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Nareit REIT Week: 2024 Investor Conference

Jun 4, 2024

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

So, welcome everybody to the 11:00 A.M. company presentation for American Healthcare REIT. My name is Austin Wurschmidt. I am the covering analyst at KeyBanc Capital Markets for the Healthcare, Residential, and Lodging REITs. Here in a moment, I'm gonna hand it over to Danny Prosky, President and CEO of American Healthcare REIT, to introduce his team and provide a quick overview and background on the company. We'll then follow up with some question and answer session, and then towards the end, I will open it up to the floor for any questions anyone may have. Danny?

Danny Prosky
President and CEO, American Healthcare REIT

Thanks, Austin. Good morning, everyone. Thank you for joining us. Hopefully, you came to hear us and not just to get a good seat for Essex, who's coming up next. I'm Danny Prosky. I'm the President and CEO of American Healthcare REIT. With me are Brian Peay, our Chief Financial Officer, to your left, and then Gabe Willhite, our Chief Operating Officer, to your right. American Healthcare REIT was formed in the fall of 2021 through a tri-party merger. It was a merger between two public non-traded REITs that were launched, one in 2013 and one in 2016, as well as our management platform. So we formed the REIT and recently conducted an IPO.

We raised about $770 million on February seventh, and 100% of that was used to pay down floating rate variable floating short-term debt. So we focus on clinical healthcare real estate. We're diversified. So clinical means a type of real estate where patients are being seen by providers. We primarily focus in medical outpatient buildings and long-term care, which can be skilled nursing, assisted living, as well as our integrated senior health campuses, also known as our Trilogy investment, which is our biggest differentiator. We like the diversified strategy within healthcare. We like it from an asset management perspective. I think it really proved itself out during COVID, where about a third of our portfolio was medical outpatient. Did very well during COVID.

We actually grew our occupancy in 2020, as opposed to our long-term care side of the business, which struggled during COVID, like the industry as a whole, mainly because people couldn't move in for an extended period of time. We also like it from an acquisitions perspective. We're able to look at the best risk-adjusted returns that are available at any particular point in time and focus on that type of asset. So we don't have predetermined percentages that we focus on. We look at what are the best opportunities at that point in time. For example, on medical office, medical outpatient, depending on what you're calling it nowadays, we acquired most of those early on in our life cycle, call it from 2013 to 2016.

Cap rates compressed significantly on medical outpatient over the last few years, so we've actually been net sellers over the last few years, because cap rates remained stubbornly low for that asset class, and we focus a lot more on growing our long-term care portfolio. A couple of things that differentiate us from some of the other non-traded REITs, some of the other traded REITs, excuse me, are size. We're about $4.5 billion in assets based on purchase price, kind of a mid-size healthcare REIT. We like that size from a growth perspective. We don't need to do multi-billion dollar deals to grow our portfolio. We can grow, you know, using one-off transactions and still have a substantial effect on the overall portfolio.

We also are differentiated because we have a significant portion of our investment base in RIDEA or managed assets. We're about 60% managed versus leased, and most of that is within our Trilogy portfolio, our integrated senior health campuses, which are a mix of assisted living, skilled nursing, memory care, and a little bit of independent living. Focuses on a higher acuity resident. They're mostly purpose-built buildings, newer, nicer. They tend to be the best assets in their markets. Trilogy operates in four states: Southern Michigan, Northern Kentucky, Ohio, and Indiana. So they're our largest investment by far, and they're also our best-performing operator by far. We did file a new set of slides just prior to NAREIT.

A lot of it is information that we put out publicly before. I think the most relevant slides are the earlier slides in the deck that give you an update on occupancies and then a summary of our first quarter results. Occupancies continue to do very, very well this year, as they've done in 2022 and 2023. I think we're beyond COVID recovery at this point. I think most of our occupancy growth now is coming from the dislocation between supply and demand that we're seeing right now. We've got the baby boomers will start turning 80 very, very soon. That's really where you start seeing a lot of demand for long-term care within our space, both assisted living and skilled nursing.

