The medical office sector is undergoing significant changes driven by long-term demographic trends and near-term reforms under the Affordable Care Act. Over the next decade, baby boomers will increase the senior population to over 20% of the total, driving substantial growth in demand for healthcare services. The ACA aims to reduce costs through measures promoting consolidation and integration among providers and insurers. This is accelerating the trend of smaller physician practices being acquired by larger healthcare systems. Overall, these changes are reshaping the delivery of healthcare and the real estate needs of the medical office sector.
Mercer Capital's Value Focus: Healthcare Facilities | Mid-Year 2014Mercer Capital
Mercer Capital's Healthcare Facilities Industry newsletter provides perspective on valuation issues. Each newsletter also includes a macroeconomic trends, industry trends, and guideline public company metrics.
A selection of key indicators from "Health at a Glance 2019: OECD Indicators", released on November 7, 2019. More info at http://www.oecd.org/health/health-at-a-glance.htm.
Mercer Capital's Value Focus: Healthcare Facilities | Mid-Year 2014Mercer Capital
Mercer Capital's Healthcare Facilities Industry newsletter provides perspective on valuation issues. Each newsletter also includes a macroeconomic trends, industry trends, and guideline public company metrics.
A selection of key indicators from "Health at a Glance 2019: OECD Indicators", released on November 7, 2019. More info at http://www.oecd.org/health/health-at-a-glance.htm.
In Healthcare, we provide detailed analysis and projections of healthcare fields, occupations, and their wages. In addition, we discuss the important skills and work values associated with healthcare fields and occupations. Finally, We analyze the implications of our findings for the racial, ethnic, and class diversity of the healthcare workforce in the coming decade.
Social Health Insurance vs. Tax-Financed Health Systems—Evidence from the OECDEyesWideOpen2008
A WHO study that proves that Social Health Insurance healthcare systems DO NOT WORK.
It increases costs, have no positive effect on national health, and even has negative effects on employment and some areas of health.
National Health Care Reform: The Proposals and the Politicssoder145
Presentation by Elizabeth Lukanen at the University of Minnesota Academic Health Center's Student Leadership Summit in Minneapolis, MN, December 5, 2009.
This fourth edition of Health at a Glance: Europe presents key indicators of health and health systems in the 28 EU countries, 5 candidate countries to the EU and 3 EFTA countries. This 2016 edition contains two main new features: two thematic chapters analyse the links between population health and labour market outcomes, and the important challenge of strengthening primary care systems in European countries; and a new chapter on the resilience, efficiency and sustainability of health systems in Europe, in order to align the content of this publication more closely with the 2014 European Commission Communication on effective, accessible and resilient health systems. This publication is the result of a renewed collaboration between the OECD and the European Commission under the broader "State of Health in the EU" initiative, designed to support EU member states in their evidence-based policy making.
In Healthcare, we provide detailed analysis and projections of healthcare fields, occupations, and their wages. In addition, we discuss the important skills and work values associated with healthcare fields and occupations. Finally, We analyze the implications of our findings for the racial, ethnic, and class diversity of the healthcare workforce in the coming decade.
Social Health Insurance vs. Tax-Financed Health Systems—Evidence from the OECDEyesWideOpen2008
A WHO study that proves that Social Health Insurance healthcare systems DO NOT WORK.
It increases costs, have no positive effect on national health, and even has negative effects on employment and some areas of health.
National Health Care Reform: The Proposals and the Politicssoder145
Presentation by Elizabeth Lukanen at the University of Minnesota Academic Health Center's Student Leadership Summit in Minneapolis, MN, December 5, 2009.
This fourth edition of Health at a Glance: Europe presents key indicators of health and health systems in the 28 EU countries, 5 candidate countries to the EU and 3 EFTA countries. This 2016 edition contains two main new features: two thematic chapters analyse the links between population health and labour market outcomes, and the important challenge of strengthening primary care systems in European countries; and a new chapter on the resilience, efficiency and sustainability of health systems in Europe, in order to align the content of this publication more closely with the 2014 European Commission Communication on effective, accessible and resilient health systems. This publication is the result of a renewed collaboration between the OECD and the European Commission under the broader "State of Health in the EU" initiative, designed to support EU member states in their evidence-based policy making.
Mercer Capital's Value Focus: Healthcare Facilities | Year-End 2015 | Sub-Sec...Mercer Capital
Mercer Capital's Healthcare Facilities Industry newsletter provides perspective on valuation issues. Each newsletter also includes a macroeconomic trends, industry trends, and guideline public company metrics.
April 2011In the fall of 2010, the Alliance for Health R.docxjewisonantone
April 2011
In the fall of 2010, the Alliance for Health
Reform, with support from the Robert
Wood Johnson Foundation, held a series of
Capitol Hill briefings on issues pertaining to
the health care workforce. The first brief-
ing in the series examined the physician
workforce. It looked at supply and demand
issues that may be changing as a result
of health reform. Panelists were: Edward
Salsberg, National Center for Workforce
Analysis, HRSA; Thomas Ricketts, Cecil G.
Sheps Center for Health Services Research,
University of North Carolina at Chapel Hill;
and Jay Crosson of the Kaiser Permanente
Institute for Health Policy. The second
briefing focused on nurses, allied health
professionals, direct care workers and the
various provisions of the health reform law
pertaining to them. Panelists were: Joel
Teitelbaum, George Washington University;
Bob Konrad, Cecil G. Sheps Center; Linda
Burnes Bolton, Cedars-Sinai Medical Center
and Catherine Dower, University of Califor-
nia, San Francisco.
Health Care Workforce:
Future Supply vs. Demand
Physician and nursing shortages
make headline news on a regular
basis. Debates continue in policy
circles among researchers, analysts
and stakeholders on whether the
shortages are due to insufficient
numbers of providers, or maldistri-
bution of those providers.
