Feasibility Study Company Independent Feasibility Analysis

Medical Office & ASC · Asset Class

Medical Office & ASC Feasibility & Market Studies

Independent, lender-grade analysis for medical office buildings, ambulatory surgery centers, and dental, veterinary, and physician practices across SBA 7(a) and 504, USDA, conventional bank, CMBS, life-company, and agency capital. This page is our standing read on the one distinction that governs the asset class, the going-concern practice valued on cash flow versus the income-producing medical building valued on net operating income, how each fails review, and the demographic and outpatient tailwind underneath both.

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$5.3T
2024 U.S. national health expenditure, 18.0% of GDP1
9.57%
National medical-office vacancy, Q3 20247
$45.7B
2024 U.S. ambulatory surgery center market4
16.1%
Dentists DSO-affiliated in 2024, up from 7.2% in 20152
The Medical Office & ASC Thesis

One asset class, two valuation bases.

Medical, dental, and veterinary space is the one asset class that straddles two fundamentally different valuation and lending bases, and the single most common underwriting error is to conflate them. The operating practice is a going-concern business, a dental, veterinary, or physician practice bought and sold on cash flow through an EBITDA or SDE multiple, comprising practice goodwill plus equipment and any real estate; the practice is the business, its acquisition loan is frequently SBA 7(a), and it is goodwill-heavy. The medical office building (MOB) is income-producing real estate, valued on leases, net operating income, cap rate, tenant credit, and weighted-average lease term, exactly like the retail and warehouse monitors; its loan is conventional, CMBS, life-company, or agency debt and is driven by tenant credit. Different methods, different loan programs, different risk. We prepare the study aligned to whichever basis, and whichever standard, will judge the file.

Under both bases sits the same durable demand story. U.S. national health expenditure was $5.3 trillion in 2024, 18.0 percent of GDP and $15,474 per person, and the CMS Office of the Actuary projects it to grow an average 5.8 percent annually, faster than the 4.3 percent GDP path, lifting health care to 20.3 percent of GDP by 2033.1 Care continues to migrate from inpatient to outpatient settings, inpatient admissions per 1,000 population fell 32.2 percent between 1970 and 2023 while hospital outpatient admissions per 1,000 rose 272.2 percent, and the ambulatory surgery center market reached roughly $45.7 billion in 2024.34 Consolidation is reshaping every practice segment, and multiple arbitrage, corporate buyers paying 8 to 14 times EBITDA against 4 to 8 times for independents, is the engine driving acquisition-finance demand.20

What follows is organized as a working desk: a national supply and demand monitor across both bases, the practice and MOB failure forensics that sink healthcare studies, the capital-source routing that decides which deliverable a deal needs, and the study-type distinctions competitors state loosely. Every figure is dated and attributed in the sources below, and every metric is labeled by basis, because practice going-concern value and MOB real-estate value must never be netted.

The Supply & Demand Monitor

Where the medical-office market stands, market by market.

A read across both bases, the medical office building as real estate and the practice as a going concern, compiled from named primary sources. MOB fundamentals are current through the first quarter of 2026; practice-consolidation data are labeled to their source vintage. Metrics on different bases are never netted.

The national picture frames every market. On the real-estate side, medical outpatient buildings are a favored, defensive class: national MOB vacancy was 9.57 percent in the third quarter of 2024, triple-net asking rent set records at $24.86 per square foot in the second quarter of 2024, up 14 percent year over year, and reached $25.40 by the first quarter of 2026, and average single-asset cap rates held between 6.9 and 7.0 percent for four consecutive quarters before edging to 6.9 percent by early 2026.78 Medical tenants sign 7-to-15-year leases with renewal rates commonly above 80 percent, and the construction pipeline sits near a cyclical low of roughly 33.5 million square feet, so the sector combines low vacancy, sticky tenancy, and thin new supply.910 On the going-concern side, the U.S. supports more than 202,000 active dentists, over 34,000 veterinary practices averaging about $1.5 million in gross revenue, and a physician base shifting rapidly out of independent ownership, all three segments feeding a steady pipeline of acquisition financing as owners retire and corporate platforms consolidate.215

