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Healthcare Realty Trust (HR)
Q4Â 2019 Earnings Call
Feb 13, 2020, 10:00 a.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Good day, and welcome to the Healthcare Realty Trust Fourth Quarter 2019 Financial Results Conference Call and Webcast. [Operator Instructions] I'd now like to turn the conference over to Mr. Todd Meredith, CEO. Please go ahead.
Todd Meredith -- President & Chief Executive Officer
Thank you, Nick. Joining me on the call today are Carla Baca, Bethany Mancini, Rob Hull and Kris Douglas. Ms. Baca, If you could read the disclaimer.
Carla Baca -- Associate Vice President of Investor Relations
Except for the historical information contained within, the matters discussed in this call may contain forward-looking statements that involve estimates, assumptions, risks and uncertainties. These risks are more specifically discussed in the Form 10-K filed with the SEC for the year ended December 31, 2019. These forward-looking statements represent the Company's judgment as of the date of this call. The Company disclaims any obligation to update this forward-looking material. The matters discussed in this call may also contain certain non-GAAP financial measures, such as funds from operations, FFO, normalized FFO, FFO per share, normalized FFO per share, funds available for distribution, FAD, net operating income, NOI, EBITDA and adjusted EBITDA.
A reconciliation of these measures to the most comparable GAAP financial measures may be found in the Company's earnings press release for the fourth quarter ended December 31, 2019. The Company's earnings press release, supplemental information, Forms 10-Q and 10-K are available on the Company's website. Todd?
Todd Meredith -- President & Chief Executive Officer
Thank you, Carla. I will focus on three key topics today. First, the increased momentum of FFO per share growth in 2019. Second, Healthcare Realty's key building blocks for growth, including a higher level of net investment. And third, our positive outlook for 2020.
Healthcare Realty reported strong results for the fourth quarter and full year 2019. Normalized FFO per share grew from $1.57 in 2018 to $1.60 per share in 2019. Momentum increased throughout the year built on solid fundamentals of sustainable internal and external growth. Our portfolio again performed well with same-store NOI growing right in line with expectations around 3%. Most importantly, our focus is on driving steady revenue growth with contractual rent increases, tenant retention and cash leasing spreads. We also contained expenses quite well, which accelerated NOI for the multi-tenant properties. 2019 external growth was led by robust acquisition volume, approaching $400 million, nearly double our historical pace. Equally important, we sold far fewer properties than in recent years. It's worth noting we sold some of our last post-acute properties in 2019, along with a handful of MOBs at more indicative cap rates.
Following a period of costly dispositions and reducing leverage, Healthcare Realty's portfolio and balance sheet are in great shape. With the environment for medical office and -- while the environment for medical office investment remains competitive, our confidence to invest at an attractive pace is based on our established relationships, financial strength and access to accretive capital. A key part of our strategy is to avoid bidding wars and portfolio premiums is often as possible. In 2019, we sourced nearly 70% of our acquisitions working directly with owners and brokers before the properties were widely marketed. We rely on our deep relationships to buy what we target rather than what is listed for sale. A great example is the MOB we recently acquired in Orange County, a property we've been pursuing for years through direct dialog with the owner and the help of a local broker.
We are also using our MOB experience and operational expertise to help our health system partners meet their expanding real estate needs. Hospitals and physicians are increasingly providing outpatient services across a range of settings to achieve market share and revenue growth, while balancing value and efficiency, critical in today's healthcare environment. As an example, we're working with Baptist Memorial Health Care in Memphis to redevelop 111,000 square foot property into a strategic hub within their outpatient network. This off-campus property will include a surgery center, a large orthopedic clinic, a lung practice and other complementary services. Outpatient expansions like these are happening across the country and correlate with favorable national trends. In 2019, more than two-thirds of all new healthcare jobs were in the ambulatory and outpatient sector. What's most gratifying to us is seeing these trends initiated through our well-established -- throughout our well-established network of health system relationships.
As another example in Nashville, we're working with St. Thomas, part of Ascension to redevelop one of our smaller existing properties into a state-of-the-art 100,000 square foot MOB tied directly into their new women's hospital and the creation of a new front entrance to the campus.
Looking ahead to 2020, the pipeline for acquisitions is strong. And moving forward, we are planning for fewer dispositions at better cap rates. And we expect a couple of developments to begin soon. Higher, more consistent net investment volume, steady same-store growth and disciplined capital spending are the key building blocks we will use to grow FFO per share and improve dividend coverage in 2020 and the years ahead.
Now, I'd like to turn over to Bethany for an update on the healthcare trends.
Bethany A. Mancini -- Corporate Communications
2019 was an active year for the Trump administration's regulatory agenda and congressional attempts to address certain healthcare costs. The legal standing of the ACA was challenged in the appellate court and in the end health policy finished the year relatively status quo. Congress specifically addressed two voter-friendly healthcare initiatives. One, the rise in pharmaceutical prices and the other, a bipartisan bill to limit patient costs for out-of-network medical care. Both efforts failed to gain traction with party line division over the issue of market intervention and price control amid intense industry lobbying from insurers, providers and pharmaceutical companies. These initiatives are already beginning to resurface in 2020. Both sides and Congress would like a voter friendly win on healthcare in an election year, but a partisan standoff could again stalemate any real movement on legislation, if neither side is willing to compromise and concede a political win to the other.
