Multi-site healthcare M&A multiples — Q2 2026 (DSO, vet, derm).

01 The Q2 2026 headline read

PCE Investment Bankers reports healthcare-sector median TEV/EBITDA compressed from approximately 14.9x in Q1 2024 to 12.7x in Q1 2026 — roughly 2.2 turns off the early-2024 level for the broader healthcare-services category. Peakstone's Q1 2026 industry report puts the all-deals median healthcare EV/EBITDA at approximately 12.5x with revenue multiples in the mid-2x range. Capstone Partners' 2025-2026 Middle Market Valuations Index shows the all-industry average purchase multiple at 9.8x in 2025, with healthcare flagged as a resilient, above-average-multiple sector. Inside the broader healthcare envelope, the multi-site provider sub-sector — DSO, vet, derm, medspa — runs both above and below the headline, depending on sub-sector and platform quality.

The pattern in 2025-2026 is consistent across advisors: platform multiples have compressed several turns from the 2021-2022 peak, add-on multiples have held relatively firm at 5-8x EBITDA, and the bid-ask gap that froze the market through 2024 has narrowed but not fully closed. Sponsors with mature platforms approaching 6-9 year hold periods are increasingly motivated to exit, and PwC notes that 2026 "could mark the start of renewed movement" in PPM as long-stalled portfolios in dermatology, orthopedics, behavioral, women's health, and dental finally begin to trade.

02 DSO — continued compression at the platform tier

DSO platform multiples in Q2 2026 are running in the 9–12x EBITDA band for groups in the 12-to-40 location range, with FOCUS reporting that strong DSO platforms can stretch to 11-15x at the top of the market and that the bulk of platform deals trade in the 9-12x band. This is several turns below the 14-16x range that defined 2021-2022 and well below the mid-teens peak some platforms cleared at the height of the consolidation cycle. Add-on multiples — single-location and small-cluster acquisitions into existing platforms — have held at 5-8x EBITDA, with most of the deal flow currently concentrated in this tier rather than at the platform level.

The compression at the platform tier reflects three operating realities. First, same-store growth in DSO platforms has decelerated to 2-4% in mature markets, after several waves of consolidation have left fewer easy-fragmentation gains. PwC and TUSK Practice Sales both call this out explicitly: revenue growth from genuine same-store volume gains is increasingly rare; most reported growth comes from price increases, mix shift toward higher-margin procedures (less common in commodity-heavy practices), or expansion-related cannibalisation of existing locations. Second, labor cost has compounded persistently: hygienist and dentist compensation, sign-on bonuses, locum coverage costs, and central-services staffing have all moved higher faster than reimbursement rates have caught up. Kaufman Hall's Physician Flash Report shows compensation per wRVU rising faster than collections per wRVU across the broader physician services category. Third, payor mix has shifted toward lower-pay commercial plans and Medicaid as platforms have expanded geographically into markets where the high-commercial mix that defined the original platforms is not available.

The same-store conversation in DSO QoE

Buy-side QoE on DSO platforms now focuses heavily on the same-store narrative. The standard methodology: lock the same-store definition under a conservative interpretation (locations open for the full trailing 24 months, no COVID-window normalisations, no cherry-picking), pull the same-store production and collections by location, and surface the cohort that is genuinely growing versus the cohort that is held up by acquisitions and price moves. Across the integrations we have advised on, the share of locations showing real same-store growth runs 30-60% of the platform — well below what the seller's narrative typically claims. Sellers who arrive at the process with their own honest same-store cut clear at the top of the multiple band; sellers who present blended growth without surfacing the same-store/acquisition decomposition absorb the adjustment in negotiation.

For DSO sellers reading these bands, the question is rarely whether to transact at the new multiple — the question is whether to position the group as a platform candidate or as an add-on candidate. Most groups in the 5-15 location band are now add-on candidates regardless of historical aspiration. The transaction value is materially higher at the platform tier, but the bar — $10M+ EBITDA, multi-state footprint, centralised operations, demonstrated same-store growth, clean payor mix — is now meaningfully higher than it was in 2021. Our DSO Day 1–100 integration playbook lays out what an acquirer expects to inherit; the work to deliver that profile takes 12-18 months of operating preparation.