And we've seen very, very little new construction over the last six years. New construction dropped in 2018 and 2019. That was mainly lender-driven. Lenders thought that there was too much new development going on, and they turned the spigot off. And then in 2020 and 2021, we had COVID. New development really slowed down. And then in the last two years, the lenders are out there, they're lending, but they're charging much higher interest rates, and they're providing much lower proceeds. And of course, they've tightened their lending restrictions as well, right when construction costs have gone through the roof. So new construction starts over the last few years are back down to kind of 2010 levels as a percentage of total product out there.

We feel very, very strongly that over the next three to five years, this will continue. We're gonna see, increased demand for long-term care just because of the aging of the baby boomers, right when we've seen very little new, development coming out of the ground, very few new beds opening up over the next three to five years. So I think that's why we've seen such good occupancy growth. Our margin growth has been good. RevPOR has been good. Expense growth has kind of slowed back to kind of pre-COVID levels. It was very, very high during COVID. As you can imagine, a lot of that was wages. So I've been in the, space for 32 years. In my opinion, this is the best environment I've ever seen.

Healthcare REITs typically relied on external growth to grow their earnings, and we still look to do external growth. We're doing some of that, but I think the vast majority of our earnings growth is gonna be more organic over the next three to five years. We hope and expect to see margin improvement and RevPAR growth to continue to improve over what we've seen in the last few years. So, unless Brian or Gabe unless you wanna add anything, why don't we, I'll give it back to Austin, for Q&A?

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

Oh, that's great, great intro there, and I wanna go back to kind of your, your comment a little bit on the integrated senior health campuses and really kind of. You touched on it a little bit, but why do the integrated senior health campuses, you know, why, why is it an attractive, you know, business to you, and why does it differentiate you versus the other healthcare REITs?

Danny Prosky
President and CEO, American Healthcare REIT

So we like the model, but we really like the operator. Trilogy, in our opinion, is a best-in-class operator. I think if you look at their performance, and I'm not just talking about financial, I'm talking about outcomes, 'cause that's really what it's be more and more about, right? This is a health, you know, we're in the healthcare real estate business. We all want a good bottom line. Obviously, it's very important, but what we really want are good quality outcomes, because it's always been important, right? Without good quality outcomes, without less recidivism, without good patient care, your assets just aren't gonna perform well in the long term.

That's even more important today as we move more and more to value-based care, and we're seeing it not just on Medicare Advantage, we're seeing it on regular Medicare and Medicaid and private insurance as well. So Trilogy's always excelled on with that. You know, they built this company over 25 years. We've owned them for a little over eight, but Trilogy's been around since 1999. They've been grown incrementally in their four-state footprint. They started out as pure skilled nursing, realized that they were their residents were leaving and typically moving into AL, and they said, "Hey, why not capture that business?" So 20 years ago, they decided to expand into AL and IL as well. That's become a bigger and bigger part of the business. They do a great job.

You know, first question we get about Trilogy, and we still get it, although not as much, is, "Well, isn't that a CCRC?" And the answer is no. These are not CCRCs. CCRCs tend to be larger. They tend to be primarily independent living focused. Kind of, most people move into IL, and then if they need AL or skilled, it's available. And it's typically an entrance fee model as well. Trilogy, as well as the rest of our buildings, none of them have an entrance fee model. Trilogy is higher acuity. It's typically, typically kind of a 50/50 split between skilled nursing and private pay AL and IL, and they actually tend to see residents move more the other direction. Typically, their admits on the skilled side come directly from hospitals.

It's a post-hospitalization model for the most part. The average length of stay there is less than 30 days, and about 42% of their AL residents come directly from skilled, and 70% of their AL residents have spent time in a Trilogy skilled facility. So either they came directly, or they got better, went home, somewhere down the line, they required AL or desired IL and looked at a Trilogy facility. So they do a very good job moving residents back and forth depending on the needs. They're very efficient. They're not only newer and nicer, but, like, they'll have a single kitchen to serve, you know, both wings of the building, and it is two separate wings.