Experts also debate over whether
the solutions are to build more
schools and enlarge classes to
graduate more physicians, expand
the number of residency slots, find
incentives to attract providers to
health professional shortage areas,
or change the way we deliver care.
We begin to see the complexity of
analyzing the problem and matching
the solutions to the challenges if we
also consider:
• Is there an adequate and efficient
ratio of primary care providers to
specialists?
• Are we training for the right skills?
• Are those with skills using them to
their maximum potential?
• Where do nurses and licensed and
unlicensed allied health profession-
als fit into the picture?
Some key factors affecting
the adequacy of the health
care workforce include
growth in the insured
population as a result of the
health reform law, an aging
U. S. population, an aging
health care workforce, the
Fast Facts
n 40 percent of practicing physicians are older than 55; about one-third of
the nursing workforce is over age 50.
n Economists say a third of physicians could retire in the next 10 years.
n More than half of nurses over 50 say they plan to retire in the next de-
cade.
n Team-based care and an expanded role for advance practice nurses and
physician assistants could mitigate the shortage of primary care providers.
n The Institute of Medicine recommended, in October 2010, that nurses be
allowed to practice to the full extent of their education and training. Cur-
rently only eleven states allow nurse practitioners to practice independent
of a physician.
n Student medical school debt averages $.
April 2011In the fall of 2010, the Alliance for Health R.docxjustine1simpson78276
April 2011
In the fall of 2010, the Alliance for Health
Reform, with support from the Robert
Wood Johnson Foundation, held a series of
Capitol Hill briefings on issues pertaining to
the health care workforce. The first brief-
ing in the series examined the physician
workforce. It looked at supply and demand
issues that may be changing as a result
of health reform. Panelists were: Edward
Salsberg, National Center for Workforce
Analysis, HRSA; Thomas Ricketts, Cecil G.
Sheps Center for Health Services Research,
University of North Carolina at Chapel Hill;
and Jay Crosson of the Kaiser Permanente
Institute for Health Policy. The second
briefing focused on nurses, allied health
professionals, direct care workers and the
various provisions of the health reform law
pertaining to them. Panelists were: Joel
Teitelbaum, George Washington University;
Bob Konrad, Cecil G. Sheps Center; Linda
Burnes Bolton, Cedars-Sinai Medical Center
and Catherine Dower, University of Califor-
nia, San Francisco.
Health Care Workforce:
Future Supply vs. Demand
Physician and nursing shortages
make headline news on a regular
basis. Debates continue in policy
circles among researchers, analysts
and stakeholders on whether the
shortages are due to insufficient
numbers of providers, or maldistri-
bution of those providers.
Experts also debate over whether
the solutions are to build more
schools and enlarge classes to
graduate more physicians, expand
the number of residency slots, find
incentives to attract providers to
health professional shortage areas,
or change the way we deliver care.
We begin to see the complexity of
analyzing the problem and matching
the solutions to the challenges if we
also consider:
• Is there an adequate and efficient
ratio of primary care providers to
specialists?
• Are we training for the right skills?
• Are those with skills using them to
their maximum potential?
• Where do nurses and licensed and
unlicensed allied health profession-
als fit into the picture?
Some key factors affecting
the adequacy of the health
care workforce include
growth in the insured
population as a result of the
health reform law, an aging
U. S. population, an aging
health care workforce, the
Fast Facts
n 40 percent of practicing physicians are older than 55; about one-third of
the nursing workforce is over age 50.
n Economists say a third of physicians could retire in the next 10 years.
n More than half of nurses over 50 say they plan to retire in the next de-
cade.
n Team-based care and an expanded role for advance practice nurses and
physician assistants could mitigate the shortage of primary care providers.
n The Institute of Medicine recommended, in October 2010, that nurses be
allowed to practice to the full extent of their education and training. Cur-
rently only eleven states allow nurse practitioners to practice independent
of a physician.
n Student medical school debt averages $.
Mercer Capital's Value Focus: Healthcare Facilities | Mid-Year 2016 |Mercer Capital
Mercer Capital's Healthcare Facilities Industry newsletter provides perspective on valuation issues. Each newsletter also includes macroeconomic trends, industry trends, and guideline public company metrics.
5 Trends to Watch in the Medical Device Industry in 2016Mercer Capital
Demographic shifts underlie the long-term market opportunity for medical device manufacturers. While efforts to control costs on the part of the government insurer in the U.S. may limit future pricing growth for incumbent products, a growing global market provides domestic device manufacturers with an opportunity to broaden and diversify their geographic revenue base. Developing new products and procedures is risky and usually more resource intensive compared to some other growth sectors of the economy. However, barriers to entry in the form of existing regulations provide a measure of relief from competition, especially for newly developed products.
Mercer Capital's Value Focus: Healthcare Facilities | Mid-Year 2015Mercer Capital
Mercer Capital's Healthcare Facilities Industry newsletter provides perspective on valuation issues. Each newsletter also includes a macroeconomic trends, industry trends, and guideline public company metrics.
Regulatory changes, plus advances in cloud computing and analytic technologies, are making it possible for U.S. healthcare providers, payers and patients to connect, commmunicate and collaborate seamlessly, and ensure that the right care is provided at the right place, at the right time.
Analytics-Driven Healthcare: Improving Care, Compliance and CostCognizant
In the face of skyrocketing costs, the healthcare industry is addressing inefficiencies by improving data sharing and collaboration across the industry value chain and applying analytics to improve operations and patient outcomes.
As Medicare costs continue to rise fueled in large part by new devices and pricey drugs, the federal government now spends 50% more on health care than it does to fund the department of defense—a monumental figure. Cardiovascular disease (CVD) remains the largest driver of health care costs in the United States. By 2030 43.9 per cent of Americans are projected to have some form of CVD, driving a more than $550 billion increase in the total costs of CVD care annually.
Chapter 2Where Are WeAmerican health care is in a state of flJinElias52
Chapter 2
Where Are We?