National MOB real-estate fundamentals, Q3 2024 → Q1 2026
Income-producing real-estate basis only. Vacancy and occupancy are different metrics on different universes and are not netted.
MetricQ3 2024Q1 2026Basis / source
National vacancy9.57%~9.46% (fcst end-2025)CBRE, 59-market universe7
Occupancy (alt. metric)~92.7–92.8%~92.7–92.8%Revista / JLL, top-1009
Triple-net asking rent$24.97 / sq ft$25.40 / sq ftCBRE ($24.86 Q2 2024, +14% YoY)7
Single-asset cap rate7.0%6.9%CBRE; portfolio ~6.5% (Revista 2Q 2025)8
Investment volume (T4Q)~$8.5B~$13.9BCBRE trailing-four-quarter8
Construction pipeline—~33.5M sq ft (2Q 2025)Revista, cyclical low9

Sources: CBRE Q3 2024 U.S. Medical Outpatient Buildings Figures and 2025–Q1 2026 updates; Revista via PwC/ULI Emerging Trends in Real Estate 2026. The ~9.46% end-2025 vacancy is a CBRE forecast, not an actual. CBRE tracks a 59-market universe of Class A/B/C buildings 7,500 sq ft and larger, excluding hospitals and single-tenant owner-user facilities; Revista/JLL occupancy uses a different, top-100 universe.

Feasibility signal by market archetype: Tight / low-vacancy Development racing demand Thin / underserved. Organized by market type, not a fixed metro table, because provider density, payer mix, and MOB fundamentals vary more by market maturity than by raw population.
Market archetype Demand structure MOB fundamentals Consolidation Signal
Sun Belt / high-growthPhoenix, Austin, Nashville, FL, TX, Carolinas Faster senior-population growth fueling outpatient demand across all ages Slightly higher cap rates as development races population Heavy DSO / corporate entry erodes practice pricing power Balanced
Mature / high-barrierNortheast, coastal CA, upper-Midwest metros Higher incomes and commercial-payer mix; higher provider density (saturation risk) Lower vacancy, higher rents, higher construction and union buildout cost Established; provider-density signals saturation, not scarcity Tight
Rural / underservedUSDA B&I thesis markets Low competition; thinner labor pool, transition risk, Medicaid-heavier payer mix Thin, single-tenant-heavy; anchors the rural-healthcare access case Light; 71.5% of Dental HPSAs are rural or partially rural Thin data

Compiled from CBRE 2025–2026 U.S. Healthcare Real Estate Outlook, JLL 2024, HRSA via Rural Health Information Hub (September 30, 2025), and AHRF 2022–23. Granular metro-level dental and veterinary practice data are thin; ADA HPI publishes dentist-per-capita and DSO affiliation by state while CBRE and Revista publish MOB fundamentals for roughly 59 to 100 markets, and the two geographies rarely align. The ADA declines to publish a recommended dentist-to-patient ratio, so provider-per-capita is a directional, not deterministic, saturation signal.24

MOB vacancy and occupancy are different rulers

No figure on this page is more misused than the vacancy rate. CBRE reports vacancy of 9.57 percent across a 59-market universe of Class A/B/C buildings 7,500 square feet and larger, excluding hospitals and single-tenant owner-user facilities, while Revista and JLL report occupancy near 92.7 to 92.8 percent across a different, top-100 universe; these are different metrics on different footprints and cannot be netted.79 Inventory itself is contested: Revista counts roughly 42,260 buildings totaling about 1.6 billion square feet, whereas Yardi Matrix, using a broader definition that folds in owner-user and administrative space, cites about 2.2 billion square feet across 28,726 properties.911 A circulating "$18.2 billion 2024 MOB transaction volume" figure comes from a non-institutional source and conflicts with CBRE's roughly $8.5 billion trailing-four-quarter reading; the CBRE figure is the more defensible. Any study that cites a single MOB vacancy or volume number without stating its universe is not defensible.

The outpatient shift and ASC migration are structural, not cyclical

The master demand driver is demographic. Annual health spending per capita runs roughly $8,000 for Americans under 64 but rises to about $20,000 for ages 65 to 84 and more than $35,000 for those over 85, and the 65-to-84 and 85-plus cohorts are projected to grow 17 percent and 56 percent respectively by 2034; the AAMC separately projects the 65-plus population to grow 34.1 percent and the 75-plus population 54.7 percent between 2021 and 2036.625 Care is migrating with them: inpatient admissions per 1,000 fell 32.2 percent from 1970 to 2023 while outpatient admissions per 1,000 rose 272.2 percent, and the ambulatory surgery center market reached roughly $45.7 billion in 2024, with 6,394 Medicare-certified ASCs, of which about 68 percent are physician-owned.345 Health care is also recession-resistant: healthcare employment fell only 6.4 percent year over year at the 2020 pandemic trough versus 11.2 percent for the broader economy, which is a recurring underwriting positive for both bases.6