There's a skilled wing and an AL/IL wing with separate entrances, separate dining rooms, but they share a kitchen, they share administrative staff, they share maintenance staff. They even share clinical staff. So if you know, one of the reasons they look so good for the RN mandate or the total mandate, the care mandate, is because they're able to move care providers back and forth across the different sides of the facility. So it's a great model. You need patients to build a company like Trilogy. You can't do it overnight. Trilogy is not gonna go out and buy 10 or 20 buildings and convert them to their model. It's not what they do. They occasionally do an acquisition, but they're much more likely to grow through development.

We develop, you know, anywhere from two to four assets a year is pretty typical.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

So you talked about some of the efficiencies of this model and why you like it. Why is this attractive to residents that you know come and stay in your buildings?

Danny Prosky
President and CEO, American Healthcare REIT

I think for quite a few reasons. They're typically. You know, the average age of a Trilogy facility is about nine years, so they're just nicer, right? You look at. I've visited a lot of skilled nursing facilities in my career, and this is not what a Trilogy asset looks like a typical skilled nursing asset. They're very nice. It looks like a nice AL facility, which it really is. Their outcomes are better. You know, right now, they've got a higher five-star rating. That's become more and more important. Residents want to be in Trilogy facilities, both on the skilled side and on the AL and IL side.

I think it also, if you look at the AL/IL side of the business, people get an extra sense of security having the skilled nursing available on-site. And by the way, a lot of Trilogy's IL business is on villas, which are on adjacent land. They're not within the building itself, but they still have access to all the Trilogy services, right? They have access to the dining, they have access to activities, even though they have their own clubhouse, where a lot of the activities take place. If they need rehab, it's available right there. Typically, they can walk to it. That's how close these facilities are, or they'll have a golf cart if they need it.

It gives them an extra level of security being adjacent to the skilled nursing services, and I think that is a big attraction to the AL and IL residents at Trilogy.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

So maybe when you think about, you know, you being one of the only REITs that really has that operating exposure to skilled nursing, how do you manage the risk of that large net exposure across the company, and what's sort of the risk, reward, or opportunity that you see both in the near term and over time?

Danny Prosky
President and CEO, American Healthcare REIT

Yeah, I think... So that does differentiate us a little bit 'cause we have a higher percentage of our RIDEA assets in skilled bed, right? Everybody who's got RIDEA has some skilled, whether it's a CCRC, you know, a lot of, you know, Ensign is, you know, they've got AL. We've got a lot of AL providers that have a skilled component. So it's not like it, we're the only ones that have it, but it's a larger percentage for us. I think it's a little bit of a misunderstanding as far as what the risk. You know, frankly, from a liability risk, I don't think you're in any worse position with skilled than AL. Gabe, I don't know if you wanna chime in, but we look at this all the time.

I believe that the cost per incident may actually be a little bit lower for a skilled facility than an AL facility. Correct me if I'm wrong there.

Gabe Willhite
COO, American Healthcare REIT

Spot on.

Danny Prosky
President and CEO, American Healthcare REIT

You know, you do have. You know, you do get a higher, a lot more of your, of your income from Medicare and Medicaid. It's very important that you manage that, and, you know, make sure that you are billing at a correct rate, which Trilogy is very, very good at. They are conservative as far as their billing. But, you know, we really don't view. If you look at the 8.5 years of track record we have with Trilogy, we've had no issues at all from a, whether from a liability perspective, whether it's been through reimbursement or through PL/GL. So we feel really good about it.

Gabe Willhite
COO, American Healthcare REIT

Yeah, I totally agree. I think on the PL/GL side, that's where people get a little bit distracted by it. I think in the assisted living space already today, you're seeing higher acuity than you did three years ago-

Danny Prosky
President and CEO, American Healthcare REIT

Mm-hmm.

Gabe Willhite
COO, American Healthcare REIT

For sure. And with that higher acuity, people are generally associating maybe a higher PL/GL spend. The most important thing for the entire equation is, by far, the operator and the quality that they're committed to.

Danny Prosky
President and CEO, American Healthcare REIT

Mm-hmm.

