PRESENTATION TO: Puerto Rico Hospital Association April 26, 2011 Table of Contents Alternative Structures Update FHA Office of Healthcare Programs AMS Health Care Mortgage Corporation, An Approved FHA Mortgagee 1 Alternative Structures Update Section I 2 Alternative Structures Update Temporary measures created by American Recovery and Reinvestment Act (ARRA) and other congressional action have largely expired Build America Bonds • Taxable bonds with 35% subsidy Bank Qualified Bonds • Limits reverted to lower levels ($30mm vs $10mm) • Per bond issuer not borrower Federal Home Loan Bank • Can no longer support tax-exempt hospital financing USDA available funding amount has reverted to previous levels 2009 – 2010 were quadruple previous years FHA implements refinancing program for hospitals 3 Alternative Structures Update USDA Financing Options Project must be in town or rural area with up to 20,000 population Grants Direct Loan Program • Typically $1 – $3 million (Largest was $31 million) • Historically limited availability • 4.25% ; 40 year amortization Guaranteed Loan Program • Federal/state budget allocations generally limit to $10 million but may be larger • US Government guarantees 90% of the loan • 25-30 year amortization 4 FHA Office of Healthcare Programs Section II 5 FHA’s Office of Healthcare Programs Section 242 – Office of Hospital Facilities Section 232 – Office of Residential Care Facilities MISSION: To enable the affordable financing of needed health care facilities, thereby improving access to quality health care nationwide and contributing to HUD's community development goals, at no cost to the taxpayer. 1 6 Definition of Terms HUD U.S Department of Housing and Urban Development FHA Federal Housing Administration 242 Section 242 of the National Housing Act (NHA) gives HUD/FHA the authority to insure mortgages for acute care hospitals. 232 Section 232 of the National Housing Act (NHA) gives HUD/FHA the authority to insure mortgages for nursing homes, assisted living, and other long-term care residential facilities 223 (f) Section 223 (f) of the NHA Act gives HUD/FHA the authority to insure mortgages for 100 % refinancing loans pursuant to 242 and 232 241 Section 241 of the NHA gives HUD/FHA the authority to insure mortgages for supplemental loan for HUD portfolio hospitals. 2 7 Program Accomplishments Support HUD’s mission, the Secretary’s goals, and the Commissioner’s priorities – for example: Run programs that complement President’s healthcare agenda — Reduce cost of care and increase accessibility – Allow borrowers to achieve at least an AA credit rating Strengthen communities - healthcare facilities are economic engines — Employ 7.9 million, support $2.7 trillion in economic activity nationwide — FY10 FHA hospital projects: 15,700 jobs, $3.9 billion in economic stimulus — Improve access to quality healthcare 3 8 Hospitals That Use FHA FHA serves hospitals Capital Health System Trenton NJ $755.9 million mortgage 9 9 nationwide Acute care hospitals Rural and Critical Access Hospitals Large urban teaching hospitals University hospitals Not-for-profit, for-profit, and government-owned hospitals Borrowers include small critical access hospitals… Rio Grande Hospital (CAH) Del Norte, CO $11.9 million insured mortgages 10 …and large urban hospitals. Hospital for Special Surgery New York, NY 11 Coulee Community Hospital Grand Coulee, WA North Valley Hospital Whitefish, MT HOSPITAL BUSINESS Barrett Hospital and Healthcare, Libby, MT Highline Medical Center Burien, WA FY05 to date Baraga County Memorial Hosp L’anse, MI Stillwater Community Hosp, Columbus, MT Santiam Memorial Hosp. Stayton, OR Ridgecrest Regional Ridgecrest, CA The Memorial Hospital Craig, CO Kennewick General Hospital, Kennewick, WA North Canyon Medical Center Gooding, ID Fall River Health Services Hot Springs, SD Melissa Memorial Holyoke, CO Meadows Med. Center, North Las Vegas, NV Community Memorial Hosp. Ventura, CA) Mercy Hospital Chicago, IL Hayes Green Beach Hosp., Charlotte, MI Hudson Valley Courtland Manor, NY Hospital for Special LRGH Surgery Healthcare