The building looks good on the tour. The rent comps check out. The operator’s numbers pencil. But then you dig into the facility report—and everything changes. Roof nearing end of life. Outdated HVAC. Noncompliant fire suppression. Half a million in deferred maintenance that nobody wanted to talk about up front. This is happening more and more in medical deals, especially with older MOBs, behavioral health campuses, and repurposed assets. And it’s not just a buyer problem. Lenders are flagging it. Inspectors are catching it. And tenants are using it to rework lease terms at the last minute. In this market, condition matters. You can’t assume a building’s value based on rent roll alone. If the infrastructure is shot, or upgrades are needed to meet licensing or life safety codes, that’s real money—and it’s hitting valuations hard. For landlords, this means getting ahead of the issue. Know what’s aging out. Budget for it. Document what’s been updated. For buyers and tenants, it means asking the right questions early and building in capital reserves that match the risk. Everyone talks about location and cap rate. But right now, what’s behind the walls might matter just as much. 📅 Want to review a facility or talk through capex risk? Book a 15-minute call 📰 Subscribe for updates

Operators and landlords in the healthcare space are looking at alternative deal structures to navigate high interest rates, tight credit, and rising construction costs. One model that’s getting renewed attention is lease to own. While not new, lease to own arrangements are being considered more frequently in 2025 as a strategic alternative to conventional leasing or immediate acquisition. These deals often provide an operator with immediate occupancy through a lease, while securing the option—or obligation—to purchase the property after a defined period or upon meeting certain performance benchmarks. This structure is becoming attractive in medical real estate for several reasons: Financing remains challenging.  Lenders are being more selective, and some operators prefer to stabilize operations in a space before taking on full ownership risk. Cap rates have shifted.  As valuations adjust and price discovery continues, lease to own offers a way for both parties to align expectations without forcing a premature sale. Ownership demand is up.  According to JLL, medical condo sales and owner-user transactions have increased year over year, pointing to more healthcare groups prioritizing real estate control. Private landlords are open to flexibility.  In suburban and secondary markets especially, private owners are often willing to offer purchase options in exchange for reliable tenancy and long-term alignment. This isn’t a market-wide trend, but it is one that fits the moment—particularly for behavioral health, outpatient specialty care, and dental practices looking to scale responsibly. 📅 Book a 15-minute call if you’re evaluating your lease structure 📰 Subscribe for market insights

In a normal market, you negotiate rent, you sort out TI, you sign the lease. But right now? The structure of the lease itself is what’s killing or saving the deal. We’re seeing more groups walk from otherwise good locations because the lease terms don’t work. Base rent looks fine on paper, but the escalations kill the long-term value. Or the landlord wants the tenant to front six figures in improvements without any rent abatement. Or the renewal terms are vague and make the entire investment shaky. In behavioral health and senior living especially, lenders are looking at lease terms hard. If your rent coverage is too thin, your financing is dead on arrival. If you’re trying to sublease or JV and the lease isn’t structured cleanly, forget about bringing in capital. The market isn’t offering a lot of room for mistakes right now. You’ve got to get this stuff right on the front end—clear rent schedules, reasonable escalations, options to extend, and protection against CPI volatility. None of it’s glamorous, but it’s what holds the deal together. You don’t win deals by offering the highest rent anymore. You win them by offering the cleanest structure. 📅 Want to review a deal or term sheet together? Book a 15-minute call 📰 Sign up for insights

Medical office space isn’t sitting. The good spots are getting picked off fast, and the days of slow negotiations and soft LOIs are over. Landlords are being selective. Construction costs are still high. TI packages are tighter. And if you show up without financials, a real buildout plan, or a clear operating history—you’re probably not getting the space. This is especially true for behavioral health and specialty outpatient care. Demand is there, but inventory is limited. And the groups landing space aren’t always offering more money. They’re just showing up more prepared. Their paperwork is ready. They have licensing timelines mapped out. They know their CO path. The landlord’s risk is lower, so the deal gets done. If you’re shopping space right now, understand that you’re not just competing on rent. You’re competing on certainty. And landlords have options. There’s still opportunity. There are still good deals to be had. But they’re going to the operators and developers who are ready to execute on day one—not the ones who need three weeks to figure out who their architect is. 📅 Need help tightening your pitch or reviewing your lease strategy? Book a 15-minute call 📰 Or get these updates straight to your inbox

