Sleep Apnea and Driver Wellness

1. Attention Attendees: • Thank you for attending! • The presentation will start in a few minutes at 1:00 PM Central. • Please use your computer speakers to listen to the event. If you have audio issues, dial-in info is below. • You will be muted during the event. • Please use the Question feature to text questions to “Q & A”. We’ll try to answer them during the Q&A period if they are not covered in the presentation. • The slides will be posted in 1-2 days and the recording in 7 days at http://www.jjkeller.com/nptcinfo Sleep Apnea and Driver Wellness This webcast will cover ... Regulatory and Legal Overview, Walmart’s Sleep Apnea Program, Screening, Diagnosis and Treatment of Sleep Apnea, and Question & Answer Moderator Dr. Gary Petty, President & CEO, National Private Truck Council Panelists Bob Rose, Editor – Transportation Management, J. J. Keller & Associates, Inc. Tom Moore, Vice President of Education, National Private Truck Council Rick Foster, Senior Director-Fleet Safety, Walmart Transportation LLC

2. Dr. Gary Petty President & CEO National Private Truck Council

3. Introduction • Regulatory and Legal Overview – Bob Rose • Screening, Diagnosis and Treatment of Sleep Apnea – Tom Moore • Walmart’s Sleep Apnea Program – Rick Foster • Housekeeping issues: • You will be muted during the event. • Please use the Question feature to text questions to the Q&A Panelist. We’ll try to answer them during the Q&A period if they are not covered in the presentation. • If you lose sound at any point, you can dial-in by phone using the number and Pass Code listed below. • If you lose the program window and need to re-loginbe sure to enter a different e-mail address to avoid being denied access for multiple logins. Gary Petty National Private Truck Council

4. Disclaimers • The content in this webcast is intended for information purposes only and should not be construed as providing legal or medical advice. • This is an introductory course and is intended to highlight critical safety and compliance topics. Time constraints limit our ability to go in depth. • We invite you to ask questions. We will answer them throughout today’s webcast. Gary Petty National Private Truck Council

5. Bob Rose Editor, Transportation Management J. J. Keller & Associates, Inc.

6. What is Obstructive Sleep Apnea (OSA) • “Apnea” is an episode of not breathing • Causes • Blocked or narrowed airways in your nose, mouth, or throat • Large tonsils or adenoids or a large uvula • Overweight, use of certain medicines or alcohol before bed, or sleeping on back • AHI can be used to classify the severity of disease: • Mild: 5-15 events per hour of sleep • Moderate: 15-30 events per hour of sleep • Severe: greater than 30 events per hour of sleep • OSA afflicts at least 15 million in the US—over 90% remain undiagnosed; FMCSA study indicated 26% of drivers have OSA Bob RoseJ. J. Keller

7. FMCSRs Driver Qualifications • 391.41(b) A person is physically qualified to drive a commercial motor vehicle if that person— • (5) Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his/her ability to control and drive a commercial motor vehicle safely • FMCSA Medical Examination Report for Commercial Driver Fitness Determination contains a question:“Sleep disorders, pauses in breathingwhile asleep, daytime sleepiness, loud snoring” Bob RoseJ. J. Keller

8. FMCSA FAQs -- Medical • “Drivers should be disqualified until the diagnosis of sleep apnea has been ruled out or has been treated successfully. As a condition of continuing qualification, it is recommended that a CMV driver agree to continue uninterrupted therapy (e.g., C-PAP), monitoring and undergo objective testing as required.” • “A driver with a diagnosis of (probable) sleep apnea or a driver who has Excessive Daytime Somnolence (EDS) should be temporarily disqualified until the condition is either ruled out by objective testing or successfully treated.” Bob RoseJ. J. Keller

9. FMCSA OSA Activity • 1988, 1991, and 2008 – FMCSA convened Medical Expert Panels (MEP) to provide recommendations on revising the Medical Examiner’s Guidelines for OSA • 2009 – FMCSA’s Medical Review Board essentially adopted the recommendations of the 2008 MEP and included screening at a BMI of 30 • June 30 - Medical Review Board held public meeting updating industry on sleep apnea • August 29 – FMCSA scheduled to meet with Medical Review Board and the Motor Carrier Safety Advisory Committee to discuss options for regulating OSA Bob RoseJ. J. Keller