American health care is in a state of flux as new scientific knowledge and clinical experience continue to change our definitions of illness and wellness. As a society, we respond by changing the ways health care is delivered. Health services increasingly impact our society—from health status to employment to budgetary economics to recreation to professional concerns to our perceptions of our own well-being.
American health care is also in flux because now that it has grown to more than one-sixth of our economy it threatens to squeeze out public goods such as education and infrastructure maintenance. People have wanted to do something about cost and access to care problems for a long time. The 2010 Affordable Care Act (ACA) is doing much to address access issues, but opposition to certain provisions is strong. Employers are steadily shifting more risk to employees and their families, and there is a real tension between Washington and the state capitols over Medicaid expansion. Medicare trust funds are forecast to disappear over the next decade or so. Washington is unlikely to tolerate another major health reform battle, although major changes may come as a side effect of a “grand” government overhaul of spending and tax policies. The future is highly uncertain, and still we must plan and act as we go along.
This chapter reviews the current status of the U.S. health care system from several points of view:
• Current outcomes and costs
• Quality
• Leadership
• Complexity
• Industrializing structures for delivery
• Medicalization of our society
• Redistribution of wealth
2.1 Current Outcomes and Costs
Previous section
Next section
2.1 CURRENT OUTCOMES AND COSTS
Health care expenditures were projected to rise to close to 20% of the U.S. gross domestic product (GDP) by 2015 (Borger et al., 2006), but more recent estimates from the Centers for Medicare & Medicaid Services (CMS) project it to be 18.2% for 2015 and 19.5% by 2021 (CMS, 2012). Average annual family health insurance premiums were estimated for 2012 at $15,745, with $11,429 paid by employers. The 4% growth rate for 2012 was slow by historical standards but still more than twice the growth rate of wage income. The comparable total insurance cost for a single individual was $5,615. Large employers (98%) offered health care benefits to workers but were cutting back on retiree health benefits. Only 50% of firms with 3 to 9 workers and 73% with 10 to 24 workers offered health benefits. Many small companies do not provide health benefits. At the same time, control of health care by health professionals is being threatened by outsiders calling for more reliance on government programs, more consumer-centered care, or both.
High Comparative Costs and Low Comparative Outcomes
The United States spends far more on health care per capita and as a percentage of GDP than other developed countries, yet does not seem to be much better off for it. Table 2-1 illustrates this ...
photo 1.JPGphoto 2.JPGLESSON 16 Transition to Elec.docxrandymartin91030
photo 1.JPG
photo 2.JPG
LESSON 16
Transition to Electronic Health Record
LEARNING OUTCOMES
______________________________________________________________________________
In this lesson, you will do the following:
Evaluate the factors that drive an organization to adopt a strategy to create an electronic health
care record.
READINGS
The following reading assignments are for Lessons 13 through 16:
Gartee Text:
Chapter 2, pp. 27 - 41
Chapter 7, pp. 152 - 181
Chapter 8, pp. 182 - 206
ACTIVITIES / ASSESSMENTS
The following activities/assessments are for Lessons 13 through 16:
1. Read the assigned pages from the Gartee text, Unit 4 PowerPoint, and Lecture Notes.
2. Participate in the weekly discussion question.
3. Complete the written assignment.
WRITTEN ASSIGNMENTS
Research and discuss three challenges facing an organization, and review how the conversion to
a full electronic health record could address the challenges identified.
PLEASE NOTE: All graded assignments for the lessons in this unit should be grouped together
and submitted as ONE document using the Assignment Submission form accessed from your
course homepage or http://www.sjcme.edu/gps/assignments.
All activities/assignments for this unit should be as follows:
1. Should include a cover sheet for each assignment stating the following:
Course (HA 214)
Your Name
Unit and Lesson Number
Date Submitted
2. Each individual assignment number and copy of the assignment directions should be
included in the submission as the starting header of each lesson.
3. Carefully check grammar and spelling.
4. Use APA format for any research or sources that are being used or quoted.
5. Email the instructor if you have questions regarding the assignments.
http://www.sjcme.edu/gps/assignments
LESSON 16
Transition to Electronic Health Record
LECTURE NOTES
______________________________________________________________________________________
The push for the conversion from paper-based to electronic health records is clear and definite.
The mandate comes from the federal government in terms of regulatory requirements, financial
incentives, and a desire to reduce costs and improve quality. Research and experience has
indicated that a fully deployed electronic health record system will achieve these desired
outcomes. The ability to enhance the productivity of personnel is another business outcome that
health care providers will need to consider. However, there are major challenges and barriers to
achieving full implementation of interoperable electronic health records.
Costs of Care
The costs of health care in the United States are reported to be almost 17% of the gross national
product (GNP), or about $7000 per capita for every person in the country. The costs for health
care continue to rise faster than consumer inflation.
This makes the cost of h.
Factors Affecting Consumer Health Care Services Delivery in Private Health Fa...AI Publications
Background: In 2007, the government of the republic of Tanzania has launched the Primary Health care services development programme as one of the renewed efforts to effectively engage the healthy sector in poverty reduction strategies. The study was dealing with evaluation on the factors that affects health services delivery to private hospital facilities Method: Data was collected from 169 patients who are customers of KMH and two sampling techniques were used, namely purposive sampling and random sampling. The study use questionnaire and interviews together with documentary review together information concerning the study objective. Quantities data were analyzed through SPPS data were coded ruined to observe to which percent the variables were significant or not significant towards research objectives. Results: The study finding that there are factors that are challenges towards delivering health services to patients including absence of good communication, customer care, shortage number of health professionals and most of patients are not attended on time, however on other hand study discover that there factors pull health services delivery including presence of social media, good infrastructures that support patients from far and presence of NHIF services to KMH. Recommendations: This study recommends that Private Public Partnership should be more emphasized and applied in health sector for the aim of improving health survives delivery to patients. Conclusion: The study concludes that although much has been done over many years to restructure the health care system and to improve the quality of care being rendered to patients, the literature reveals that a lot of people in Mwanza city still suffer from getting quality health services from health facilities including hospitals which are owned by private institutions.
