Mar 03, 2023
On February 23, The Capitol Forum hosted a conference call with researchers Robert Tyler Braun, of Weill Cornell Medical College, and David G. Stevenson, of Vanderbilt University, to discuss their research which found a link between REIT ownership of nursing homes and staffing of inexpensive licensed practical nurses and certified nursing assistants in place of more expensive registered nurses. The full transcript, which has been modified slightly for accuracy, can be found below.
KIM GEIGER: Hello, everyone. Thank you for joining The Capitol Forum’s Conference Call on Real Estate Investment Trusts and the effect they have on the staffing of nursing homes. I’m Kim Geiger, a Correspondent at The Capitol Forum.
I’m joined today by Tyler Braun and David Stevenson, who recently completed the first peer reviewed study of this topic, which is published in the Journal of Health Affairs. Tyler Braun is an Assistant Professor of Population Health Sciences at Weill Cornell Medical College and is the lead author of the study. David Stevenson is a Professor of Health Policy at Vanderbilt University and a coauthor of the study. Tyler and David, thank you so much for being here and taking the time to talk with us.
TYLER BRAUN: Thank you.
KIM GEIGER: Before I get started, I want to walk through the format and some instructions for people who want to participate with questions. We will start off with an interview, and then we’ll open it up to questions from the audience. If you have questions, please email them to editorial@thecapitolforum.com. That’s editorial@thecapitolforum.com and capitol is spelled with an “o”.
All right. Let’s get started. So, Tyler and David, your study looks at real estate investment trusts known as REITs, which apparently can come in two different structures. Can you walk us through what is a REIT? What are the two different structures? And why would these investment vehicles be involved with nursing homes?
TYLER BRAUN: Sure, absolutely. Thanks, Kim, for having us. And special thanks to The Capitol Forum for also inviting us on here. We really appreciate that. So yeah, let me just give you like a 10,000 foot overview, in hopefully less than 10 minutes, of what a REIT is, and these multiple structures.
So the most basic question here is what is a REIT? Well, it’s a for profit public or private corporation advice. It invests in fully owned income producing properties. Through these investments, or these ownership structures, they’re typically called pass through entities. And so basically, as a pass through entity, when they invest in these real estate facilities or nursing homes, it could be in a physician practice or whatever, they have tax exemptions. And the REIT must satisfy a series of requirements related to sources of income. The biggest one is disbursing 90 percent of their taxable income to shareholders annually in the form of dividends.
So let’s say they don’t do that. If those requirements are met, they’d lose that tax preferred stocks. And so I’m going to just say—what is a rhetorical question—is like what if a facility is not affiliated with the investment trust? And then also, what is the most viable asset of a nursing home? Well, the answer to the second question is the actual real estate itself. But if you’re not affiliated with a real estate investment trust, you actually could pay corporate double taxation.
And so basically, let’s say that you separate the property from the nursing home real estate operations. This is essentially called an Opco/Propco. And you can generate additional revenue that’s only taxed by capital gains. So basically, when you separate the real estate from the nursing home operations, you pay rent to the real estate investment trust, that real estate investment trust then disperses tax free that money to shareholders or owners in the form of dividends and then they pay capital gains.
Now, let’s say that I am a nursing home with no affiliation with the real estate investment trust. Well, I’m going to pay taxes on the operations and the revenues that I make from that. And then whatever I pay out to owners of the nursing home facility or chain nursing home, you’re going to take capital gains. So hence the form, corporate double taxation.
And so that’s kind of what REITs do and they have very good tax benefits. And so there’s two forms of typical REIT structures. The first is the triple net leasing agreement. And so in a triple net leasing agreement, REITs essentially acquire the nursing home operators property and pay back to the operator under a long-term lease. Think of this as like a landlord/tenant relationship. And this is the more traditional model that you see in skilled nursing.
