The U.S. Ambulatory Surgery Center (ASC) Investment & Outpatient Migration Atlas, 2026 Edition
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The medical outpatient building market just crossed a threshold investors have been waiting on for almost two years. In the first quarter of 2026, CBRE reported that U.S. medical outpatient building investment volume rose 78% year over year to $2.9 billion, the average cap rate fell 13 basis points to 6.9% — the first sub-7 print since the third quarter of 2024 — and asking rents climbed to a record $25.40 per square foot. Within that headline, a quieter story has been compounding: ambulatory surgery centers, the highest-acuity slice of outpatient real estate, are now pricing on their own curve.
According to CREG Healthcare's "Medical Office Building Cap Rates 2025-2026" research, premium multi-specialty ASCs with strong payer mix and hospital joint-venture partners are trading at 6.8% to 7.3%, while single-specialty or marginal-location ASCs clear at 7.5% to 8.0%. That spread — both inside the ASC bucket and against the broader MOB average — is the analytical center of gravity for 2026. It is also, in our view, the most underserved capital-markets niche in healthcare real estate, because the federal financing stack built for physician-owned operating companies (SBA 7(a), SBA 504, USDA OneRD/B&I, and in limited cases HUD Section 242) is rarely paired thoughtfully with the real-estate side of these deals.
This atlas sets out the data, the regulatory map, the financing mechanics, and a metro-by-metro ranking that lenders, developers, and physician-owners should use to underwrite the next 24 months.
The Cycle, in Numbers
Hospital admissions per capita in the United States have been trending downward across two decades, while the Peterson-KFF Health System Tracker, drawing on American Hospital Association data, documents a 31% increase in the rate of outpatient visits between 2000 and 2023. Sg2's national forecast, summarized by the AHA in mid-2024, projects outpatient volumes will rise another 17% over the next decade to 5.82 billion encounters, with outpatient surgical services among the fastest-growing categories. JLL projects 10.6% U.S. outpatient volume growth over the next five years alone.
The implication for real estate is structural rather than cyclical. JLL's 2026 Medical Outpatient Building Perspective puts national MOB occupancy at a record 92.7%, with rent growth outpacing traditional office. CBRE forecasts another 26% decline in MOB construction completions in 2026, on top of the 2025 drop — pushing more demand into second-generation retail and office conversions and pressuring rents higher into 2027.
ASCs sit at the intersection of those forces. The Ambulatory Surgery Center Association counted 6,394 Medicare-certified ASCs as of September 2024; ASC Data's August 2025 industry overview placed the total U.S. universe (including non-Medicare-certified facilities) at roughly 12,294 centers with a market value near $45.6 billion. CMS's CY 2026 OPPS/ASC final rule, released November 21, 2025, raised ASC payment rates by 2.6% and added 560 procedures to the ASC Covered Procedures List, including 271 codes coming off the inpatient-only list and a long-awaited slate of cardiovascular electrophysiology, ablation, and percutaneous coronary intervention codes, plus posterior lumbar interbody fusion. The inpatient-only list itself will be fully eliminated by January 1, 2029.
That is the single most important policy event of the cycle. It converts revenue that historically lived in hospital outpatient departments into revenue that can, in principle, migrate to a freestanding ASC — and into real estate that an investor can underwrite at an ASC cap rate rather than a hospital-credit cap rate.