Mercer Capital's Value Focus: Medtech & Device Industry | Q3 2019 | Article: ...Mercer Capital
"Mercer Capital provides medical device manufacturers, related start-up enterprises, and private equity funds with valuation services, including purchase price allocation, 409a compliance, goodwill impairment testing, and other transaction and valuation advisory services.
Each issue includes a segment focus, market overview, mergers and acquisitions review, and more."
Similar to Colliers US Medical Office Report 2014 Outlook (20)
HORIZON TOWER
520,094 RSF
17-story medical + biomedical space
13-level parking garage; 2,700 stalls
Under Construction and
On-Schedule for 4Q2023 Delivery
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
1. 2014 OUTLOOK | MEDICAL OFFICE
UNITED STATES
HIGHLIGHTS
Medical Office Trends
and 2014 Outlook
ANDREA CROSS National Office Research Manager
KEY TAKEAWAYS
UNITED STATES MARKET STATS
YEAR-END
2013
2012
2011
U.S. healthcare
employment average
annual growth
1.9%
2.0%
1.8%
FIRST HALF*
2013
2012
2011
12.26%
12.25%
12.56%
Overall vacancy rate
Leasing activity 4.54 MSF 4.76 MSF 4.73 MSF
Absorption 1.56 MSF 2.52 MSF 1.41 MSF
Asking rent PSF
(weighted avgerage)
Construction
completions
$23.79
$23.80
$23.82
• Drivers of health care demand: In the short term, an additional 32 million people insured by the
Affordable Care Act (ACA); long term, more than 20% of the U.S. population will be 65 or older
by 2029.
• ACA regulations mean more consolidation among health care providers and insurers, further
tilting medical office demand to large companies.
• Medical office accounts for 25% of all U.S. office space under construction. Construction has
decreased significantly since the recession: 1.8 MSF in 1H 2013 vs. 8.4 MSF in 1H 2009 (markets
tracked by Colliers).
• Decrease in construction is attributable to conversion of non-traditional properties, especially big
box retail and suburban shopping centers, and uncertainly regarding impact of ACA on health
care delivery mechanisms.
• Investment: $2.47B of medical office transactions in Q4 2013 was highest since Q4 2006,
exceeding even the Q4 2012 surge prior to 2013 tax increases. 2014 should be a strong year,
given scarcity of properties, availability of capital, and opportunities in secondary/tertiary markets.
1.01 MSF 2.61 MSF 1.53 MSF
Square footage
1.82 MSF 4.19 MSF 5.76 MSF
under construction
*In 32 surveyed Colliers markets
INVESTMENT STATS
YEAR-END
2013
2012
2011
MOB transaction
volume
$7.17B
$6.66B
$5.76B
FOURTH QUARTER
2013
2012
2011
Average price
paid PSF
$225
$208
$198
Average cap rate
7.40%
7.72%
7.79%
SOURCES: Bureau of Labor Statistics, Real
Capital Analytics, Colliers International
www.colliers.com
SOURCE: Bebeto Matthews/AP
2. HIGHLIGHTS | 2014 OUTLOOK | MEDICAL OFFICE | UNITED STATES
Health Care Trends
The U.S. health care industry is undergoing a seismic shift due to longterm changes in demographics, and near-term structural and policy changes. Compounding the long-anticipated surge in demand for health care services from the aging baby boomer population, the passage of the Affordable
Care Act (ACA) is expected to add 32 million to the ranks of the insured.
At the same time, implementation of ACA regulations concerning patient
care, cost control, electronic recordkeeping, etc., will fundamentally alter
the business models of health care providers of all sizes.
ANNUAL PHYSICIAN OFFICE VISITS BY AGE | PER 100 PEOPLE
700
600
500
400
300
DEMOGRAPHICS
During the next ten years, the population aged 65 and over is projected to
increase an average of 3.3% per year, resulting in an increase of nearly
17 million people in this cohort by 2023. (By comparison, total population growth during the same period is projected to average only 0.8%.)
By 2029, the 65+ age cohort will account for more than 20% of the U.S.
population, up from 13.7% in 2012.
200
100
0
Under 15 years
15-24
25-44
45-64
65-74
75+
SOURCE: CDC, 2010 National Ambulatory Medical Care Survey
U.S. POPULATION 65 YEARS AND OLDER
IMPACT OF ACA: CONSOLIDATION, DISRUPTION
25%
80
70
20%
60
50
15%
40
10%
30
20
5%
10
30
20
28
20
26
20
24
20
22
20
Pop 65+ (Mil.)
20
20
18
16
20
20
20
20
14
0%
12
0
65+ % of Total Pop
SOURCE: U.S. Census Bureau
With the delay of the employer mandate and the troubled launch of the
Health Insurance Marketplace website (healthcare.gov), the timing of the
ACA rollout is unclear. However, its impact on the health care industry and
real estate market will be profound—and not just in terms of an additional
32 million insured individuals upon implementation. The ACA also aims to
rein in health care costs and improve the quality of care through a variety
of measures that will fundamentally change the industry.
U.S. health care spending is by far the highest in the world, about 50%
higher on a per-capita basis than second-ranked Norway. Also, health care
spending as a percentage of GDP increased significantly during the last
60 years, to nearly 18% in 2009. (The percentage was flat between 2009
HEALTH CARE JOBS AS SHARE OF TOTAL WORKFORCE | LARGE METROS
This growth will translate into a substantial increase in demand for medical
services, due to the greater need for health care among the older age cohorts:
The annual number of physician office visits per 100 people in the 65–74
year-old cohort is nearly 70% higher than in the 45–64 year-old cohort.