Dental, veterinary, and physician consolidation, and the multiple arbitrage

Roll-up is reshaping every segment at a different speed. Dental DSO affiliation reached 16.1 percent of dentists in 2024, up from 7.2 percent in 2015 and 27 percent among dentists fewer than 10 years out of school, with LEK Consulting forecasting DSO share of dental offices toward roughly 39 percent by 2026, a projection, not an actual.231 Veterinary is the most corporatized: consolidators controlled about half the market by 2021, and by 2023 veterinarians owned 51 percent, private equity 29 percent, and other corporate owners 19 percent, with Mars alone owning roughly 3,000 U.S. clinics and private equity having poured $51.6 billion into the sector from 2017 through 2023.1317 Physician private-practice ownership fell to 42.2 percent in 2024 from 60.1 percent in 2012, with hospital-owned share at 34.5 percent and private-equity-owned at 6.5 percent, a drop equivalent to roughly 80,000 fewer private-practice physicians, and private equity has been the more active acquirer, at 38.3 percent of post-2019 practice purchases versus 10 percent for hospitals, against global healthcare PE deal value near $115 billion in 2024.1219 The economic engine is multiple arbitrage: independent dental and veterinary practices sell to individual buyers at low-to-mid-single-digit EBITDA multiples while DSO, corporate, and PE platforms pay 8 to 14 times, with the largest veterinary practices, above $3 million of EBITDA, reaching 11 to 13 times.202122 One caution belongs on the desk: despite the pet-humanization narrative, veterinary in-hospital visits fell 2.3 percent year over year through August 2024 and invoice growth was negative for three consecutive years, and APPA lowered its 2030 pet-spend forecast from $250 billion to $192 billion, so veterinary terminal value must be underwritten explicitly, not assumed; the veterinary workforce shortage is itself disputed, AVMA-commissioned Brakke Consulting finding no shortage justified by 2030 or 2035 against a Mars-sponsored 25,000-FTE projection.161426

Common Review Failures

How medical practice and MOB studies fail review.

The failures split by basis: a going-concern practice loan breaks on goodwill, ramp, and transition, while a medical office building loan breaks on tenant credit, lease term, and re-tenanting cost. Each failure below is tied to a real mechanism or number.

  1. Conflating the two bases

    The single most common error is underwriting a going-concern practice loan as if it were real estate, or an MOB loan as if it were a business. A practice is a business secured largely by cash flow and goodwill; an MOB is real estate secured by leases and NOI. The valuation method, loan program, appraisal standard, and risk profile all differ, and netting a practice EBITDA multiple against an MOB cap rate produces a number that means nothing.

  2. Goodwill overpayment and collections verification

    In dentistry 60 to 80 percent of a practice's purchase price is typically goodwill. Verify seller collections, not production, over the trailing 36 months, and confirm add-backs are defensible, because EBITDA normalization can swing by as much as 50 percent across bidders. Where goodwill exceeds roughly 70 percent of price, expect a 12.5-to-15-percent down-payment overlay above the 10 percent floor.3020

  3. De-novo ramp and credentialing lag

    A start-up practice is not stabilized on day one; patient-volume and production ramps typically span two to four years, and a new provider incurs 90 to 180 days of credentialing before insurance payments flow. Underwrite a ramp, not stabilized cash flow, and size adequate working capital for the gap.30

  4. Transition and single-provider dependence

    When the selling provider leaves, patient and referral attrition can impair cash flow, and specialist fragility, the loss of a founding surgeon, can collapse a service line. PE and corporate buyers require 2-to-5-year post-sale employment and retention agreements from the owner and key associates precisely to mitigate this; a solo practice with no associate depth caps the defensible multiple at the low end.21

  5. Tenant credit and lease-rollover / WALT (MOB)

    MOB NOI is only as strong as the credit behind the leases. Hospital-affiliated or investment-grade tenants such as Fresenius price tighter than independent practices, and short or expiring leases raise cap rates. Underwrite tenant credit first, then weighted-average lease term and the rollover schedule; single-tenant assets with under five years remaining and no renewal commitment need re-tenanting reserves and lower leverage.23

  6. Going-dark risk on single-tenant net-lease medical

    A dialysis or urgent-care STNL asset with one to three years remaining and uncertain renewal carries re-tenanting risk masked by a superficially high cap rate. Dialysis is the most-traded net-lease medical subtype, more than 55 percent of net-lease medical supply, dominated by DaVita and Fresenius at roughly 6.68 and 6.90 percent cap rates; lenders price risk by tenant credit, then lease term, then location.23