Cap Rates: Decoupling Inside the Stack
CBRE's Q1 2026 average of 6.9% conceals a wide distribution. Drawing on CREG Healthcare's Q1 2026 analysis and recent broker commentary, the working stack looks like this:
Asset type | 2026 cap rate range | Notes |
Trophy on-campus MOB, health-system credit, 10–15 yr WALT | 5.5%–6.0% | Investment-grade tenant, primary metros |
Core multi-tenant MOB, on-campus | 6.0%–6.75% | Strong sponsor, stabilized occupancy |
Off-campus MOB, large physician group anchor | 6.5%–7.2% | Suburban, 2-million-plus metro |
Premium multi-specialty ASC, hospital JV | 6.8%–7.3% | EBITDAR coverage ≥2.0x |
Single-specialty / marginal-location ASC | 7.5%–8.0% | Re-tenanting risk priced in |
Value-add MOB / secondary metros | 7.5%–8.5% | Lease-up or rollover risk |
The Welltower-to-Remedy Medical Properties/Kayne Anderson disposition of 296 MOBs for $7.2 billion, announced in October 2025, set the high-water mark for portfolio pricing — Welltower has not publicly disclosed the cap rate in its 8-K, but JLL noted MOB cap rates compressed roughly 60 basis points year over year in the fourth quarter. Healthcare Realty Trust, in its 2025 10-K filings, reported disposing of 70 properties for approximately $1.1 billion at a weighted-average cap rate of 6.7%, a useful proxy for the institutional bid on stabilized, on-campus product. On the smaller, physician-owned end, transaction advisor ASCs Inc. cites a Dublin (Ohio) Surgery Center sale at $6.0 million on a 6.62% cap rate with a new 15-year lease to SCA Health — a clean illustration of what a well-structured sale-leaseback to a top-five operator can fetch.
The 80–120 basis-point premium that an ASC carries over a comparable MOB reflects three real risks: operational complexity, re-leasing universe (a hospital-grade OR build-out is expensive to repurpose), and tenant credit concentration when the operating LLC is physician-syndicated rather than backed by an investment-grade health system. That premium is exactly where the alpha sits for sponsors who can underwrite operator quality.
Outpatient Migration: Where the Volume Is Going
Total knee and total hip arthroplasty have moved fastest. On Tenet Healthcare's Q3 2025 earnings call, CEO Saumya Sutaria reported that "same-facility revenues grew by 8.3% in the third quarter, highlighted by 11% growth in total joint replacements in the ASCs over the prior year." More than 70% of Surgery Partners' surgical facilities are now equipped for complex orthopedic cases, and 41% perform total joint replacements as of year-end 2024. Cardiology is the next frontier — Becker's ASC has documented executives at SCA Health publicly calling the 2026 addition of cardiac catheter ablation, EP, and PCI codes the most consequential update in years, though volume migration in cardiology will lag the policy change as ASCs build out hybrid suites and credential interventionalists.
The economic logic is hard to argue with. A 2025 PubMed-indexed analysis cited by Anzolo Medical found that ASCs deliver 42% lower total costs than hospital outpatient departments for comparable surgical procedures. The American Academy of Orthopedic Surgeons, in March 2024 data, reported 35% total cost savings, 41% facility-fee savings, and 28% patient out-of-pocket savings at ASCs versus HOPDs.
The CON Map: 2026 Investment Screen
Certificate of Need remains the single most important regulatory variable for ASC site selection. According to the National Conference of State Legislatures, 35 states plus Washington, D.C. operated CON programs as of late 2025; the National Academy for State Health Policy's December 12, 2025 update is the cleanest current source. South Carolina's S.164 (signed May 16, 2023) eliminated CON for ASCs effectively immediately and will end hospital CON on January 1, 2027 — with the new wrinkle that post-2023 ASCs must provide 2%–3% of adjusted gross revenue in indigent/charity care. Georgia's HB 1339 (effective July 1, 2024) carved out new single-specialty ASC exemptions; North Carolina's HB 76 phases CON exemptions for ASCs in counties over 125,000 population beginning November 21, 2026; Tennessee removed CON for most ASCs in 2024.
For investors and brokers, the 2026 map looks like this:
CON-required for ASC development (representative): Alabama, Alaska, Connecticut, D.C., Georgia (partial), Hawaii, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Mississippi, Nevada, New Hampshire, New Jersey, New York, North Carolina (phasing out in urban counties), Oregon, Rhode Island, Vermont, Virginia, Washington, West Virginia.
No CON for ASCs (representative): Arizona, Arkansas, California, Colorado, Delaware, Florida, Idaho, Indiana, Kansas, Louisiana, Minnesota, Missouri, Montana, Nebraska, New Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Wisconsin, Wyoming.
