DOT Certifcation - By the Numbers
The Federal Motor Carrier Safety Administration (FMCSA) affected the certification requirements for medical examiners beginning May 21, 2014. Before that, there were an estimated 440,000 medical providers, including MD’s, DO’s, Chiropractors, Nurse Practitioners and Physicians Assistants. Drivers are now required to obtain their FMCSA medical examination from a certified medical examiner that is listed on the National Registry (of the FMCSA). The initiative was designed to improve safety by achieving high-quality medical exams that are consistent with Federal regulations and guidelines. The National Registry will help commercial motor vehicle drivers, and employees, find trained and qualified medical examiners to perform physical qualification examinations. for drivers to obtain or retain their Commercial Drivers License (CDL).
Though it was expected that the number of providers performing Department of Transportation (DOT) Medical Exams would decline with the enactment of these standards, it was not the objective.
Certainly, the lack of standards had contributed to tremendous abuse of the issuance of CDL’s to drivers and allowed the examiners to conduct exams as they saw fit with little documentation to support their findings. Though it has contributed to some inconvenience for drivers and some companies, most agree that standards were required and have contributed to better quality medical exams.
The initiative didn’t stop with requirements for certification. Providers are now required to record their findings on a standard report form and to maintain those records for review by others as need be. Additionally, each medical examiner is required to routinely report certain statistics on medical exams that are performed to the FMCSA.
Urgent Care Advisors has conducted its own review of the newly defined population of medical examiners to get a better understanding of the make up, distribution and trends for the group as well as project some level of need going forward.
Certification Process & Timeline
The process of getting and maintaining (renewing) a CDL has been a mess for a long time. Drivers and providers alike have taken advantage of the lack of consistency in administering the process and the lack of guidelines relative to the quality and administration of medical exams. The lack of qualification of providers along or method of standardized reporting allowed for a broad interpretation by the providers who took advantage by passing drivers whose medical qualifications were beyond questionable. Providers attempting to conduct proper exams were often times criticized and even shunned by the more desperate drivers/fleets in need of putting or keeping a driver behind the wheel. It should be noted that many fleets consistently adhered to or even provided standards that were more strict than the FMCSA standards, however, that made it difficult for them to compete for drivers.
In December 2008 the FMCSA issued final rules modernizing, streamlining and simplifying recordkeeping obligations for drivers, carriers and state governments by requiring that a driver’s medical certification record be merged with state-issued CDLs. FMCSA also set forth a new requirement, as part of the certification process for providers, to establish a uniform Medical Examination Report for Commercial Driver Fitness Determination referred to as form 649-F (6045). The creation of this form and the requirements for its use and maintenance were mad part of the new rules governing the certification process for examiners. States received support from FMCSA to implement the necessary IT system upgrades and merge records into one, on0line database – the Commercial Driver’s License Information System (CDLIS).
Certified DOT Medical Examiners Requirements and Trends
There was a great deal of concern on the part of drivers and fleets in early 2013 about the changes that the FMCSA was putting into place to formalize and standardize the medical exam requirements for commercial drivers. In fact, may industry experts and those providing medical exams at the time believed that the FMCSA would delay the enactment of the more stringent regulations. Looking at Figure 1, it is pretty easy to see the date that the regulations were enacted and the number of providers that became certified in response to the requirement. Clearly, the providers didn’t actually pursue the certification process until it was clear that it was going to be made affective. Most were confident that the FMCSA would delay the requirement. When it became clear that it would not, they became certified.
To become certified, providers must take a sectional exam and must study ahead of each section from a study guide. The study guide and the exam are focused on the requirements of the examination process and the basis therefor as well as the reporting and administration requirements of the examiner. The entire process can take a few days to complete but can be done virtually through on-line programs.
Providers can be M.D.’s, D.O’s, Chiropractors, Nurse Practitioners or Physician Assistants. It is unclear what the breakdown was prior to the certification process but the breakdown of the providers Certified as of February 2015 are shown in Figure 2.