New York, NY Laconia, NH Kaleida Health System Buffalo, NY (3) FF Thompson Hospital Canandaigua, NY Mendota Community Edgerton Hosp. Edgerton, WI Hospital Mendota, IL Cambridge Memorial Hospital, Cambridge, NE Carlinville Area Hospital, Carlinville, IL Pinckneyville Community Hosp. Pinckneyville, IL Chambers Mem.Hosp. Danville, AR Montefiore Med Ctr Bronx, NY (2) Unity Hospital, Rochester, NY Ellis Hospital, Schenectady, NY Kirby Hosp Monticello, IL Allen Memorial Hospital Moab, UT Blue Mountain Hosp. Blanding, UT Methodist Hospital Arcadia, CA Albany Med Center Albany, NY Oswego Hospital Oswego, NY Bucyrus Hosp. Bucyrus, OH (2 ) Wheeling Hosp., Wheeling, WV New York Hosp Queens, NY Western MD Health System Cumberland, MD Capital Health Systems, Trenton NJ New Regional Med. Ctr., East Norriton, PA Wills Memorial Hosp Washington, GA Onslow Memorial Hospital Jacksonville, NC Hillcrest Baptist Med Ctr Waco, TX Parkview Hospital, Riverside, CA Rio Grande Hosp. Del Norte, CO Johnston Memorial Smithfield, NC Morehead Memorial Hosp. Eden, NC Guadalupe Regional Medical Center Seguin, TX Sandoval Regional Med Center, Rio Rancho, NM University of New Mexico, Albuquerque, NM Baptist Hosps SE Texas Beaumont, TX Platte Valley Hospital Brighton, CO Commitments/Insured Loans (55) [18] Applications in Process (7) [3] Pending Applications (15) [3] Red = Critical Access Hospital Loris Healthcare System Loris, SC Summit Hospital Phenix City , AL Valley Baptist Med Center, Harlingen and Brownsville, TX St. Luke's Roosevelt NY, NY NY Presby Hosp NY, NY Lakeway Regional Med Center, Lakeway, TX 12 Rowan Regional Hosp. Salisbury, NC Neshoba County General Hospital, Philadelphia, MS Delta Regional Med Ctr Greenville, MS Meadows Regional Med Ctr Vidalia, GA Matagorda County Baton Rouge General Medical Center Baton Rouge, LA Hospital District, Bay City , TX Medical Univ. of S. Carolina Charleston, SC Chatham Hospital Siler City, NC Effingham Hosp. Springfield, GA Mennonite General Hospital Cayey, PR 3-27-10 History of Office of Hospital Facilities Organization Transition from HHS completed 4 years ago Turnaround Team initiated 3 years ago New organization – Office of Hospital Facilities within Office of Healthcare Programs – established 2 years ago Divisions for Underwriting and Asset Management established one year ago Volume 80% of all insured loans added in last 8 years 13 Office of Hospital Facilities Qualifications 14 8 10 1 25+ Former Health Care Executives, including: - 8 former health care system executives Former Business Executives Professional Society Fellows Former State Finance Authority Executive Graduate Degrees, including: - 2 Juris Doctors - 20 Masters (11 MBAs, 9 MPHs) 6 1 1 Accountants / CPAs Professional Engineer Registered Nurse 14 Office of Healthcare Programs Organization Chart Secretary of Housing and Urban Development Appointee Level Assistant Secretary of Housing / FHA Commissioner Healthcare Programs Deputy Assistant Secretary for Healthcare Programs ----------------------Associate Deputy Assistant Secretary Deputy Assistant Secretary for Risk Management Council of Experts - 4 Consultants Section 232 OAE Policy and Continuous Improvement Advisor Health Systems Advisor Director, Office of Architecture and Engineering Director, Office of Hospital Facilities Director, Underwriting Risk Management Special Assistants Administrative Staff Director, Office of Residential Care Facilities Section 242 Director, Asset Management Team Leader, Turnaround Team 15 Section 232 Program FHA insures mortgages on Nursing Homes, Intermediate Care, Assisted Living , and Board and Care Facilities under the Section 232 of the National Housing Act. — Over 2,500 facilities presently insured under this program — The facilities are located in 49 states, the District of Columbia and the Virgin Islands. Over $16.0 billion in mortgages are insured under this program 15 16 242 Program Performance Insurance Commitments Issued (cumulative) Billions ($) 9 • Since 1968, over 400 commitments totaling over $17 billion $7.93 8 7 $6.21 • Currently, over 110 insured loans 6 