AAFP President Sarah C. Nosal, M.D., on vaccine schedules, stocking costs and the back-to-school visit

Back-to-school season is filling primary care schedules, and the vaccine conversation waiting in those rooms is longer than it used to be.

Parents arrive with questions they did not have two years ago, and a growing number arrive with exemption paperwork. Roughly 3.6% of kindergartners had an exemption from at least one required vaccine in the 2024-25 school year, according to the most recent count from the Centers for Disease Control and Prevention (CDC), or about 138,000 children, with 17 states above 5%.

Part of what makes those visits longer is that more than one schedule is in circulation. Federal childhood vaccine recommendations were narrowed in January and stayed by a federal court in March, and the case is on appeal. The American Academy of Family Physicians (AAFP) published its own 2026 child, adolescent and adult immunization schedules in March, and the childhood version aligns fully with the American Academy of Pediatrics' schedule. Parents comparing notes are not always comparing the same document.

The economics have gotten harder to read at the same time. Three CPT codes for immunization counseling on days when no vaccine is administered, 90482 through 90484, took effect Jan. 1, the first built to capture the time a physician spends on a conversation that ends without a shot. Payment is a separate question. Coverage varies across commercial and Medicaid plans, and the AAP is still pressing payers to recognize the codes.

The conversations keep getting longer without a reliable way to bill for them, and the cost of carrying inventory has some practices weighing whether to keep stocking vaccines at all.

Sarah C. Nosal, M.D., FAAFP, works both ends of that. She is president of the AAFP, which represents 124,500 family physicians and medical students, and vice president for innovation and optimization and chief medical information officer at The Institute for Family Health, a federally qualified health center network with sites across the Mid-Hudson Valley, the Bronx, Manhattan and Brooklyn. She has practiced in the South Bronx for nearly two decades and is board certified in family medicine and in clinical informatics.

Medical Economics spoke with Nosal about which schedule to work from this fall, whether stocking vaccines still pencils out for an independent practice, what a physician gives up by sending patients to a pharmacy and what actually moves a parent who arrives with exemption paperwork.

Our conversation, lightly edited for length and clarity, follows.

With more than one schedule in play, what should a family physician be working from this back-to-school season?

Sarah Nosal, M.D., FAAFP: 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 and 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.

More vaccines now sit in shared clinical decision-making categories than a year ago. What does that change at the point of care, and how should physicians handle those conversations?

There are a couple of different ways to think about this. 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 maybe didn't know to ask about but that is important in them thinking about keeping their family healthy, keeping themselves healthy.

So shared decision-making really means evaluating your own health, or your family's 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. That's really what we mean, when we're family docs talking about it, by shared decision-making.

A practice deciding whether to reorder is weighing what a dose costs against what it gets paid to administer it. Is stocking vaccines still smart business?

You are absolutely correct that family docs are still giving vaccines, but they are expensive, and the most common concern is reimbursement rates. Nonetheless, the majority of vaccines that children are receiving are in 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, are more likely to be found outside of a smaller practice.

Those large networks 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.

The reason I talk about that is, 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-19 vaccine, or just a vaccine to get them up to date somewhere else, whether it's the pharmacy or a specialist's 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."

So it's 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.

Vaccine counseling has gotten longer and more complicated, and none of that time is separately reimbursed. Is there anything a practice can capture for it, or is it an absorbed cost?

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 and 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. It is making sure that we can actually be paid for the work and time we're spending on keeping our patients in America healthy.

Kindergarten vaccine exemptions continue to rise each year. When a family arrives with exemption paperwork rather than a question, how should physicians approach that conversation?

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 have known since birth.

If a form were brought in and they're looking to have an exemption, I acknowledge it: "I see you're asking for exemptions for 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 the opportunities are 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 kid and their family, and they're effective for our community at large.

Some physicians offer staggered schedules to families who won't accept the full one. Where does the AAFP land on that: harm reduction that keeps the family in the practice, or a concession that makes the next conversation harder?

We really strongly, as an AAFP and as a family doc, recommend that patients 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 is absolutely going to be my recommended and the effective approach for vaccination.

The advantage I have as a family doc, 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 PCP, with your family doc, helping the family make those choices.

I would really strongly encourage it. 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 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.

What does the evidence say about which counseling approach actually moves a hesitant parent? Presumptive versus participatory framing, motivational interviewing, something else?

When I'm working with families, I use a lot of those pieces together. I really like to help prepare families ahead of time so that they know what's going to happen.

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-19 vaccine if they're appropriate for that vaccination.

And so my patients are already setting an anticipation, not just at the individual visit, like "Dr. Nosal 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 is going to happen occur.

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 it for themselves. Like, "I'm really worried this will hurt my kid," or, "This is going to give them an infection." Well: "Tell me more about that. Where have you heard that? What would happen? What would you imagine would happen if they were to get sick with this illness? What would you look to do next?"

And kind of walking through the concerns until 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.

Longitudinal relationships are a real advantage of family medicine, but consolidation, panel size and visit length are eroding them. Is that model still available to most family physicians, or does it work best in practices that are already well resourced?

Absolutely, your family doc wants to be seeing you regularly over time. Doing that has become more challenging. I'm working in an under-resourced community. We have relatively short appointments, but I'm seeing whole families, and I'm often seeing maybe one member of a family, and sometimes additional family members are with them.

So I would tell you that it is using the opportunity, not just of the individual appointment. I might be seeing grandma. She's here with a grandkid that day. We get the 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 regular relationship 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 communities to feel the most prepared to make healthy decisions for their families.

Say a practice stops stocking vaccines and starts sending patients to a pharmacy or health department. What does the physician lose?

I would really encourage family docs and all physicians to continue to advocate with the AAFP and your local chapter to be able to make vaccine stock 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, there is 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 for adults who are receiving vaccines, it will 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 getting a dose at all, or 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 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 trusted for often most of their life, that that makes a huge difference for how likely my patients are to be fully vaccinated.

Is there anything else you'd like to share?

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 WhatsApp groups, getting 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.