Admittedly I've not worked in many environments that could ever be described as being anything less than 'enterprise', and within orders of magnitude larger than medium/large businesses.

If you had a niche market and only needed a small footprint. I can see a handful of VPS' or similar being suitable.

But once you get to the 200+ people mark, it gets messy. And gets much worse at 2,000 head. And worse yet at 20,000.