25%
Demand for health care will likely remain strong across geographic locations. Northeast and Midwest metro areas tend to have above-average concentrations of health care workers because of their relatively older populations, who demand greater amounts of care. However, Sunbelt cities in
the South and West dominate the list of fastest-growing metro areas for
health care employment, supported by above-average population growth.
In-migration to Sunbelt metro areas should increase further as job prospects in these areas improve and the recovering housing market enables
greater household mobility in the United States. With large, in-place senior
populations in the Northeast and Midwest, and rapid population growth in
the Sunbelt, demand for medical office space should increase across a
broad range of geographies.
10%
P. 2
| COLLIERS INTERNATIONAL
21.9%
20%
15%
18.1% 17.8%
17.1% 17.1% 16.7% 16.6% 16.4% 16.3% 16.3%
12.7%
5%
Du
rh
am
-C
M
cA
lle
n,
ha
TX
pe
lH
ill,
Ne
NC
w
Ha
ve
n,
W
or
CT
ce
st
Yo
er
,M
un
gs
A
to
Sc
w
n,
ra
Pr
OH
nt
ov
on
id
-W
en
ce
ilk
,R
es
-B
I
ar
re
,P
Al
len
A
to
w
n,
Cl
PA
ev
ela
nd
Ph
,O
ila
H
de
lph
UN
ia,
IT
PA
ED
ST
AT
ES
0%
SOURCE: EMSI 2013.3 Class of Worker data.
Includes QCEW Employees, Non-QCEW Employees & Self-Employed
3. HIGHLIGHTS | 2014 OUTLOOK | MEDICAL OFFICE | UNITED STATES
FASTEST-GROWING METROS FOR HEALTH CARE &
SOCIAL ASSISTANCE EMPLOYMENT
MSA
2012 JOBS
2013 JOBS
80,073
84,658
21.9%
309,332
325,411
18.1%
39,116
40,953
17.8%
Grand Rapids, MI
56,336
58,801
17.1%
Las Vegas, NV
75,041
78,288
17.1%
Knoxville, TN
46,322
48,238
16.7%
Virginia Beach, VA
89,627
93,312
16.6%
Nashville, TN
111,969
116,567
16.4%
Atlanta, GA
242,277
252,179
16.3%
Austin, TX
86,429
89,939
16.3%
El Paso, TX
39,570
41,170
12.7%
Richmond, VA
Houston, TX
Boise, ID
% CHANGE
SOURCE: EMSI 2013.3 Class of Worker data.
Includes QCEW Employees, Non-QCEW Employees & Self-Employed
20%
16%
14%
12%
12.5
10%
8%
13.8 14.5
16.2 16.4 16.8
15.4 15.9 16.0 16.1
17.9 17.9 17.9
9.2
6%
7.2
5.2
4%
2%
0%
0
6
19
70 980 990 000 001 002 003 004 005 006 007 008 009 010 011
2
1
1
2
2
2
2
2
2
2
2
2
2
2
19
SOURCE: Center for Medicare & Medicaid Services
HEALTH EXPENDITURES PER CAPITA
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
S ay nd ds ia da ny ark rg ce um en lia nd om nd 34
a m ou an gi ed tra la d
la D
TE rw rla lan str na
e
TA No itze her Au Ca erm en emb Fr Bel Sw us Ir King Fin EC
S
A
G D x
O
t
d
D
Sw Ne
Lu
ite
TE
NI
Un
U
Note: Data is for 2011 or most recent available year
SOURCE: OECD Health Statistics 2013; WHO Global Health Expenditure Database
The ACO component of the law is rapidly accelerating the consolidation
trend in the health care industry, as larger hospital systems are better
positioned to handle the scale, complexity and capital costs of establishing
and maintaining these networks. Larger hospital systems also benefit from
greater negotiating power with insurance companies. Although still well
below peak deal volumes during the last hospital mergers and acquisitions
(M&A) boom in the late 1990s, 105 M&A deals occurred in 2012, more than
double the annual average of 55 between 2005 and 2009. Booz & Company estimates that 1,000 of the 5,000 hospitals in the U.S. could attempt
to merge with another hospital during the next five to seven years.
Recent large transactions included:
NATIONAL HEALTH EXPENDITURES AS A PERCENT OF GDP
18%
and 2011, largely attributable to the recession and increased generic pharmaceutical sales due to patent expirations.) In just ten years, the average
cost of a hospital stay increased by 90%, according to the Health Industry
Distributors Association, reaching more than $33,000 in 2010 due to higher
premiums, increased technology costs and greater consumer usage of laboratory tests. One way the law seeks to reduce costs is the introduction of
Accountable Care Organizations (ACOs), which are intended to improve patient care through better communication and coordination among providers,
offering financial incentives for successful, lower-cost outcomes.
• Mount Sinai Medical Center’s merger with Continuum Health Partners,
owner of Beth Israel Medical Center, St. Luke’s and Roosevelt
Hospitals, and New York Eye and Ear Infirmary, completed in
September 2013; the combined system will have approximately 36,000
employees (including 6,600 physicians), 3,500 hospital beds, and
200,000 inpatient admissions and 2.5 million outpatient visits annually;
• Completed in October 2013, Dallas-based Tenet Healthcare’s
acquisition of Nashville-based Vanguard Health Systems for $4.3
billion; the expanded company employs more than 100,000 people and
operates 173 outpatient centers, 77 acute care hospitals, five health
plans and six ACOs;
• Community Health Systems of Tennessee’s recent acquisition of
Florida-based Health Management Associates for $7.6 billion; the
company now totals 206 hospitals and approximately 27,000
physicians.
