A health care overhaul is like the rumble that occurs nanoseconds before a powerful earthquake hits. It foretells of seismic shifts to come in the expansive health care delivery landscape.

Expect consumers to be more proactive and hospitals to work to improve their outcomes. Insurers will adjust to consumer protections and doctors will face new economic realities.

It will be up to the California Medical Association to guide its member physicians through the jumble of changes. Dr. Paul Phinney, the new president of the CMA, is a pediatrician at Kaiser Permanente in Sacramento. He will help plot the course through coming challenges that confront the state's physicians.

How would you characterize the professional road ahead for doctors?

We live in turbulent and uncertain times that very likely will produce the most rapid change in the delivery of health care that we've seen in decades. In health care, it's a really, really tumultuous period. The Affordable Care Act, in some way, is responsive to these times.

How we deliver health care is shifting quickly. Physicians will enter into new sorts of arrangements – away from the traditional solo practice, which may or may not still thrive.

What will those arrangements look like?

Because the medical economic consequences are different, we will see doctors joining large health care delivery groups that have some clout. A major trend is integration. Examples of it are already out there, like the system at Kaiser Permanente, which is very integrated and coordinated.

There's a lot of consolidation, with doctors looking to link up with others in order to survive. That's happening very swiftly.

Doctors are looking for ways they can do what they want, which is to take high-quality care of patients and also bring home a paycheck after paying their staff.

Is the bottom line really that problematic?

As the cost of providing health care continues to rise, the pressure on reimbursement rates for solo physicians is downward and significant. A study in 2008 showed California ranking last in the nation in the amount that doctors are reimbursed (by the state through Medi-Cal).

The state spends about $3,300 per Medi-Cal beneficiary, whereas the national average is $5,300. We're not only way low when compared to the rest of the nation, but when you add in the high cost of doing practice in California, we're exceedingly low.

Why are Medi-Cal reimbursement rates so low?

The state just doesn't have the money and has not taken full advantage of federal funds. Medi-Cal care ends up being something that most doctors do as charity care.

What about the concierge doctor trend? Is that going to grow bigger?

It's well-established, but it's a very small percentage of the practices out there.

It meets the needs of a very select group of patients, those who can afford to pay on top of what they spend for catastrophic coverage for hospitalization. These are patients who pay a $1,500 to $2,000 annual fee to have access to a specific doctor 24/7 throughout the year.

But it doesn't solve the problems of health care delivery. I don't see it becoming dominant.

One of the prominent concepts in health care reform is for providers to establish a "medical home" model for patients.

What does that mean?

It's a place or practice where you can go to meet your medical needs in the larger sense – and that of course is different for everybody.

It depends on your age, on what conditions you're either born with or born to develop. So the medical home is a primary care setting that's your first stop in coordinated care.

Unfortunately, many people use the emergency room as their primary medical home – a very, very expensive proposition. I would argue that that's really an example of not having a medical home.

Can you address the doctor shortage, if there is one?

There is a doctor-shortage problem. A study looked at the issue and concluded that, going forward, the aging physician population combined with millions of newly insured people creates a perfect storm.

It's a perfect storm of conditions all pointing in a direction that no doubt will aggravate the physician shortage – particularly in primary care.

How do you grow the physician workforce?

No. 1, you can increase the number of slots in medical schools. No. 2, you can start new schools, but they're having an incredibly tough time getting the funding to get off the ground.

These steps might produce another 100 to 150 doctors a year.

You can also create mentorship programs. In San Joaquin County, there's a program where they bring in high school students for a week. It's almost like a pre-internship.

Being a mentor is a very important role for physicians because you work with the people coming up, guiding them and teaching them. In medicine you have the added layer that these are the kids who will be our physicians of the future.

What's your main message to your colleagues as the new head of the CMA?

It's really important that physicians are involved in providing input and guidance as health care reform moves along. Because we want to have a system that's patient-centric, not profit-centric, in which quality is really high and constantly increasing.

And we want the system to be evidence-based-driven and universally accessible to everyone, not just those who can afford it. Those are the things we strive for.

© Copyright The Sacramento Bee. All rights reserved.

• Read more articles by Cynthia H. Craft

Order Reprint