Gabe Willhite
COO, American Healthcare REIT

That's the way to manage the risk. If I have the best PL/GL program in the world and the worst operator in the world, I'm still in a bad spot. So partnering with somebody like Trilogy, who's been doing it for a long time, who's committed to a higher quality standard than is typically seen in the industry, is probably the best way to manage the risk.

Danny Prosky
President and CEO, American Healthcare REIT

Yeah. So, you know, this is not something we expect to do in the future with additional skilled operators. We were very happy to do it with Trilogy. I've known Trilogy for over 20 years. When I was at Healthpeak, we had a portfolio with Trilogy. So, you know, I've known the company and the founder since the early 2000s. We view them as a best-in-class operator, and we're very happy to do the RIDEA transaction with Trilogy, but it's not something we necessarily look to do with other skilled operators.

Gabe Willhite
COO, American Healthcare REIT

Yeah.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

So recently, there was the passage of, you know, the minimum staffing, you know, laws that's currently being challenged. But just from Trilogy's perspective, can you talk about, you know, if things are to move forward, as the law or mandate currently states, you know, how Trilogy's positioned, you think, relative to the industry?

Danny Prosky
President and CEO, American Healthcare REIT

So I'll let maybe Gabe talk about specifics of Trilogy, since he does a real good job with it. But overall, they're in great shape, and the reason they're in great shape is they already have a higher acuity model to begin with. They've got a higher five-star rating, et cetera. They focus more on short-term post-hospitalization residents versus long-term Medicaid residents, so they have a higher staffing ratio already. If you look at Trilogy's staffing ratios, they look really good. The problem with the mandate, along with many other things, is that it doesn't differentiate between the different types of skilled nursing facilities, and they're all different. So if you've got a lot of long-term residents that are lower acuity, you're probably gonna have lower staffing.

It's gonna be harder for you to meet that mandate. Trilogy is in very good shape. Maybe I'll let you give the specifics.

Gabe Willhite
COO, American Healthcare REIT

Yeah. So the proposed staffing rule for skilled nursing is 3.48 hours per patient day. It means you need to provide that level of direct care every day on average for the month. At Trilogy, they already are exceeding that. Their typical run rate is about 3.8 hours per day, so they're, you know, almost 10% higher than what the requirement is already. Partially because what Danny said, it's a higher acuity setting, partially because their commitment to excellence means we need a excellent experience for employees, and excellent experience for employees will drive outcomes within your facility. So Trilogy, retention is about half of, or about double what the industry average is. Turnover is about half of what the industry average is. They've got training programs where they train their nurses within.

The CNA component of the proposed rule is, you know, 2.45 hours a day that you need to find a CNA to, to provide in your setting. At Trilogy, they've created a CNA training program, and they've got regional scale to do this, where they can have trainers in specific regions of their portfolio to go out and train people who have come in and started working at Trilogy in a different level. Maybe they even came from maintenance or hospitality, and they want to become CNA certified. Trilogy will do that for them, and they're on pace to train 1,000 people to serve that function just this year, and that's something that's scalable and repeatable for years to come.

The more we talk about Trilogy as an operator, I think the more you peel back the layers, and you hear kind of these anecdotal things where in almost every operational category you can think of, they've figured out a way or they're further ahead than everybody else in optimizing it, and partially because they're really good, and partially because they've been doing it for 30 years. And you learn from the mistakes as you go, and you just get better, and once you do it better in one facility of your 130, you can roll it out to the rest of them and optimize the performance.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

So, so what is it? I mean, labor has clearly been, you know, a challenge for the industry, you know, through COVID, coming out of COVID. You know, how did Trilogy fare, I guess, through that period, and what have they done to, you know, stand out relative to the industry overall, to the point that they're already there from a, you know-

Danny Prosky
President and CEO, American Healthcare REIT

Yeah

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

nursing hours perspective?