On the regulatory front, the Trump administration and CMS remained quite active. BMS issued rulings last year requiring hospitals to list standard prices beginning in 2021. And this year site neutral Medicare payment rates will apply to clinic visit in all off-campus hospital outpatient departments. These rulings, among others, are being challenged and installed in the quarter. CMS admittedly is adhering to an aggressive regulatory approach in spite of the certain opposition and legal roadblock. The administration acknowledges partly bringing these issues to light through the regulatory process in the hope of eventually influencing legislation.
On the judicial side, the ACA remains under scrutiny in the Texas v. Azar case. The federal appeals court remanded the case back to the District Court to consider it favorability from the now-defunct individual mandate. The Supreme Court is expected to ultimately rule on this case most likely not before 2021.
Moving past the political realm, hospital fundamentals appear strong with positive reimbursement rates and commercial price increases in 2020 and signs of stable admissions and revenue growth. With pressure to lower costs, health systems are focused less on their number of admissions and more on improving margins by treating patients in efficient care settings. Health systems are expanding outpatient facilities across markets and focusing their hospital campuses on higher acuity inpatient and outpatient care. The AHA's 2020 Hospital Stats report confirms these trends. Hospital saw a decrease in their outpatient visits by 0.9% in 2018, specifically in the number of ER visits, which are moving in part to lower cost settings more convenient to patients. Other areas of hospital outpatient utilization were stable or up slightly from the prior year with higher acuity leading to an increase in total outpatient revenues, up 4.5%.
We continue to see among Healthcare Realty tenant and health system partners in sizable fast-growing markets. The outpatient care is on the right across the spectrum of service setting. Outpatient facilities represent one of the few proven strategies to remove unnecessary costs from the healthcare system. While CMS insurers and providers continue to explore value-based care and quality incentive payments, most reimbursement rates are still largely fee for service and volume-driven. Accordingly, outpatient care is expected to remain one of the most critical and attractive strategy for health systems and providers to meet rising demand, lower cost and enhanced profit margin. Healthcare Realty will continue to selectively invest in outpatient facilities that are well located and aligned with strong health system, positioned relevant to current healthcare trends and with the potential for long-term growth.
Now, I'll turn it over to Rob for an overview of investment activity. Rob?
Rob Hull -- Executive Vice President of Investments
Thank you, Bethany. I'm going to summarize Healthcare Realty's 2019 investment activity and provide our outlook for the coming year. Healthcare Realty finished 2019 with strong acquisition volume, annual net investment activity with more than seven times that of 2018, well above our historical pace. Increased acquisition volume was driven by our internal sourcing process, targeting well-located buildings with the greatest potential for growth.
To summarize the year, we acquired 18 properties in 16 separate transactions for $381 million at a blended cap rate of 5.5%. And we're very accretive at our cost of capital. What I really like about these properties is about one-third establish new relationships or in new markets that will further our growth in the coming years. And each property on and off-campus is important to our health partners as they shifted the delivery of care into the most appropriate setting. Also during the year, we funded $29 million of several developments, including Charlotte, Seattle and Memphis. We sold 10 MOBs for $28 million at a combined cap rate of 5.5% and disposed of our last skilled nursing facility and two independent inpatient rehab facilities. Dispositions for 2019 totaled $55 million, about half of our recent average annual sales volume.
Now, I'll give you an overview of our acquisitions in the quarter. We purchased six properties for a total of $107 million. Included are two MOBs I mentioned on last quarter's call. One in Raleigh was purchased for $22 million is adjacent to WakeMed's North Hospital and is our first building in the market. The other a $20 million investment anchored by an ASC is located in Dallas adjacent to Baylor Scott & White's Plano hospital. Additionally, we acquired three MOBs in Seattle, bringing total square footage in the market to 1.4 million square feet. The first of these was a $23 million MOB with the primary tenant being EvergreenHealth, a new relationship for Healthcare Realty. The building is conveniently located in a dense area with direct access to Interstate 405 and just three-tenths of a mile from Evergreen's 318-bed main hospital. Second was an MOB we purchased for $10 million adjacent to CommonSpirit's Highline Medical Center. We now own nearly two-thirds of the MOB space around this hospital, giving us flexibility to accommodate tenant expansions and best serve our healthcare partners. Last in Seattle was an off-campus MOB we purchased for $24 million anchored by Overlake and UW Medicine, two of our long-standing relationships.
Each system is offering services at this location integral to increasing its market share and serving the rapidly growing population. These five acquisitions totaled almost $99 million at a blended cap rate of 5.7%. This excludes the purchase of a building in Memphis related to a redevelopment, which is expected to stabilize at a 7.6% yield. Looking ahead, we expect acquisition volumes for 2020 to remain robust. So far this year, we have purchased an 87,000 square foot MOB in Los Angeles for $42 million. The building is adjacent to MemorialCare's 252-bed Saddleback Medical Center. The real opportunity here is that leasing discussions are under way that would take occupancy from 80% to over 90% and would increase the yield to over 6%.