  7. Specialized buildout and re-tenanting cost (MOB)

    Purpose-built medical space, imaging shielding, surgical suites, dialysis plumbing, is expensive to re-tenant; medical office buildings cost roughly $498 per square foot to build, versus $214 for distribution and $313 for suburban office. Highly specialized single-purpose space leased to a weak-credit tenant warrants a higher debt yield, because the specialized buildout is a re-leasing liability if the tenant departs.30

  8. Payer-mix, reimbursement, and the veterinary demand caution

    Reimbursement pressure is real across bases: dental equipment, supply, and wage costs are rising faster than reimbursement, about one in four dentists have dropped some insurance networks, and government-payer concentration carries rate risk, DaVita reports 90 percent of dialysis patients are government-insured. In veterinary, negative invoice growth for three consecutive years and 52 percent of owners skipping needed care warn against assuming a continued boom. Medicaid-heavy and single-payer-concentrated cash flows warrant a lower advance rate.21618

Capital-Source Routing

Which channel funds the deal, and what it requires.

The first question is always which basis, a going-concern practice or income-producing MOB real estate, because that answer routes the deal to a different program and a different deliverable. The study is built to the union of requirements across the channels actually in play.

The medical & healthcare lender matrix
Deliverable and terms by capital source and basis. Terms are program conventions; confirm the operative SBA SOP edition at underwriting.27
Capital sourceBasis & deliverableTerms convention
SBA 7(a) (practice acquisition)Going-concern business valuation; goodwill financedUp to $5M; 10-yr (goodwill) / 25-yr (RE >50%); ~10% equity
SBA 504 (owner-occupied building)Real-estate appraisal via CDC debentureOwner-occupied; fixed-rate; no goodwill / WC alone
Conventional / CMBS / life-co / agency (MOB)Income-approach appraisal, rent roll, WALTTenant-credit-driven; DSCR / debt yield
USDA B&I (rural healthcare)Owner-operated or facility feasibilityPop. <50,000; up to $25M; up to 30-yr RE; ~80% guarantee
Bridge / hard moneyTransition or value-add planShort-term, pending stabilization or permanent take-out

Sources: SBA SOP 50 10 (confirm 50 10 7 vs 50 10 8 at underwriting); USDA Rural Development Business & Industry term sheets; CBRE/GlobeSt Q1 2024 MOB lending mix. See sources 27–29.

One point is worth stating plainly, because it decides most healthcare deals: SBA 7(a) uniquely finances goodwill that conventional lenders will not lend against on cash flow, which is exactly why professional-practice acquisition is among the most common and favored SBA 7(a) uses, and why dentists, veterinarians, and physicians, recurring-revenue, recession-resistant, goodwill-heavy borrowers, are prized. Specialty lenders such as Live Oak, which has originated well over $1.5 billion in dental loans, bring segment-specific underwriting.27 The medical building, by contrast, is real estate: it routes to conventional bank, CMBS, life-company, or agency debt sized on tenant credit, WALT, and DSCR or debt yield, and in the first quarter of 2024 alternative lenders held 47.2 percent of MOB lending, banks 22.7 percent, and life companies 21.3 percent.29 For real estate held in the practice, the owner-occupancy test, at least 51 percent for an existing building or 60 percent for new construction, determines whether SBA 504 or 7(a) can reach the building at all.

  • Practice acquisition (dental, veterinary, or physician)SBA 7(a) going-concern underwriting with goodwill financed; SBA 504 pairs for the building.
  • Owner-occupied medical or dental building purchaseSBA 504 fixed-rate CDC debenture, often paired with a 7(a) for goodwill and working capital.
  • Income-producing MOB acquisition or refinanceConventional, CMBS, life-company, or agency debt on an income-approach appraisal, tenant credit, and WALT.
  • Rural healthcare facility (population under 50,000)USDA Business & Industry, up to $25M, up to 30-year real-estate term, ~80% guarantee; health care facilities explicitly eligible.28
  • Transition or value-add pending stabilizationBridge or hard-money capital to a permanent take-out once cash flow or lease-up stabilizes.
Study Types

Market study, feasibility study, appraisal: three questions, two bases.

These documents answer different questions, and in this asset class each answers them twice, once for the going-concern practice and once for the income-producing building. Lenders and sponsors conflate them constantly; underwriters do not.