Danny Prosky
President and CEO, American Healthcare REIT

Yeah. So they were at an advantage because of what Gabe mentioned about their turnover. Their turnover is about 42% a year. I think the industry is closer to 100%. What Trilogy was able to do is they formed what's called their Flex F orce, and they, you know, back when COVID hit, you kind of saw what was happening with agency nursing. Trilogy realized early on that, hey, you know, we cannot just rely on outside agencies, so they created their own in-house agency. So they've got a team of 100+ nurses located around the four-state region where they operate, that are paid a little bit more than a regular Trilogy nurse, but, you know, maybe 10, 15% more, not 2x-3 x. And they're available to loc- to.

And by the way, when I say travel, we're talking about driving for the most part. It's not like they need to get on a plane and get a hotel necessarily. They will go out on an as-needed basis to cover any kind of shifts where there's a shortfall. Because of that, Trilogy hasn't relied on its outside agency nursing since the height of COVID, I think in 2020, maybe early 2021. Not only is it better from a cost perspective, but it's better from a labor perspective as well. You don't have the animosity between the existing staff who has to train the temporary staff, and then that temporary nurse is making 2x-3 x what they make.

The nurse that shows up is part of the Trilogy family, knows the Trilogy systems, knows where everything is. That travel nurse can show up and be productive immediately. It's not like they need to be taught what to do. But they're able to do that because of their size and scale and regional concentration.

Gabe Willhite
COO, American Healthcare REIT

Mm-hmm.

Danny Prosky
President and CEO, American Healthcare REIT

So it's that, as well as their culture. They're able to promote people. You know, Trilogy expands annually, right? They add new campuses, or they expand their campuses. They're able to provide growth for employees. So you may, you know, enter their administrator-in-training program, which is a 12-18-month program, and then when you finish that program, you're gonna have an opportunity, right? Maybe there'll be a new campus opening up where you can come in there as an assistant administrator. Maybe the administrator in your building will move over to the new campus, which is pretty typical, and you can take over at that existing campus. There's lots of opportunities to grow. Every time we tour Trilogy, well, a lot of times we'll go out and see a new campus, and you meet the staff.

It's someone who started out- I mean, sometimes they started out, you know, bussing tables-

Gabe Willhite
COO, American Healthcare REIT

Hmm

Danny Prosky
President and CEO, American Healthcare REIT

30 years ago.

Gabe Willhite
COO, American Healthcare REIT

Awesome.

Danny Prosky
President and CEO, American Healthcare REIT

Now they're an assistant administrator. They've gone through all the training. They've worked at, you know, several facilities. They don't necessarily have to get up and move their family, right? They've got facilities within driving distance, and it's just a great opportunity, and Trilogy's been able to take advantage of that.

Gabe Willhite
COO, American Healthcare REIT

And one more point on that before we leave it, because I think, I don't wanna get lost. So we get a lot of questions about the regional concentration at Trilogy and being in the Midwest and picking Indiana, Kentucky, Ohio, Michigan, where they focus. And that would probably not be on anybody's list of, raise your hand, of your preferred market to enter and say, this is the most ideal market with the highest median income, the highest home prices, and everything like that.

I understand that, but what you have at Trilogy is an operator that's got the scale and concentration within a region that unlocks those opportunities, that de-risks it in a way that if you just focus purely on geography and state, you're gonna miss the point that having this presence all so concentrated in a, in one spot allows you to have a Flex F orce that can travel, allows you to train EDs from within your system that have been with the program for 20 years and open up new buildings, allows you to have a SWAT team that goes out and opens up your new developments and can do the sales, all from the mothership that's, you know, two hours away from most of your locations.

That is a significant advantage, and one that's probably not repeatable if you try to have a national footprint.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

Maybe that's a good segue, just talking about the fact that Trilogy draws from various payer sources, you know, one of which is, you know, government and, you know, federal government and state reimbursement. Maybe just talk about the reimbursement landscape and just how you guys feel about, you know, the states that they operate in, and then just more broadly.

Danny Prosky
President and CEO, American Healthcare REIT

Sure. So, you know, it's a wide range, right? And we actually publish, you know, our rates. You know, we talk about RevPOR on the AL-IL side, but on the skilled side, we actually show the daily rates, which is typically how you look at it from a skilled perspective. So they've got, you know, Medicare, Medicare Advantage, they've got Medicaid, they've got a lot of private pay, a lot of private insurance within their skilled. They've got a much higher quality mix than the industry as a whole. And, you know, it's been a good environment the last few years, not just because the reimbursement increases have been strong, both at the federal and state levels, but because we've seen a movement away from typical reimbursement.