In return, after this acquisition, the operator actually pays all the expenses of the property, including the taxes, building, insurance and maintenance. And that’s in addition to the rent and utility costs paid to the REIT by the operator.
Now, I must emphasize this—and this is a very important thing with a triple net leasing agreement and a REIT structure. REITs in this type of structure are prohibited from directly operating and collecting revenue from operations. So I just have to emphasize. But that will kind of be a little more cloudy as we kind of go along with the conversation. But the second structure is the Real Estate Investment Diversification and Empowerment Act of 2007 or a REIDEA structure. It’s a long acronym there.
But in a REIDEA structure, this is used to generate additional management contracts and revenue for the REIT. They’re allowed to collect taxable revenue from the nursing home operations themselves. Which differs from the actual triple net leasing agreement. And how they do this is basically the REIT will actually lease one of its properties for fair market value to a Taxable REIT Subsidiary, which they own, what we call a TRS. That TRS then contracts with an independent nursing home operator. And like in the triple net leasing agreement, operators pay all of the property expenses. But the REIT and TRS receives a management fee for dedicating employees and time management of the property and providing operational guidance.
So not always greater getting an infusion of capital through this rent structure, rent/landlord structure, rent/landlord/tenant structure, the operator essentially will also be given incentive payments if certain profitability targets are achieved. So in this REIDEA structure, the REIT, through its TRS, can be more hands on or hands off in any operations that they want. But any revenue that originates from the clinical operations of the nursing home are taxed at a regular rate. While the rent or any revenues that are generated from the property itself still have that tax benefit.
And so even in these REIDEA structures, you have these triple net leasing agreement structures, they have typically in the leasing agreements rent escalators, and these are typically over six percent a year or they’re tied to an inflation index. So you can kind of see where I’m going with this, where this might actually create some issues for a nursing home later on. And I’ll get more into that in a second.
But you might also be asking yourself is it an appealing investment? Well, obviously, the tax advantages I talked about before. But also, there’s a steady and growing demand for nursing home care services, the baby boomer generation, the aging and to using these types of services, skilled nursing facility services, a lot more post-acute care services in general, a lot more. And then relatively—I say with air quotes—predictable reimbursement from Medicare and Medicaid. And then also to a topic for another day, but related parties where you can vertically integrate other commonly owned businesses that you own with a skilled nursing facility in which you own the property. So think like maid services, food services, and you can have these related party transactions that take place, which could be very profitable for the REIT or the parent company that owns them. But that’s a topic for another day and has all their own issues.
What are the advantages for nursing homes? Well, typically within these they have these master lease agreements. And so a master lease agreement is basically the operator pays an aggregate base rent to the REIT for all of the facilities in which the operator provides care in their properties. This provides greater flexibility in allocating resources to the facility. So let’s say that one of the operating facilities is performing financially way better than another one, that can pick up the slack for the other less performing or poorer performing nursing home and allocate rent evenly across these facilities. So it gives the operator a little more flexibility from a financial standpoint.
And then REITs also can create a lot of efficiencies. They provide properties that they acquire from that the operator, they offer proprietary IT infrastructure, layers of quality performance monitoring. They can help facilitate group purchasing. And then more importantly, where alliances provide operational expertise, even in a triple net lease agreement where they’re supposed to not have any influence on day-to-day operations.
And then probably the most important thing is infusion of capital. And when an operator sells their property, they receive infusion of capital. And this can be used to conceivably improve quality of care, keep the lights on, increased staffing. How they use that actual capital or infusion of capital is a little more of a gray area.
And so in return through these proprietary IT infrastructure, quality performance monitoring, operational expertise and infusion of capital, it allows the operator to focus on brand strength, market share growth, consumer experience and clinical care. And this frees up time so they don’t actually have to manage the real estate, which is a pretty burdensome thing.