totaling over $9 billion $5.13 5 $4.41 $3.76 4 operates at no cost to the taxpayer $2.82 3 $2.03 2 1 • Low default rate– program • Reduced processing time– 9.5 months to 3 months $0.70 $0.30 $0.45 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 • LEAN Office process streamlining 17 242 Program Performance Portfolio Overview at end of FY 2009 Total Loans Outstanding 97 Total Dollars Outstanding $8.3 Billion Average Loan Size $83 Million # of Hospitals in Portfolio 77 # of Hospitals Troubled* 9 Unpaid Balance Troubled (%) $309 Million (3.7%) Claims 2000-2010 4 Claim Rate Net of Recoveries 0.64% *Troubled hospitals place on Priority Watch List and assigned to Hospital Turn Around Team. 18 242 Program Performance As demand has increased, a lower percent of potential applicants has passed initial screening. Preliminary Reviews Completed FY Total Approvals % Approved 2007 11 8 73% 2008 30 21 70% 2009 43 20 47% 19 Economic Stimulus and Job Creation Economic activity generated during construction ≈ $3.9 Billion Construction jobs created ≈ 4,700 Hospital jobs from the projects ≈ 2,500 Community jobs after projects ≈ 8,500 * Results from IMPLAN Model 20 Attractive Program Features • • • • No maximum loan amount Loan term up to 25 years FHA insures 99% of mortgage Fixed annual premium of 0.5% of remaining balance • One-time fees of 0.8% • Section 241 supplemental loan advantage 14 21 FHA pre-qualification requirements Needed and necessary community institution Three year average profit margin > 0% Three year average debt service coverage ratio ≥ 1.25x Ability to mortgage assets Loan-to-value less than 90% 22 Advantages of FHA Insured Mortgages No affirmative ongoing financial covenants (no minimum Debt Service Coverage Ratio (DSCR), operating margin, or days cash on hand) Closing costs are financed in the mortgage High maximum Loan-to-Value ratio (up to 90% of replacement cost) Loan is non-recourse Loan is assignable Pre-payment restrictions (non-call period or “lock-out”) match bonds or GNMA funding agreements 23 FHA Timeline Preapplication Pre-Application Period: 14 to 230 todays 4 weeks Application HUD Review Application Preparation cycle: 12 HUD time: 12 to 14 weeks Preparation 10 Review 4days weeks to 12 weeks to 6 weeks HUD Risk Review 4 weeks Funding 4 to 8 weeks A/E Drawings: Schematic Design Design Development Working Drawings Site Work Supervision Construction Manager Selection Part A - Value Engineering Part B - GMP Mobilization and Site Preparation Early Start of Construction Financial Feasibility Consultant Selection Financial Feasibility Study Feasibility Sensitivity Studies Respond to questions Agreed Upon Procedures Preliminary Mortgage Sizing 2013 Application Mortgage Sizing 2013 Modified Mortgage Sizing 2013 Modified Mortgage Sizing 2013 Final Mortgage Sizing 2013 HUD Need Tool Previous Participation 2530 Proposed Covenants Modified Covenants Funding Source Level 1 Report Environmental Assessment Special Conditions Modified Special Conditions Closing 24 The application process is complex, the bond rating the highest, and FHA a “relationship lender” The application process to obtain a Commitment to Insure is complex If FHA agrees to insure the loan, the debt obligations would be highly rated. Tax-exempt or taxable bonds would carry an “AA” rating at minimum. GNMAs issued to fund the loan would carry a rating of “AAA”. FHA is a “relationship lender” that would not attempt to force a borrower out of the program. FHA takes a practical and helpful stance should the Project become troubled. 