What each document answers, by basis, and the standard that governs it.
DocumentQuestion answeredGoverning basis
Appraisal (practice)What is the going concern worth? Goodwill plus equipment/FF&E plus any real estate, on an EBITDA or SDE multiple.Business valuation
Appraisal (MOB)What is the building worth? Income approach on NOI, tenant credit, WALT, and cap rate, cross-checked by sales comparison.USPAP income approach
Market studyIs there demand? Demographics, provider density, and payer mix for a practice; trade-area absorption and achievable rent for an MOB.Demand analysis
Feasibility studyDoes it pencil? The market study plus a conservative ramp and DSCR for a practice, or stabilized NOI, DSCR, and debt yield for an MOB.Lender underwriting

A practice is valued as a going concern, goodwill plus equipment and FF&E plus any real estate, via the income approach on cash flow using an EBITDA or SDE multiple or a capitalized-earnings or market-multiple-of-collections method. The goodwill component is large, 60 to 80 percent of dental purchase price, and is the key SBA financing point, because conventional lenders will not finance goodwill on cash flow the way SBA 7(a) will; the allocation among goodwill, equipment, and real estate drives loan structure and term.30 An MOB, by contrast, is valued via the income approach on NOI through direct capitalization and discounted cash flow, supported by a rent roll, tenant-credit analysis, and WALT, cross-checked by sales comparison per square foot, the same basis as the retail and warehouse monitors and entirely distinct from going-concern practice valuation.

One scope boundary is worth stating. Dental amalgam, X-ray, and medical-waste considerations exist but generally present lower Phase I ESA risk than fuel or auto uses, and in any case the feasibility or market-study author does not itself perform the Phase I or II environmental site assessment; that is a separate environmental professional's engagement. The study normalizes cash flow, tenancy, and value; it does not opine on environmental condition.

Medical & healthcare sub-segments, each with a distinct study scope

Medical Office & ASC Questions

Medical, practice, and MOB feasibility questions.

What is the difference between a going-concern practice loan and a medical office building (MOB) loan?

They underwrite two different things on two different bases. A dental, veterinary, or physician practice is a going-concern business valued on cash flow through an EBITDA or SDE multiple, and it is goodwill-heavy, so it most often finances through SBA 7(a), which will lend against goodwill that conventional lenders will not. A medical office building is income-producing real estate valued on net operating income, a cap rate, tenant credit, and weighted-average lease term, exactly like retail or warehouse, so it finances through conventional bank, CMBS, life-company, or agency debt. The practice is the business; the MOB is a building leased to healthcare tenants. Underwrite each on its own basis and never conflate them.

How is a dental, veterinary, or physician practice valued, as a business or as real estate?

As a going-concern business. The value combines practice goodwill, equipment and FF&E, and any real estate, capitalized on cash flow through an EBITDA or SDE multiple or a multiple of collections. Goodwill is typically 60 to 80 percent of a dental practice's purchase price, which is why SBA 7(a) financing is central. Independent dental and veterinary practices sell to individual buyers at roughly 4 to 8 times adjusted EBITDA, while DSO, corporate, and private-equity platforms pay 8 to 14 times, and that multiple arbitrage is the economic engine of consolidation (FOCUS, Transitions Elite, Ad Astra Equity, 2024 to 2026). Any associated real estate can be valued separately on an income basis.

Can a medical or dental practice be financed with an SBA loan?

Yes, and dentists, veterinarians, and physicians are among the most prized SBA 7(a) borrowers. Practices are recurring-revenue, recession-resistant, and goodwill-heavy, and SBA 7(a) uniquely finances goodwill, equipment, working capital, leasehold improvements, and real estate in a single loan up to $5 million, with a 10-year term when the value is primarily goodwill and up to 25 years when real estate exceeds half the use of proceeds (SBA SOP 50 10). Where the deal is the owner-occupied building itself, SBA 504 finances real estate and major equipment through a fixed-rate CDC debenture, often paired with a 7(a) for goodwill and working capital. Real estate held for lease to third parties routes instead to conventional, CMBS, life-company, or agency debt.

Why does the ambulatory surgery center (ASC) and outpatient shift matter to healthcare real estate?

Because care is migrating structurally from inpatient to outpatient settings, which underpins both practice demand and medical office building fundamentals. Between 1970 and 2023, U.S. inpatient admissions per 1,000 population fell 32.2 percent while hospital outpatient admissions per 1,000 rose 272.2 percent (Trilliant Health analysis of CMS data, 2024). The U.S. ASC market was roughly $45.7 billion in 2024 (Fortune Business Insights), with 6,394 Medicare-certified ASCs and about 68 percent physician-owned (ASCA, September 2024; BH Sales Group, Q2 2024). This migration, layered on an aging population, is why CBRE frames medical outpatient buildings as propelled by long-term demographic and health-spending trends.