HOSPITAL MERGERS & ACQUISITIONS
120
100
67
52
80
40
60
40
16
38
22
38
34
22
20
0
34
32
22
2005
2006
22
16
2007
2008
2009
For-Profit Buyers
36
41
38
24
2010
2011
2012
2013*
Nonprofit Buyers
*Year to date, August 2013
SOURCE: Irving Levin Associates
COLLIERS INTERNATIONAL |
P. 3
4. HIGHLIGHTS | 2014 OUTLOOK | MEDICAL OFFICE | UNITED STATES
PHYSICIANS BY EMPLOYMENT STATUS
500,000
400,000
300,000
200,000
100,000
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
*
0
Estimated count of independent physicians
Estimated count of Healthcare System-employed physicians
*Projected
SOURCE: AMA, Accenture, Becker’s Hospital Review
Cost pressures also are spurring alliances and affiliations between health
care systems, even competitors. Southern California health care titans
UCLA Health System and Cedars-Sinai Medical Center recently signed a
15-year lease at the former general care Century City Hospital in Los Angeles, which has been vacant since 2008. In partnership with Select Medical
Holdings Corporation, a Pennsylvania-based rehabilitation facility operator,
they will open a 138-bed state-of-the-art acute rehabilitation hospital in
2015, following extensive renovations to the 170,000 square-foot facility.
Other recent examples include two partnerships in North Carolina: UNC
Health Care’s assumption of operations management for non-profit Nash
Health Care; and Duke LifePoint, a joint venture between Duke Health and
LifePoint Hospitals. The trends of consolidation and strategic alliances—
particularly for smaller community hospitals—will likely continue with the
implementation of the ACA and its associated challenges.
Another significant trend is the integration of large health care providers
with insurance companies. Alignment of provider and insurer interests creates greater incentive for successful patient outcomes without prescribing
excessive tests and treatments, thus containing costs while providing highquality care. Examples of these integrated systems include UnitedHealth,
Kaiser Permanente and HealthPartners. Health systems also are forging
alliances with insurers to create fully integrated systems to boost provider
collaboration, improve outcomes and lower costs, such as Blue Cross’s
Aligned Incentives Contracts program. Ten large health systems are participating in the program, including Allina Integrated Medical Network, which
announced the creation of BluePoint, a new integrated health plan with
Blue Cross Blue Shield of Minnesota, in August 2013.
Smaller physician practices are being acquired and folded into larger health
care systems due to cost pressures and uncertainties regarding the implementation and effect of the ACA. The percentage of independent practicing
physicians has declined from 57% in 2000 to a projected 36% in 2013.
According to an Accenture survey, the greatest concerns facing physicians
were business expenses (87%), the prevalence of managed care (61%) and
maintenance of electronic health record (EHR) requirements (53%). Also
driving this trend is a projected physician shortage, prompting health care
systems to acquire independent physician practices.
| COLLIERS INTERNATIONAL
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
90%
78.4%
71.8%
80%
70%
57.0%
60%
48.3% 51.0%
48.1%
42.0%
50%
39.6%
34.8%
33.9%
40%
29.2%
27.9%
23.9%
21.8%
30%
20.8%
16.9%
18.2% 17.3% 17.3%
20%
10.5% 11.8%
10%
0%
600,000
P. 4
U.S. OFFICE-BASED PHYSICIANS WITH EMR/EHR SYSTEMS (%)
Any EMR/EHR system
Basic system
Note: “Any EMR/EHR system” is a medical or health record system that is all or partially electronic
(excluding billing systems); “Basic system” meets certain functionalities
SOURCE: CDC, NCHS Data Brief #143, January 2014
Many office-based physicians seek to implement EHR systems in order to
reap financial incentives from Medicare and Medicaid. Created as part of
the American Recovery and Reinvestment Act (ARRA) of 2009, the Health
Information Technology for Economic and Clinical Health (HITECH) Act
includes incentive programs that reward participants who demonstrate
“meaningful use” of EHR systems that meet certain criteria. Participants
must meet the specific objectives of each of the three stages of the programs, focused on the creation of electronic health information (Stage 1),
the exchange of this information (Stage 2), and the use of this information
to improve patient outcomes (Stage 3). Payments to providers meeting
Stage 1 criteria began in 2011, and Stage 2 payments will begin in 2014.
In addition, Medicare and Medicaid providers that do not meet the program
requirements will be subject to financial penalties beginning in 2015.
Although adoption of EHR systems continues to grow, the percentage of
physicians with systems that meet the criteria for Stage 2 incentives is low.
According to the National Center for Health Statistics (NCHS), the percentages of office-based physicians with any EHR system or a basic EHR system have been trending upward since 2006. However, among physicians
that plan to participate in the Medicare or Medicaid incentive programs, just
13% have a system that can handle 14 of the 17 Stage 2 core objectives,
according to the most recent survey. Furthermore, this understates the
percentage of providers capable of meeting the Stage 2 requirements, as
the HITECH incentive program requires that providers meet all 17 core objectives, as well as three out of six additional “menu” objectives. The ability
of physicians to meet the requirements of the HITECH program will be a
key trend to monitor, potentially contributing to a continued increase in the
share of hospital-employed physicians given the difficult of implementing
qualified EHR systems independently.
Technological developments also are transforming the health care landscape and driving the consolidation trend. Improvements in, increased patient comfort with, and the cost-effectiveness of medical technology practices are expected to drive increasing demand for telehealth and mobile
health (mHealth) systems, ranging from online appointment scheduling to
remote patient data collection and monitoring. With the ACA emphasizing cost containment, interest in lower-cost delivery mechanisms such as
5. HIGHLIGHTS | 2014 OUTLOOK | MEDICAL OFFICE | UNITED STATES
these will likely increase. Again, large organizations with the capital to invest in these technologies and deploy them across a range of facilities and
specialties are well-positioned to capitalize on this trend.
This consolidation trend is likely to continue, and has significant implications for the medical office market, both in terms of leasing activity and
construction of new facilities. The shift to the ACO model will likely result
in a continued increase in the number of hospital-employed physicians due
to the cost of running these programs, which will favor large organizations
that benefit from economies of scale. This will contribute to stronger tenant demand from large heath care systems rather than small physician
practices.