We had PDPM, right, which has been very good for Trilogy, but you've seen a move towards value-based care, and Trilogy's been able to, you know, because they've got better staffing, they've got better outcomes, less recidivism, they've been able to increase their rates at a much faster pace than the typical increases that we've seen across the industry. And even on Medicare Advantage, which, you know, is typically a little bit lower rate than regular Medicare, it's shorter lengths of stay, if they don't like the Medicare Advantage rate with any particular, you know, insurer or system, they'll opt out of it. They won't participate in it. And they'll still get a lot of residents because, people demand Trilogy, and the Medicare Advantage systems will, or networks will negotiate with Trilogy outside of network.

But they're, you know, they're able to pick and choose, you know, who they wanna work with, and they'll only work with those networks that reimburse them accordingly.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

Yeah. So you guys have a majority stake within Trilogy, and can you just speak to, as the real estate owners, the importance of that investment, and then maybe also talk a little bit about this purchase option that you have to acquire the remaining stake within the operator?

Danny Prosky
President and CEO, American Healthcare REIT

Yeah. So our ownership structure on Trilogy is a little bit atypical. It's a RIDEA structure. There is an EIK called Trilogy Management Services. However, you know, they don't really manage for other owners, with the exception of what they need to do in order to maintain EIK status. They manage pretty much for us. There's a board of directors that we control. We have investment committee that we run every six weeks. We are very, very close. At Trilogy, it's not a typical kind of vendor-client relationship that you see within RIDEA. It's much more of a they look at us as a capital partner, is really how they look at it. Their senior management team has an STIP, a short-term incentive plan, and a long-term incentive plan.

Very similar to the ones we have. The, you know, the STIP is based on meeting metrics, such as budget, et cetera. The LTIP is a three-year look back on FFO growth, margins, et cetera. Very similar to what we have in our plan. So they are really focused on bottom line at Trilogy. Clearly, you know, good care comes first, but they are incentivized to focus on overall company performance, and not just top-line revenue. As far as the purchase option, we own 76% of Trilogy. We own it in a joint venture structure, along with another REIT called NorthStar Healthcare Income. They're in liquidation mode. Their goal is to liquidate the company by the end of next year.

So about a little more than six months ago, we entered into a purchase option agreement with them to buy out the 24% that we do not own. That has a fixed price. I mean, the price does increase a little bit over time, but it's a fixed dollar number. It's not a cap on NOI or anything like that. We've got a lot of flexibility there, not just on time. You know, as I mentioned, we've got, you know, well over a year to exercise that, a year and four months. We have till September of next year. We can do it through cash, preferred. We can do it through a combination of those two things. Our goal, you know, we intend to exercise that purchase option at some point.

It is very, very accretive to our earnings. We want to own 100% of Trilogy. The price is fixed, so all of the growth at Trilogy will inure to us, regardless of when we exercise that purchase option. That being said, as Brian will tell you, if he, y ou know, he's getting over a cold, so he's a little bit hoarse. You know, we did this IPO. We raised a lot of money. We dropped our debt multiple down to into the low sixes, which is kind of where we want to be. We're not interested just turning around and borrowing and having that multiple go back up. So we're gonna, you know, continue to cull our portfolio. We continue to expose medical outpatient buildings to the market.

Most of what we sell is kind of the smaller, off-campus stuff that we're less excited about. Our EBITDA growth has been very, very strong. If you take a look at the slides that we posted, we've shown very good growth over the last year, so far this year, and our hope and expectation is that will continue, and we expect that we will be able to buy out that 24%. And maybe we, you know, issue more shares this year or next year. Our expectation is we'll exercise that purchase option, and we will do so without just levering up.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

That's great. We're quickly running out of time here, actually, and time flies when you're talking healthcare real estate. I would like to open it up to anybody that does have any questions from the audience.