So yeah, those are the benefits. But now kind of segue into, okay, what could be the problems with a sale leaseback through a triple net lease agreement or a REIDEA structure? Well, rent escalations are a big one if they’re especially tied to inflation—which we’re in a period of high inflation right now—this could put considerable financial strain on nursing homes. Because due to rising costs to operate, increase in wage inflation for health care workers, especially skilled nurses. And then states in which there’s poor Medicaid reimbursement. So if you’re in a nursing home with a high proportion of residents with Medicaid, those increases in rent might have some serious repercussions on your operations. And so the triple net leasing structure also minimizes risk to the REIT. This lease revenue remains consistent regardless of the operator’s financial performance inflation.
And then under the REIDEA structure, think of it more from an institutional investment standpoint where these financial incentives that the REIDEA/REIT structure may have may not align with resident care because their fiduciary duty is to maximize as much profitability as they possibly can in the shortest periods of time, which may not come at the benefit of residents care.
So in a nutshell, these critics argue that these complex ownership structures limit REIT liability and piercing the corporate veil through wrongful death lawsuits or malpractice are a lot harder because the most vital assets are actually separated from the operations and put into the properties themselves. So there’s been a couple of court cases I’m not going to go into that has actually pierced the corporate veil and there’s other cases that haven’t. But critics suggest that these ownership structures can deter actual accountability.
So I’ll just kind of leave it there. And then I hope that is kind of like a quick 10,000 foot overview of what a REIT is and what are the issues surrounding them.
KIM GEIGER: Yeah, that’s great. That’s very helpful. Do you have any sense of how many or what portion of nursing homes are affiliated with a REIT versus not? How common is this structure?
TYLER BRAUN: Yeah, so about 12 percent of all nursing homes have REIT investment, and that’s probably an under estimate. So most of what we are able to gather is through publicly traded rates, which typically have more transparency in listing what their portfolio is. So private REITs aren’t as transparent. So yeah, it’s around—what we found was 1,806 nursing home facilities that had REIT investments.
KIM GEIGER: And so my understanding is that your study is the first to look into the connections between the ownership and staffing decisions. And I gather that doing this required collecting data from a variety of sources. Can you give us a high level overview of how you did the study and what your findings were?
TYLER BRAUN: Yeah. So kind of just going back with a little bit of background with rent escalations year by year, increasing inflation and the nursing homes’ highest operating expense being staffing, which would be conceivably the easiest thing to reduce is staffing. We were interested in looking at nursing home patterns, staffing patterns, before and after an acquisition took place.
And so what we did is we used Capital IQ merger and acquisition data as well as Ervin 11 mergers acquisition data, along with this thing called PECOS—which is a government data set that is proprietary. It’s not publicly available—that tracks ownership over time of nursing homes and other health care related facilities. And so what we did was try to identify these investments over time longitudinally.
And so in order to quantify this, each nursing home has a CMS certification um, number. Think of it as a tax ID. We captured that through fuzzy matching through this data set called the provider service file. And that provider service file has the legal business names, the CMS certification numbers of all nursing homes in the United States that are Medicare eligible.
And so from that, we were able to merge this onto actually quantifiable data to look at staffing patterns. And we used the Medicare cost reports. And these are submitted every fiscal year to CMS. And within this data, they have various staffing level metrics as well as financial metrics of each individual nursing home in the United States that is eligible for Medicare. And so we were able to track longitudinally over time all of nursing homes in the United States, their staffing patterns and also at the point of time or exposure of which a real estate investment trust made an investment in one of these nursing homes. So we can see changes in staffing patterns for Registered Nurses, Licensed Practical Nurses or LPNs and Certified Nursing Assistants.
KIM GEIGER: And can you kind of walk us through what it is that you found?
TYLER BRAUN: Yeah, sure. Oh, where to begin? Basically, we found about 1,800 nursing home facilities that received REIT investment. And they were all located around the lower 48 states, with 42 percent of them located in the South, 27 percent in the Midwest, 19 percent in the West and 12 percent in the Northeast. States with the largest number of REIT owned nursing homes were in Texas, Florida, California, Indiana and Ohio. And then nursing homes with the highest proportion of total beds in a region were in Owensboro, Kentucky, Lakeland, Florida. Boulder, Colorado, Terre Haute, Indiana – sorry if I’m mispronouncing that—and Hudson, Florida.
