. Thank you for your participation, and have a wonderful day.

You may all disconnect.