Phoenix Sleep Solutions’ Greg McDermand, RT, steers commercial truck drivers and fleet managers through obstructive sleep apnea testing, treatment, and long-term management. In doing so, he helps raise bidirectional awareness between trucking and sleep medicine.

Almost three years after President Obama signed the “sleep apnea bill” into Public Law #113-45, it can finally be said that the government is making apparent progress in developing specific rulemaking for sleep apnea screening, testing, and treatment of truck drivers and other commercial motor vehicle operators. The 2013 law forbade the issuing of informal guidance regarding sleep apnea in commercial transportation; at the time, the law was both applauded for initiating the rulemaking process and decried for delaying guidance (guidance is a faster and less involved process than rulemaking).

It will likely be several years before any new rules are issued—and indeed they may not be issued at all. But 2016 has seen the rulemaking effort move through several critical steps. In March, the Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration jointly published an Advance Notice of Proposed Rulemaking (ANPRM), which sparked public discourse on sleep apnea in commercial transportation. The agencies accepted online comments and held public meetings. In August, the FMCSA’s Medical Review Board issued official recommendations. And at press time, public meetings had been scheduled to discuss how the implementation of these recommendations may impact drivers. It is hard to think of a time in recent history when concerns about sleep apnea in trucking were so much in the public consciousness.

For Greg McDermand, issues relating to sleep apnea and trucking have been in his consciousness for much longer. A respiratory therapist (RT) since 1978, McDermand was approached by a company in 2006 to take a look at truck drivers and sleep apnea. “Barely anyone knew anything about treating drivers at that time, or even if any rules or regulations existed,” McDermand says. But the issue of drivers and sleep concerned McDermand, and he delved deeper into it. “Some things started bothering me,” he recalls, “for example, I’d see ads in trucking magazines saying things like ‘truckers with CPAP need not apply.’”

So, in 2006, he started Phoenix Sleep Solutions to combine his expertise in sleep with his interest in commercial transportation. Today, the Melbourne, Fla-based company tests, treats, and manages sleep apnea for several large commercial fleets, as well as for hundreds of individual truck drivers. McDermand is equal parts sleep professional and driver advocate, a unique position balancing two industries that sometimes seem to be at odds with each other. “My business is sleep, but I am very concerned with how these drivers are treated on the road. So I’ve become an advocate for drivers,” McDermand says. For example, he hired truck driver-sleep apnea patient advocate Bob Stanton as a consultant early on, and McDermand is open to drivers obtaining a second medical opinion in cases where it may be indicated.

Phoenix Sleep’s latest campaign is dubbed “FAST,” which stands for “Fair Affordable Sleep Testing.” “The whole idea of Phoenix is to provide a low cost, high-quality sleep study and treatment, and do it in a very timely manner,” McDermand says. I recently interviewed McDermand on the perceptions, awareness, and changes in sleep apnea screening, testing, and treatment among the trucking industry. An edited transcript of our conversation follows.

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Home sleep tests and, if needed, CPAPs, are mailed directly to drivers. McDermand prepares a shipment.

McDermand: People ask the question to me all of the time: Do I think there should be regulations written on sleep apnea? The answer is yes, but it’s not for the obvious reason. My reason is there wouldn’t be all of these gray areas. The rules would be cut and dry.

One of the things I always mention is that there has been a rule about sleep apnea since 2000, but it is a very vague rule. It’s CFR 391.43, which in summary states that any condition that interferes with oxygen exchange and may result in incapacitation—including emphysema, chronic asthma, carcinoma, tuberculosis, chronic bronchitis, and sleep apnea—needs an examiner to detect that respiratory dysfunction and find ways to test for it.
This has always been an underlying rule; it just has never been in the forefront like it is now.

SR: How has the intimation that there may be new rules coming affected Phoenix Sleep, if at all?

McDermand: Now people seem to be going by the new FMCSA Medical Review Board recommendations issued in August, even though those are just recommendations and not rules. I get the impression that a lot of examiners almost over-follow the guidelines, to the point where almost anyone who walks in the door has to be tested for sleep apnea. That’s why I’m for rulemaking: it would set strict and clear criteria.
The notice of proposed rules was when people, especially the drivers and the safety directors, started taking this seriously. I get more calls from fleet safety directors, many of whom didn’t want to deal with this until rulemaking was on the table.