In this market, it’s not just about the building. It’s about who’s in it. Buyers are getting more aggressive with their underwriting, and operator credit is right at the top of the list. If your tenant doesn’t have clean financials, a strong payer mix, and a clear growth plan, you’re either getting retraded or skipped altogether. We’ve seen this play out across behavioral health, senior living, and even specialty outpatient. Same building, same layout, same market—but two very different valuations depending on who’s operating inside. Strong operators are still pulling premium cap rates. Everyone else is getting shaved down or asked to bring in a management group before closing. It’s not personal. It’s capital discipline. In a tighter lending environment, investors want stability. They want to know that rent’s going to clear every month. They want contracts, census trends, referral sources—all of it. And they’re digging deeper than they used to. If you’re planning to sell or refinance, your operator’s story better be ready. Not polished—real. That means audited financials, updated pro formas, and a clear explanation of how this location fits into a larger clinical or geographic strategy. The building matters. But the people running it? That’s what closes the deal. 📅 Book a 15-minute call 📰 Get weekly updates

Not much fanfare this week but serious moves are still unfolding. These are the under‐the‐radar shifts that could shape the next quarter. A big one— a new $265 million hospital in Frisco, Texas  is set to open in July. This full‑service facility spans 340,000 sq ft and includes emergency, inpatient, and outpatient care. It’s the largest for‑profit healthcare project in North Texas right now  . For anyone tracking suburban expansion or future campus deals, Frisco is the next one to study. Turning point in Scottsdale.  Cushman & Wakefield just closed a $44.6 million sale  on a 163K sq ft outpatient MOB that used to be general purpose. The new owner got it at 78% full—with oncology, cardiology, ophthalmology tenants—and they used a 1031 exchange to structure the deal (). If you’re watching conversion plays or tax‑driven portfolios, this one is worth noting. Senior living recap?  BMO Healthcare Real Estate stepped up as the sole lender on a $45 million term loan  for Kisco Senior Living (). That’s capital in play—for those refinancing, buying, or repositioning assets in senior care. Plus, keep an eye on loan appetite tightening  in senior housing. As of early July, lenders are facing thinner spreads and slightly stricter terms across the board (). For anyone raising debt or shopping deals, that one matters. Why it matters Deals like these show a few things: Suburban hospital campuses aren’t dead—they’re still launching big, new projects in growth markets. Outpatient conversion plays are real and liquidity is there—if you know where to look. Capital is still flowing into senior living—but expect tighter underwriting and more scrutiny. 📞 If you’re sizing up your next deal, questioning capex assumptions, or just want to dissect underwriting trends for this quarter, I’m around. 📅 Book a 15‑minute chat: https://calendly.com/contact-loveladyperspective/15min 📰 Want more straight-up CRE intel? Sign up here: https://www.loveladyperspective.com/contact

Most people in medical real estate are still guessing. They’re looking at last year’s comps. They’re underwriting based on a phone call from three months ago. They’re trusting that the guy on the other end of the table has the same version of the market they do. He doesn’t. The groups that win right now are the ones with current, specific market intel. Not noise. Not theory. Just straight clarity about what’s happening and what isn’t. We’re seeing deals fall apart in the eleventh hour because someone assumed zoning would be quick. It wasn’t. Or because someone expected the rent to appraise where it did last year. It didn’t. AI is everywhere. It can give you averages. It can summarize a market report. But it can’t tell you that the operator just pulled out of two other locations. It can’t walk a site and spot the permitting issue that’s going to add 90 days and fifty grand to your timeline. Real intel still comes from people who live and breathe this space every day. People who talk to lenders, underwriters, city planners, and operators all week long. If you’re trying to close something this quarter or set up a play for the second half of the year, get in the room with people who can tell you where the landmines are buried. Here’s the link if you want to talk 📅 Book a 15-minute call Or just want the good stuff in your inbox 📰 Sign up for the newsletter

The biggest threat to your next medical real estate project might not be interest rates. It might be zoning. Across the country, developers and operators are hitting walls when it comes to entitlements—especially in behavioral health and senior living. Cities love healthcare projects in theory. But when it comes time to approve the site plan or issue a conditional use permit, things slow down fast. In many cases, the delay isn’t about the use. It’s about perception. Behavioral health facilities get lumped into the same mental model as “group homes” or “drug rehabs” by planning boards and local residents. Senior living often gets caught between multifamily and healthcare zoning buckets—creating gray areas that can take months to navigate. That’s not something you fix with a better lease comp or cap rate. It takes local relationships, strategic positioning, and a zoning narrative that’s aligned with community priorities—public health, aging in place, job creation. If you’re building in this market, you need to plan for zoning friction. It’s not just a box to check. It’s a deal breaker if you don’t get ahead of it. Working on a deal and running into zoning issues? Let’s talk through it. 📅 Book a 15-minute call 📰 Subscribe for updates

