Speaker 1 0:00
Every parent that comes in, whether they're seeking exemptions or they're there to vaccinate their kid, the goal is that they want their family to be healthy.

Austin Littrell 0:20
Welcome to Off the Chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell, and I associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, I sat down with Dr. Sarah Nozel, president of the American Academy of Family Physicians, and a family physician herself, who's practiced in the South Bronx for nearly two decades, here in late August, back-to-school season is filling primary care schedules, and the vaccine conversations waiting in those exam rooms are longer than they used to be. More than one immunization schedule is in circulation. Exemption paperwork is showing up more often, and three new counseling codes took effect in January for the visits that end without a shot, but almost nobody's paying for them. Today, we get into which schedule a family physician should actually be working from this fall, and whether stocking vaccines still makes financial sense for an independent practice, and what physicians give up when those doses move to the pharmacy down the street. A quick note: we've recorded this conversation prior to August 10th, when President Trump signed the executive order calling for the number of diseases covered by universal childhood vaccine recommendations to drop from 18 to 11, shifting others into shared clinical decision-making categories and directing that the measles, mumps, and rubella vaccine be split into separate shots. So Dr. Nozal does not address that order here, but the question at the center of this episode, which schedule to trust, only got harder to answer. With all that said, Dr. Sarah Nozel, thank you for joining us. Let's get into the episode. Today I'm here with the president of the American Academy of Family Physicians, Dr. Sarah Nozel. Thank you for joining me.

Speaker 1 1:49
I'm glad to be here.

Austin Littrell 1:50
I guess just jumping in with the question that a lot of physicians have on their mind around this time of year: What should a family physician actually be working from this back-to-school season, with several schedules in play now,

Speaker 1 2:03
so for vaccinations, our family docs and docs around the country are looking at the American Academy of Family Physicians vaccine recommendations. We've partnered with other major medical organizations at the Vaccine Integrity Project to make sure that we have the most up-to-date and accurate vaccine recommendations, and so that's definitely where I would direct you as a physician.

Austin Littrell 2:23
Under new federal guidelines, there's vaccines that sit in shared clinical decision-making categories. What does that change at the point of care, and how should physicians approach those conversations with patients?

Speaker 1 2:34
So there's a couple different ways to think about this. So when you're looking at the AAFP guidelines, many of the vaccines that we know have had strong evidence based in science continue to be recommended, and those vaccines that have been put in a category of shared decision making-that's something you do with your family doc every day. Whenever we are discussing a recommendation for treatment, it is always making sure that my patient has had questions answered, that I offer information that they didn't maybe know to ask, but are important, and then thinking about keeping their family healthy, keeping themselves healthy. So shared decision making really means evaluating your own health or your family or child's risk factors, and whether or not this is something that would be appropriate or recommended for you, and then your ability to make that informed decision. And that's really what, when we're family docs talking about it, what we mean by shared decision making.

Austin Littrell 3:25
I want to talk about kind of the economics of our primary care practices still stocking vaccines and whether that's smart for them to do so. You know, as a business, you know, a practice deciding right now whether it's to reorder is looking at what it pays, what it gets to administer, the chance coverage shifts before the dose is given. So, I guess, what is your recommendation? What is your take on that?

Speaker 1 3:47
So, you're absolutely correct that family docs are still giving vaccines, but they are expensive, and that the most common concern is reimbursement rates. Nonetheless, the majority of vaccines that children are receiving are in their their primary care family physician's office. The most likely vaccines stocked in your doctor's office are going to be childhood vaccines and flu vaccines. Some of those other vaccines that get covered under other parts of insurance, like Medicare Part D, those vaccines are more likely to be found often outside of a smaller practice, those large networks now they have a lot more capital and are able to have in-house pharmacies and large stocks of vaccines, which has limited the ability of the most important place to have vaccines, which is your primary care doctor's office. And the reason why, when I talk about that, when I think back to all of the last few seasons, when I'm speaking with my patients about vaccines, I know that even when they're offered a flu vaccine, a COVID vaccine, or just a vaccine to get them up to date somewhere else, whether it's the pharmacy or a specialist office, they often say, "I asked them to wait and came back to you to ask you if this was the right vaccine or if I'd already had it." And so, making sure both that we have their information if they are receiving vaccines elsewhere, because in the end we're the trusted source for our patients of that information, and whether or not they hear it from the doctor they know and trust, that's how my patients make their vaccine choices.