So the top five nursing home operators and REIT owned facilities was Genesis, Ensign Group, Trilogy Management, HCR ManorCare—now ProMedica—and Consulate Health Care. And then the top five REITs were Omega ,Welltower CareTrust, Sabra, Griffin America/Northstar. And basically, kind of getting into the more nitty gritty causal analysis, we used a difference in difference model with an event study framework. So basically what we’re doing is looking at, okay, we look at these facilities before they got acquired and then after they got acquired relative to other for profit nursing homes that never received REIT reinvestment. And so we’re able to parse out kind of the causal effect of any changes in staffing that may take place.
And so what we found was that there was about a 2.15 percent increase in LPNs and about almost a 2 percent increase in certified nursing assistants. Those were significant at the .05 level, or P value of .05. And then there was at 3.13 percent reduction in registered nurses, but that wasn’t significant. It was bordering at significant. It was at around a .1 P value.
But if you were to extrapolate that by year—so this is just the aggregate pre/post measure of changes in staffing—if you were to aggregate that or extrapolate that out by year, what we find is that in years two and three after REIT acquisition, there’s about a 6 percent reduction in registered nursing and years two and three. And about the same increases that you’ve see in LPN and certified nursing assistants. So if you’re going to take anything away from this, there might be some kind of substitution effect going on where they’re replacing more expensive labor, registered nurses, for less expensive labor than RNs and LPNs. So that’s kind of the main gist of the main results of the paper.
KIM GEIGER: Okay. So it sounds like there’s a little bit of a delay there, but eventually there is this shift that happens. I’m curious, do we have any idea if our RNs are better for nursing home duties than LPNs and CNAs? Because my grandmother is in a nursing home staffed by LPNs and CNAs instead of RNs. Should I be worried about her health or safety?
TYLER BRAUN: I’ll let David answer that question.
DAVID G. STEVENSON: Sure. I’ll jump in. So there’s a pretty robust literature about the relationship between nurse staffing and quality of care. So, I mean, first of all, the general message of that literature is that higher staffing levels are associated with better quality of care. And thinking about the RNs versus LPN staffing in particular—just so everyone is kind of on the same page, I mean, RNs typically have additional years of training relative to LPNs and their salaries are higher. If you look at national average, it’s probably around 30 to 40 percent higher for RN staff salary levels relative to LPN staffing levels, or salary levels. And the studies have shown the critical—despite the overlap between LPNs and RNs and what they do, having RNs available in the nursing home is really critical to management of resident care and also assessment of resident care and medication management, et cetera. It doesn’t mean that RNs in combination with LPNs can’t be a good strategy.
So if you have an RN supervising LPN staff, that can be a solid strategy for success. So there’s overlap. But having RNs really available on the staff is critical. I mean, it’s one of the only areas where there are explicit standards on the books from over 87 for RN staffing. You have to have an RN onsite for 8 hours a day and available 24 hours a day. And the recent National Academies of Science, Engineering and Medicine report on Nursing Home Quality made specific recommendations around RN staffing. Really, it should be available 24/7 in a facility. It did not in contrast make recommendations about LPN staffing.
So I think the bottom line is you need to have RNs. They have a skill level that’s really necessary. That can be in combination with LPNs, but you have to look first to make sure that you have sufficient RN staffing, I think.
KIM GEIGER: Were you guys able to tell, as you were looking at each individual home, if they’re losing all of their RNs or just a portion of them? Does the data show you that?