The spotlight used to be on the big metros—Dallas, Phoenix, Atlanta, Nashville. And they’re still strong. But lately, the real action is showing up in second-tier cities and overlooked regions. Investors are chasing yield. Operators are chasing affordable growth. And both are finding it in places like Chattanooga, Des Moines, Greenville, and mid-sized cities across the Midwest and Southeast. Here’s why: 1. Lower basis, better margins. Land and existing assets are cheaper, but the demand is there—especially for behavioral health, urgent care, and senior-focused services. 2. Less competition. Fewer institutional players means faster deal cycles, less bidding pressure, and more room for creative structuring. 3. Real demographic tailwinds. These markets are pulling in retirees, young families, and remote workers. They need outpatient care, senior living options, and mental health infrastructure—now. The big funds are already watching. But the ones who move early—especially local developers or operator-aligned capital—have the advantage. Don’t wait for everyone else to flood in. If you’re looking for growth, secondary markets are giving you the runway. Want help identifying high-potential markets or structuring a play? Let’s talk. 📅 Book a 15-minute call 📰 Join the newsletter

Operators sitting on real estate are starting to get more strategic—and sale leasebacks are back on the table. We’re seeing more behavioral health and specialty care groups quietly test the market for sale leaseback deals, especially if they’ve owned the property for five years or more. With interest rates still high and cash flow tightening, unlocking equity from real estate can provide the capital needed for expansion, debt reduction, or staffing investments. And buyers are interested—especially if the tenant is strong. Healthcare real estate investors are hungry for credit-backed leases in high-demand sectors. They’re not just looking at hospital systems anymore. They’re looking at outpatient psych, MAT clinics, and group practices with growth trajectories. The key is structure. Sale leasebacks only work if the rent is sustainable for the operator and still pencils for the investor. That takes planning. You’ve got to know your numbers, your valuation, and your long-term footprint goals. Done right, a sale leaseback isn’t just a financial tool. It’s a growth strategy. Thinking about selling but staying in place? Let’s walk through it. 📅 Book a 15-minute call 📰 Get insights each month

Tenant improvement costs in medical real estate have quietly climbed over the past 12 months—and they’re not slowing down. In some markets, we’re seeing $100 to $150 per square foot  just to get space clinic-ready. And for behavioral health or surgical use? Even more. This matters. Because when TI costs go up, deal structures change. Landlords are becoming pickier about who they lease to. Generous TI packages are drying up. And in a lot of cases, tenants are expected to front more of the cost—or take longer lease terms to offset the investment. For buyers, this also impacts capex planning. An otherwise solid building can become a drag if you’re underwriting a major backfill with heavy medical build-out needs. And for operators, the decision to lease vs own starts to look different when you realize you’re spending hundreds of thousands to improve someone else’s property. It’s not all bad news. But it does mean you need a plan. Whether that’s baking TI costs into your negotiation, renegotiating rent escalations, or exploring sale-leasebacks to free up capital—you can’t afford to ignore the impact. Need help modeling a deal with realistic TI numbers? Let’s run it together. 📅 Book a 15-minute call 📰 Get our weekly updates

Last week we talked about how ground-up medical development is starting to creep back into the conversation. But here’s the truth: it’s not happening everywhere. And it shouldn’t be. So where does it make sense? Markets with real population growth. You need rooftops, not just demand on paper. Texas, Florida, Tennessee, and the Carolinas continue to draw inbound migration and aging demographics—two key ingredients for new builds, especially in behavioral health and senior-focused outpatient care. Land that doesn’t kill the deal. Rising construction costs are already a problem. Add overpriced land or heavy site work, and you’re underwater before you ever pour concrete. The best projects right now are on shovel-ready sites that were banked years ago or offered through JV partnerships with health systems or municipalities. Operators who know what they’re doing. A ground-up build only works if it’s tied to a scalable operating model. Lenders and equity partners want to see a team that has already proven they can fill and run a facility—not just build one. No one’s gambling on first-timers right now. The takeaway? Ground-up isn’t back for everyone. But for the right group in the right market with the right playbook—it’s a competitive advantage. Curious if ground-up fits into your growth strategy? Let’s talk. 📅 Book a 15-minute call 📰 Get our newsletter