Austin Littrell 5:15
Vaccine counseling has gotten longer and more complicated than it has been in the past, and none of that time is separately reimbursed. Is there anything a practice can legitimately capture for it, or is this just an absorbed cost?

Speaker 1 5:28
So, in the sense that we can capture the work we're doing, both through documentation and the use of CPT codes, unfortunately, those codes are not yet reimbursable by CMS, and most private payers also are not paying for those codes. This is something the American Academy of Family Physicians, other organizations, have recognized that we are spending more time, as reported by our family docs, talking to our patients, making sure they feel prepared and well informed when they make choices to vaccinate and keep their family healthy. But that time right now is not being paid for. We continue to do advocacy work. We have the codes existing, making sure that we can actually be paid for the work and time we're spending on keeping our patients in America healthy.

Austin Littrell 6:11
Vaccine exemptions, particularly in kindergarten, they've been you know rising every year. When a patient comes into the office with exemption paperwork rather than a question about a vaccine. How should physicians approach that conversation?

Speaker 1 6:27
So, as a family doc, I see whole families in my office, and lucky for me, often families I've known most of their life. Probably that kindergartner I've known since birth. When, if a form were brought in, and I, you know, they're looking to have an exemption. I acknowledge your. I see you're asking for you know exemptions for vaccines. Vaccines today. Let's talk a little bit about what you're thinking about. Tell me about what your plan is. And I partner with that patient. Every parent that comes in, whether they're seeking exemptions or they're there to vaccinate their kid, the goal is that they want their family to be healthy. They may not be fully informed or aware of what that means, of what opportunities and how important that vaccination is yet. And hearing it from me in a thoughtful, collaborative way, acknowledging concerns they have, recognizing that there are risks with any treatment that we do, including vaccinations, but that the benefit of vaccination far outweighs any of the risks, and vaccines are safe and effective, and they're effective for their their kid and their family, and they're effective for our community at large.

Austin Littrell 7:30
Some physicians offer spaced or staggered schedules to families who won't accept the full schedule. Where does the AFP land on that? Is that harm reduction that keeps the family in the practice, or a concession that makes the next conversation harder.

Speaker 1 7:43
So we really strongly, as an AFP and as a family doc, recommend that we receive the full appropriate vaccination dosing regimens at each scheduled appointment. That doesn't mean I'm going to turn a patient away who declines that approach, but it's absolutely going to be my recommended and the effective approach for vaccination. The nice an advantage I have as a family doc, and that I'm seeing the whole family, is that I'm going to have that longitudinal relationship where I will be seeing that family over time. And we know so much of the choices we make are based on having a trusting relationship with your with your PCP with your family doc, helping the family make those choices. I would really strongly encourage, and most patients who've come in and asked initially for a reduced or staggered schedule, when they've discussed with me why it makes the most sense to do it all today, how the studies have shown that is not only safe but really effective and the most well-studied and effective way to protect your family, most parents or guardians are choosing to follow the traditional schedule once they've had a moment to really take their time in a thoughtful manner, hear about the risks and benefits, and understand that their kid will be the healthiest, their family will have the the least missed school and work days, both because of number of doctor's visits and wellness of their kid, and the long-term impact on their family's health.

Keith A. Reynolds 9:13
Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven real-world tactics you can plug into your practice today, whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom; they come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to be true. Shoot me an email at kreynolds at mjhlifesciences.com with your topic, quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute.

Austin Littrell 10:04
What does the evidence say about which counseling approach actually moves a hesitant parent? Presumptive versus participatory framing, motivational interviewing, something else. I just like to give rigor something more than you know having trust already with the patients.

Speaker 1 10:19
So I would tell you that when I'm working with families, I kind of use a lot of those a lot of those pieces together. So I really like to help prepare families ahead of time so that they know what's going to happen. So one of the things is that I have been talking since my spring appointments with patients that when they come back in the fall, they will be getting their flu and COVID vaccine if they're appropriate for for that vaccination, and so my patients one are already setting an anticipation not just at the individual visit, like Dr. Nilso is going to provide you with your flu vaccine today, but actually months ahead, so that the idea that they're actually showing up for that sets that standard, and there is good evidence that when you say this is what's going to happen versus what would you like to have happen? You're more likely to have the thing that you said this is what's going to have happen occur. In in addition to that, making sure that we are giving the time to dig through parents and families' concerns and help go to the root of it and help them dispel for themselves. Like I'm really worried this will hurt will hurt my kid, or this is going to give them an infection. Well, tell me more about that. Where where have you heard that? You know what what would happen? What would happen? What would what would you imagine would happen if that if they were to get sick with this illness? What would you look to do next? And kind of walking through the concerns till parents or guardians themselves sort of walk themselves out of the idea that there's something to be concerned about, and walk themselves into the idea that they do recognize that they know vaccines are safe and effective.