TYLER BRAUN: So we didn’t look at each individual facility per se. It’s kind of more on an aggregate level. And so, typically you measure staffing in nursing homes by hours per resident day. So that’s just how many direct hours of care that’s being allocated by a specific type of nurse to a patient per day. And so, our results show about a 6.25 percent reduction in RN care or direct care hours per day. So if you were to actually extrapolate that or do the math, it’s .02 hours per resident day reduction. That may not seem like a lot. But if you were to actually extrapolate that out to minutes per resident week, that’s about 17 minutes per resident week. So you see about a 17 minute reduction in contact minutes per resident in a given week after one of these REIT investments. But on the flip side of that, you can say that there’s about a 17 minute increase for LPNs and about an eight minute increase for CNAs. So there’s this substitution effect going on. So that doesn’t directly answer your question. It’s kind of indirectly, But I hope that kind of sheds light into what you’re asking.
DAVID G. STEVENSON: I think the other piece, Tyler, just to add onto that a little bit, is that we didn’t—and we really can’t with the data that we had—look at whether these staffing levels were sufficient to provide high quality care. That’s not what we did. We looked at relative increases or decreases in these staffing levels. The context for this study and others that look at nurse staffing is that recent studies that have been done and that are in the literature have generally shown that RN and other types of nurse staffing in nursing homes currently or in recent years has been insufficient to meet those needs. And, in fact, that’s why there’s a big discussion now with CMS considering they’re instituting staffing mandates in terms of levels.
KIM GEIGER: Got it. You guys mentioned in the study that there are some issues around transparency and the ability to kind of collect and review data. Can you talk a little bit about that? And you specifically mentioned that the Affordable Care Act has some provisions relating to this and that they haven’t been implemented. I’m curious if you know why. CMA’s been around for a pretty long time now.
DAVID G. STEVENSON: Yeah, I can jump in a little bit. And Tyler, feel free to add in. But you’re correct that there are many nursing home transparency provisions that were included in the Affordable Care Act. And so this has been an issue that’s been around for a while. I mean, if people remember in the early 2000s, kind of 2005 to 2010, 2011, that’s when there was a lot of attention on private equity investment in nursing homes. And so the impetus behind some of the transparency and accountability provisions that were included in the ACA revolved around that dynamic. But there’s those transparency provisions that were included in the nursing home Transparency and Accountability Act, which was folded into the ACA, they were fairly broad. Some have been implemented and some have not.
So some of the ones that have been implemented, for instance, relate to staffing, using payroll based records as opposed to self-reported staffing levels, looking to include staff turnover, weekend staffing, things like that. Those have been implemented. Others have not been fully implemented. Some of the things around transparency of ownership, for instance, have been partially implemented, I think, over the years. Tyler mentioned PECOS data, which are available in somewhat limited form through publicly downloadable datasets. You can look at nursing home ownership of all currently active facilities, and those data are all from PECOS. And those data are much better now than they used to be.
So there is some information available on ownership, but it’s not kind of fully there. And if you want to see providers back in time, for instance, changes of ownership that may have occurred five, ten years ago, which researchers and policymakers and others could be interested in, that’s not currently possible with the available data that is publicly available at least. Some of the other provisions—I’m sure many on the call pay attention to the announcement about ten days ago of the administration wanting to include REIT and private equity ownership in the ownership data that is collected. So specific provisions that would define what those entities are and require those aspects to be reported. That has not been available in the data. You remember Tyler’s detailed description of how we captured REIT invested facilities, that wouldn’t have to be so detailed if those data were more easily available.
In addition, the other thing that hasn’t been fully implemented relates to financial transparency. So ownership, transparency is one element. Financial transparency is another. In terms of having not only accurate cost reports, but thinking about the related party transactions that might be occurring where you have common ownership among facilities or operators and therapy companies or staffing companies or dietary companies, things like that, you should have these consolidated cost reports that are audited on a regular basis if you want to have full information on the financial health of these organizations.