Beyond this investment, we have several properties we expect to close by the end of this quarter and a solid pipeline of directly sourced and targeted acquisitions. We are setting initial guidance for 2020 at $250 million to $350 million, 70% greater than our initial guidance at this time last year and which reflects the strength and current visibility of our pipeline. We expect cap rates to average 5% to 5.8%, consistent with 2019. Dispositions for 2020 are expected to be generally in line with last year's reduced sales volume at lower average cap rates and with non-MOB sales largely behind us. We expect $25 million to $75 million of dispositions this year at an average cap rate of 5.5% to 6.5%.
Regarding development activity, our embedded pipeline continues to produce a steady source of investment. We commenced construction at our Memphis Redevelopment that I introduced last quarter, and we are already in discussions with several tenants to expand their space. The redevelopment is 85% pre-leased and is anchored by a surgery center. In Seattle, our first tenant and ASC [Phonetic] occupancy this month at a 151,000 square foot on-campus development. More importantly, quarterly NOI is projected to be over $600,000 once all leases -- once all signed leases take occupancy in the third quarter. We are also talking to several prospective tenants about taking space in the building, including additional hospital services and a third-party women's health practice.
Looking ahead, for 2020, we expect to start two to three more developments in Tennessee, North Carolina, Washington or Texas, driven by an expansion of services from our healthcare partners. As an example, Ascension St. Thomas Hospital in Nashville has announced an expansion plan of over $300 million on a 683-bed Midtown campus. Included will be a new women's hospital, a related surgical addition and an inpatient rehab facility. With Healthcare Realty's prior redevelopment on this campus fully leased, we are in discussions with the hospital to replace and expand another building we own at the front door to the new women's hospital. The 100,000 square foot MOB redevelopment has a budget of $40 million.
As we move into 2020, I'm pleased with the pace of acquisition and development activity produced by our internal sourcing process and our team's ability to foster key relationships. Together with lower disposition levels at better cap rates than in years past, our outlook for the year's net investment activity is bright.
Now, I will turn it over to Kris to discuss financial and operational performance for the quarter and full year.
Kris Douglas -- Executive Vice President & Chief Financial Officer
Thanks, Rob. The fourth quarter, much like the year itself, was defined by the continued strong performance of our same-store properties complemented by an increased acquisition pace. Combined, those factors resulted in a normalized FFO per share increase for 2019 of 1.7%. Growth accelerated in the second half of the year with fourth quarter FFO per share increasing 4% year-over-year to $0.41. Sequentially, FFO was $3.1 million higher than the third quarter of 2019, primarily due to a $1.2 million contribution from net investment activity and an $800,000 reversal of third quarter seasonal utilities. The remaining increase was split between higher leasing activity, lower G&A and lower interest expense.
On the operations front, trailing 12-month same-store NOI increased 2.9%, led by the reliably strong growth of our same-store multi-tenant properties at 3.2% and single-tenant net lease properties at 1.8%. Single-tenant NOI growth is consistent with our expectations, given that nearly 30% of the leases have non-annual escalators that have not had an increase in the past 24 months. NOI growth will remain at this level for the first three quarters of 2020, an increase in the fourth quarter with the next non-annual rent increase occurring in October. We anticipate occupancy within the single-tenant portfolio to remain at 100%. There is only one lease expiration this year, an 83,000 square foot on-campus MOB in [Indecipherable]. And renewal discussions with the tenant indicate a favorable outcome. The solid growth from our same-store multi-tenant properties was due to a combination of reliable revenue growth and prudent expense management.
Revenue per occupied square foot increased 2.6%, while operating expenses grew just 1.5%. Lower-than-average expense growth was primarily the result of a 3% reduction in utility expenses. In addition, successful tax appeals resulted in a historically low 1.3% increase in real estate taxes during the year. We continue to proactively manage all line items and expect overall expenses to increase in 2020 within our long-term expectation of 2% to 2.5%. Internal revenue growth indicators are strong as evidenced by the following key performance metrics from the quarter. Cash leasing spreads averaged 4.2%. Tenant retention was 86.6%. The average in-place contractual increase was 2.9%, and for the leases executed in the quarter, future contractual increases are 3.16%. These metrics point to the viability of ongoing internal growth.
Shifting to capital and the balance sheet. The fourth quarter saw an increase in maintenance capex as expected. Even with the higher spend in the quarter, total capex for the year was $1 million less than in 2018. As a result, the FAD payout ratio improved 500 basis points to 95%. Looking forward to 2020, the midpoint of our maintenance capex guidance is $60 million. This is 4.9% above 2019 actual and compares favorably when considering portfolio square footage is up approximately 6% in 2020. We raised $103 million of equity during the quarter through the ATM, which was used to fund the $149 million of acquisitions closed during the quarter and last month. Including the January acquisition, debt-to-EBITDA would have been 5 times, which is at the low end of our target leverage. As a reminder, our line balance will reduce at the end of this month when we draw down our $150 million seven-year term loan. Our flexible balance sheet, improving payout ratio and availability of capital positions us well to fund our growth opportunities. And looking ahead, our compounding internal growth, coupled with increased net investment activity, will drive FFO per share growth.
Operator, we are now ready to open the line for questions.
Questions and Answers:
Operator
We'll now begin the question-and-answer session. [Operator Instructions] First question comes from Nick Joseph with Citi. Please go ahead.
Nick Joseph -- Citigroup -- Analyst
Thanks. You mentioned the portfolio cap rate premium versus relationship-driven deals. I'm wondering if you could put some numbers around that in terms of what you're seeing, in terms of portfolio deals today versus the guidance that you provided for 2020.