MEDICAL OFFICE VS. TRADITIONAL OFFICE
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
1H09
1H10
CBD
Medical Office Market
Colliers’ medical office data includes on-campus, offcampus, single- and multi-tenant medical office buildings
totaling 10,000 square feet or more, as well as office
buildings in which medical tenants occupy 50% or more of
the space. Our coverage universe includes 39 U.S. markets
encompassing approximately 337 million square feet of
medical office space. Our historical time series, beginning in
2009, includes 32 U.S. markets totaling 304 million square
feet. As we build our inventory database, we will add
markets to future iterations of this report.
2H09
2H10
1H11
Suburban
2H11
1H12
2H12
Note: Medical office data includes 32 U.S. markets
SOURCE: Colliers International
to the recession and had above-average medical office vacancy rates as
of 1H 2013. Construction has fallen off sharply since then in most of these
markets, and thus demand going forward will drive the absorption of existing space with limited competition from new product.
LOWEST OVERALL VACANCY RATES | 1H 2013
MARKET
OVERALL VACANCY RATE
Greenville-Spartanburg, SC
Despite major changes occurring in the health care industry and the deepest recession since the 1930s, the medical office market has been stable
compared with other commercial property types, including traditional office
properties. Long lease terms (typically 7–10 years), as well as the expensive and extensive tenant improvements required by medical users, lend
stability to the medical office property type. The vacancy rate increased
from 12.29 percent in 1H 2009 to 12.82 percent in 1H 2010, and since
then generally has trended downward, lowering to 12.26 percent in 1H
2013. By comparison, the vacancy rate for traditional office increased more
substantially during the recession and remained elevated in 1H 2013 relative to medical office properties. Medical office rental rates also were relatively stable, decreasing by less than $1 per square foot to $23.79 in 1H
2013 compared with $24.65 in 1H 2009. Net absorption remained positive
throughout this period, and the amount of both construction completions
and construction underway decreased significantly.
Small southeastern markets lead the list of the lowest vacancy rates as of
1H 2013. Although not immune to the effects of the recession, new supply
levels were very low in most of these markets in the years leading up to and
following the downturn, contributing to current low vacancies. In contrast,
substantial construction in many larger Sunbelt markets—including many
that had housing bubbles—led to a surfeit of vacant space in those areas,
resulting in the highest vacancy rates nationally. Atlanta, Las Vegas, Phoenix and Tampa Bay-Clearwater all were active development markets prior
1H13
Medical Office
3.00%
Savannah
3.80%
Columbia, SC
4.30%
Memphis
5.20%
Richmond
6.30%
Nashville
6.50%
New York – Manhattan
6.50%
Seattle
6.50%
Milwaukee
7.22%
Miami
8.37%
SOURCE: Colliers International
COLLIERS INTERNATIONAL |
P. 5
6. HIGHLIGHTS | 2014 OUTLOOK | MEDICAL OFFICE | UNITED STATES
UNITED STATES | MEDICAL OFFICE MARKET STATISTICS
MARKET
EXISTING
INVENTORY
(SF)
JUN 30, 2013
Atlanta
OVERALL VACANCY
DIRECT
RATE (%)
VACANCY RATE (%)
JUN 30, 2013
JUN 30, 2013
ABSORPTION
1H 2013
(SF)
AVG. ANNUAL
QUOTED RENT
(USD PSF)
JUN 30, 2013
YEAR-TO-DATE
NEW SUPPLY
(SF)
UNDER
CONSTRUCTION
(SF)
16,166,458
13.60
13.10
95,580
22.53
47,500
100,786
Bakersfield
1,183,984
11.99
10.51
81,296
20.64
90,000
30,000
Baltimore
5,649,274
20.80
20.20
-16,935
24.02
51,524
52,000
Birmingham
1,711,119
23.61
23.61
-153,411
19.70
0
0
Boise
1,771,733
11.62
11.62
-
16.80
85,000
0
Charlotte
8,629,775
11.33
11.01
82,757
24.79
133,945
0
Chicago
23,621,725
14.80
14.50
103,618
21.09
168,180
51,400
Cincinnati
3,928,227
11.23
11.23
101,179
21.64
0
0
Columbia, SC
2,742,721
4.30
4.30
11,863
18.98
0
0
18,991,977
13.24
13.15
200,266
22.81
44,065
176,000
Denver
9,467,489
11.48
11.14
155,600
23.23
92,979
0
Detroit
4,370,087
41.50
41.50
10,566
19.47
0
0
Fort Lauderdale
6,359,878
9.59
9.47
96,585
22.96
0
38,670
Grand Rapids-Western MI
4,425,528
10.47
10.47
46,832
14.81
0
60,000
Dallas-Fort Worth
Greenville-Spartanburg, SC
3,689,102
3.00
3.00
-12,695
13.54
0
0
26,664,926
11.30
11.10
467,399
23.02
30,000
0
Indianapolis
5,204,940
9.06
9.06
22,921
17.90
0
274,000
Jacksonville
1,381,502
25.60
24.90
-41,405
19.07
11,300
0
Kansas City
7,492,420
8.70
8.70
30,960
19.38
0
70,000
Las Vegas
5,282,610
22.35
22.30
-71,908
25.32
0
0
Long Island
9,182,894
8.90
8.80
57,127
27.04
0
74,999
27,087,400
10.80
10.50
-9,980
29.52
41,000
456,300
Memphis
5,845,782
5.20
5.20
83,686
19.21
0
0
Miami
8,272,147
8.37
8.36
-70,991
27.61
29,621
0
Milwaukee
6,600,916
7.22
6.99
-83,842
16.87
0
0
10,427,201
9.20
8.60
26,095
16.40
155,200
477,881
Nashville
7,769,000
6.50
6.30
-26,176
20.43
0
36,000
New York – Manhattan
3,700,418
6.50
6.40
72,790
40.16
0
0
Orange County
13,581,566
10.10
10.00
80,292
29.52
81,000
0
Philadelphia*
14,656,137
9.07
8.90
151,662
20.13
10,200
0
Phoenix
16,056,190
19.80
19.30
-12,733
22.70
18,000
0
1,760,772
9.80
9.80
-1,704
20.21
0
0
Houston
Los Angeles County
Minneapolis-St. Paul
Reno
Richmond
4,135,321
6.30
6.10
-29,646
18.91
0
0
12,912,815
12.49
12.23
142,468
28.24
65,076
0
Savannah
1,477,081
3.80
3.80
10,300
18.42
0
0
Seattle
6,966,672
6.50
6.10
-65,076
34.15
0
0
Tampa Bay-Clearwater
3,654,197
24.10
24.04
-12,399
18.81
21,145
0
San Diego County
Washington, DC
16,359,466
9.80
9.50
113,178
29.66
76,504
382,267
8,210,280
14.31
14.14
-11,018
24.48
0
116,000
337,391,730
11.99
11.75
1,625,101
23.47
1,252,239
2,396,303
West Palm Beach
TOTALS
*Metro area, including counties in PA, NJ and DE.