25 The Borrower applies to the mortgage lender for an Insured Loan HUD Borrower GNMA securities Mortgage Lender Tax-exempt bonds Mortgage Loan 26 Tax-exempt bond funded FHA Insured Mortgages are “structured financings” In the late 1970’s, investment bankers developed a methodology to use the FHA Mortgage Insurance benefits as “collateral” for the issuance of taxexempt bonds. HUD does not insure bonds FHA Tax-exempt bond issues are “collateralized mortgage obligations”, that is the FHA insurance benefits are used to assure payment on tax-exempt bonds All of the standard components of an FHA Insured Hospital mortgage loan exist 27 The collateralized mortgage obligation structure adds complexity in exchange for a lower mortgage rate Authority Borrower HUD Mortgage Lender/ Trustee Underwriters LOC Bank Bond Proceeds Mortgage Loan 28 Case Study • • • • • Borrower: Mennonite General Hospital (est. 1948) Borrower Type: Acute Care Hospital System Borrower Locations: Cayey (155 Beds), Aibonito (150 Beds), Cidra Par Amount: $129,966,100 Deal Uses: Refinancing, Renovations, 61-bed Addition, Garage Addition, HVAC conversion to water cooled chillers • • • • • Deal Structure: FHA 242 GNMA Enhancement: FHA 242 Mortgage Insurance Rating: AAA (S&P) Term/Amortization: 25 Years Notes: — MGH sponsors two Section 202 Elderly Housing Projects (Casa Aibonito and Casa Barranquitas) — MGH Sponsors a HUD Section 811 project for persons with disabilities (Aurora Home) — First 242 deal in Puerto Rico since 1985 — Seven 242 deals have been funded in Puerto Rico since 1973 29 Recent Transactions $129,966,100 FHA / GNMA Insured Mortgage Loan January 20, 2010 Mennonite General Hospital in Cayey, Puerto Rico retained AMS to refinance its non-investment grade tax-exempt bond debt, approximately $48,000,000, and expand one of its three hospitals for a total FHA Insured Mortgage Financing of $129,966,100. Mennonite has served the people of the central highlands of Puerto Rico for 65 years as the near sole provider of medical care. Begun as an outpatient clinic, Mennonite has grown to three hospitals, a major outpatient treatment center, three HUD housing facilities for the aged, including a section 811 facility for the disabled elderly. Operating their newest hospital, completed in 1998, at over 100% occupancy required Mennonite to add a major expansion project. Concerned with the rising cost of energy, the proposed Project also included conversion of air-cooled chillers with water cooled equipment. Mennonite also operates a health plan and manages three 24-hour emergency rooms for the Government of Puerto Rico. Mennonite funded its FHA Insured Hospital Mortgage loan with GNMA Securities. 30 Recent Transactions $196,920,400 FHA Insured Tax-exempt Mortgage Revenue Bonds November 5, 2010 The Unity Hospital of Rochester is the acute care provider of Unity Health System, a network of senior care services located in western Monroe County, New York. The proposed project is an addition and total renovation of this 1974 hospital. Upon project completion, Unity will be state of the art. The complex nature of the construction of additions to and total renovation of an operating hospital while it remains in full service added to the necessity of close cooperation between the construction project team, the financing team, and required significant coordination with the New York State Department of Health. AMS worked closely with one of the leading underwriters of municipal bonds to achieve a timely and cost effective financing for Unity. A pre-existing Section 232 financing for a sister company presented some special opportunities to work closely with the two divisions of the HUD Office of Healthcare Programs: hospitals and nursing homes. 31 Recent Transactions $755,874,500 FHA / GNMA Insured Mortgage Loan April 7, 2009 AMS staff served as mortgage banker to Capital Health System (CHS) is a two-hospital system with both of its primary acute care hospitals located in urban neighborhoods. CHS had limited ability to expand or replace either of its two hospital campuses. CHS identified three potential Greenfield sites suitable to build a replacement hospital for its Mercer campus. The proposed project with an estimated cost of approximately $650 million would include a new 230bed acute hospital, medical office building and central energy plant. This coupled with the approximately $200 million of refinancing resulted a total project requirement of approximately $880 million. Once CHS had obtained its mortgage insurance commitment, December 2008, for $755,874,500, a funding source became the next key decision point: taxable or tax-exempt. Reinvestment rates were at an all time low, resulting in over $50 million of expected negative arbitrage. The capital markets had collapsed. It was decided by the project team that the best use of the mortgage insurance commitment would be through a taxable GNMA funding. The GNMA option eliminated the negative arbitrage on the construction portion of the loan, did not require a Debt Service Reserve Fund, bond ratings, an Official Statement, or an issuing authority. 