The “Other” category consists of the combination of APN’s (Advanced Practice Registered Nurses), Nurse Practitioners and Physician Assistants accounts for nearly half of the total medical examiners. It was interesting to note that in the “other” category (94 in all) are: Registered Nurses (36), Other (22), Doctor of Nurse Practice (15), Natureopath (15), Medical Assistant (2), Physical Therapist (2), Doctor of Physical Medicine (1) and Podiatrist (1).
Nurse Practitioners, APN’s and Physician Assistants make up nearly half of the total, demonstrating their importance in the delivery of DOT medical exams. It is unclear how Medical Assistants, Physical Therapists and Podiatrists made the list, as they are not referenced in the statutes governing medical examiner qualifications, though the documents do reference “not limited to” when listing the qualified medical professions. In any case, these specialties are not significant in the total medical examiner list.
Included in the total list of 1,290 providers with no contact information whose files are marked as “please do not contact to schedule an examination”. This group is a mix of provider qualifications and it is unclear why they are labeled as such, but this would lessen the total available providers by that number.
A host of inconsistencies in the Registry make it difficult to use as a reference and locator database. Among the issues with the database are: Inconsistent reporting of hours of operation, no indication of the prices, no mechanism showing feedback from drivers and absence of a handheld adaptation of the program for use on smart phones or other portable devices that are the standard for drivers. These shortcoming make the registry somewhat less valuable to a user than it otherwise could be. Additionally, the data appears to have been loaded by the sites, who took the liberty of varying in their interpretation of what goes into the individual fields evidenced by the many different variations of how the data reports. With these inconsistencies, the Registry loses it intended function. Nonetheless, the FMCSA has taken the action that necessary to formalize this important element of the governance for transportation safety in the United States and it will, no doubt, improve from here.
In addition to the training and certification requirements, medical examiners must also comply with the U.S. Department of Transportation guidelines (49 CFR – Drug and Alcohol Regulations). The Medical Examination Report for Commercial Driver Fitness Determination form must be completed and retained for a defined period of time at the examiners offices. Further, medical examiners are required to submit reports regularly to the FMCSA of the drivers examined and the results of those exams. Examiners that fail to follow the guidelines are routinely removed from the registry of medical examiners.
Impact of the Regulations
It is too early to say that the regulations and standardization have yielded a safer transportation arena, however, there was and is a clear purging of examiners that has resulted in a significant change in the way drivers purchase there exams and how examiners go about providing them. Additionally, there are enhanced risks associated with performance of exams that did not exist prior to the changes.
The American Trucking Association (ATA), requested a delay in enacting the National Registry. With the request, ATA CEO Bill Graves said that “while the association supports the rule, some areas of the country may not have enough certified examiners for the number of drivers that live in the area. Not only with the registry lack sufficient numbers of examiners in sum, but the system will be hindered by the inadequate geographic coverage”. Graves wrote in his letter: “Without an adequate supply of medical examiners appropriately dispersed around the country...drivers and motor carriers may be unable to fully comply without excessive expense and costly delays,” the letter stated.
The FMCSA set a target of 40,000 examiners to cover the needs of the 4.4 million drivers in the United States. At first blush, it would appear that this is true, since it would only be 110 examinations per examiner per year, even assuming that every driver received an exam every year. Drivers can achieve a two-year certification at most, but many drivers do not qualify for that long of a certification and some have medical conditions that prevent them from being certified for more than three to six months at a time. Urgent Care Advisors estimates that the average certification is approximately nine months. In that case, the adjusted number of medical exams required would be almost six million. This would require the average medical examiner perform 150 exams per year in order to cover the market. There is a lot to consider when assessing the ideal number of medical examiners providing DOT Medical Exams:
- Geography: The American Trucking Association’s argument about geographic location is a bit flawed in that truckers are mobile and geographic concerns are mitigated since they can get their exams while performing their work while on the road. There isn’t really a need to have geographic dispersion of examiners; in fact, this could lead to some examiners whose practices don’t allow for very many exams to be done to dilute the value of the Registry.
