Joint venture ambulatory surgery centers (JV ASCs) have existed for decades. However, in recent years the market and critical success factors surrounding them have shifted dramatically. JV ASCs are driven increasingly by physician-hospital alignment rather than by the immediate margin lift from hospital outpatient department (HOPD) rates. Our clients contact us when they want to develop an ambulatory strategy that generates a strong alignment with both independent and employed physicians in their market; this may be prompted by a competitive opportunity or threat, a push from payers (including large employers) for a lower-cost alternative, or the effort to advance a population health strategy. While each client comes from a different starting point and has their own dynamics with which to wrestle, we have identified three components that, if not handled appropriately, can make or break a joint venture.