Todd Meredith -- President & Chief Executive Officer
I think in terms of portfolio deals [Indecipherable] 50 basis point to, in some cases, 100 basis point premium on portfolio deals related in regards to what we're seeing transactions that are being produced by our internal sourcing process and through direct relationships that we have.
Nick Joseph -- Citigroup -- Analyst
And is that -- given that premium, is there an opportunity to put together a portfolio sell into that strength?
Kris Douglas -- Executive Vice President & Chief Financial Officer
Certainly, if we felt like we needed to, I think we could certainly see that coming together. I think our view would be -- it really just comes down to, as we talked about, we really see our portfolio being in great shape and probably don't see a super large portfolio or need to put together a large portfolio to sell. Certainly, I think if we did that, we could certainly drive those kind of premiums like, as Rob said, other sellers have been doing, but for us, we're really viewing this more as a maintenance level activity now that the portfolio is in such great shape.
Nick Joseph -- Citigroup -- Analyst
Thanks. Just maybe on guidance, appreciate all of the line items that you provide. What are your thoughts of not providing FFO and normalized FFO guidance?
Kris Douglas -- Executive Vice President & Chief Financial Officer
I think our view is philosophically, we really like to have folks have the building blocks and put that together and understand all the pieces. It's not that we couldn't do that along with FFO guidance. I think probably, the biggest issue is keeping the focus on those pieces and if we saw that folks were having a difficult time using those pieces to put together their own estimates or it was materially wide range of estimates or materially off our own expectations, I think we would certainly put more emphasis on that, but I think we're more comfortable with the pieces and think it seems to be working pretty well with those that follow us and put together their estimates like yourself.
Nick Joseph -- Citigroup -- Analyst
Sounds good. Thanks.
Kris Douglas -- Executive Vice President & Chief Financial Officer
Thank you.
Operator
Our next question comes from Jordan Sadler with KeyBanc Capital Markets. Please go ahead.
Jordan Sadler -- KeyBanc Capital Markets -- Analyst
Thanks. I just wanted to sort of continue on the investment prospects. I think, Rob, we mentioned that the outlook for investment activity is bright, and you've obviously had a lot of success in '19. Can you talk to what's driving this is as a sourcing process just continuing to evolve? Is it sort of this adjacency that seems to be unfolding in terms of new investments relative to existing investments that's driving it? What's sort of the -- it's one of the key drivers, if you will, and what keeps you so optimistic?
Todd Meredith -- President & Chief Executive Officer
Sure. I think you hit it the key driver, sort of the leading concept there is really the effort to source these acquisitions through our own direct channels and relationships, and we've really just seen that pipeline build through that effort, I would say, over the last couple of years. And you've heard us picking up our discussion about that in the last several quarters. So we're really just building that confidence from sort of the reach we have with our team, the depth and market reach very targeted in certain markets that we want to build in and go into some new markets and then, obviously, expanding with our health system relationships and partners there. So it's really putting those pieces together the strength and experience, the depth of our team has really been translating. And certainly, we're trying to really target using our cost of capital, where it makes sense accretively and obviously that helps and you saw a big contrast in that '18 versus '19. So it's -- but I would say primarily it's really that internal sourcing effort.
Jordan Sadler -- KeyBanc Capital Markets -- Analyst
Is your focus and -- I think we've talked about this also in the past, is there a sort of like a little bit of an increased appetite for off-campus? Or how is that factoring into the sort of underwriting? At this point, it seems they're like more of these are seem to be adjacent or off-campus as opposed to on.
Kris Douglas -- Executive Vice President & Chief Financial Officer
Right. If you look at 2019, about 70% were on our adjacent and 30% were just outside that. I would say it was a bit of a unique year in that regard and that we had quite a cluster of assets that as you just pointed out, sort of live between this quarter mile and a third of mile. So that's obviously not going very far out on the risk curve. And I would say it's also been in very dense markets like Seattle. So that's been -- Rob walk through some of those. And some of those are just outside that quarter mile definition. So we're sort of live and by our own tight definition of that. And so, you're picking up on that, not really an intention to move away from campus. However, we're certainly willing to look off-campus. You've heard of several of us talk about the shifting of outpatient. Obviously, it's shifting to outpatient from the hospital, but that's a lot of that's on campus. But we're also willing to work with our health system partners, if that means going off-campus. You've often heard us talk about reservation about off-campus. Really that issue is just understanding the real estate value and then making sure any additional risk we see that there is some additional return related to that. So really, there was only one building in our whole activity set for '19 that was materially away from a hospital, I think, it was about 3.5 miles. It was also in the Seattle area that Rob -- as Rob described it. And I think the yield was just over 6% and reflected that at additional perceived risk that we have of being off-campus.
Jordan Sadler -- KeyBanc Capital Markets -- Analyst
Okay.
Todd Meredith -- President & Chief Executive Officer
And I would just add to that, then that $1 billion we had two systems that are -- we have deep relationships with. So that was the driving force as well.
Jordan Sadler -- KeyBanc Capital Markets -- Analyst
Yeah. That's helpful. And then just on the cap rate on sort of deals expected for 2020, that low end 5%, I mean, are we -- where do you see the market headed right now? Rob, obviously, your cost of capital has kind of come back and you've got some support, but is there a greater level of availability at that price point or is it -- or is pricing sort of getting a little bit more aggressive relative to last year? How would you characterize that?