- Quality: Even at 150 exams per year, it is doubtful that examiners can maintain a level of proficiency that the FMCSA desires and the trucking needs to maintain a high standard of exams. A primary care or urgent care provider that performs DOT Medical Exams would see over 4,000 – 5,000 patients per year (per provider/examiner). Given this, 150 exams would of little significance to the business (less than 3-4%) There is an argument to made that fewer examiners performing a higher volume of exams can and would lead to improved quality of exams. This is especially true given the foundation that the Registry and FMCSA has provided.
- Price: The prices being charged are extremely varied. In a survey conducted by Urgent Care Advisors, prices were shown to vary from a high of $250 to as low as $30 for a DOT Medical Exam.
- Access: The Registry lists all examiners that have become certified, however, many have extremely restricted access and some provide services only to specific organizations or by appointment only. This makes the Registry significantly less valuable than it could otherwise be and challenges drivers and fleet as to how to best identify and schedule their DOT exams.
The Registry database demonstrates that there are many different models of examiner offices. The make-up is a mixture of urgent care, occupational medicine, primary care, retail clinics and some company-based clinics. The top 25 providers account for 5,400 of the total medical examiners with Concentra, Minute Clinic (Walgreens), US Healthworks, MedExpress and the Little Clinic (Kroger) accounting for just over 10% of the nation’s medical examiners.
Fleet operators and their contracted Third Party Administrators (TPA’s) address their contracting and referral practices differently. Some select a single local provider to provide the services while others create networks of providers that are called upon as the need arises. Some fleets have begun to shift the responsibility entirely to the driver out of frustration with the process.
Generally, one could interpret that the certification standards along with the other changes that the FMCSA has enacted focus increased attention on the entire process that will inevitably result in even greater changes that the private market will pursue to advance the project on their own initiative.
Trends in Crash Statistics
The FMCSA reports the following summary of statistics on its website:
- In 2012, 3,802 large trucks were involved in fatal crashes, a five percent increase from 2011. Large truck and bus fatalities per 100 million vehicle miles traveled by all motor vehicles increased by 3 percent, from 0.137 in 2011 to 0.141 in 2012.
- For 2.1 percent of large truck drivers in fatal crashes in 2012, the blood alcohol concentration was 0.08 grams per deciliter or more, compared with 22.8 percent of passenger vehicle drivers. Alcohol was detected in the blood of 3.5 percent of large truck drivers in fatal crashes in 2012, compared with 26.3 percent of passenger vehicle drivers.
- Over the past 10 years (2002 through 2012):
- The number of large trucks involved in fatal crashes decreased from 4,587 to 3,802, a drop of 17 percent.
- The number of large trucks involved in injury crashes decreased from 94,000 to 77,000, a drop of 18 percent.
- The number of large trucks involved in property damage only crashes decreased from 336,000 to 253,000, a drop of 25 percent.
- The number of buses involved in fatal crashes decreased from 274 to 251, a decrease of 8 percent.
- On average, intercity buses accounted for 13 percent, and school buses and transit buses accounted for 41 percent and 34 percent, respectively, of all buses involved in fatal crashes.
- Over the past year (from 2011 to 2012):
- The number of large trucks involved in fatal crashes increased by 5 percent, from 3,633 to 3,802, and the vehicle involvement rate for large trucks in fatal crashes (vehicles involved in fatal crashes per 100 million miles traveled by large trucks) increased by 4 percent.
- The number of large trucks involved in injury crashes increased by 22 percent, from 63,000 to 77,000, and the vehicle involvement rate for large trucks in injury crashes increased by 22 percent.
- The number of large trucks involved in property damage only crashes increased by 14 percent, from 221,000 to 253,000, and the vehicle involvement rate for large trucks in property damage only crashes also increased by 14 percent.