And on the one hand, you can say this is incredibly cumbersome to report this information and why do we have to do it? And I think there are a number of reasons why it’s important, and we can certainly have a discussion about that. There’s the ownership transparency, which is we want to know who owns facilities and kind of what their ownership structures are. Because certain ownership types have been shown to have more issues with quality of care. But then the other piece relates to the financial health facilities.
As many on the call probably know, there’s a large debate about the adequacy of Medicaid payments. Medicare payments as well, but Medicaid is where a lot of nursing homes have focused. And it inevitably gets into an argument on both sides with advocates for residents saying that while we don’t know where these dollars go, we can’t increase rates without knowing that. And the provider’s saying, well, you can look at Medicaid rates and on their face they’re insufficient. If we had better data, we could have a more informed discussion about that, I think. So again, there are a number of uses of these data and but transparency and accountability as an issue I think is incredibly important.
KIM GEIGER: Okay, great. And so in addition to the transparency and data, are there any policy implications you want to highlight that came out of the study?
TYLER BRAUN: Sorry, can you repeat that one more time?
KIM GEIGER: I’m asking if there were any policy implications beyond the data and transparency issues that came out of your study?
TYLER BRAUN: I would say – Dave, chime in if you’d like—I guess kind of getting more in detail about ownership transparency and these consolidated costs reports, having this ownership data for everyone to use, including consumers, policymakers, researchers, is very important, especially state licensures, state licensing groups, state regulators. Let’s say that a large nursing home chain that may be owned by a REIT or a private equity firm or some institutional investor wants to make an investment in a state in which they don’t currently operate, and in other states in which they currently own facilities, they have a bad track record of providing care. The state licensure group or state regulators may actually want that information to see if they should approve that merger or that acquisition.
So that’s one component to it. I think that the second component, you know, I’m just kind of picking off the top of my head here from a policy implications standpoint is if you look at the actual nursing home ownership data, a REIT is rarely ever listed in there as an indirect or direct owner. And from our study, there is some evidence that they may have some influences on staffing patterns or operations themselves, which kind of goes against the traditional narrative that, hey, we’re just the landlord, we don’t have any influence on daily operations. Now, I’m not saying that’s good or bad, they could be providing better care or worse care. We really can’t say that at this point. But it kind of violates that narrative, previous narrative. I don’t know, Dave, if you want to jump in there too.
DAVID G. STEVENSON: I think those conclusions, along with the broader transparency and accountability pieces, are really the broad take‑homes. I mean, if we have better and more publicly available data, I mean, because some of these things are empirical questions. And if we and others could pursue researcher analyses that shed more light in the coming years on the impact of these transactions and kind of the structure of the nursing home industry, access to capital, things like that, I just think it’s broadly helpful to have that information than to not.
KIM GEIGER: And I have one more question, and it’s kind of like a two part question. You mentioned in the study that you did have to remove some large scale acquisitions in order to kind of crunch the data. It sounds like maybe those deals were throwing things off. And I’m wondering if you could kind of explain that. And then I’m also wondering if you identified any like particularly bad actors where you saw staffing reductions that you think regulators should be looking at.
TYLER BRAUN: Yeah, that’s a good question. So we didn’t have to remove them. It was just we wanted to see that if there’s certain large acquisitions—meaning we define large acquisitions as the top three acquisitions with the most facilities involved in that deal—were driving the results. They could be different from each other. And kind of what we found was that when you remove the top three largest facilities, which was 253 facilities or three deals equating to 253 facilities, they actually averaged a 6.25 percent relative decrease in RN hours and no changes in LPN and certified nursing assistant hours per resident day.