Rob Hull -- Executive Vice President of Investments
Jordan, I'd say that if you look at 2019, we averaged about 5.5% on our cap rates. It's early this year. We've seen that so far the deals that we're looking at and that we're pursuing, cap rates have been consistent with that. So I think it's a little early to tell at this point. We aren't seeing much movement in cap rates, but kind of going back to the way we source deals and our internal sourcing process versus chasing marketed deals, we may be a little insulated from that. So -- but for us, right now, it seems to be somewhat consistent with last year, but continue to keep our eye on that.
Todd Meredith -- President & Chief Executive Officer
And Jordan, I would say to the point about marketed deals, the large portfolios that were mentioned earlier, I think that's where you tend to see that come out and people follow that trend more. So I think, as Rob said, it's early and if we do see some larger transactions later this year, I think those will be the ones to watch to see if those bigger portfolios drive lower on cap rates, as you say, in terms of just -- and it kind of makes sense. There is obviously a lower cost of capital, especially in the debt markets for a lot of potential bidders, so you could see that. But our view, as Rob said, is we're probably little insulated from that based on our internal sourcing focus.
Jordan Sadler -- KeyBanc Capital Markets -- Analyst
Okay. And then just lastly, I guess, Kris, you mentioned that capex is expected to increase in the fourth quarter. I don't know if I missed this, but just specifically as it relates to leasing costs from renewals, I think they were up to 23% of cash NOI in the quarter. TI's up to $3.15 per square foot per year. Any -- was there a particular lease or two that sort of drove this spike and maybe just offer a little bit of color?
Kris Douglas -- Executive Vice President & Chief Financial Officer
Yeah. I had a couple of points there. I guess, first on the commitments that, yes, you're correct. It was a bit higher, and it is related to one specific lease, be it was well over $3 in total. We have one lease that made about 70,000 square feet that was higher than -- significantly higher than the average, up closer to $4.50. And that was due to the fact that it was multiple suites associated with this tenant. And as part of the renewal, we made the determination to consolidate and move a lot of the space across contiguous space, which is going to be more efficient for them, but it also opens up for us the ability to have larger blocks of space to drive occupancy and future growth in the periods ahead. So it was a strategic decision to do that.
We also did have almost 10% cash-leasing spread on that renewal, and we were able to increase the in-place contractual escalators from 2.5% to 3%. So an example of maintenance capex decisions that have good investments and good returns associated with them. So that was in the commitments, and part of those dollars are going to run through your spend in this quarter that some of it in the last quarter and some of it will be in future quarters. But as we will talk about regularly, you will see actual spin fluctuate from quarter-to-quarter. It's just not as consistent as you would see in earnings. But overall, the spend for the year on total maintenance capex of $57 million is down $1 million from last year and was within our expectations and consistent with that payout ratio of 95% that we had indicated, we expected for the year when we talked on our last call.
Jordan Sadler -- KeyBanc Capital Markets -- Analyst
How big did you say that one lease was?
Kris Douglas -- Executive Vice President & Chief Financial Officer
It was 70,000 square feet. So it's about 20% of the overall renewal volume in the quarter.
Jordan Sadler -- KeyBanc Capital Markets -- Analyst
Okay. Thank you.
Operator
Our next question comes from Chad Vanacore of Stifel. Please go ahead.
Tau -- Stifel Nicolaus -- Analyst
Hi, good morning. This is Tau [Phonetic] on for Chad. My first question is a follow-on question on the acquisition guidance. Looks like your acquisition for 2020 guidance is still solid, but it's lower compared to the 2019 deals that you guys completed. Is it just a matter of being conservative? Are you guys seeing more increased competition in your targeted price point for the assets or are you seeing any change in pricing? I think while towering the call, you used the word frenzy and hinted that large portfolio cap rates have been compressed. So how should we think about the market in general and also the cadence of the acquisition throughout the year?
Rob Hull -- Executive Vice President of Investments
Yeah, I think if you look at, again the cap rates we did last year there in that mid-fives range and we see that being -- early in the year, we see that being consistent with what we did last year. I think as you referred to the guidance, I mean, we have a solid pipeline of opportunities. We're off to a strong start. We've closed on a $42 million deal. Already, we have a good number of additional deals that are under contract or LOI. I think what you'll find with our pipeline is that a majority of it is internally sourced deals through relationships that we have. Those buildings are not often for sale. And so, we spend a lot of time working with owners and brokers on those deals
And so, as we look out for the year, the predictability of what we can close early in the year is only so visible as you look toward the end of the year and that becomes more and more -- as we go through the year, that becomes more and more confident. And we have more and more confidence in that. So it's really about kind of setting the initial guidance that was significantly above where we were last year, but setting that guidance with some reasonable amount of confidence and what we can get close based on that pipeline that's internally sourced.
Tau -- Stifel Nicolaus -- Analyst
Okay. And also you've lowered the cash NOI growth outlook to 2.3% to 3.2% in 2020. That's a little bit lower compared to 2019 because you realized 2.9%. I'm just wondering what are the primary driver of that lower guidance? It looks like the midpoint of [Indecipherable] outlook is a little bit higher than 2019. But maybe rate is a little bit softer, but it is also in the kind of the expense outlook.