SR: What is the most common motivation for a driver to contact Phoenix Sleep?

McDermand: They’ve usually been given a DOT (Department of Transportation) 45-day medical card or a 90-day medical card to be diagnosed, which means they’ll lose their ability to drive or have an income after that time period if they are not tested and, if needed, treated.

Drivers typically turn to Phoenix Sleep because of our reputation for being inexpensive; also, we’ll follow them for as long as they are a patient with us to give them the CPAP data downloads.

Sometimes drivers will call us a week before their card expires. It usually takes on the average about a 7- to 10-day turnaround from the time a driver gets the test to complete the process. So if drivers are a couple of weeks out from card expiration, we can definitely get them tested.

SR: What is the most common motivation for a fleet safety director to contact Phoenix Sleep?

McDermand: They are seeking a common place to send all of their drivers. They know drivers will be taken care of quickly and well. We’re an all-in-one spot, so it’s a time saving tool for the safety directors/HR directors.

SR: From the time you first began working with the transportation industry to today, how has the transportation industry evolved with regard to its perceptions and interest in sleep?

McDermand: A lot of truck drivers do still think we’re part of the government and are “out to get them.” In the early years, many thought we were snake-oil salesman doing a test that didn’t need to be done.

But, in the last 3 or 4 years, that attitude has changed quite a bit. I still get pushback sometimes, but drivers realize they have to do the test. So now we’re more of a place to get a needed test done.

SR: At times, it seems like two sleep-transportation stakeholders are talking past each other. Sleep medicine professionals advocate trucker sleep apnea screening for health and safety reasons, and truckers say they are being unfairly targeted and the sleep industry wants to line its own pockets. How can we reach an agreement?

McDermand: I think it boils down to the cost.

Because there are programs out there, and I’m not saying that they’re not good, that aren’t cost effective for drivers. Think of a driver who has a family and is making $40,000 a year. Now he has to pay say $1,000 for a sleep test, plus he’s lost a day of work for the sleep study and a day of work for the titration study. And then he gets put on the CPAP. Since many truck drivers have a high-deductible insurance plan, they are going to wind up paying for the CPAP out of pocket. Then there’s also an issue with some labs not being able to get them in and out quickly.

I think the sleep industry needs to let the trucking industry know that they are doing a service for the trucking industry. In that way, it’s the same as any other medical issue. For example, a truck driver knows that if you have diabetes, you’ll have to get treated. And truck drivers may not realize that some of the other problems they face because of their lifestyle, such as high blood pressure, can be helped by treating their sleep apnea.

And a truck driver will say, “Oh, I sleep fine. I don’t have any problems.” But the sleep industry needs to emphasize that when you’re asleep, the body is supposed to recuperate. But when a person has sleep apnea, the body is actually working harder when it’s sleeping because it’s having to handle the starting and stopping of breathing. So once the driver gets treated, it’s an amazing difference in their lives.

I don’t want drivers to look at the sleep industry as a money-grabbing business. It’s no different than any other medical group; we’re just targeting something new to the truck driver.

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SR: One concern that seems common among the transportation industry is the cost burden. How can we keep the costs down while still adequately treating sleep-related safety risks, as well as making sufficient revenue to keep a sleep lab open?

McDermand: I hope over time more labs come down to a reasonable price to do a sleep study, and they do studies as one-night split-night studies instead of two-night studies (with a separate titration night).

And of course most insurance companies now do HSTs first because of the cost savings. The average for in-lab testing is probably $3,000 to $4,000 from start to finish, from diagnosis to treatment. In my market with HSTs, we can complete the process for under $1,000.

Sleep labs are the gold standard, and I don’t deny that. But the clients can’t afford it. Though HSTs don’t necessarily show the EKG, they are usually at least 4 channels so it gives a very good picture of obstructive sleep apnea.

SR: In what ways does Phoenix Sleep help truckers meet the 90-day diagnosis-to-compliance requirement quickly?

McDermand: We use Priority Mail for the sleep test, so it’s usually 2 to 3 days to anywhere in the United States. We tell drivers to take at least 5 to 6 hours for the sleep study. We include a label for them to mail it back to us, and we usually get it within that 2 to 3 day Priority Mail window. Then we have it interpreted within 48 hours.

