By Ryan McCullough, partner, managing director, Partners Real Estate
Over the last decade, medical office buildings (MOBs) have become one of the most in-demand asset classes in commercial real estate.
This shift did not happen by chance. Two major changes in the broader real estate market reshaped investors’ priorities and positioned medical office as a durable, long-term investment vehicle.
The first was the rise of e-commerce. As consumers moved toward online shopping and same-day delivery, traditional retail properties faced elevated pressure. Investors began searching for asset types with consistent demand and limited exposure to technological disruption. As a result, MOBs, anchored by in-person healthcare delivery, benefited directly from this shift.
The second was the COVID-19 pandemic. While retail and hospitality experienced sharp declines, MOBs proved far more resilient. Healthcare services remained essential, patient volumes recovered quickly and medical tenants continued operating. This period reinforced the reputation of MOBs as a defensive investment with stable demand through economic cycles.
That surge in investor interest, however, has also led to confusion and, in some cases, unnecessary risk.
Understanding the Diversity of Healthcare Assets
As a commercial investment, healthcare is not a single, uniform product type.
Properties vary widely in use, cost, complexity and demand. Behavioral health facilities, outpatient clinics, ambulatory surgery centers and micro-hospitals all fall under the same umbrella but trade at vastly different price points. For example, in Texas, behavioral health facilities may transact in the $100- to $200-per-square-foot range, while micro-hospitals can exceed $1,500 per square foot.
Because of this variation, underwriting MOBs requires a more detailed approach than traditional office or retail. Investors must understand real market comparables, achievable rents, demographics, regulatory constraints and replacement costs. While many factors influence performance, two consistently have the greatest impact: basis and market functionality.
Basis: More Than Just a Cap Rate
Basis is often discussed but frequently misunderstood in the world of MOB investing.
A common scenario involves a physician practice selling to a private equity-backed operator, followed by a new long-term lease with a strong guaranty. The property is then marketed at an attractive cap rate and draws significant interest. On the surface, a 7.5 percent or higher cap rate supported by a credit tenant appears compelling.
The risk becomes clear when price per square foot is examined. Paying $500 per square foot for a building that would trade closer to $250 per square foot without the lease introduces meaningful downside. When the lease expires, the property’s value may reset closer to its real market basis. At that point, tenant leverage increases, equity erodes and exit options narrow.
This risk is often obscured by selective data that appears to justify an elevated valuation. Careful analysis of buildout costs, use-specific demand and truly comparable sales is critical. Basis should be evaluated independently of lease terms rather than justified by them.
Market Functionality, Future Flexibility
Market functionality refers to both the physical usability of the building and the depth of demand in the surrounding market.
Consider an ambulatory surgery center. While these facilities can be strong investments, not all of them offer the same long-term utility. Small operating rooms designed for limited procedures, outdated licenses or buildings tailored to declining specialties can restrict future use. If local demographics do not support those procedures, the cost to reposition the property may be significant.
Building size also plays a role. A 20,000-square-foot, single-tenant medical building carries more risk than a divisible asset. Investors should evaluate whether the space can be broken into smaller, functional suites, such as multiple 5,000-square-foot units, where tenant demand is typically deeper. The ability to reconfigure space provides flexibility and helps protect downside risk.
A well-structured healthcare investment, whether traditional MOB or otherwise, accounts for change. If a tenant vacates, a specialty loses demand or regulations shift, the business plan should allow for adaptation without undermining returns.
Identifying the Best Medical Office Investments
The strongest medical office investments tend to combine a favorable basis with high market functionality. For example, a 5,000-square-foot podiatry clinic with a short-term lease in place that was acquired below market pricing may present less risk than a fully leased but overvalued specialty facility.
If the clinic can be divided into smaller suites or repurposed for other clinical uses, the investor maintains leverage at lease rollover. Even in a vacancy scenario, there are multiple paths to improving performance through re-tenanting, reconfiguration or repositioning.
The Importance of Specialized Representation
Medical office investing requires specialization. Brokers who focus exclusively on medical properties understand how these assets trade, how buildouts affect value and where risk is often overlooked. These nuances are rarely captured by generalist underwriting.
In a sector where small misjudgments can materially impact returns, specialized representation is essential for informed decision-making.