Across the healthcare real estate market, one trend is hard to ignore: hospitals and health systems are increasingly buying back medical outpatient buildings (MOBs) they once sold to investors. These “reverse monetizations” signal a dramatic shift in how systems view real estate ownership — and they carry major implications for strategy, capital allocation, and future growth.
According to a recent Healthcare Real Estate Insights (HREI) article, citing data from RevistaMed, health system acquisitions of MOBs hit $2.8 billion in 2024, the highest total in the past eight years. The momentum hasn’t slowed. In the first half of 2025, health systems accounted for $761 million in MOB acquisitions — nearly 23% of all transactions. In the first quarter alone, their share reached 35%, a record high since Revista began tracking.
These numbers confirm what industry observers have been seeing on the ground: hospitals and health systems are back in the real estate buyer’s seat. But what’s driving this shift — and is ownership always the best path forward?
At Boldt Real Estate, we see the opportunity for a balanced approach. Our flexible financial models provide the control health systems want, without the long-term capital strain of full ownership.
Why Health Systems Are Buying MOBs
- Financial strength has returned: Health systems’ operating margins, badly bruised during the pandemic, have steadily improved. As noted in HREI’s coverage of CBRE’s 2025 Capital Markets Recap, system cash flow margins are projected to rise to 7.1% this year, up from 4.9% in 2022. With stronger balance sheets and favorable access to tax-exempt financing, hospitals have more flexibility to act.
- Ownership offers strategic control: Hospitals are increasingly viewing MOBs as critical to care delivery and competitive positioning. By buying back outpatient facilities — particularly those on or near campuses — systems can ensure long-term access, maintain physician alignment, and prevent competitors from gaining a foothold. As HREI reports, many systems are targeting properties where they already have high occupancy, ensuring continuity of services and future expansion options.
- Tax advantages create savings: For not-for-profit systems, owning real estate can provide significant tax benefits. Eliminating property taxes on owned MOBs can dramatically reduce long-term occupancy costs, particularly in high-cost markets. In addition, systems that own their real estate no longer face rent escalations tied to private investor returns.
The Risks of Ownership
Despite the recent wave of acquisitions, HREI’s advisory board cautions that ownership isn’t always the best move. Several challenges can undermine the benefits:
- Capital drain: Acquisitions consume capital that could otherwise support clinical operations, physician recruitment, or digital transformation.
- Deferred maintenance: Ownership shifts the burden of upkeep and modernization squarely onto the health system.
- Volatile priorities: As HREI points out, CFO tenures average less than five years. Strategies around “lease vs. own” often shift with leadership changes, leaving systems with assets that may not fit evolving goals.
- Low-margin realities: Many systems operate in razor-thin margin environments, where locking capital into real estate can create strain.
Ownership may offer control — but it often comes at the cost of flexibility and financial resilience.
Why Flexible Financing Matters Now
This is where Boldt’s flexible financing provides a smarter alternative. By combining long-term alignment with capital efficiency, Boldt helps health systems capture the benefits of ownership — without the drawbacks.
- Joint Venture Structures: Boldt invests alongside the health system, ensuring shared risk and shared upside. Systems preserve capital while still building equity in their real estate.
- Predetermined Path to Ownership: With a purchase price established upfront, health systems retain the option to buy 100% of the property in the future — with clarity, certainty, and no surprises.
- Tax-Exempt Opportunities: Structures can be designed to maximize nonprofit property tax exemptions, capturing the same advantages as full ownership while minimizing upfront costs.
- Long-Term Partnership: Unlike REITs or short-term developers, Boldt is a true strategic partner. We stay invested, aligning with system goals for market growth, physician alignment, and community impact.
- Operational Freedom: Boldt manages development, compliance, and capital reserves, allowing systems to focus on patient care while retaining strategic influence over real estate.
A Fluid Market Calls for Flexible Solutions
One of the key insights from HREI’s reporting is that health system strategies around real estate remain fluid. Some systems are aggressively buying back MOBs, while others are preparing to monetize large portfolios through sale-leasebacks. In fact, HREI recently reported that a major health system is pursuing a $300 million monetization, proving that acquisitions and dispositions can coexist in a single portfolio strategy.
“This variability underscores why a rigid “own vs. lease” mindset no longer works,” said Alex Brewer, VP of Real Estate. “Today’s environment calls for creative, flexible capital solutions that adapt as markets, leadership, and strategic goals evolve.”
That’s the heart of Boldt’s philosophy: helping systems balance control with capital efficiency, adapt to shifting priorities, and protect financial health while expanding access to care.
Looking Ahead
Healthcare leaders are under mounting pressure to do more with less: expand outpatient networks, improve patient access, manage costs, and strengthen physician relationships — all while navigating uncertain reimbursement models and rising construction expenses. Real estate is central to this equation.
Yes, the recent wave of acquisitions shows that systems want control. But control doesn’t have to come at the cost of capital flexibility. As the market continues to evolve, systems that embrace innovative real estate models will be better positioned to grow, adapt, and deliver care for generations to come.
FAQs
Why are health systems buying back MOBs now? After years of margin pressure, many hospitals are in a stronger financial position. Improved cash flow, access to favorable tax-exempt financing, and the strategic value of controlling outpatient facilities are motivating acquisitions. Healthcare Real Estate Insights (HREI) reports that health systems accounted for nearly 35% of all MOB purchases in early 2025 — a record share.
What are the main benefits of owning MOBs? Ownership can provide long-term control of critical outpatient facilities, tax savings for nonprofit systems, reduced exposure to rent escalations, and a way to ensure space for future growth.
What risks come with MOB ownership? While appealing, ownership isn’t without challenges:
- Capital strain – diverting funds away from clinical care and technology
- Maintenance obligations – managing repairs, upgrades, and compliance costs
- Shifting strategies – new CFOs or executives may rethink real estate philosophy
- Market uncertainty – reimbursement models and patient demand can change
How are Boldt’s models different from traditional leasing or owning? Boldt’s flexible financial structures blend the best of both worlds:
- Shared investment with Boldt, preserving system capital
- Predetermined purchase option, ensuring clarity and future control
- Structures designed to maximize tax benefits
- Long-term alignment with a partner invested in your success
What’s the bottom line for health systems? Today’s market demands flexibility. Ownership may seem like the safest play, but it ties up capital that could fuel patient care and innovation. Leasing alone can limit control. Boldt creates a third path — balancing control, capital efficiency, and long-term certainty.