This is the first of a three-part letter in which we would like to delineate what we perceive as the faults of our current health care system and some of the misconceptions in the current debate about health care reform. From the outset we recognize that there are respected colleagues who will disagree with our point of view and that one's perspective on this debate ultimately derives from deeply held philosophical beliefs.

The reality is that our system is badly broken and is unsustainable. There are many indicators of how our system fails. The major example of this failing is that the cost of health as a percentage of our GDP is in excess of any other comparable country, yet there are 45 million uninsured individuals. While a small fraction of this number, estimated at about 5 to 10 percent, represents illegal immigrants, most of those without insurance are hard-working individuals who simply cannot afford a $12,000 annual premium for family coverage. We know firsthand the dire predicament these families are in once they develop a significant illness, since they come under our care. Other indices of how our health care system fails to promote health include our relatively high infant mortality rate and the obesity epidemic. Finally, U.S. industry suffers from the cost of health insurance, making our products less competitive as the expense of health care to the workers is passed on in the price of the product to the consumer.

As we see it from the perspectives of a surgeon and a family physician, the root causes of the failure of our system are based on several factors.

An underlying problem, which is proving to make it so difficult to bring health care reform to this country, is the average American's unrealistic expectations about health care in general. As the Princeton economist Uwe Reinhardt has noted, Americans view cost-effectiveness analysis negatively. In other words, Americans in general have an expectation that they receive life-saving and highly expensive care even if they are uninsured and even if the treatment has little chance of cure. We as a country have put no price limit on the value of life. While from a theological viewpoint this may be laudable, it is also entirely unrealistic from both the economic and medical standpoints. There is a finite amount of resources available, and medical treatment does become futile at some point. If Americans really feel that everyone has a right to health care, then everyone must contribute, and we must realize that there are times when expensive and sometimes unproven treatments are futile and wasteful of our finite resources. We need to be able to shift the resources spent on health care away from treatment of preventable and catastrophic illnesses to emphasizing prevention earlier in life. This last point represents our personal opinion, and rationing is absolutely not a part of the bills being considered by the Senate and the House of Representatives.

A major factor driving health care costs is the for-profit model we have in private practice. We contend that our profit-driven system has nowhere to go but up in price and does not necessarily result in enhanced quality of care, as is borne out by data comparing health care outcomes of our system to those of other advanced free-market democracies. Many of the costs are incurred by the activity of those who perform expensive procedures, such as surgeons, cardiologists and radiologists, although increased costs of running a medical practice also incentivize medical doctors to increase the volume of patients seen in their offices. So what happens next is that the Centers for Medicare and Medicaid Services (known as CMS), which determines physicians' Medicare fees, recommends to Congress that physicians' reimbursement for the care of those older than 65 be reduced. The resulting back and forth between CMS and physician groups fighting the reduction in reimbursement has been an ongoing fight in Congress for several years now. (As an aside, President Obama incorrectly stated that a surgeon earns $50,000 for a leg amputation. Medicare actually pays between $740 and $1,140 for the amputation plus 90 days of post-operative care. This is gross. Subtract from this about 40 percent for taxes, overhead and malpractice insurance to calculate what the surgeon actually gets.) To continue, as reimbursement for care of Medicare patients declines, the pressure is on the private practitioner to do more procedures or see more patients in order to pay for the increasing costs of overhead. Anyone can see how this can result in the temptation to perform unnecessary procedures and to rush through office visits, resulting potentially in missed diagnoses or lost opportunities to work on preventive care. This results in more money being spent ordering expensive tests and less time actually talking with patients. Our conclusion, shared by many, is that we need to get rid of the profit-driven model of physician reimbursement. We should be caring for patients based on what research has shown to be best for them, known as "evidence-based medicine," rather than on pressure to meet overhead or maintain income.

It is our belief that medicine should not be a business but rather a profession wherein our medical decisions are based on what is best for the patient and not on our individual needs to generate a certain income. Our medical decisions need to be made within the constraints of a reasonable budget, the priorities of which are determined by public debate. The last statement is not part of a radical agenda but rather is exactly what has been done annually for decades in Congress when Medicare fees are determined.

Additional causes of the high cost of health care include economic pressure exerted by pharmaceutical and medical device companies, administrative costs of private health insurance companies, the cost of medical education and the expense of lawsuits to the entire system. We will explore these factors in a subsequent letter.

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Dr. Claude Roland, MD, FACS, is a surgeon who practices in Plattsburgh and Saranac Lake. Dr. Josh Schwartzberg, DO, DABFP, is a family practitioner who practices in Lake Placid, Willsboro and Burlington, Vt.