A peer-reviewed 2024 study by Thomas Stratmann, Markus Bjoerkheim, and Christopher Koopman (GMU Working Paper No. 24-23, April 2024; published in Southern Economic Journal 92(1), 2025) found that "CON law repeals increase ASCs per capita by 44–47% statewide and 92–112% in rural areas," without raising hospital closures. That is the empirical basis for capital flowing into newly deregulated Southeast markets.
Top 50 Metro ASC Opportunity Ranking
Our ranking weights physician density per 10,000 population, Medicare-eligible population growth, surgical procedure volume, CON status (non-CON markets get a structural premium), commercial payer mix, operator concentration, competitive saturation, and the spread between going-in cap rate and stabilized development yield. State-level Medicare-certified ASC counts (ASCA, September 2024) provide the volumetric base; MedPAC's March 2024 Report to Congress provides the per-Part-B-beneficiary normalization.
Top 10 (detailed):
Dallas–Fort Worth, TX — Non-CON; USPI headquarters; deep physician-owner pool; orthopedic and spine leadership. Going-in 7.0%–7.4% on quality multi-specialty product.
Houston, TX — Non-CON; largest medical center cluster in the U.S.; CBRE notes Houston led 2024 MOB absorption. ASC cap rates 7.0%–7.5%.
Phoenix, AZ — Non-CON; demographic tailwind; Arizona added 12 ASCs since December 2022 to reach 233. Cap rates 7.1%–7.6%.
Tampa–St. Petersburg, FL — Non-CON; Florida added 41 ASCs to 509 statewide; retiree migration. Cap rates 7.0%–7.5%.
Atlanta, GA — Partial CON but recent HB 1339 carve-outs; Georgia is second nationally in ASCs per Part B beneficiary (22 per 100,000, per MedPAC). Cap rates 7.2%–7.7%.
Nashville, TN — Post-CON-reform; Surgery Partners and HCA headquarters; physician-friendly. Cap rates 7.0%–7.4%.
Charlotte, NC — CON phase-out for urban counties beginning late 2026 — a uniquely attractive forward-looking entry. Cap rates 7.3%–7.8% with compression catalyst.
Orlando, FL — Non-CON; visitor-economy procedure flow; strong commercial payer mix. Cap rates 7.1%–7.5%.
Austin, TX — Non-CON; fastest job and population growth in the South; under-supplied on multi-specialty ASCs. Cap rates 7.0%–7.4%.
Denver, CO — Non-CON; commercial-skewed payer mix; physician-owned model entrenched. Cap rates 7.1%–7.6%.
Ranks 11–50 (summary):
Rank | Metro | CON for ASCs | Cap rate band |
11 | Salt Lake City, UT | No | 7.1%–7.6% |
12 | Indianapolis, IN | No | 7.2%–7.7% |
13 | Las Vegas, NV | Yes | 7.3%–7.8% |
14 | San Antonio, TX | No | 7.2%–7.7% |
15 | Raleigh–Durham, NC | Phasing out | 7.3%–7.8% |
16 | Jacksonville, FL | No | 7.2%–7.6% |
17 | Kansas City, MO/KS | No | 7.3%–7.8% |
18 | Columbus, OH | No | 7.2%–7.7% |
19 | Minneapolis–St. Paul, MN | No | 7.2%–7.7% |
20 | Miami–Fort Lauderdale, FL | No | 7.0%–7.5% |
21 | Sacramento, CA | No | 7.1%–7.5% |
22 | Riverside–San Bernardino, CA | No | 7.3%–7.8% |
23 | St. Louis, MO | No | 7.4%–7.9% |
24 | Cincinnati, OH | No | 7.4%–7.9% |
25 | Pittsburgh, PA | No | 7.4%–7.9% |
26 | Cleveland, OH | No | 7.4%–7.9% |
27 | Detroit, MI | Yes | 7.5%–8.0% |
28 | Boise, ID | No | 7.3%–7.8% |
29 | Oklahoma City, OK | No | 7.3%–7.8% |
30 | Tulsa, OK | No | 7.4%–7.9% |
31 | Memphis, TN | No (post-reform) | 7.4%–7.9% |
32 | Knoxville, TN | No (post-reform) | 7.4%–7.9% |
33 | New Orleans, LA | No | 7.4%–7.9% |
34 | Birmingham, AL | Yes | 7.5%–8.0% |
35 | Greenville, SC | No (post-repeal) | 7.3%–7.8% |
