Health systems and physician groups form the defining relationships for every market’s healthcare delivery system. Their degree of alignment can be seen as a structural choice that ranges from loose affiliation to full employment, with a discrete menu of options in between. However, this framing misses that this alignment spectrum is really a measure of trust between health systems and physicians, both as individuals and groups. The underlying principles that drive the progression from one model to the next along this spectrum include agreement on why the partnership exists, the balance between physician autonomy and shared identity, embrace of interdependence, and clarity around clinical versus operational ownership. Time and urgency shape the path as well, as more nimble physician groups can resent the slow-moving bureaucracy of some health systems. But relationships benefit from time as well, allowing an organic progression from left to right as certain principles become more developed. Time allows both parties to develop their belief that, by increasing the commitment to their partnership, they increase the mutual benefits as well.