- The number of buses involved in fatal crashes increased from 245 to 251, an increase of 2 percent, but the vehicle involvement rate for buses in fatal crashes decreased by 4 percent.
- Vehicle miles traveled (VMT) by large trucks increased by 0.3 percent, and bus VMT increased by 6.9 percent.
Of note, the number of registered large trucks in the United States increased by nearly 33% from 2000 to 2012, making some of these statistics even more compelling.
More Changes Ahead
There are more changes in the works for commercial drivers and fleet operators. A final rule creating a central database for commercial drivers with positive drug and alcohol test results and refusals by drivers to submit to testing is projected for September 2015. Employers would be required to query the clearinghouse to vet recruits and would likely face additional liability exposure if violated.
Additionally, a final rule requiring the use of electronic logging devices (ELDs) for drivers (currently paper documents are the focus of the planned September 2015 publication. Enforcement of ELD standards would begin in 2017. Devices will be certified by the FMCSA and a list will be made available on the FMCSA website. There are currently 22 ELD manufacturers with roughly 90 devices certified for such use.
Population Health Management
Few can dispute the professional driver lifestyle lends itself to some unhealthy and often life-threatening habits and practices. The sedentary nature of the profession (sitting for long periods of time with lacking exercise) creates an ideal opportunity for drivers to fall victim to obesity and all of the compromising medical conditions that go with it. The aging driver population is increasingly called upon to extend the typical professional driver career span in order to meet the needs of the market. Fewer and fewer new entrants to the profession means that the trucking industry is facing a critical shortage as has previously been discussed.
Today’s healthcare professionals are increasingly focusing on population health management as a means of enhancing health outcomes and extending professional careers. Fleet operators have addressed this in a variety of ways but few have connecting with medical professionals in a meaningful way to facilitate improved population health. Though some fleets have enacted programs focused on improved health of their driver population, the industry is dominated by independent drivers that lack access and opportunity for any such programs. Moreover, there are no standards that require attention to population health or personal health measurement.
With a focus on highway safety, driver retention and enhanced productivity, It is likely that telehealth and broader initiatives involving population health management will find their way to the trucking industry sooner rather than later.
The trucking industry is arguably one of the unhealthiest of all in the United States and multiple tiers of intervention will be required in order to combat the compromised productivity and driver shortage that are the result thereof.
Transportation is the backbone of the United States economy and the American Trucking Association (ATA) estimates that there is a shortage of qualified drivers in excess of 30,000. The turnover rate at large truckload carriers rose by one percent in 2014 and now stands at 92%. This is up from a low (four years ago) of 39%. In 2005, the turnover rate averaged an astounding 130%.
The balance of meeting the economic demands of the nation by maintaining a healthy professional driver population and keeping the highways safe are an ongoing challenge. No one wants more regulation, however, the actions taken by the FMCSA to improve the qualifications of medical examiners and to enforce tighter controls on driver health and safety appear to have had a positive affect on the accident rates, especially considering the increase of large trucks on the highways.
Nonetheless, the industry suffers from a lack of qualified workers and with a reported median annual income of just under $40,000 (The Bureau of Labor Statistics), the shortages will likely continue. Bloomberg Business reports that the average of a commercial driver is now 55. Even so, with extended careers, the need for better medical screening and monitoring of chronic medical conditions that could affect driver safety are even more important.
The new standards enacted by the FMCSA pave the way for new ways of delivering high-quality medical exams and improved reporting of the results. This effort will need to be coupled with improved methods of delivery that must include population health management programs and a focus on driver wellness beyond the DOT Medical Exam.
It may well be that genetic testing, focused on identifying risk of conditions that are endemic in this industry, will be one of the next steps toward population health management but one thing is for sure…our economy, highway safety and the future of transportation industry depend upon us finding ways to make the professional drivers of this country a healthier/more productive population.