36 | Charleston, SC | No (post-repeal) | 7.3%–7.8% |
37 | Richmond, VA | Yes | 7.5%–8.0% |
38 | Albuquerque, NM | No | 7.5%–8.0% |
39 | Tucson, AZ | No | 7.3%–7.8% |
40 | Reno, NV | Yes | 7.5%–8.0% |
41 | Omaha, NE | No | 7.4%–7.9% |
42 | Des Moines, IA | Yes | 7.6%–8.1% |
43 | Madison, WI | No | 7.4%–7.9% |
44 | Milwaukee, WI | No | 7.4%–7.9% |
45 | Louisville, KY | Yes | 7.6%–8.1% |
46 | Baltimore, MD | Yes | 7.4%–7.9% |
47 | Washington, D.C. metro | Yes (DC/MD), No (VA) | 7.3%–7.8% |
48 | Philadelphia, PA | No | 7.4%–7.9% |
49 | Boston, MA | Yes | 7.5%–8.0% |
50 | New York City metro | Yes | 7.4%–7.9% |
CON-state metros score lower not because demand is weak — most are dense and demographically attractive — but because development optionality is constrained, which compresses the spread between an acquisition cap rate and a development yield. Non-CON Sun Belt metros offer the cleanest entry for sponsors willing to build.
The Underserved Stack: SBA, USDA, HUD
Most physician-owned ASC deals end up in one of three financing pockets, none of which is well-marketed to the typical CRE broker.
SBA 7(a) offers up to $5 million for ASC acquisition, partner buyouts, working capital, or owner-occupied real estate. The June 1, 2025 effective date of SOP 50 10 8 reinstated pre-2021 underwriting discipline, raised the minimum SBSS score from 155 to 165, required a 10% equity injection (up to 5% may come from a seller note on full standby SBA Form 155), and reduced the small-loan threshold from $500,000 to $350,000. For an ASC, the 7(a) is most useful for the operating company rather than the real estate.
SBA 504 is the natural product for the real-estate side. A typical structure pairs a 50% conventional first mortgage with a 40% CDC debenture (fixed-rate, 20- or 25-year amortization) and a 10% borrower equity injection. The current debenture maximum is $5.5 million for most projects ($5.0M for standard, with higher caps for energy-efficient or manufacturing projects). The SBA 504 program's eligible passive concern (EPC) and operating company (OC) structure — codified at 13 CFR §120.111 and detailed at pages 40–45 and 52–55 of SOP 50 10 8 — is what makes physician-owned ASC deals workable: a real-estate LLC holds title, leases at fair-market rent to the operating ASC under a co-terminus lease, and each 20%-plus owner of either entity provides a personal guarantee. Owner-occupancy must be at least 51% for existing buildings and 60% for new construction.
This is the pocket the market underuses. A well-structured 504 lets a physician group acquire its own facility with 10% down on a 20- to 25-year fixed-rate CDC tranche — pricing in 2026 in the 6.5% to 7.5% range — while leaving the operating company with capital headroom for equipment and partner buy-ins.
USDA OneRD/B&I, governed by 7 CFR Part 5001 (effective October 1, 2020), is the program nobody talks about. It guarantees up to $25 million in lender loans for businesses in towns under 50,000 population, with FY2026 guarantee percentages of 85% on applications below $5 million and 80% above. For rural ASCs — and the Stratmann–Bjoerkheim–Koopman study suggests rural ASC supply more than doubles when CON is repealed — this is unmatched. Loans can cover land, hard and soft costs, equipment, and working capital under a single facility, with 24-month interest-only construction-to-perm structures available.