03 Veterinary — stabilisation at a re-set band

Veterinary multiples have moved further from the peak than any other sub-sector in multi-site medical. KPMG's veterinary market report documented 18-20x EBITDA for 10+ unit platform acquisitions in H1 2022; VetPartners pegged corporate prices at 18-22x at the 2021 peak. By Q4 2025, RL Hulett's Pet M&A Update reports the median PE pet sector deal at 9.9x EBITDA, compressed from 16.8x in 2024 — a single-year drop of nearly 7 turns. Q2 2026 has settled into the 8-15x band for platform deals, with the upper end reserved for specialty/ER hospitals with 24/7 footprint and the lower end for general-practice consolidators in saturated markets.

The compression has multiple drivers. Visit volumes declined 2.8% YoY in 2025 per Vetsource/Simmons data, while revenue grew only 2.5% — meaningfully behind the 8% veterinary service inflation rate that dvm360 reports. Time between visits has extended 48% to approximately 86 days, reflecting client price sensitivity and inflation pressure. Staffing — particularly DVMs and licensed technicians — remains in chronic shortage, with wage inflation compounding margin pressure. The integration synergies that sponsors underwrote in 2021 — central RCM, central scheduling, procurement leverage, marketing efficiency — have proven slower and less complete than pro forma models assumed, leaving many platforms carrying duplicative G&A through 2024-2026.

The Mars-Heska transaction in June 2023 ($1.3B at $120/share, approximately 38% premium to Heska's 60-day average) illustrates the strategic logic now defining the sector: vertical integration of diagnostics into clinic ownership rather than pure-play clinic roll-ups at peak multiples. Mars' broader pet platform — Banfield, VCA, Linnaeus, and the post-acquisition Heska — represents the deepest pocket and the most disciplined buyer in the category. NVA's earlier acquisition of Ethos Veterinary Health captured the specialty/ER consolidation thesis. Pathway Vet Alliance (now Thrive Pet Healthcare) continues to operate through its multi-year Heska diagnostics relationship — now sourced from a direct competitor in clinic ownership — illustrating the increasingly interlocked nature of the consolidator ecosystem.

Where the bid-ask gap is narrowing

The bid-ask gap that defined 2022-2024 has measurably narrowed, particularly for well-run multi-DVM practices in the 8-14x EBITDA range. Mandelbaum Barrett's 2025 outlook calls this "cautious stability." Ackerman Group reports consolidator deals creeping up to 8-14.5x in 2025 versus the 8-13x range through 2024. The advisor consensus — VetPartners, Simmons, Transitions Elite — is that the peak of this cycle may be right now, with private buyers benefiting from somewhat lower rates (from 6% into the low 5s) and more accessible financing. Sellers anchored to 2021 valuations remain a problem at the platform tier, but at the single-practice and small-cluster tier, the bid-ask gap is sufficiently narrow to support volume recovery into 2026.

04 Dermatology — re-pricing complete, cosmetic mix the swing variable

Dermatology has compressed faster than DSO or vet through 2024-2026, and Q2 2026 reads as the first quarter where the re-pricing appears complete. FOCUS 2026 dermatology benchmark data: solo practices at 3-5x EBITDA, small groups at 4-7x, regional platforms at 8-10x, and large integrated platforms (above $10M EBITDA) at 12-15x. Scope Research's 2025 dermatology multiples show essentially the same tiering. The PE strategy described by TUSK Practice Sales is consistent across the cycle: aggregators buy practices at roughly 6x blended entry multiples, then exit the combined platform at 12-14x — the classic 2-turn multiple arbitrage. The compression at the exit multiple has narrowed that arbitrage but not eliminated it; the math still supports the roll-up thesis at current levels.

The single most important variable now defining where a derm practice or platform clears within its tier is the cosmetic versus medical revenue mix. Cosmetic-heavy practices command higher multiples because cosmetic revenue is typically cash-pay or self-pay, higher margin, less exposed to government reimbursement cuts, and more adaptable to membership and subscription monetisation. Medical-heavy practices — particularly those with material commercial-insurance and Medicare exposure — face structural margin pressure from rate increases that lag wage inflation, plus the operational complexity of payer-mix management at scale. The cohort gap inside Q2 2026 derm transactions: cosmetic-heavy practices clearing above the FOCUS band median, medical-heavy practices compressing below it. Multi-site derm platforms with predominantly medical revenue mix can compress below 9x EBITDA even at scale.