It can be done quickly. It can be mailed to wherever they sleep. If they want to sleep in their cab and do the test, we can do that. But we try to schedule them at home where they’re comfortable sleeping in their bed and their own surroundings; that seems to be the best place to take a sleep test, so we usually do it on the time when they’re going to be home.

So we try to find out when they think they’ll be home and then we mail it about 2 or 3 days beforehand, so it’s there when they get home. And we test daytime drivers too [who sleep at home every night], such as FedEx drivers. Our model works really well for the home drivers.

Regardless, it’s all based on the drivers’ schedule and when they need it.

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Many drivers cannot be available for appointments at an in-person DME, so Phoenix Sleep stays in “constant”contact with them via phone and e-mail.

SR: Do you have a problem with drivers getting the HST back to you?

McDermand: No, though sometimes drivers get diverted and they keep it a couple of weeks. We put a little note in the package that we need to have this back within 2 weeks, but we honestly have not had a whole lot of problems. In all the years that I’ve been doing this, I’ve only lost 2 monitors.

I think drivers are finally realizing that at least Phoenix is here to help them through this and make it easier for them, not make it a burden for them.

SR: For truckers who are willing to use CPAP, there are hurdles that are unique to truckers, for example idling laws that may not allow them the power needed for heated humidification. Any tips or CPAP accessories that you find useful?

McDermand: With every CPAP that we sell, they have an option to include a mobile power adapter, so drivers can run the CPAP off a cigarette lighter; there are a lot of no-idle states out there.
I’m not a big advocate of heated humidity. If drivers need it, we sell that to them, but I think in many cases it’s just an unneeded upcharge to the CPAP. Bob [Stanton] will argue to the death with me about this. I think there are cases where you need it, such as if you’re in a very arid climate or if you’re in high altitudes. I find maybe 1 in 10 truly require a humidifier. We do offer it to them, but it saves them $130 if they don’t want it.

SR: Other than the mobile adaptor, are there any other accessories that come up?

McDermand: We include an interface with every CPAP that we sell, and we have a return policy that if the mask doesn’t fit them properly, within 30 days they can return it at no cost and we’ll replace the mask for them. To provide the right interface size, we ask questions such as, “What size is your hat?” We ask if they breathe through their mouth or if they’re a nose-breather. Usually with our questionnaire, we get it pretty spot-on as to what type of mask they’re going to need, but if they do have problems with it we have them call us and we send a different mask right back out.

We monitor the compliance, or the usage, of the CPAP, and my staff will send an e-mail out every month asking drivers to send their compliance in to us. We’ll see if their AHI is where it belongs, see if they’re wearing it enough hours a night to get their 4 hours in, and coach them along.

We keep in constant contact with them, sometimes too much, but I’d much rather be in contact with them all the time to make sure everything’s okay. Their lifestyle does not fit a traditional DME [durable medical equipment provider]—they can’t stop by a DME any time and get a new mask or see an RT. So by e-mail and phone I think we take care of them very well.

SR: So it sounds like most of your clients don’t come in person for the mask. Do they have problems figuring out how to put the mask on their face and make sure it’s not too tight?

McDermand: No, there are instructional videos and written illustrations that go with each one. It’s just simply hooking the mask onto the tube and then adjusting the straps. The mask itself has instructions on it, and the CPAP has a DVD they can watch or it has a users’ manual that has illustrations on using the CPAP. So no, that’s not been a problem.

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McDermand and Tommy Snider, service center manager for the Ft. Pierce R&L Terminal, discuss home sleep testing.

SR: In 5 years, where would you like to see the transportation industry with regard to sleep apnea?

McDermand: I’d like to see a set of rules and regulations that everybody can agree on: the FMCSA, the Medical Review Board, the safety directors, and other stakeholders, and for everybody to work in conjunction to help with sleep apnea. Because sleep apnea is a problem and it’s going to continue to be a problem because of the lifestyle of the trucker. I’d like to see us all get along for a mutually beneficial outcome.

This is truly no different than high blood pressure, high blood sugar, loss of sight in one eye, or any other medical issue. Today, if a safety manager in the trucking industry knows that you have to be 140/90 in order to pass your blood pressure test, you accept that if you don’t pass, you’re sat down for a while. It needs to be the same accepted scenario with CPAP. This needs to be integrated into the treatment of the individual drivers like any other medical concern is. And there are some big fleets out there that are starting to do that.

Sree Roy is editor of Sleep Review.