HUD Section 242 is more limited. Under 24 CFR Part 242 it insures mortgages on acute-care hospitals at up to 90% of replacement cost, with terms to 25 years and no statutory loan maximum. Freestanding ASCs are not eligible standalone — they qualify only when integrated into a Section 242 hospital project. Physician-controlled hospital ownership receives additional scrutiny under §242.9. The product is therefore relevant for health-system joint ventures that wrap an ASC inside a broader hospital recapitalization, not for typical physician syndicates.
Conventional bank debt still anchors the institutional end of the market. Going-in DSCR covenants of 1.25x to 1.40x, LTC of 65% to 80%, and recourse construction-to-perm structures are typical in 2026. Pricing on a 7- to 10-year hospital-anchored MOB ranges roughly SOFR + 175 to SOFR + 250.
Unit Economics: What Underwriters Should Actually Model
A two-OR single-specialty ASC typically delivers in 8,000 to 12,000 square feet for $2.0 million to $3.5 million in hard costs. A four- to six-OR multi-specialty facility runs 15,000 to 25,000 square feet at $4.5 million to $9.0 million. JLL's 2026 fit-out guide pegs the national all-in MOB fit-out at $412 per square foot; ASC-specific construction sits materially higher, with Clear House Lending citing $500 to $750 per square foot for full ASC build-out (OR-grade HVAC, medical gas, backup power), and BSA Design's 2026 hospital cost report citing $650 to $800 per square foot for outpatient surgery centers built into hospital settings.
Mature multi-specialty ASCs run 1,000 to 1,800 cases per OR annually. EBITDA margins span a wide band: HealthCare Appraisers' benchmarking has historically pegged the median at roughly 20%, while Shields Health's 2024 analysis notes that top-decile multi-specialty ASCs run above 40% EBITDA margin and bottom-quartile centers below 15%. VMG Health data, summarized at Becker's ASC, places average net revenue per case at roughly $1,500–$3,000 depending on specialty mix, with orthopedics anchoring the top end at $8,000-plus per case.
Going-in cap rates of 7.0% to 7.5% versus stabilized development yields of 8.5% to 9.5% on well-located new-build ASCs produce 150 to 200 basis points of spread — the bid for that spread is exactly why USPI, SCA, and Surgery Partners are buying everything that moves.
Operators and Capital Flows
USPI (Tenet Healthcare) ended 2025 with interests in 533 ASCs and 26 surgical hospitals across 37 states, having spent roughly $350 million in M&A and de novo activity during the year and added 35 facilities. Tenet has flagged a $250 million annual M&A target for USPI in 2026. SCA Health (Optum/UnitedHealth Group) operated more than 320 ASCs at year-end 2025 and acquired U.S. Digestive Health (24 endoscopy ASCs) in January 2025. Surgery Partners ran roughly 160 centers, with revenue guidance of $3.275–$3.3 billion for full-year 2025. HCA's Surgery Ventures division held 124 ASCs at year-end 2024. The most consequential deal of 2025 was Ascension's June 17 announcement to acquire AmSurg for approximately $3.9 billion, a transaction that, per Becker's ASC and Healthcare Dive reporting, will expand Ascension's ASC footprint from 58 centers to more than 300 in 34 states.
On the real-estate side, the Welltower–Remedy/Kayne Anderson $7.2 billion MOB disposition reshaped the institutional landscape. Remedy now controls a portfolio above 1,100 properties and 55 million square feet, eclipsing Healthcare Realty Trust's 36 million square feet. Healthcare Realty's $1.1 billion of 2025 dispositions at a 6.7% weighted-average cap rate suggests the institutional bid for stabilized on-campus MOB has firmed materially.
Reimbursement: Tailwinds, Headwinds
CMS's CY 2026 rule is the cleanest tailwind in years: 2.6% payment update, 560 procedures added to the ASC Covered Procedures List, IPO list elimination phased through January 1, 2029. The headwinds are real but manageable. CMS is expanding site-neutral payments to drug administration services in excepted off-campus provider-based departments — per the CMS CY 2026 OPPS/ASC Final Rule fact sheet (CMS-1834-FC, November 21, 2025), "this provision will reduce OPPS spending by $290 million, with $220 million of the savings accruing to Medicare, and $70 million saved by Medicare beneficiaries in the form of reduced beneficiary coinsurance" — but the change is largely irrelevant to ASCs. Commercial payer site-of-service differentials continue to push elective volume toward ASCs. The Wasteful and Inappropriate Service Reduction (WISeR) model and the December 2025 prior-authorization demonstration in 10 states (Arizona, California, Florida, Georgia, Maryland, New York, Ohio, Pennsylvania, Tennessee, Texas) for selected procedures like rhinoplasty and vein ablation will create short-term revenue cycle drag but do not change the structural arithmetic.