Kris Douglas -- Executive Vice President & Chief Financial Officer
Yeah. So first off, I would say the short answer is, it has a lot to do with comps and comparability with some great results that we saw in the last year that will fall into the prior periods that will create some changes in terms of your comparability year-over-year. But as you're looking out through the year, we expect the NOI -- same-store NOI to come in similar to where, if not above where we came in this year, 3% plus up close to the top end of the range. But -- because of the comparability issues and some of the previous periods, it will create a little bit slower momentum in the first half of the year.
You can see that if you look at the quarterly NOI year-over-year growth and specifically, if you look at the first quarter of '19 and fourth quarter of 2018, both of those periods had 4% plus year-over-year NOI growth. And so, those will now end up in the prior period comp that we will be comparing off of moving forward. So if those move out of the comparable period, you're going to get back to the 3% plus that we had historically been reporting. But if you look to the underlying growth metrics that really drive revenue in terms of cash leasing spreads, tenant retention, contractual escalators, all of those are staying in the 3% range on the growth that we've historically seen and that's what gives you the confidence and insight as to the expectations of long-term growth.
But overall, you kind of look at it and say, quarter-to-quarter, you could see growth anywhere between 2% and 4% on a quarterly basis with a midpoint around 3%. It will moderate a bit when you look on a trailing 12-month basis, maybe more in that 2.5% to 3.5% range. But still, overall, we are looking at -- right at plus or minus 3% growth long term.
Tau -- Stifel Nicolaus -- Analyst
Okay. And lastly from me, you have close to 20% of your lease that you expire in 2020. Are there any large leases that we should be aware of?
Kris Douglas -- Executive Vice President & Chief Financial Officer
In any year, you're always going to have certain amount of leases rolling. I'll say, last year, we actually had more than 20%. So we're down a little bit, but plus or minus 20% is what we would generally expect. We do have fitness center in Dallas that we have talked about on previous calls that we are in the process of working with the hospital to -- as they are looking to transition operations to a new operator, they're probably going to take about half of the 100,000 plus square feet, and we are working on backfilling the rest of that space as well as a potential redevelopment of the entire building to capitalize on the momentum that's coming from the new fitness center as well as a 300,000 square foot new administrative building that the hospital is completing directly next door, which is creating a lot of vibrancy in that area. So that will be occurring this year.
We also have a general office tenant and a building also in Dallas that's about 60,000 square feet that in the back half of the year, we don't expect to renew. We're already in the process of working on backfilling that space and have -- a 10,000 square foot user has already signed up to take a portion of that. So there will be, maybe, a little bit of timing as we backfill, but it's in a great area of Dallas right near the NorthPark Mall right on the Expressway there, and we've had tremendous leasing success in a couple of buildings we own right there. So, feel good about it, but that is a larger exploration for us given that our average tenant size is about 4,000 square feet.
Tau -- Stifel Nicolaus -- Analyst
Thanks for the additional details. Thanks for taking my call.
Operator
Thank you. Next question comes from Connor Siversky, Berenberg. Please go ahead.
Connor Siversky -- Berenberg Capital Markets LLC -- Analyst
Good morning everybody, and thanks for having me. Just a couple of questions on dispositions. I'm seeing the purchase option schedule in the 10-K. Can you provide any kind of color on the timing or execution of these contracts?
Todd Meredith -- President & Chief Executive Officer
Yeah, in the K, what that lays out are any options that are available. There are a portion that are available today. That does not mean they have been exercised, none of them have been exercised and they've been available for quite some time. I can't remember off the top of my head. There is a footnote on there. I think there has been 10 to 15 years that these on average have been available and have not been exercised, but they're basically perpetually open, but we don't have any expectation that they're going to be exercised at this time.
Connor Siversky -- Berenberg Capital Markets LLC -- Analyst
Okay. Thanks for that. And then on this acquisition in Los Angeles at the beginning of the year, any additional color you could provide on the building? Is it specialized for any specific function? And then any details on the existing lease term as well?
Rob Hull -- Executive Vice President of Investments
On the building we acquired in Los Angeles, it is adjacent to settle back hospital there. It's a sizable hospital, and it's a multi-tenant building typical of what we would be pursuing. And I would say it's not special-purpose asset by any means, but just more in line with the multi-tenant buildings that we like to purchase with good tenancy that is representative of the quality health system that's adjacent to it.
Connor Siversky -- Berenberg Capital Markets LLC -- Analyst
Got you. Got you. Thanks for that again. And then in terms of future capex expectations, are you guys seeing any developing regulations or maybe building code adjustments that would necessitate an increase in capex spend going forward.
Kris Douglas -- Executive Vice President & Chief Financial Officer
It really goes jurisdiction by jurisdiction. We've had some of that in California frankly that we've been experiencing over the last three, four, five years. And so, it's already inside of our spend in that area. But overall across the country, we're not seeing anything that materially is changing our expectation on what our spend. We do expect -- obviously, there is going to be inflationary pressures on capital, including TI and building capex, but we think that with being able to continue to drive rent growth in that 3% plus range that we are able to more than accommodate and get a return on the capital that is associated with all of our TI projects.