How consolidated are dental, veterinary, and physician practices?

Consolidation is advancing at different speeds by segment and is the main driver of acquisition-financing demand. Dental DSO affiliation reached 16.1 percent of dentists in 2024, up from 7.2 percent in 2015 and 27 percent among dentists fewer than 10 years out of school (ADA HPI, 2024). Veterinary is the most corporatized: consolidators controlled roughly half the market by 2021, with Mars alone owning about 3,000 U.S. clinics (KPMG and Fortune, June 2024). Physician private-practice ownership fell to 42.2 percent in 2024 from 60.1 percent in 2012, with private-equity-owned practices at 6.5 percent (AMA Physician Practice Benchmark Survey, May 2025). The arbitrage between independent multiples of 4 to 8 times EBITDA and corporate multiples of 8 to 14 times fuels the roll-up.

What are current medical office building (MOB) vacancy, rent, and cap rates?

MOB real estate remains a defensive, low-vacancy asset. National vacancy was 9.57 percent in the third quarter of 2024, and triple-net asking rent set records, reaching $24.86 per square foot in the second quarter of 2024 (up 14 percent year over year) and $25.40 by the first quarter of 2026 (CBRE). Average single-asset cap rates held between 6.9 and 7.0 percent for four consecutive quarters through the third quarter of 2024, then edged to 6.9 percent by the first quarter of 2026, with portfolio cap rates nearer 6.5 percent (CBRE; Revista, 2Q 2025). Medical tenants sign 7-to-15-year leases with renewal rates commonly above 80 percent, and MOB investment volume rose to roughly $13.9 billion on a trailing-four-quarter basis by early 2026.

Can rural medical, dental, or veterinary facilities be financed?

Yes. USDA Rural Development's Business & Industry (B&I) Guaranteed Loan Program explicitly makes health care facilities eligible in communities under 50,000 population, with loans up to $25 million, real-estate terms up to 30 years, and guarantees around 80 percent. Rural demand is real: 5,185 of the nation's 7,254 Dental Health Professional Shortage Areas, or 71.5 percent, were rural or partially rural as of September 30, 2025, and rural areas have 4.7 dentists per 10,000 people versus 7.8 in urban areas (HRSA via Rural Health Information Hub; AHRF 2022 to 2023). The offsetting risks are thinner labor pools, transition risk, and a payer mix weighted toward Medicaid, which underwriting must price.

By Market

Medical office & ASC feasibility studies by state.

Provider density, payer mix, and MOB fundamentals are local. Explore the state markets where demographics, the competitive set of providers, and healthcare real-estate absorption determine whether a practice or a building pencils.

Underwriting a practice or a medical building? Start with the basis.

Feasibility Study Company prepares independent Medical Office & ASC feasibility and market studies, built to the review standard your capital source applies. A methodology briefing walks through the going-concern-versus-real-estate distinction, the deliverable your capital source requires, and the current supply, demand, and consolidation data for your segment and market.

Request a methodology briefing
Sources

Data sources and dates.

Every figure on this page traces to a named authority. Healthcare and real-estate readings are point-in-time and provider-dependent; practice and MOB metrics sit on different bases and are labeled, not netted, throughout. Practitioner and advisory sources carry a selling interest and are treated as directional ranges.