Investment Outlook
Three calls for the next 24 months.
First, the ASC-to-MOB cap-rate spread will not close. Operational complexity, re-tenanting universe, and physician-syndicate credit will keep premium multi-specialty ASCs in the high-6s to low-7s and single-specialty product in the high-7s. Sponsors who can underwrite operator quality — EBITDAR coverage, physician retention, payer mix, CMS Quality Reporting status — will capture that premium without taking on undue risk.
Second, the Southeast non-CON corridor (South Carolina post-2023, Tennessee post-2024, Georgia post-HB 1339, North Carolina urban counties post-November 2026) is the single best development opportunity in U.S. healthcare CRE. Going-in cap rates of 7.3% to 7.8% on de novo product, paired with development yields north of 9%, will reward sponsors who move first and build relationships with local physician groups before USPI, SCA, and Surgery Partners' M&A teams arrive.
Third, the SBA 504/USDA B&I/conventional construction-to-perm financing stack for physician-owned ASCs is the most underserved capital-markets niche in healthcare CRE. A well-structured EPC/OC 504 deal with a Stark/Anti-Kickback-compliant syndication agreement, paired with conventional working-capital lines for the operating company, can fund a new four-OR ASC for $6–$10 million with 10% physician equity. The brokers and lenders who build that competency in 2026 will own a fragmented market that the institutional players cannot reach.
The next decade of U.S. healthcare real estate will be written outside the hospital walls. The atlas above is where to start reading.
Sources:
CBRE, Q1 2026 U.S. Medical Outpatient Buildings Figures, May 2026
CREG Healthcare, "Medical Office Building Cap Rates 2025-2026 Market Insights"
JLL, 2026 Medical Outpatient Building Perspective; 2026 Fit-Out Cost Guide
Cushman & Wakefield, MOB Capital Markets Midyear 2026 Outlook
Colliers, "Ambulatory Surgery Center Valuation: Understanding Risk, Rent Structure, and Returns"
Newmark Healthcare research
Marcus & Millichap, 2026 National Medical Office Report
CMS, CY 2026 OPPS/ASC Final Rule (CMS-1834-FC), November 21, 2025
CMS, ASC Covered Procedures List 2026 (Table 131)
CMS Provider of Services file, 2023
MedPAC, March 2024 Report to Congress, Chapter 10
American Hospital Association, Costs of Caring 2025; Sg2 forecast
Peterson-KFF Health System Tracker, 2024 utilization analysis
Ambulatory Surgery Center Association (ASCA), state-by-state ASC counts, September 2024
AAASC (American Association of Ambulatory Surgery Centers) policy briefs
ASC Data, August 2025 Industry Overview
National Conference of State Legislatures (NCSL), Certificate of Need State Laws, 2025
National Academy for State Health Policy, CON database, December 12, 2025
Becker's ASC Review, "Certificate-of-need laws by state in 2026"
South Carolina S.164 (2023); Tennessee CON reform 2024; Georgia HB 1339; North Carolina HB 76
Stratmann, Bjoerkheim & Koopman, "The Causal Effect of Repealing Certificate-of-Need Laws for Ambulatory Surgical Centers," Southern Economic Journal 92(1), 2025
Definitive Healthcare, SurgeryCenterView (state-level public summaries)
American Academy of Orthopedic Surgeons, March 2024 cost analysis
Anzolo Medical, ASC Reimbursement 2026 analysis
SBA, Standard Operating Procedure 50 10 8, effective June 1, 2025
13 CFR §120.111 (EPC/OC structure)
USDA Rural Development, Business & Industry Guaranteed Loan Program
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