For sellers in dermatology specifically, the work between today and the process opening is to surface the cosmetic revenue stream cleanly. Most medical-led practices have cosmetic revenue running through ad-hoc procedure coding, with limited visibility into the contribution margin of the cosmetic line, the patient-cohort behaviour, and the elasticity of the cash-pay book. Rebuilding the cosmetic-line P&L — separating it from medical, modelling the contribution per cosmetic patient, demonstrating the recurring-revenue or membership behaviour where it exists — moves the multiple meaningfully. We see this work pay back 0.5-1.0 turns of EBITDA multiple on engagements where the cosmetic mix is material but obscured.

05 Medspa — the highest-multiple sub-sector if positioned well

Pure medspa M&A data is the least systematically tracked of the four sub-sectors, but the bands triangulate from cosmetic-heavy dermatology comps, home-care and hospice multiples, and PitchBook deal comp commentary on scaled medspa platforms. Single or small-cluster medspas with sub-$2M EBITDA trade at 5-8x EBITDA, with significant dependence on the owner-operator injector and local brand goodwill. Scaled multi-state medspa chains — dozens of centres, strong brand, heavy membership revenue — trade at 10-14x EBITDA in 2025-2026, with some top-tier growth platforms approaching mid-teens on forward EBITDA.

Where medspa platforms clear above the 10x baseline: same-store comp growth that is genuinely positive (not just price), high-margin services dominating the mix (injectables, energy-based devices, GLP-1 prescribing in some states), robust membership or subscription revenue with documented lifetime value, and member-density metrics that demonstrate retention. Where medspa platforms compress below the baseline: heavy reliance on Groupon-style discounting to drive volume, lower-margin retail product mix, owner-operator concentration on a small number of injector personalities, weak member retention. The variance within the medspa category is wider than within DSO or vet because the operating-model differences between premium-membership platforms and discount-discovery platforms are larger than the within-sub-sector differences in dental and veterinary.

06 The operating drivers underneath the compression

Three operating drivers explain most of the cross-sub-sector compression from 2021-2022 peak to Q2 2026 trough, and they recur with consistent weight in every QoE walk we run. Same-store growth deceleration is the first. Mature platforms in DSO, vet, and dermatology are running 2-4% same-store growth in core markets, with the growth concentrated in price increases and mix shift rather than volume gain. The PE underwriting cases that supported mid-teens multiples in 2021 assumed mid-single-digit volume growth on top of the price layer, and that volume growth has not materialised in most cohorts.

Labor cost compounding is the second. Across the broader physician services category, Kaufman Hall's Physician Flash Report documents compensation per wRVU rising faster than collections per wRVU, with many systems reporting negative physician enterprise margins. In DSO, hygienist and dentist wage inflation, sign-on bonuses, and locum coverage costs have pushed staff salaries-and-benefits as a percent of revenue up several hundred basis points since 2021. In vet, DVM and licensed-technician shortages have driven wage inflation past 8% annually in tight markets. In derm and medspa, injector and nurse-practitioner compensation has tracked similar paths. Platforms that underwrote 20-25% EBITDA margins at acquisition are now operating in the 15-18% band, with the gap showing up in compensation lines.

Centralisation and G&A synergy under-delivery is the third. PE roll-up models assumed rapid centralisation of revenue cycle management, intake and scheduling, procurement, and marketing — with corresponding G&A leverage as the platform scaled. In practice, central-services build-outs have required structured change management, often faced operational resistance, and produced uneven savings per acquired site. Many platforms are now carrying duplicative G&A — legacy local administration alongside central administration — and technology bloat from multiple EHRs and overlapping practice-management software. The G&A leverage that supported the multiple at exit has materialised more slowly than the underwriting assumed.

07 Sponsor activity and the 2026 exit pipeline

Sponsor activity in multi-site healthcare in 2026 is concentrated in a recognisable set of names. Welsh, Carson, Anderson & Stowe (WCAS) operates one of the deepest healthcare-services portfolios in the sponsor market, with historical positions in Kindred at Home, United Surgical Partners International, Concentra, and US Anesthesia Partners; WCAS XIII raised $4.3 billion in oversubscribed commitments and continues to target healthcare providers and specialty facilities. TPG is active in larger consortium deals — the TPG-WCAS-Humana acquisition of Curo Health Services in 2018 ($1.4 billion for 245 hospice locations in 22 states) is the template. KKR remains competitive on scaled specialty practices, ASC platforms, and tech-enabled service businesses. Bain Capital is active in larger multi-site physician platforms. In the middle-market healthcare specialist tier, Audax, BPOC, GTCR, Linden, Cressey, and Nautic continue to run the roll-up playbook in orthopedics, dental, dermatology, behavioral, veterinary, and adjacent specialties.