32 Recent Transactions $422,060,000 FHA Insured Mortgage Hospital Facilities and Revenue Refunding Bonds December 2004 AMS staff was mandated to assist by Medical University Hospital Authority (MUHA) of South Carolina in Phase I of its replacement project. MUHA is an instrumentality of the State of South Carolina, created to operate the teaching hospitals of the Medical University of South Carolina (MUSC), the oldest medical school in the South, founded in 1824. MUHA was founded to move the hospitals of MUSC out of the governmental sector and into the not-for-profit arena. South Carolina has been growing recently through an influx of retirees from the Northeast, who expect and demand access to high quality academic medical centers. The MUSC hospitals had operated at a loss for a considerable time, with limited access to capital and tired facilities. MUHA changed the operating result and now need to change the facilities. October 2002, AMS began developing a plan to utilize FHA242 Mortgage Insurance to fund Phase I of an ambitious $900 million total replacement and expansion plan for MUHA. In December 2004, MUHA funded its capital needs through a taxable and tax-exempt bond issue, $61,000,000 Central Energy Plant, and $50,000,000 tax-exempt equipment lease. 33 AMS Health Care Mortgage Corporation FHA Licensed Mortgagee Section II 34 AMS Health Care Mortgage Corporation is a FHA approved lender committed to meeting the capital needs of hospitals Founded in 2008, AMS’s staff consists of seasoned professional staff with 97 years of mortgage banking and real estate experience. We have completed 3 FHA hospital mortgage insured transactions valued at $1.2 billion in the past three years. AMS brings an independent view to the table and is committed to providing a financing tailored to the needs and priorities of Clients. Our experience will make a complex process understandable and manageable for your clients. 35 AMS is a leader in FHA hospital finance 2009 and 2010 Mortgage Banking Rankings Rank Firm Volume % 1 2 3 4 5 6 7 8 9 10 11 12 AMS 1,082,761,000 38.6% 16.9% 12.8% 10.4% 6.0% 5.7% 3.0% 2.7% 2.2% 1.3% 0.1% 0.1% 100% Tyll & LaVigne Bank of America Goldman Sachs Walker & Dunlop Lancaster Pollard Innovative Capital Dougherty Berkadia Red Capital Column Guaranteed Capmark Finance 473,815,900 359,156,000 292,500,000 168,372,800 159,176,200 84,755,000 76,650,000 63,000,000 36,175,000 2,985,700 2,345,000 2,801,692,600 Source: Hud, for Gov't fiscal years ended 9/30/2009 and 9/30/2010 $196,920,400 $755,874,500 36 $129,966,100 THANK YOU www.amshcm.com 37 Resumes Resumes Appendix A 38 Financing Team Experience Joseph A. Spiak President AMS Health Care Mortgage Corporation Mr. Spiak has been active in the field of healthcare administration and finance for over 30 years. He began his healthcare career in the US Army, serving in the Medical Service Corps, at several assignments including the First Infantry Division, First Medical Battalion. As a graduate of the Columbia University School of Public Health, Joe did his residency at Montifiore Medical Center, New York, Department of Community Medicine. For seven years he served as Director of Planning, United Hospital, Port Chester, New York. It was at United that Joe was introduced to the FHA Section 242 Mortgage Insurance program. Acting as United’s point person for the financing, he organized the application and approval process. United had the distinction of being the first publicly offer FHA/GNMA tax-exempt hospital issue. From United Joe moved to Merrill Lynch, where he spent 18 years in Healthcare Public Finance and continued a