  1. CMS Office of the Actuary / Health Affairs, National Health Expenditure Projections 2024–33 (June 25, 2025): U.S. NHE $5.3 trillion in 2024 (18.0% of GDP, $15,474 per capita); projected 5.8% average annual growth versus 4.3% GDP; 20.3% of GDP by 2033 (from 17.6% in 2023); ~$8.6 trillion by 2033. CMS figures beyond 2024 are projections.
  2. ADA Health Policy Institute (HPI): U.S. dental expenditure $189 billion in 2024, 3.6% of health spending (January 2026); 202,485 active dentists, 59.5 per 100,000 (2024); DSO affiliation 16.1% of dentists in 2024 (7.2% in 2015; 27% among dentists <10 years out); private-practice ownership 72.5% (2023); average retirement age 68.7; overhead benchmark 55–65% of collections; hygienist/assistant retirements with ~11% capacity reduction; ~one in four dentists dropped some insurance networks.
  3. Trilliant Health analysis of CMS National Health Expenditure data (2024): U.S. inpatient admissions per 1,000 population fell 32.2% while hospital outpatient admissions per 1,000 rose 272.2%, 1970–2023.
  4. Fortune Business Insights (2024): U.S. ambulatory surgery center (ASC) market ~$45.7 billion in 2024.
  5. Ambulatory Surgery Center Association (ASCA, September 2024): 6,394 Medicare-certified ASCs in 2024; BH Sales Group (Q2 2024): ~68% of ASCs physician-owned.
  6. CBRE Research / U.S. Census / CMS (Q3 2024): per-capita health spend ~$8,000 (under 64), ~$20,000 (65–84), >$35,000 (85+); 65–84 cohort +17% and 85+ +56% by 2034; healthcare employment fell 6.4% YoY at the 2020 trough versus 11.2% for the broader economy (CBRE, 2021).
  7. CBRE, Q3 2024 U.S. Medical Outpatient Buildings Figures: national MOB vacancy 9.57% (59-market universe of Class A/B/C buildings 7,500 sq ft and larger, excluding hospitals and single-tenant owner-user); single-asset cap rates 6.9–7.0% for four consecutive quarters (7.0% in Q3 2024); triple-net asking rent record $24.86/sq ft (Q2 2024, +14% YoY) and $24.97 (Q3 2024); MOB investment ~$8.5 billion trailing-four-quarter. The ~9.46% end-2025 vacancy is a CBRE forecast.
  8. CBRE, 2025 U.S. Healthcare Real Estate Outlook and Q1 2026 update: triple-net asking rent $25.40/sq ft and single-asset cap rate 6.9% (Q1 2026, first sub-7.0% since Q3 2024); MOB investment ~$13.9 billion trailing-four-quarter; off-campus development growth, with on/near-campus buildings ~150% larger.
  9. Revista, via PwC/ULI Emerging Trends in Real Estate 2026: U.S. MOB stock ~42,260 buildings / ~1.6 billion sq ft; occupancy ~92.7–92.8% (top-100 universe); portfolio cap rate ~6.5% (2Q 2025); in-progress pipeline ~33.5 million sq ft (2Q 2025, cyclical low), TTM completions ~19.2 million sq ft; new purpose-built NNN rent ~$33.06/sq ft versus ~$24.78 existing.
  10. JLL (Q4 2025): same-asset / top-100 MOB rent growth ~3.3% YoY; medical leases run 7–15 years with renewal rates commonly above 80% (CBRE/JLL/Revista).
  11. Yardi Matrix (2025): broader MOB definition ~2.2 billion sq ft across 28,726 properties (includes owner-user and administrative space).
  12. AMA Physician Practice Benchmark Survey (published May 29, 2025): private-practice physician share 42.2% in 2024 (from 60.1% in 2012); hospital-owned 34.5%; PE-owned 6.5%; ownership stake 35.4% (from 53.2% in 2012); ~80,000 fewer private-practice physicians versus 2012 (AMA / Berkowitz analysis).
  13. KPMG / Fortune (June 2024) and Brakke Consulting: corporate consolidators controlled ~half the veterinary market in 2021 (~25% of GP, ~75% of specialty/ER); in 2023 veterinarians owned 51%, private equity 29%, other corporate 19%; Mars ~3,000 U.S. clinics (~45% of corporate-owned).
  14. APPA 2025/2026 State of the Industry: total U.S. pet-industry spend $152 billion (2024, +3.4%) and $158 billion (2025); veterinary care and product sales $39.8 billion (2024, +3.9%); 2030 forecast lowered from $250 billion to $192 billion; 22% of owners spent less on pets in 2025.
  15. AVMA (2024 Pet Ownership and Demographics Sourcebook; data via BusinessCapital.com): more than 34,000 U.S. veterinary practices in 2024 (~1.3% annual growth), averaging ~$1.5 million gross revenue; ~163.5 million cats and dogs.
  16. Vetsource / AVMA Practice Pulse (2024): in-hospital patient visits −2.3% YoY (Aug 2023–Aug 2024) with revenue +3.9% on price and ~$622 average annual revenue per patient; Ackerman Group (via Ad Astra Equity): negative veterinary invoice growth in 2022, 2023, and 2024 (down >2%/yr).
