Two kinds of American exceptionalism emerged from last week’s release of the Commonwealth Fund’s International Health Policy Survey, which focused on primary care and was published November 2 on the Health Affairs Web site.

The first kind of American exceptionalism was unambiguously bad. According to the survey, primary care doctors in the United States are less likely than those in several other countries to be able to offer patients access to care outside regular office hours or to have systems that alert doctors to potentially harmful drug interactions. U.S. primary care physicians are also less likely to receive financial incentives for improving patient care.

The merits of the second kind of American exceptionalism are more debated. Compared to health care systems in other nations, the U.S. system depends more on the free market and is more fragmented or pluralistic, with multiple payers and large but not universal public programs. At the Commonwealth Fund’s 2006 international symposium on health care policy -– at which the results of the primary care survey were released — Robin Osborn, director of the Commonwealth Fund’s International Program in Health Policy and Practice, noted that the United States has “fantastic pockets of innovation,” such as Kaiser Permanente, the Department of Veterans Affairs (VA), and several creative Medicare demonstration projects, not to mention fifty states that serve as laboratories for new ideas. But she also said that “systems matter,” as does “the capacity to implement national policies from the top down.” Osborn commented, “At the end of the day, we [the U.S.] generally lack the ‘systemness’ to move to scale.”

Government projects. That doesn’t mean that the American government is doing nothing towards health care reform, stressed Carolyn Clancy, the director of the Agency for Healthcare Research and Quality, and Alex Azar, deputy secretary at the Department of Health and Human Services. Clancy noted that HHS is working with “all parts of the federal government -– we haven’t done this before -– to work toward one set of goals for quality of care. We’ve launched six collaborative projects in different regions across the country.”

Azar pointed out that the world’s largest health care payer is the U.S. government, which pays directly or indirectly for the health care of seventy-five million Americans. In previous efforts to improve health care quality, “the player that brings seventy-five million beneficiaries to the table” has been missing, Azar said, but “now we’re going to use our market power to try to effect change and create the appropriate values and preconditions for value-driven health care in the United States.”

IT and consumer-directed mandates. In an August 22 executive order, Azar said, President Bush mandated that health care entities doing business with the U.S. government would have to be price and quality transparent, would have to ensure that any health information technology (IT) adopted be interoperable with other systems, and would have to offer “incentives for consumer-directed health care plans that offer consumers more empowerment and accountability.” Azar said that these efforts were designed to push toward a value-driven health care system, but “what that looks like, I can’t tell, I don’t want to tell you, because I don’t know the answer to that.” The idea, he said, was to provide the right incentives in health care so that “competitive markets can develop the way they have in so many other sectors . . . towards higher-quality and lower-cost production of goods and services.”

Will this strategy work? Well, Health Affairs founding editor John Iglehart noted that according to the Commonwealth survey, only 28 percent of U.S. primary care physicians use electronic medical records, a figure dwarfed by the 100 percent of physicians in the publicly funded VA health care system who use EMRs. Jonathan Perlin, who until recently led the VA health care system, said that the VA had determined that the correct question was not “how can we afford to have EMRs, but how can we afford not to have them.”

In 2004, President Bush announced a goal of having EMRs available to most Americans within ten years. The question is whether the efforts Clancy and Azar talked about are setting the stage for private health systems to make the same determination about EMRs that the VA did, despite the absence of public funding explicitly for health IT, or whether the contrast between the VA and rest of the U.S. system proves Osborn’s point about the importance of “systemness” and the necessity of doing some things from the top down.