PwC expects 2026 to "mark the start of renewed movement" in physician practice management as the bid-ask spread finally narrows. PrivateEquityInfo reports median PE holding periods reaching approximately 6.0 years in 2025 — a "bulge in the exit pipeline" flowing into late 2025 and 2026. McKinsey's 2026 Private Markets Report puts the typical hold above 6.5 years, with more than 52% of buyout-backed companies held 4+ years. The implication for multi-site medical: 2017-2020 vintage platforms are now at the 6-9 year hold point and are increasingly being exited, with sponsor-to-sponsor sales running through 2026 and 2027.

Cambridge Associates data shows US private equity healthcare investments averaging approximately 2.9x MOIC over historical hold periods. Practical underwriting expectation for 2026 multi-site healthcare exits: 2.3-2.7x MOIC over 6-7 years for baseline platforms, 3.0x+ for strong execution. The valuation gap between held and exited assets has closed substantially, per McKinsey — median exits land approximately 0.3 EBITDA turns above held value, with top-quartile exits stretching to 1.6 turns above last marked value.

08 What this means for sellers and buyers right now

Three operating implications come out of the Q2 2026 read.

1. 01
   For DSO sellers in the 5-15 location band: You are almost certainly an add-on candidate at 5-8x EBITDA rather than a platform candidate at 9-12x, regardless of historical aspiration. Platform positioning requires $10M+ EBITDA, multi-state footprint, centralised operations, demonstrated same-store growth, and a clean payor mix. If the platform path is not realistic, the right answer is often to optimise for add-on positioning — clean financials, clear doctor compensation, documented same-store data — and clear at the top of the 5-8x band rather than waiting for the platform multiple.
2. 02
   For veterinary sellers: The 8-15x band is real and meaningfully better than the 8-12x consolidator-deal range that defined 2023-2024. Advisor consensus across VetPartners, Simmons, and Transitions Elite is that this may be the peak of the current cycle, with private buyers benefiting from rate relief. A sale process opened in the next 12-18 months has favourable conditions; waiting beyond that introduces cycle risk.
3. 03
   For dermatology and medspa sellers: Cosmetic revenue mix is the single most multiple-relevant attribute in 2026. Plan accordingly. Rebuilding the cosmetic-line P&L — separating it from medical, modelling contribution per cosmetic patient, demonstrating membership/recurring behaviour where it exists — moves the multiple 0.5-1.0 turns on assets where the cosmetic mix is material but obscured.

For buyers across all four sub-sectors, the recurring theme is preparation. Platforms that present clean same-store data, documented payor-mix forward cases, transparent doctor-comp normalisation, and honest add-back schedules clear at the top of their respective bands. Platforms that arrive at marketing without that preparation absorb the adjustment in negotiation, regardless of which sub-sector they sit in.

Methodology and what we are watching into Q3

Multiples cited above synthesise FOCUS Investment Banking 2026 dermatology and dental benchmarks, Capstone Partners Middle Market Valuations Index 2025-2026, PCE Healthcare M&A Update, Peakstone Healthcare Q1 2026, RL Hulett Pet M&A Update Q4 2025, KPMG veterinary market reporting, VetPartners practice-valuation commentary, Ackerman Group veterinary transaction data, Mandelbaum Barrett 2025 outlook, Simmons veterinary economics 2026, and Transitions Elite market commentary. Sponsor activity references PwC 2026 Healthcare Investment Themes, Bain Global Healthcare PE Report 2026, McKinsey 2026 Private Markets Report, and Cambridge Associates US PE performance data.

Three signals matter into Q3 2026. First, whether DSO platform multiples stabilise at the 9-10x level or continue to compress — sub-9x would signal that the platform thesis is being further re-priced and would force sponsors to shift focus toward roll-up optimisation rather than new platform formation. Second, whether vet exit volume picks up materially as the 2017-2020 vintage platforms reach 6-9 year holds. Third, whether the cosmetic-versus-medical derm spread widens or narrows — if cosmetic-heavy practices continue to outperform, the operating implication for derm sellers is that cosmetic-line build-out is now multi-year-multiple-relevant work.