Gabe Willhite
COO, American Healthcare REIT

You nailed it, Danny. Good job.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

I was going to say-

Danny Prosky
President and CEO, American Healthcare REIT

You rocked it.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

Maybe, maybe we'll talk a little bit more broadly on just capital allocation here, because you hit on obviously one of the main priorities, which is the Trilogy purchase option. But given where your cost to capital is, how are you thinking about capital allocation, and what's, you know, really the most attractive to you beyond the purchase option?

Danny Prosky
President and CEO, American Healthcare REIT

Yeah, so clearly, our capital is limited, right? I mean, our expectation is our stock will, you know, re-rate in the future as we continue to meet our earnings guidance and maybe even exceed it, which is our hope. That being said, you know, we have to look at what the best risk-adjusted return opportunities are for us today. You know, right now, those are within Trilogy, not just the purchase option, but I mentioned the Trilogy Villas. We continue to, w e've got five projects that we started on building the Trilogy Villas. These are duplexes that are adjacent. We already own the land. These are adjacent to Trilogy facilities. They're very, very popular. They lease up. It's about a 12-month build, so you build them quickly, and they lease up immediately.

They're typically leased prior to construction being complete, and the yields on those meet our criteria as far as, you know, they exceed our cost of capital. So we're doing some of those. Trilogy expansions, Trilogy campuses are built to be expanded if there's demand. So if you've got a building where the AL is full with a waiting list or the skilled is full with a waiting list, it's very easy to add on to the wings. The wings basically end, and you can add on to them. So we continue to do those. Those exceed by a wide margin our cost of capital. You know, we have built, developed a lot of Trilogy campuses over the last few years. You know, construction costs have gone up.

The yields on those still exceed our cost of capital with a pretty good margin. That being said, you know, they take longer to build, and they take longer to fill up. So there's a little bit higher risk than, say, the IL villas. So I think, you know, we're planning on slowing down the new campus developments. We'll probably, you know, instead of doing two to four a year, I think you'll see us do one a year for the time being until, you know, either our cost of capital comes down, or, you know, the returns increase back to where they were prior to the increase in construction costs. So long as we have so many opportunities within Trilogy outside of new campus development, you'll probably see us focus more on those.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

Maybe just sneak in the last one here. Just kind of curious where the dividend fits within sort of your capital allocation, and then how are you thinking about the balance sheet in general from a leverage perspective? And certainly, the IPO, you know, brought down leverage, but where you'd like to be, you know, over time.

Brian Peay
CFO, American Healthcare REIT

I thought I was just here for window dressing. Fair, fair point. The dividend is not quite fully covered in 2024. We anticipate that with the organic earnings growth that's embedded in our portfolio, that it will be covered in 2025.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

By the way, it's AFFO you're talking about.

Brian Peay
CFO, American Healthcare REIT

Yeah, after AFFO. On NFFO, it's fully covered. So the thought was, did it make sense to cut the dividend in 2024, simply to go back and raise it out in 2025? As Danny had mentioned, we were very mindful of the balance sheet. We worked very hard to get our debt to EBITDA down in the 6s. We're quite comfortable in the mid-5s to low-6s times, and so, you know, we're protective of that. We know that the best-traded REITs have the highest multiple, that have low leverage. It's also important to be able to grow externally, but at our current cost of capital, we're not anticipating doing a lot of that.

The thought is that we will re-rate, and that the stock will be a better reflection of the true value of our portfolio. And, we're in a little bit of a prove-it phase, which we fully understand, and our numbers hopefully will speak for themselves.

Austin Wurschmidt
Analyst for the Healthcare, Residential, and Lodging REITs, KeyBanc Capital Markets

Well, I wanna thank everybody for coming today. I don't know if you have any closing remarks that you'd like, but I'll pass it back to you, Danny, and-

Danny Prosky
President and CEO, American Healthcare REIT

I just want to thank everybody for coming. You know, you know, I think we're a little bit over our time, but we appreciate it. Appreciate your interest in American Healthcare REIT. We look forward to a very good rest of 2024 and 2025, and look forward to seeing everybody at the next NAREIT.

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