career of completing 242 insured mortgages, note worthy was the then largest FHA insured transaction, Buffalo General Hospital, $210 million. His career has included all types of hospital financing including Merrill Lynch’s first fixed to floating swap. In 2000 Joe joined Banc of America Securities and as head of its Healthcare Finance Department and established an FHA insured hospital mortgage program. The $422 million Medical University Hospital Authority, Charleston, SC, financing was the flagship deal for Banc of America Securities. In 2004 Joe joined UBS Investment Bank, where he established an FHA Hospital Mortgage funding program. In 2008 Joe established AMS Health Care Mortgage Corporation, to provide FHA mortgage banking services to select hospitals and health systems. 39 Financing Team Experience James H. Cooper, Jr. Senior Vice President AMS Health Care Mortgage Corporation Mr. Cooper joined AMS in 2009 as Senior Vice President. Mr. Cooper has completed more than $2 billion of tax-exempt and taxable financings for healthcare organizations and facilities serving the needs of America's senior population. He has extensive experience executing complex transactions utilizing a variety of financing modes and structures, including letters of credit, bond insurance, credit ratings, unenhanced non-rated structures, taxable and tax-exempt seed capital, and derivatives. Prior to joining AMS, he was an Executive Director in the Healthcare group at J.P. Morgan where he led the firm’s senior living effort. Previously, Mr. Cooper was a Senior Vice President with Herbert J. Sims & Co. where, in addition to traditional bond underwriting, he oversaw the firm's risk management activities successfully structuring nearly $1 billion of hedging and reinvestment transactions. Mr. Cooper earned a B.A. from Washington & Lee University, and a M.A. from the Monterey Institute of International Studies. 40 Financing Team Experience John T. Sefton Senior Vice President AMS Health Care Mortgage Corporation Mr. Sefton served as a partner for 23 years with the national law firm of Foley & Lardner LLP. His practice included financings, securitizations, commercial real estate loans, negotiated acquisitions and bank regulatory work. Mr. Sefton was also a member of the senior living practice group, and participated in loans and workouts for continuing care retirement communities. Mr. Sefton received his BA degree magna cum laude from Vanderbilt University in 1971, and his juris doctor degree from Yale Law School in 1974. He is a member of the bar of the United States Supreme Court and the Fifth and Eleventh Circuit Courts of Appeals. Mr. Sefton was selected as Trustee of the Year by each of the Florida Association of Homes and Services for the Aging and the American Association of Homes and Services for the Aging. He currently serves as chairman of the board of directors of Cathedral Gerontology Center, a 120 bed skilled nursing facility, located in downtown Jacksonville, Florida. 41 Financing Team Experience Maura E. Davalos Vice President AMS Health Care Mortgage Corporation Ms. Davalos joined AMS in July 2008. Ms. Davalos assembles the Pre- Application and FHA Application and monitors the information flow with the various divisions of HUD. Ms. Davalos joined Banc of America Securities in Healthcare Finance Department in 2000 and has assisted in the development of the Healthcare Finance Department of Banc of America Securities. In 2004 Maura joined UBS Investment Bank, and assisted Mr. Spiak, where he established an FHA Hospital Mortgage funding program. Ms. Davalos has worked on a substantial number of healthcare engagements including MUHA, Mennonite General, and Capital Health System. Specializing in the preparation of all phases of the FHA hospital mortgage insurance application process, Ms Davalos has completed FHA 242 screenings, Pre-Applications, Applications, organized HUD site visits and maintained day-to day contact and working relationships with HUD OIHCF staff. Ms. Davalos is continuing her formal education at Florida State University at Jacksonville. 42