P. 6
| COLLIERS INTERNATIONAL
7. HIGHLIGHTS | 2014 OUTLOOK | MEDICAL OFFICE | UNITED STATES
CONSTRUCTION
Nationwide, medical office properties account for approximately 25% of
all office space currently under construction, totaling 21.0 million square
feet. Although the largest metro areas generally have the largest amount of
space under construction, only 9 MSAs have more than 500,000 square
feet underway. Indicative of the trend of health care providers locating near
their patients, construction is spread out across metropolitan and micropolitan areas, as well as places too small for geographical categorization.
However, in the 32 markets tracked by Colliers, medical office construction activity, especially speculative, decreased significantly in recent years,
from nearly 8.4 million underway in 1H 2009 to just 1.8 million square feet
in 1H 2013. One reason for the decline was the increased usage of nontraditional properties, notably retail, by medical tenants. Retail properties
increasingly are being repurposed for medical uses as providers seek to
locate close to patients and reduce costs by providing outpatient services
in non-acute settings. High retail vacancy—particularly in suburban and
exurban areas—due to overbuilding prior to the recession and housing crisis, and increasing online retail sales, resulted in opportunities for health
care tenants. In particular, well-located “big box” retail properties in the
20,000-to-50,000 square-foot range with ample parking (such as those
occupied by defunct tenants like Borders, Circuit City and Linens ‘n Things)
are well suited for many medical tenants and are more accessible for patients than many urban campuses.
Other types of retail space are being used as well, such as the Maury
Regional Cancer Center at Columbia Mall in Columbia, TN, which offers
cancer treatment, a pharmacy and other services in a large block of vacant
mall space. Another example is Vanderbilt University Medical Center’s conversion of vacant upper-floor space at 100 Oaks Mall in Nashville, TN, for
medical office and ambulatory center usage. Retail clinics will remain an
important delivery mechanism as health care providers seek to cut costs
and handle the surge in newly insured patients with the implementation of
the ACA. Accenture expects the number of retail health clinics to double
to more than 2,800 by 2015, handling 10.8 million patient visits and saving
$800 million annually.
The shift from on-campus, in-patient care to out-patient treatment in offcampus facilities is already well underway: According to an Avalere Health
survey, inpatient hospital admissions averaged 111.8 per 1,000 people in
2011, down from 123.2 per 1,000 people in 1991. Also, outpatient visits
increased to 2,105.6 per 1,000 people in 2011, up from 1,273.4 in 1991.
Improvements in medical technology are also facilitating the trend toward
non-traditional space, such as less invasive surgical techniques that allow
for increased outpatient procedures in off-campus facilities.
Health care employment statistics also underscore the broadening of delivery options for medical services. Although three subsectors—physicians’
offices, hospitals, and nursing/residential—still account for the lion’s share
of medical employment, the outpatient care center and home health care
subsectors have been expanding fastest for the last decade.
HEALTH CARE SUBSECTOR EMPLOYMENT GROWTH
10%
8%
6%
4%
2%
0%
-2%
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
Offices of Physicians
Outpatient Care Centers
Home Health Care
11
20
12
20
13
20
Nursing and Residential
Hospitals
Note: Growth rates are year-over-year; data are seasonally adjusted; latest data as of Dec 13
SOURCES: Federal Reserve Bank of St. Louis, Bureau of Labor Statistics, Colliers International
As health care systems focus on cost containment, providers are integrating post-acute, transitional care units into outpatient facilities in order to
keep patients out of the hospital. Other aspects of the ACA will contribute
to this ongoing expansion of delivery mechanisms for health care, including new funding for the construction and expansion of community health
centers, and the Community First Choice Option, which allows disabled patients access to home and community-based care rather than institutional
care in a nursing home.
SPACE UTILIZATION TRENDS
Much of the space under construction is build-to-suit, and we expect this
trend of customization for the specific needs and location preference
of the tenant to continue. The preference of large medical systems for
customizing their facilities as well as the risk of speculative development
amidst uncertainty regarding the future of the health care industry will
likely support this trend going forward. Also, in terms of project size, new
construction will likely remain concentrated at both ends of the spectrum.
With the ACA shifting the focus of treatment from volume of services to
patient outcome, health care systems are demonstrating a preference
for large, integrated facilities capable of handling multiple functions and
providers in one location in order to maintain control over patient care.
These facilities typically are 50,000–200,000 square feet and offer
longer hours to accommodate a greater volume of patients than smaller
properties. Complementing these large facilities are small clinics located
near patients that focus on one or two specialties, such as urgent care or
physical therapy.
Like the traditional office market, medical tenants increasingly are desiring
more efficient, open spaces that facilitate teamwork and communication.
Many newer facilities and redesigned spaces have fewer private offices
and more shared workspaces. Technology is supporting this trend, as team
COLLIERS INTERNATIONAL |
P. 7