Connor Siversky -- Berenberg Capital Markets LLC -- Analyst
All right. Got you. And then last one from me on that. Our first investment in Raleigh, any promising trends in that market that you see that could -- can generate some continued interest investments there on your end.
Todd Meredith -- President & Chief Executive Officer
Sure. I mean Raleigh, as I mentioned, that's our first investment in that market. We think it's a strong market, good growth profile, good health systems and we think there is some opportunity there in the market to make additional investments. So we're excited about being in that market and our team is continuing to form relationships and pursue opportunities there.
Connor Siversky -- Berenberg Capital Markets LLC -- Analyst
All right. Great. That's all from me. Thank you.
Operator
Next question comes from Jonathan Hughes, Raymond James. Please go ahead.
Jonathan Hughes -- Raymond James & Associates -- Analyst
Hey, good morning. On the internally sourced deal pipeline and the better pricing there, I mean why are these healthcare systems not market those properties and get a better price? It's certainly not for lack of interest or capital chasing MOBs. I mean, do they like the certainty of sale and long-term ownership by selling to you, and that's it, or is there another piece of expertise or data analytics capabilities you bring to those systems whereby they're willing to forego a higher price from another buyer?
Todd Meredith -- President & Chief Executive Officer
Well, I would be careful to bifurcate this. We're really, as Rob said, looking more at individual properties, buying them one-by-one and frankly, most of them are not from health systems. We would tell you year-after-year that you just don't see a whole lot coming from health systems. Certainly, some do come from health systems occasionally. So there is a big difference here where you have a very fragmented owner base or seller -- list of sellers. We did 16 different transactions for 18 properties in '19. So that gives you a sense of that. So I think it's really just that issue that we're buying from individual owners.
And you're right, if somebody had that portfolio of all those properties we bought '19 and package it together, maybe they can drive that larger portfolio pricing. And that's what Rob was referring to is, when you look at some of the larger portfolios that transacted in '19 and years past, our view is that there has been a portfolio premium paid for some of those larger portfolios. And I'm really referring to sort of $1 billion -- close to $1 billion or more type size where you can get those kind of premiums. So I just think based on where we're focused with the internal sourcing and individual transactions. You're just -- it's not that we're not paying market price as we are. We think we're paying indicative pricing for those assets. It's just you're not driving additional portfolio premium beyond that.
Rob Hull -- Executive Vice President of Investments
I'd add to that, Jonathan, that where we have seen obviously, the value that we're bringing to the health systems is through development and the way we're doing development. A lot of the development we're doing now is in conjunction with the hospital and generally, you get into some strategic decisions there about not only the development you're doing, but sometimes that will lead to an acquisition opportunity, maybe it's one or two buildings, but it's really coming from that interaction with the health system and you sort of proving your value through your ability to develop and provide some services to them. A good example of that is what we're doing in Memphis on that redevelopment there. That's been an opportunity that we've worked hand-in-hand with the health system and we're seeing a lot of benefits from a relation standpoint because of that.
Jonathan Hughes -- Raymond James & Associates -- Analyst
Okay. That's helpful. I think you said 16 transactions for what 18 properties last year? I mean, how many of those 16 transactions were actually buying the real estate from a system?
Kris Douglas -- Executive Vice President & Chief Financial Officer
I don't -- well, Memphis. Yeah, the redevelopment property that I mentioned, that Memphis transaction. Other than that, I don't think there were any that were purchased from the system.
Jonathan Hughes -- Raymond James & Associates -- Analyst
Okay. And then switching to kind of looking at the lease schedule this year, 20% of the multi-tenant leases rolled. Is there potential for the cash leasing spreads there to go above 4% like last year in multi-tenant or is that unlikely given the -- I think, it's about 12% of vacancy or so in that portfolio?
Kris Douglas -- Executive Vice President & Chief Financial Officer
It's going to move around from quarter-to-quarter and depend on just the mix that you are able to achieve. If you look at this year and what we've seen historically, the majority -- we break down in our disclosure each quarter in our earnings release, the different ranges of the cash leasing spreads. And you'll have a portion that will be negative. I think it's running around 10%. That's generally consistent with what we have seen historically, but then it really comes down. Your average is going to depend on that total distribution. But if you look at distribution over time, we -- the majority of it still runs in that 3% to 4% range. We think that's the appropriate way to look at the long term, but if you're able to do a little bit better on 4% plus and moderate the negatives, then you can see results like we did this quarter. But we think that the 3% to 4% continues to be achievable and is our expectation for '20 as well.
Jonathan Hughes -- Raymond James & Associates -- Analyst
Okay. The 88% occupancy for the multi-tenant MOB portfolio, is that peak structural occupancy? Can it ever get to a low 90% range?
Kris Douglas -- Executive Vice President & Chief Financial Officer
Our view is with multi-tenant. It is certainly a lower number than you might see obviously, if you blend in a lot of single tenant. 88 to 90 certainly is probably something over time that we see being able to achieve, but it's not just pure lease-up. Sometimes, it's selling assets that may be for whatever reason stuck in the '70s and for a prolonged period. And we've made our efforts and we can't seem to move it. So maybe, it becomes a disposition or just maybe a matter of time. So it really is a portfolio effect. And I would say the example Kris gave about the large tenant that we're strategically combining space to open up larger blocks. It takes those kind of long-term moves and investments in TI to really optimize that. So it's a slow steady process of building from 88 both from a portfolio construction standpoint, but also then within buildings. So our view is probably moving slowly toward 90 is where our focus is.