10. 2008 Medical Expert Panel Recommendations • OSA at certain levels should be a disqualifying condition • Screen at 33 BMI (a BMI of 30 was discussed but that would cover ~42% of commercial drivers), high risk result on Berlin Questionnaire, or high risk based on clinical evaluation • 1-month, 3-month and 1-year conditional medical certifications depending on severity of OSA and contingent on compliance with treatment program • Symptoms: chronic loud snoring, witnessed apneas, daytime sleepiness • Risk factors: advancing age, BMI ≥ 28, small jaw, large neck (≥ 17/15.5), small airway, family history Bob RoseJ. J. Keller

11. 2008 Medical Expert Panel Recommendations (cont.) • Condition associations: Hypertension, Type 2 Diabetes, Hypothyroidism • Preferred diagnosis: Overnight Polysomnography • Preferred treatment: Positive Airway Pressure (PAP) • Certify after: 1 week of use, 4 hours per night, 70% of nights -- MINIMUM STANDARD • Alternative treatment: Surgery • Certify after: post-op confirmation of success • Alternative treatment: Dental Appliance • Not acceptable due to lack of compliance verification Bob RoseJ. J. Keller

12. Tom Moore, CTP Vice President of Education National Private Truck Council

13. Health Risks of OSA • Risks of untreated, sleep apnea: • High blood pressure (2-3x incidence of Non-OSA) • Heart failure (30% higher risk versus Non-OSA) • Stroke • Obesity and Diabetes (negatively impacts leptin and grehlin levels) • Mental Health • Other • Versus people without OSA, those with untreated OSA have health care costs 2x or $1,336 more and their risk of death is 3x greater Tom Moore National Private Truck Council

14. Crash Risks of OSA • Fatigue-induced motor vehicle crashes occur at a rate of 2 to 7x that of those without OSA • Drivers with severe sleep apnea were 4.6x more likely to be involved in a severe crash • 800,000+ drivers were involved in OSA-related car crashes in 2000, costing more than $15.9 billion in damage and claiming 1,400 lives • CPAP treatment can reduce collision cost by $11.1 billion per year Tom MooreNational Private Truck Council

15. Sleep Apnea-Related Crash Litigation • Plaintiffs’ lawyers: • Know the “disqualifying” nature of sleep apnea and the gray area of the regulations • Will tell a jury that a driver with OSA is disqualified and should not have been driving a CMV and the carrier was negligent in allowing them to drive • Will make it sound like the driver was asleep at the wheel • Cases • DOT Physicals can be a shield • No - Achey v. Crete Carrier Corp • Yes - U.S. Xpress, Inc. v. Am. Field Serv. Corp • “Sudden-medical-emergency” defense can be used if sleep apnea isn’t diagnosed before accident • No - Dunlap v. W.L. Logan Trucking Company • Yes - Slone v. Ibert • People v. Wilson – untreated OSA risks finding of criminal reckless homicide Tom Moore National Private Truck Council

16. Financial Impact of Untreated OSA • $2,727 reduction in health insurance claims per treated driver in first year after treatment • $3,086 reduction per driver in second year • $528 reduction per treated driver in 2 years of short-term disability claims after treatment • 6.9 day reduction in lost work days per treated driver over 2 year period post treatment Tom MooreNational Private Truck Council

17. Findings of Key Study on OSA in Trucking • Findings • 36% of accidents were fatigue-related (gross under-reporting of fatigue on police reports) • 28% of drivers have OSA but only 15% diagnosed • 18% of drivers with OSA have a BMI under 30 (screen all drivers) • 82% accuracy in online pre-screen questionnaire • Program • Pre-screen with online questionnaire, screen all drivers, cover all costs, monitor treatment compliance real-time for first 30 days and every 90 days thereafter • Outcomes • 12% reduction in preventable accidents • 63% reduction in the median cost of crashes • $539 monthly savings per driver in the 12 months after being diagnosed • 60% improvement in driver retention Tom MooreNational Private Truck Council

18. So What Do You Do? • FMCSA has not indicated that it will issue a specific regulation on sleep apnea, although it is under consideration by the agency • “Standard of Care” means models of managing the issue have been developed by the industry • Best approach is to have a company policy that addresses the screening, diagnosis, treatment and management of sleep apnea in drivers Tom MooreNational Private Truck Council

