For years, the most common reason Bozeman (Mont.) Health sent a trauma patient elsewhere was a head injury. The nearest neurosurgical care was a two-hour drive away in good weather, or an hour-long flight that weather often grounded.
In October, the health system launched its first neurosurgery program. The Bozeman Health Neurosurgery and Spine Clinic, based at Bozeman Health Deaconess Regional Medical Center, puts neurosurgeons and orthopedic spine surgeons on one team.
The launch comes at a time when leaders from national hospital associations warn that rural communities are likely to lose more specialty services as hospitals work to protect core emergency and outpatient access. A Journal of Neurosurgery workforce study projected the number of full-time-equivalent neurosurgeons will grow just 2.4% between 2022 and 2037, from 7,060 to 7,230, while demand climbs 18% — with nonmetropolitan areas remaining less well staffed. Spine surgeons have predicted waits for elective spine surgery will likely lengthen most sharply in midsize and rural markets.
Bozeman Health CEO Kathryn Bertany, MD, and lead neurosurgeon James Kalyvas, MD, spoke with Becker’s about what it took to build the program, how they plan to measure it and what it signals for high-acuity care outside major metros.
Trauma volume made the case
Dr. Bertany, a pediatrician who still practices as a pediatric hospitalist at Deaconess, has led Bozeman Health for seven years. Over that stretch, the system’s level 3 trauma program has more than doubled its volume, from fewer than 600 patients a year five years ago to about 1,300 projected this year.
Tourism and an outdoorsy local population drive much of that growth, she said.
“Individuals coming to our community and living in our community are extremely active and love to do activities that sometimes put them at risk,” Dr. Bertany said.
Head trauma topped the list of conditions Bozeman Health had to transfer out. The system recruited for neurosurgery for about six years, she said, holding out for a team that could open at full strength. The goal was for “the first patient that needed our care in this new service line [to feel] like we’ve been doing it for years.”
The program’s first weeks tested that. According to the health system, the team performed an emergency craniotomy on a 3-year-old with a life-threatening brain bleed after clinicians determined he could not safely wait for transfer to Utah.
Recruiting surgeons was only the first step. “Once you get the neurosurgeons, that’s just the beginning,” Dr. Bertany said. The system bought equipment and trained teams across the continuum: prehospital and emergency staff, imaging, lab, pharmacy, the OR and the ICU, where intensivists and the trauma team support patients after surgery.
Dr. Kalyvas leads the program with neurosurgeon Joseph Sramek, MD, alongside Ben Smith, DO, medical director of the Bozeman Health Spine + Joint Institute. Dr. Kalyvas trained at Phoenix-based Barrow Neurological Institute and spent 11 years in academic practice in New Orleans, most recently as medical director of neurosurgical spine and spine fellowship director at Tulane University School of Medicine.
Quality as the business case
Complex spine and cranial care is expensive to deliver, and reimbursement pressures — including Medicare’s 2.5% efficiency adjustment for many procedural services — weigh heaviest on programs that take the toughest cases. Dr. Kalyvas said the economics hinge on avoiding complications.
“The economics go awry when you’re having unexpected returns to the emergency department, reoperations, readmissions,” he said. “If you can provide quality care at the outset, then I think the economics mostly take care of themselves.”
That is his argument for putting orthopedic spine surgeons and neurosurgeons on one team. The two specialties approach spine pathology with different training and instincts, and together they cover more ground. “We are truly better together,” he said. The combined model also corrects a common assumption among patients that spine care belongs only to orthopedics.
Bozeman Health built the program on existing infrastructure. A pre-anesthesia clinic, in place for more than five years, prepares patients before elective surgery. A dedicated spine and joint floor staffs specialized teams through the perioperative period, followed by navigation and follow-up after discharge. Coordinating care weeks or months before surgery improves outcomes and limits the financial exposure of higher-risk procedures, Dr. Bertany said.
“We want to be able to provide that complex care close to home, but we want to do it safely,” she said.
What they measure
On the spine side, the team tracks patient-reported outcome measures, including Oswestry Disability Index and Promis scores, and plans to join the American Spine Registry. For cranial trauma, which has fewer standardized outcome tools, it tracks modified Glasgow Outcome Scale scores. Length of stay, readmissions and reoperations round out the list.
Dr. Kalyvas wants to add continuous data from patients’ phones. He already reviews Apple Health step counts in the clinic.
“It’s one thing to get a subjective survey about how a patient’s doing; it’s another to look at their step count on their phone,” he said. He expects passive data like this to eventually replace survey-based measures across the field — and to make distance matter less for patients who live far from Bozeman.
The procedure mix reflects the patient base. In October, the team performed Bozeman’s first Tops procedure, a motion-preserving alternative to fusion, and it offers endoscopic spine approaches. Dr. Kalyvas said both fit a population determined to stay active.
A regional destination
“Access to care should not be constrained by the happenstance of your geography,” Dr. Kalyvas said.
The clinic is already drawing patients from out of state and from across Montana, he said, and has begun adding virtual visits. The longer-term goal on the spine side is to become a regional destination center that handles revisions, spinal tumors and other cases surgeons elsewhere in the region may prefer not to take, so those patients can stay in Montana.
In a state of about 1.2 million people, Dr. Bertany said, “sometimes it just takes one center that is doing something exceptionally well that is going to support all of the state.”
Dr. Kalyvas credited the build to an entrepreneurial streak shared by the surgeons and the system’s leadership. “That’s a risk, and that takes a certain mindset,” he said of building a service line from scratch. Dr. Bertany said every one of Bozeman Health’s nearly 3,000 care team members knows about the launch and “sees a piece of themselves in that success.”
Collaborate first, compete on quality
Dr. Bertany does not frame the program as Bozeman Health going it alone. Gallatin County has about 125,000 residents, and the system will not offer everything. She said it needs to partner with Billings Clinic, Logan Health and other Montana systems to expand access statewide.
“Yes, we are going to compete with our competitors, but we don’t want to compete just for the sense of competition,” she said. “We want to compete on the quality of care we deliver.”
That includes helping critical access hospitals stay open. As Montana’s population grows, Dr. Bertany said, Bozeman Health — already running full — would struggle to absorb overflow if those hospitals faltered.
Dr. Kalyvas said those relationships already shape daily practice. Physicians at critical access hospitals call for transfers, and sometimes just for advice on managing a patient locally.
“That doesn’t mean that we necessarily need to transfer everything here,” he said. “But one of the nice things that we’re doing here is we’re limiting the number of patients that we have to transfer away.”
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