  17. PitchBook (via AAHA): private equity invested $51.6 billion in the veterinary sector cumulatively (2017–2023), plus ~$9.3 billion in the first four months of 2024; Mars' $9.1 billion VCA acquisition (closed September 2017) remains the largest veterinary transaction, with an FTC-required divestiture of 12 specialty/emergency hospitals.
  18. PetSmart Charities–Gallup (2025): 52% of pet owners reported skipping needed veterinary care in the past year.
  19. Private Equity Stakeholder Project (2024 review) and PitchBook; SovDoc; Advisory Board (citing AMA): global healthcare PE deal value ~$115 billion in 2024 (second-highest on record); outpatient-care PE deals 139 in 2024 (−28.7% from 195 in 2023); 38.3% of post-2019 practice purchases by PE versus 10% by hospitals.
  20. FOCUS, Large Practice Sales, and Peak Business Valuation (2024–2026): dental going-concern multiples (doctor-to-doctor ~70–80% of collections; DSO/IDSO 6–12x adjusted EBITDA, platforms 9–11x); physician PE 4–8x EBITDA for smaller practices, specialty platforms mid-teens, the TPG/AmerisourceBergen OneOncology 19x EBITDA put-call. Practitioner sources; directional ranges.
  21. Ad Astra Equity, VetRx, and Transitions Elite (2024): veterinary multiples (private/individual ~4–8x EBITDA; corporate/PE ~8–14x; solo sub-$500K-EBITDA SBA deals ~3.5–6x); target revenue per FTE DVM $650k–$750k (GP); labor ~30–40% of revenue; 2–5 year post-sale retention agreements.
  22. SovDoc: veterinary size-tiered EBITDA bands (<$1M ~8.0–9.5x; $1–3M ~9.5–11.5x; >$3M ~11–13x).
  23. Matthews Real Estate Investment Services, 2024 DaVita & Fresenius Tenant Report (with historical REJournals/Calkain): DaVita dialysis ~6.68% average cap rate (~10.55 years remaining), Fresenius ~6.90% (~7 years), urgent care historically ~7.3%; dialysis is the most-traded net-lease medical subtype (>55% of net-lease medical supply); DaVita reports ~90% of dialysis patients government-insured.
  24. HRSA, via Rural Health Information Hub (September 30, 2025): 5,185 of 7,254 Dental Health Professional Shortage Areas (71.5%) are rural or partially rural; AHRF 2022–23: 4.7 dentists per 10,000 rural versus 7.8 urban. The ADA declines to publish a recommended dentist-to-patient ratio.
  25. AAMC, "The Complexities of Physician Supply and Demand: Projections From 2021 to 2036" (March 21, 2024; GlobalData Plc): projected physician shortage of 13,500–86,000 by 2036; U.S. population aged 65+ +34.1% and 75+ +54.7% (2021–2036). Projections, not actuals.
  26. Brakke Consulting (AVMA-commissioned) versus a Mars-sponsored analysis: the veterinary workforce "shortage" is genuinely disputed (no excess or shortage justified by 2030/2035 versus a projected 25,000-FTE shortage by 2030); treat as unresolved.
  27. U.S. Small Business Administration, SOP 50 10 (confirm 50 10 7 vs 50 10 8 at underwriting): SBA 7(a) up to $5 million financing goodwill, equipment, working capital, leasehold, and real estate (10-year term when goodwill-driven, up to 25 years when real estate exceeds 50% of proceeds; ≥51% existing / ≥60% new owner-occupancy; ~10% equity injection, half potentially a seller note on full standby); SBA 504 owner-occupied real estate/equipment via CDC debenture; Live Oak has originated well over $1.5 billion in dental loans.
  28. USDA Rural Development, Business & Industry (B&I) Guaranteed Loan Program: rural (population under 50,000), up to $25 million, up to 30-year real-estate terms, ~80% guarantee; health care facilities explicitly eligible.
  29. CBRE / GlobeSt (Q1 2024): MOB lending mix — alternative lenders 47.2%, banks 22.7%, life companies 21.3%.
  30. CBRE US Research, Medical Office Trends (2021, directional): MOB construction ~$498/sq ft (versus $214 distribution, $245 strip retail, $313 suburban office); Modern Northwest (2026), The Dental Signal, GCMM, Desergo, NADP, and Dental Practice Insider: dental buildout $300–$500+/sq ft finished, equipment ~$35k–$55k per operatory, de-novo credentialing 90–180 days before insurance payments flow, goodwill 60–80% of dental purchase price, and a 12.5–15% down-payment overlay above ~70% intangible value.
  31. LEK Consulting (via Becker's, forecast): DSO share of U.S. dental offices projected toward ~39% by 2026. Third-party projection, not an actual.