In a previous letter, we began to outline the reasons for the rising costs of our current health care system. The factors already mentioned were unrealistic economic and medical expectations of our system and that we as physicians work in a for-profit environment. This environment drives us to do more tests, procedures and hurried office visits even if it is not necessarily the right thing to do from a medical standpoint.

To continue to explore additional factors escalating the cost of medical care, we point out that pharmaceutical and medical device companies encourage the physicians' for-profit behavior and influence patients' expectations. These industries aggressively try to influence the medical journals, which increasingly lose their scientific validity as a result.

Furthermore, the industry produces ads telling lay people they must use a certain pill, ought to have a defibrillator to extend life or have treatment of their impaired leg circulation, also known as peripheral arterial disease (PAD), as has become common parlance as a result of advertising. The fact of the matter is that it is safer not to treat PAD, and we are not aware that having an implanted defibrillator actually improves quality of life. While there are limb- and life-saving instances when these procedures are unquestionably justified, the American public has been brainwashed, similar to how we have been conditioned by Madison Avenue advertising companies to buy a particular brand of soap, into believing that all unstable hearts need a multi-thousand-dollar defibrillator and that all leg arteries need a costly stent (the stent itself costing between $600 and $2,000; this does not include the fee from the hospital and physician performing the procedure).

The marketing and availability of the medical devices often comes before mature scientific data to support their use and justify their cost to the society. The use of some of these unproven and expensive devices escalates as patient-targeted marketing influences patients to demand these technologies. This then drives hospitals to acquire these technologies simply to be able to compete in their marketing against other hospitals. A prime example of this is the multimillion-dollar Davinci surgical robot, whose benefit compared to standard cheaper procedures many call into question. These technological costs must then be passed on to the public via higher insurance premiums.

We maintain that it is prudent medically and economically to regulate the use and acquisition of new technologies until their benefit has been proven. CMS, the government agency which administers Medicare and Medicaid, has wisely done just that for carotid artery stenting, much to the ire of the companies that make the stents. Note that in an attempt to prevent restrictions on use of their drugs and devices, lobbyists for the pharmaceutical and medical device companies spent around $500,000,000 in 2008 and 2009 (Bloomberg, Aug. 14, 2009). That's a lot of money which could have been spent more wisely, say on public education on the dangers of obesity or tobacco use.

High insurance premiums are directly related, in our opinion, to the added administrative costs of private insurance. While multimillion-dollar salaries of private insurance company CEOs have minimal impact on the overall cost of health care, we would argue it is symptomatic of an industry which is based on profit rather than on ensuring health care for all patients, be they healthy or suffering from a chronic illness. Administrative costs of health care in countries which have a single-payer system are dramatically lower than in this country.

Another factor which forces physicians to look for profit is the expense of medical education. It is common for a physician to start residency (training just after having received the M.D. or D.O. degree) with a $250,000 debt. The salaries during residency are insufficient to start paying back this debt. Consequently, it is not until after residency, which lasts between two and seven years, that this debt can be paid back. There is a shortage of family physicians since their income can be as low as $100,000, not a lot if you want to start a family, service your debt and buy into a practice.

Medical liability is a factor in health care costs that cannot be ignored. The annual malpractice insurance premium a surgeon pays can be between $20,000 and $200,000. We were recently notified by our malpractice carrier that our premiums are unsustainably low due to high rates of litigation. Surgeons and obstetricians respond by being motivated to do more procedures to offset the costs of the premiums, doing less risky surgery, leaving geographical areas prone to litigation or just quitting surgery altogether.

Litigation is extremely costly for all parties, usually ends in favor of the defendant (i.e., physician being sued) and is rarely a reflection of true justice. In other words, we have seen cases where the physician was negligent, resulting in neither censure of the physician nor compensation to the patient. We have also seen cases where the physician did nothing wrong but ended up losing a case with an astronomical financial penalty. At times, such awards do not reflect justice but rather a jury's desire to redress the wrongs of society or an act of nature. Society, as represented by the jurors, needs to realize that such awards can destroy a good physician's career and only end up ultimately increasing the cost of health care for all. Tort reform must include both the ability to discipline truly negligent physicians and to limit the size of awards proportionate to the degree of negligence. Removing lawyers entirely from the equation might make these goals achievable.

The current bills being debated do not address many of these pressing issues but do go in the right direction. Along with the American College of Surgeons and the American Medical Association, we support the general concept of health care reform. The authors of this letter (and www.pnhp.org) support a government-run public insurance option, which would finally bring this country closer into alignment with other advanced free-market democracies, which have universal government-run health insurance in combination with subsidized medical education and limits on litigation.

We urge you to contact your representatives, voicing your support of health care reform. Whichever bill gets passed will be imperfect and will need years of tweaking, but let's at least get something on the books.

In a subsequent letter, we will explore what we think are the fallacies of some of the arguments against health care reform.

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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.