Austin Littrell 11:52
So you touched on it earlier, longitudinal relationships. That's a real advantage of family medicine. You know, seeing these patients for years, you know, possibly their whole life, but they're also something that private practice is losing distressors like consolidation, panel size, visit length. Is that model still available to most family physicians, or does the argument work best in already well-resourced practices?

Speaker 1 12:16
So absolutely, that your family doc wants to be seeing you regularly over time, doing that has become more challenging. In in I'm working in a under-resourced community, we have relatively short appointments, but I'm seeing whole families, and I I'm often seeing maybe one member of a family, and sometimes additional family members are with them. So I would tell you that using the opportunity not just of the individual appointment, but I might be seeing grandma. She's here with a grandkid that day. We get grandkid on the schedule to get their flu shot that hasn't been able to come in yet for a visit, and that might just be a nursing visit. But because I have a relationship with that entire family that's effective, there are also newer models of care like direct primary care, where there are longer visits. You may have a more you know regular relationship with your with your physician and clinician, it is possible, but consolidation is making it more challenging, and it does put public health at risk when we don't have the most effective longitudinal relationships that build that trust that allow our our communities to feel the most prepared to make healthy decisions for their families.

Austin Littrell 13:18
So back to something we we touched on earlier, as far as practices stocking vaccines, say a practice does decide to stop stocking vaccines and start sending patients to a pharmacy or a health department. What does the physician lose there, and why not? I guess you know what would you tell to a physician when they're considering this route? You know, it might be more expensive to stock vaccines.

Speaker 1 13:41
So I would really encourage family docs and all physicians to continue to advocate with the AFP and your local chapter to be able to make vaccine stock in your in within your office affordable. When patients do go to a pharmacy, pharmacies often will not vaccinate infants or children, so that opportunity may be lost fully. In addition, the real need for pharmacies to be taking that vaccine information and fully putting it into registries. Not all states have it required that, particularly adults who are receiving vaccines, that it'll automatically go into a vaccine registry. So patients run the risk of not knowing they've been vaccinated, missing or receiving a wrong dose, or additional dose, or not not getting a dose at all, not being able to reconcile some vaccines at one location and vaccines at another location. Those are some of the challenges when you move vaccines out of your office. I I really want to make sure that my patients, who I know are most likely to get the vaccine, when they're sitting in my office, talking to my staff with people they've known and trust for often most of their life. That that makes a huge difference for how how likely my patients are to be fully vaccinated.

Austin Littrell 14:49
I I think that really touches on most of of what I had. Is there anything else that we didn't discuss that you'd like to share?

Speaker 1 14:55
I really just want to further encourage that we know that family physicians. That your regular PCP is the place to go when there are questions. Things are really confusing right now. You used the term hesitancy earlier, and I tend not to use that. I really think that parents and families are trying to make the healthiest decision for their families, and they have questions. And it is appropriate when you are watching TV on social media, talking to your friends in unusual WhatsApp groups getting you know updates, the information isn't all in line. And in the long run, where you want to go is your family doctor's office, who knows you and your family knows you want to keep them healthy, and can be a trusted, reliable source for the information on what steps you need to take next.

Austin Littrell 15:37
Absolutely. Well, Dr. Sarah Nozel, thank you so much again for taking the time today,

Speaker 1 15:41
thank you.

Austin Littrell 15:56
Once again, that was my conversation with Dr. Sarah Nozel, president of the American Academy of Family Physicians. You can find our full written Q and A with Dr. Nozal, along with the AAFP's 2026 immunization schedules, linked in the show notes below. But with that said, my name is Austin Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask you to subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice, you can find us by searching "off the chart" wherever you get your podcasts. Also, if you like the best stories that medical economics and physicians practice, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business medicine podcast, is executive produced by Chris Masolini and Keith Reynolds, and produced by Austin Luttrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you.