Key insights from the 2026 BOMA International Medical Real Estate Conference panels are summarized below:
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 +/-200 basis points to the mid-100s, a meaningful improvement in pricing.
Charitable Foundation Leases (CFL) Gain Traction
CFLs are described as coming up in “every conversation” with health systems. They are 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 were acquired by health systems. There is a notable countertrend where some 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
Institutional capital remains under-allocated to real estate. Driven by the aging baby boomer population – the “silver tsunami” – many institutional investors have gravitated toward healthcare real estate, particularly seniors housing, in pursuit of higher yields. In turn, investors looking to capitalize on these long-term demographic tailwinds are also placing greater value on the stable, predictable cash flows of MOBs, often viewing them as a complementary allocation alongside seniors housing.
Recapitalizations as an Alternative to Outright Sales
Recapitalizations are gaining traction as a strategy for operator-investors to monetize a partial interest, unlock capital, and preserve both health system relationships and control of their business plan. For incoming JV equity partners, these transactions provide an immediate path to scale alongside experienced operators, while creating an opportunity for continued investment in the sector.
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 Rates Projected to “Stay Higher for Longer”
The consensus is that rates will stay “higher for longer,” but what matters most is the availability of efficient debt and equity capital. Some panel 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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