Todd Meredith -- President & Chief Executive Officer
You're also going to have in that your development and how much space maybe still left to lease up and a development once it's completed. But that's another example of a good opportunity to drive income as well as occupancy over time.
Jonathan Hughes -- Raymond James & Associates -- Analyst
Okay. And that's helpful. Thanks for the time.
Todd Meredith -- President & Chief Executive Officer
Thank you.
Operator
Our next question comes from Vikram Malhotra, Morgan Stanley. Please go ahead.
Selina Pi -- Morgan Stanley -- Analyst
Good morning. This is Selina [Phonetic] on for Vikram. So, thanks for taking my question. Just was curious what your expectations are for the FAD payout ratio in 2020 based on your current capex outlook.
Todd Meredith -- President & Chief Executive Officer
Sure. If you look -- obviously, as Kris described, we moved from about just under 100% to 95% going from '18 to '19. If you look at our midpoint or the range we have for capex and all the growth drivers we have. We really do see ourselves driving toward 90%. Hopefully, we can achieve most of that in '20. So our view is, we should see continued improvement in 2020 and obviously, in the years beyond that, but that's sort of the progress we're looking for is driving that toward -- certainly toward 90%.
Selina Pi -- Morgan Stanley -- Analyst
Great. And just one last question, any high-level thoughts of around how more a Medicare for all stance may impact MOB in some of your tenants?
Todd Meredith -- President & Chief Executive Officer
I would say generally speaking, we've talked about that. I think the key thing is the probabilities -- there is a lot of sequence of low probability events have to occur. So, spending a lot of time on it right now is probably -- maybe not the best use, but I think the key takeaway is, it's not going to change the fact that people need healthcare that there will be demand, you have an aging population and again some of the incentives if you make, healthcare essentially, no cost -- no marginal cost for folks, not -- setting taxes as high. No marginal cost at the incurrence of use, then you could actually see usage go up. And so, it may cause some restructuring in some uncertainty around that certainly from the health insurance side going from private to government.
But certainly, we think MOBs will be necessary doctors, will be necessary all those services. Shifting to outpatient will become, if not the same urgency -- more urgency around that. So we continue to see benefits from that. Not to discount the turbulence that might happen in that transition, we still think there's strong fundamentals behind that.
Selina Pi -- Morgan Stanley -- Analyst
Great. Thanks for taking my question.
Todd Meredith -- President & Chief Executive Officer
Thank you.
Operator
[Operator Instructions] Our next question comes from Lukas Hartwich, Green Street Advisors. Please go ahead.
Lukas Hartwich -- Green Street Advisors -- Analyst
Thanks. Can you just comment on the broader supply outlook for medical office?
Todd Meredith -- President & Chief Executive Officer
Yeah. I mean, I think if you look at the transactions that we've seen over the past five years has been above $10 billion that's traded out there. I think as you look at the developments and development pace that's out there, it's been pretty consistent in that 1% to 2% of total MOB supply that's in the market. We see that continuing to click along at a pretty steady pace over the next few years. And so, I don't see a lot of meaningful change and big chunks of supply coming on online. So it's been pretty consistent.
Lukas Hartwich -- Green Street Advisors -- Analyst
Have you seen any increase in speculative development?
Todd Meredith -- President & Chief Executive Officer
No, no, we have not seen any increase in speculative development.
Lukas Hartwich -- Green Street Advisors -- Analyst
Great.
Kris Douglas -- Executive Vice President & Chief Financial Officer
I would say, if you compare -- Lukas, I think if you compare that to 10 years ago in that cycle, it's very different than back then. I think today, you see far less of that, you see much more need for the hospital, the health system, the physicians to all be integrated and working together to generate a new building and demand for new building. And so, I think that complexity has -- and obviously learning lessons from 10 years ago or 12 years ago. So I think those combinations of things have tempered that and certainly, we're not seeing it.
Lukas Hartwich -- Green Street Advisors -- Analyst
That's helpful. Thank you.
Operator
This concludes our question-and-answer session. Now, I'd like to turn the conference back over to Mr. Todd Meredith for any closing remarks.
Todd Meredith -- President & Chief Executive Officer
Thank you, Nick. And thank you everybody for joining us on the call this morning. We will be available for any follow-up questions, if you have any. And we hope you all have a great day. Thank you.
Operator
[Operator Closing Remarks]
Duration: 58 minutes
Call participants:
Todd Meredith -- President & Chief Executive Officer
Carla Baca -- Associate Vice President of Investor Relations
Bethany A. Mancini -- Corporate Communications
Rob Hull -- Executive Vice President of Investments
Kris Douglas -- Executive Vice President & Chief Financial Officer
Nick Joseph -- Citigroup -- Analyst
Jordan Sadler -- KeyBanc Capital Markets -- Analyst
Tau -- Stifel Nicolaus -- Analyst
Connor Siversky -- Berenberg Capital Markets LLC -- Analyst
Jonathan Hughes -- Raymond James & Associates -- Analyst
Selina Pi -- Morgan Stanley -- Analyst
Lukas Hartwich -- Green Street Advisors -- Analyst
