In 1995, Paul Vessa, MD, an orthopedic spine surgeon and medical director at Bedminster-based New Jersey Spine Institute, made a bet on independence.
Two years into practice, he took his practice out of network after watching managed care reshape the economics of physician reimbursement. The decision meant giving up some of the patient flow insurers could provide and betting instead on something harder to manufacture: reputation.
More than three decades later, Dr. Vessa is still practicing independently. That longevity makes his career a case study in how physician autonomy can survive prolonged pressure from declining reimbursement, rising overhead and consolidation.
It also reveals why the same path is far harder for a young spine surgeon to follow today. Dr. Vessa’s model depends on advantages accumulated over decades: a recognizable name, established referral relationships, control over practice expenses and a patient market capable of supporting care outside traditional network arrangements.
He is now trying to teach that model to the next generation. The question is no longer whether independent spine practice can work. It is whether a surgeon starting today has enough runway to build one.
The bet on reputation
Dr. Vessa entered practice in 1993, just as managed care was becoming more influential. The pitch to physicians was straightforward: Accept lower contracted reimbursement and insurers would provide a steady stream of patients.
Dr. Vessa said the volume increased, but the economics quickly became difficult.
“I made more money between September and December of ’93 than I made in all of ’94,” he told Becker’s. By 1995, he decided the model was not sustainable for his practice and moved out of network.
That created a different problem. If an insurance network was not going to send patients to him, something else had to. The answer was performance.
“You have to be able to provide a service to be out of network,” Dr. Vessa said. “You’ve got to make sure patients are taken care of properly. You’ve got to make the right diagnosis. You’ve got to take care of them in a timely manner.”
Early in his career, he and his partner took significant spine trauma calls. Patients they treated began referring family members and friends with degenerative conditions. Over time, the referrals compounded. For Dr. Vessa, that became the foundation of independence: clinical judgment strong enough to build trust outside an insurer-directed referral stream.
“Surgical indications are 99% of it,” he said. “You have to know exactly what to do, when to do it and how to do it well.”
Independence comes with its own bill
Dr. Vessa is skeptical of physician employment models in part because he believes they can distance physicians from the economics shaping their work. In independent practice, he sees those costs directly.
Rent. Payroll. Benefits. Bonuses. Staffing.
“In my own practice here, I know what my rent is. I know what my employees cost,” he said.
That visibility gives him control. It also gives him responsibility for making the numbers work.
As reimbursement has come under pressure and practice expenses have risen, Dr. Vessa said remaining independent requires a level of responsiveness that goes beyond the operation itself.
“You have to work harder at it,” he said. “You have to deliver a product.”
If a patient develops a problem, the practice needs to get that person back into the office quickly. If symptoms change, the surgeon has to reassess. Staff have to make patients feel cared for at every step because the practice’s reputation is also its business model.
Independence, in that sense, is not freedom from pressure. It is choosing which pressures to own.
It also does not eliminate payer friction. Dr. Vessa described treating patients with significant disc herniations and neurologic weakness who still face authorization requirements before surgery can proceed. In some cases, he obtains additional testing, such as an EMG, to document the nerve injury and strengthen the case for treatment.
For Dr. Vessa, the frustration is that a surgeon may believe the indication is clear and still have to build an administrative case before acting on it.
He also believes insurers could make better use of the claims and utilization data they already collect. In his view, payers are often able to see which physicians deliver efficient care, yet that information is rarely transparent to patients deciding where to seek treatment.
The model does not work everywhere
Dr. Vessa is also candid about one limitation of his approach. Geography matters.
His practice is in an affluent market within reach of New York and Philadelphia. Patients there may have greater ability to absorb out-of-pocket costs than patients in many other parts of the country.
That gives his model an advantage that cannot simply be reproduced everywhere. A surgeon in a less affluent market can have excellent outcomes and a strong reputation and still find an out-of-network strategy difficult to sustain.
“It’s much harder,” Dr. Vessa said. That is one of the central contradictions of physician independence today. Leaving insurer contracts can give physicians greater control over the economics of their practice. It can also make the practice less accessible to patients who cannot afford greater financial responsibility.
Dr. Vessa said direct-pay patients represent only a small share of his practice, but he has watched insurance design increasingly shape who can realistically reach physicians outside traditional networks.
The viability of independence therefore depends on more than clinical skill. It depends on the market around the surgeon.
The next generation starts from a different place
Dr. Vessa is now watching the independent-practice question play out inside his own family. His son-in-law, also a spine surgeon, joined his practice in 2025. Dr. Vessa’s advice to him has not centered first on contracts or reimbursement. It has centered on how to practice.
Watch how experienced surgeons evaluate patients. See how they communicate. Learn how quickly they respond when something goes wrong. Build the reputation first.
“You need to be associated with people who have already figured it out,” Dr. Vessa said.
When Dr. Vessa began practicing, an orthopedic surgeon could build a community referral base through emergency calls, hospital relationships and years of local practice.
Today, many surgeons leave fellowship and move directly into employment. There are practical reasons. A hospital or large group can offer a salary, operating rooms, staff, technology and an immediate stream of patients. Starting independently means securing those resources while simultaneously building a reputation and surviving reimbursement pressure.
The independent model asks a young surgeon to build the airplane while already flying it. Dr. Vessa did that in the 1990s. His son-in-law is attempting it in a very different healthcare economy.
Reputation is no longer enough
The surgeon needs excellent clinical judgment. The practice needs to be responsive. Overhead has to remain controllable. Referral relationships have to be strong enough to generate patients without depending entirely on insurers. And the surrounding market has to include enough patients who can access the practice under its payment model.
Reputation remains essential. It is simply no longer sufficient. That is what makes the generational handoff inside Dr. Vessa’s practice more than a family story. It is a test of whether one of medicine’s oldest practice models can still be rebuilt under modern economics.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