19. Rick Foster Senior Director-Fleet Safety Walmart Transportation LLC

20. Walmart Fleet Operations • Fleet stats: • 6,399 Power Units • 55,000 Trailers • 7,515 CDL Drivers • Walmart serves customers and members more than 208 million times per week at more than 8,600 retail units under 59 different banners in 15 countries. With fiscal year 2010 sales of $405 billion, Walmart employs more than 2 million associates worldwide. Rick FosterWalmart

21. Why is Walmart Establishing an OSA Policy • It is the right thing to do for our drivers. • Improve overall health of drivers • Improve alertness while driving / improve safety • Compliance • Our belief is that we will get more regulation around sleep apnea and we want to be ahead of the game. • We have always tried to be in the forefront of compliance issues (i.e. Hours of Service). • Better selection of suppliers • Once the rulemaking begins, companies will scramble to contract with a supplier and may struggle to get the services they need. Rick FosterWalmart

22. Policy/Program Considerations • Who pays? Company? Driver? Shared? • Driver wellness program enhancements • Communication and education of policy, expectations, etc. to drivers and applicants • What type of monitoring program will we have? • Do we use a national health care provider to ensure consistency in our program? • Does our truck equipment spec have the means to support needed medical equipment? • Will program require more frequent physicals…with added costs? Rick FosterWalmart

23. Funding Considerations • Current program • Driver covers screening, diagnosis and treatment through company medical plan which includes deductible and co-pay. • Future plan • Our benefits group is considering a program outside our company funded benefits plan that will pay 100% of cost of the program for DOT drivers. Rick FosterWalmart

24. Driver Communication Plan • Roll Out / Communication Plan • Select pilot location • Communicate the program to drivers through depart group meetings, recorded messages delivered over the OBC to each driver, and written communication to each driver • Invite sleep center personnel to driver meetings to answer technical questions and explain the process • Make the process as convenient as possible for the driver • Remove fear of the process • Explain the benefit coverage • Reduce downtime • Reassure driver of continued certification Rick FosterWalmart

25. Screening for OSA • Currently relying on DOT examiner to evaluate and recommend screening • Future program will utilize the following: • Utilize questionnaire (Berlin or equivalent) to determine immediate testing needs • Provide ambulatory testing that can be done at driver’s home or in cab • Follow up with full PSG, if indicated, to determine appropriate treatment protocol • Central apneas • Borderline cases • Goal is to get driver back in the truck as soon as possible Rick FosterWalmart

26. Diagnosing OSA • Screening will identify drivers that should have further testing. • Utilize ambulatory test equipment that allows the driver to be tested at home or in cab • Perform full Polysomnogram if indicated by initial testing • Remove time constraints • Screen and perform ambulatory test same or next day • Send test results to sleep specialist and receive diagnosis and treatment protocol the same day the results are downloaded • Provide treatment equipment and training that day • Return driver to work with electronic monitoring Rick FosterWalmart

27. Diagnosing OSA • Polysomnogram (aka sleep study) • Brain activity • Eye movement and other muscle activity • Breathing, heart rate, and blood pressure • How much air moves in and out of your lungs while you're sleeping • The amount of oxygen in your blood • Two methods: • Sleep Centers • In-home equipment Rick FosterWalmart

28. Treating OSA • Select a provider • Select a provider who is willing to customize a program that meets your operational needs and offers sufficient coverage to serve all your driver domicile locations • Treatment Program • Full service - provider supplies screening, testing, equipment and monitoring of compliance • Local provider network - sometimes an option based on insurance requirements • Equipment: CPAP, APAP or Bi-PAP • Utilize auto-set device with 12 volt operating system • Adjusts to patient’s needs automatically • Easy implementation in sleeper berth operations Rick FosterWalmart

29. Walmart OSA Results • Number of drivers currently treated • Approximately 10-11% of our driver group based on a physical survey early last year • We have had our DOT medical examiners evaluating drivers at recertification for 3 years. • Expected number when program has been fully implemented • We expect to be between 30 and 40% when fully implemented due to our job requirements. We are mostly drop and hook and drivers normally do not load or unload freight. Rick FosterWalmart

30. Question & Answer Please submit questions to “Q&A” using the Q&A tool Bob RoseJ. J. Keller Rick FosterWalmart Tom MooreNational Private Truck Council Gary Petty National Private Truck Council

31. Closing Remarks • Checkout the archive of past topics at: http://www.jjkeller.com/nptcinfo • PowerPoint slides up in 1-2 days • Recording up in 1 week • Topics for 2011: • October 12 – Driver Discipline and Coaching Gary Petty National Private Truck Council