MOB Capital Markets Are Heating Up
Investment volume in medical outpatient buildings surged 57% year-over-year to $16.0 billion in Q1 2026. Debt liquidity is returning, and spreads on $100M+ portfolios have tightened from sub-200 basis points to the mid-100s, a meaningful improvement in debt market conditions.
Charitable Foundation Leases (CFL) Gaining Serious Traction
CFLs are described as coming up in “every conversation” with health systems. It’s being positioned as a way to access trapped equity, fund 100% of development/acquisition costs, and achieve base rents that are 10–40% lower than traditional structures, with tax advantages if a 501(c)(3) entity is involved as landlord.
Health Systems Are Rethinking Ownership vs. Control
Health systems are increasingly distinguishing between owning real estate and controlling it. They are looking at 50–100-year planning horizons, not just 10–20 years. Cleveland Clinic’s 92% ownership rate and portfolio sale are being positioned as a strategic win: owning older buildings created significant capital demands and constrained growth, while a sale-leaseback is now framed as supporting future strategy rather than relinquishing control. A portion of proceeds from the sale was allocated towards capital improvements to the buildings.
Health Systems Are Active Buyers – Not Just Sellers
Hospitals have bought 12.6% of MOBs traded over the last three years, and 20% of year-to-date sales volume was acquired by health systems. There is a notable counter-trend where health systems are re-entering the acquisition market even as others are monetizing.
Ambulatory Care Expansion is a Top Priority
Every major health system represented (Tenet, Kaiser, Stanford) identified ambulatory growth as a strategic focus. The U.S. is described as the global leader in ambulatory care growth. Key questions revolve around how to grow cost-efficiently and predictably, with preferred outpatient center sizes in the 40–60k SF range, emphasizing flexibility and room to expand.
Institutional Capital Is Flowing into Medical Real Estate
A large amount of institutional capital is described as “under-allocated” in real estate, and medical office is benefiting from that. The macro “silver tsunami” demographic trend is a primary draw, and there is a strong preference for cash yield over value-add strategies right now. Healthcare investors focused on capturing this demographic demand value the consistent cash flows from MOBs as a complement to seniors housing
Recapitalizations as an Alternative to Outright Sales
Recaps are gaining attention as a way for investors to sell partial interest while preserving health system relationships. They offer incoming investors an immediate path to scale partnering with experienced operators while allowing them to retain important health system relationships and AUM.
Shift Toward Third-Party Developers
Health systems are increasingly relying on third-party developers to manage costs, budgets, and execution risk. This reflects a broader trend of separating real estate development from clinical operations, allowing health systems to focus capital on care delivery.
Interest Rate Uncertainty Is Shaping Deal Structures
The consensus is that rates will stay “higher for longer,” but what matters most is the predictability and availability of both debt and equity capital. Some participants expect modest cap rate compression over the next 6–12 months, suggesting cautious optimism.
Standardization and Flexibility in Facility Design
Health systems like Stanford are pushing toward more “cookie-cutter” facility designs to reduce cost and complexity, while simultaneously emphasizing flexibility – such as available adjacent land for future expansion. This tension between standardization and adaptability is a recurring design and real estate challenge.
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