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Elizabeth M. Yano, PhD, MSPH, Barbara F. Simon, MA, Andrew B. Lanto, MA and Lisa V. Rubenstein, MD, MSPH

Elizabeth M. Yano is with the Veterans Health Administration Greater Los Angeles Health Services Research and Development (HSR&D) Center of Excellence, Los Angeles, Calif, and the School of Public Health, University of California, Los Angeles. Barbara F. Simon and Andrew B. Lanto are with the Veterans Health Administration Greater Los Angeles HSR&D Center of Excellence, Los Angeles, California. Lisa V. Rubenstein is with the Veterans Health Administration Greater Los Angeles HSR&D Center of Excellence, Los Angeles, and RAND Health, Santa Monica, Calif.

Correspondence: Requests for reprints should be sent to Elizabeth M. Yano, VA Greater Los Angeles HSR&D Center of Excellence, 16111 Plummer St, Mailcode 152, Sepulveda, CA 91343 (e-mail: elizabeth.yano{at}va.gov).

Objectives. Suffering from waning demand, poor quality, and reform efforts enabling veterans to "vote with their feet" and leave, the Veterans Health Administration (VA) health care system transformed itself through a series of substantive changes. We examined the evolution of primary care changes underlying VA’s transformation.

Methods. We used 3 national organizational surveys from 1993, 1996, and 1999 that measured primary care organization, staffing, management, and resource sufficiency to evaluate changes in VA primary care delivery.

Results. Only rudimentary primary care was in place in 1993. Primary care enrollment grew from 38% in 1993 to 45% in 1996, and to 95% in 1999 as VA adopted team structures and increased the assignment of patients to individual providers. Specialists initially staffed primary care until generalist physicians and nonphysican providers increased. Primary care-based quality improvement and authority expanded, and resource sufficiency (e.g., computers, space) grew. Provider notification of admissions and emergency department, urgent-care visit, and sub-specialty-consult results increased nearly 5 times.

Conclusions. Although VA’s quality transformation had many underlying causes, investment in primary care development may have served as an essential substrate for many VA quality gains.

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