So this might actually suggest that larger deals are more likely to increase LPN and CNA staffing without changing RN staffing. While on the flip side, smaller deals we’re likely to decrease RN hours per resident day and make no changes to LPN and CNN staffing hours. Now, this wasn’t tested. We can only theorize that at this point. But we think that the bigger acquisitions or investments or the impact of the bigger acquisitions of nursing homes versus smaller nursing homes might be different due to various factors such as size, resources and risk tolerance. So like bigger nursing homes or chains that might have been acquired through these deals generally have more resources and a stronger financial position which can allow them to absorb the impact of a bigger acquisition better than smaller nursing homes. They also conceivably too could have a larger market presence, which can help mitigate the risk associated with an acquisition or changes in ownership. Where in contrast, the smaller nursing homes might be more vulnerable to the impact of an acquisition due to their limited resources and financial stability. So that’s kind of our kind of theoretical answer at this point, but something that we are thinking about looking at in the future.
DAVID G. STEVENSON: I think the other thing that I’d add – I think that was a great answer, but the other thing I’d add is that, I mean, I’ve done a lot of research on the impact of ownership on both nursing home care, but also in the realm of hospice and home health. And, for instance, if you’re looking at for profit versus not for profit, there is a lot of heterogeneity within those broad categories, just as there likely is within REIT transactions, private equity ownership, things like that. And so kind of removing those bigger deals just to see how much it impacted our results was really a sensitivity analysis of sorts. But I think that’s one thing to keep in mind is that our study was looking broadly at this topic and we did not look at kind of individual deals and individual facilities. This is a broad analysis. But we would acknowledge readily that there is heterogeneity underneath this category.
TYLER BRAUN: Yeah. So I guess the answer to the second part of that question is we didn’t look at specific bad actors per se, just broadly on the aggregate.
KIM GEIGER: Got it. Okay, great. So we’re going to move onto questions from the audience. Again, if you have any questions, email them to editorial@thecapitolforum.com. I do have one here. And the question is I’m wondering if there’s anything you’re seeing that could suggest that regulators might want to take action and do something drastic like revoke tax exempt status on dividends for REITs?
TYLER BRAUN: Dave, I don’t know, you might have a better pulse on this than me, but I’ll say that probably not. I think that access to capital is very important to nursing homes. And declining reimbursement, inflation, wage inflation, have impacted nursing homes severely, especially during the period of COVID. Nursing homes are—from what we hear—are hurting financially. So government needs to be cognizant on avenues in which nursing homes receive infusions of capital. And if you were to cut off real estate investment trusts or other forms of institutional investment at this time, it may have some unintended consequences. So, I mean, that’s kind of my answer to it. David might have a different spin on it though.
DAVID G. STEVENSON: No, I largely agree with that. I think also something that Kim mentioned in the introduction is that this is really the first study that’s examined this in detail empirically. And so there will need to be additional studies. We looked at staffing, but one could look to other outcomes such as mortality or other quality of care outcomes to see what the impact is. And that’s what’s going to need to happen. And greater transparency of data will allow that to happen, to build more of an evidence base to see what’s going on. But those issues that Tyler mentioned about access to capital, those will remain whether REITs are involved in the sector or not. But again, more of a literature is really needed on the quality impacts beyond just this first study.
KIM GEIGER: Yeah, good point. All right. So I don’t have any other questions. Is there anything that we didn’t cover that you guys want to touch on?
TYLER BRAUN: Not that I can think of right now. David, how about you?
DAVID G. STEVENSON: No, the only thing I’d say is that I think this is an area where fairly quick – by area, I mean, the transparency and accountability piece—where a lot of progress and bipartisan discussion really is currently happening around it. And not only the ACA provisions, but the recommendations that came out of the National Academy’s report and just things that the current administration is putting forward. I think it is a pretty active area. And so I think stay tuned because more is going to happen. That allows not only research to happen, but that will change the policy context.
KIM GEIGER: Awesome. Tyler and David, thanks so much for your time and walking us through all of this. It’s a very interesting topic and sounds like one that we’ll need to continue to watch.
TYLER BRAUN: Thank you, Kim.
KIM GEIGER: I think we can go ahead and conclude the call.
DAVID G. STEVENSON: Okay, thanks very much.
KIM GEIGER: Thank you. Take care.
