cept, the Service Surgeons General execute, if you will, that consistent centralized policy guidance.

The Deputy Secretary of Defense, after he issued that directive, talked not only to centralized authority and responsibility, but, indeed, to responsibility for the execution in one central place, namely my office. He also directed that I prepare and justify and defend the program objective memorandum. Subsequent to the Secretary's direction, a Defense Medical Advisory Council was formed. The Council is to advise me in the execution of the Department's medical mission.

It consists of a presidential appointee from each of the military departments and a general or flag officer from each of the military Services. A general or flag representative of the Chairman of the Joint Chiefs is part of that Council, and so is the President of the Uniformed Services University of the Health Sciences.

I chair the Council as Assistant Secretary. Since issuance of that directive, I have met with the Service Secretaries personally to review the new authorities. I have chaired two meetings of the Advisory Council.

I have expanded my Office of Budgets and Programs with temporary assistance from the military medical departments in order to oversee the 1992 program execution and in order to prepare the fiscal year 1993 medical budget justification. We also have developed and issued very detailed medical defense guidance.

I am preparing the fiscal year 1994 to 1999 Program Objective Memorandum with the help of the Services. These things are occurring at a very fast pace because of the short period of time since October.

I must tell you that both meetings with the Defense Advisory Council were of particularly good quality. I was quite taken by them and quite reassured by their involvement, both out of the secretariat and out of the senior service representatives, very much indeed.

BONE MARROW PROGRAM AND BREAST CANCER RESEARCH

Mr. MURTHA. A couple of areas where we have been pleased about the Service's reaction was bone marrow indexing, in particular. I think that has been a very successful program. We know the Navy has handled that. A number of people have come to me and said that they appreciated what the Services have done because. their children or relatives' lives have been saved because of that indexing. We don't think it could have been done any place else and this was at the initiative of Congressman Bill Young. We appreciate the good job the Navy has done in that regard.

The other area we put extra money in this year was the breast cancer research.

Dr. MENDEZ. I can't tell you much in terms of results because it was being evaluated as to what the projects would be. I have no results to share with you at this time, Mr. Chairman. I can submit more material for the record in terms of the breast cancer research.

[The information follows:]

The Joint Appropriations Conference (102nd Congress) appropriated $25 million to initiate breast cancer research within the Department of Defense (DoD). Since this change to the President's Budget was appropriated, but not authorized, the funds were not released until February 24, 1992.

U.S. Army Medical Research and Development Command (USAMRDC) had no breast cancer research program prior to fiscal year 1992. USAMRDC solicited research proposals on February 5, 1992 from within the DOD and the Department of Veterans Affairs (DVA). The deadline for Federal submission of proposals was April 3, 1992. An initial review identified those proposals having considerable scientific merit. This review was completed on May 4, 1992, and each submitting organization was informed of the results. Proposals identified in this initial review as having considerable scientific merit are being further evaluated. The USAMRDC is expected to announce funding approval of the final selected proposals during the first week of June 1992.

A request for research proposals from civilian institutions was announced on April 16, 1992 in the Commerce Business Daily. The deadline for submission of these proposals is June 1, 1992. As with DoD and DVA proposals, proposals submitted by civilian institutions will be evaluated for scientific merit. Announcement of funding approval of civilian proposals is anticipated to occur between June 1, and September 30, 1992. The Army has no plan to continue this research program beyond fiscal year 92.

MEDICAL FREE ELECTRON LASER

Mr. MURTHA. Congressman Early from Massachusetts has a number of questions about laser medicine. If you would have someone answer that right away for the record and get an answer back to me and to Mr. Early.

[CLERK'S NOTE.-Questions submitted by Mr. Early, a member of the Appropriations Committee and the answers thereto follow:]

Question. I've recently been hearing a lot about laser medicine. It seems that this new technology will not only be cost effective by being less invasive and by moving inpatient care to the outpatient arena, but in fact it will decrease both morbidity and mortality for U.S. citizens. Additionally, it seems to be a very effective method of technology transfer. The United States is a leader in biotechnology and the military has always been a major player in biomedical research, as demonstrated by their work in vaccine development; therefore, I am very pleased to note that the Department of Defense is again on the cutting edge of medical research as demonstrated by the very successful work of the Medical Free Electron Laser program. For example, the development of "smart lasers" for the diagnosis and treatment of burns is an excellent demonstration. As a result of this impressive program, we are continuing our traditional excellence in medical research and biotechnology.

I am interested in your plans regarding support of this very successful and productive program. What has the President requested? Answer. For fiscal year 1993, the Presidential Budget request contains a $20 million support for continuation of the medical free electron laser program.

Question. What did you spend last year?

Answer. In fiscal year 1991, approximately $20 million was obligated in support of this program.

Question. How do you intend to make that a priority program this year?

Answer. For fiscal year 1992, this program is still under the cognizance of the Director, Defense Research and Engineering. The medical free electron laser program has been maintained at a stable funding level of $20 million for fiscal year 1992.

[CLERK'S NOTE.-End of questions submitted by Mr. Early.] Mr. MURTHA. Mr. Young.

BONE MARROW PROGRAM

Mr. YOUNG. Thank you, Mr. Chairman. Dr. Mendez, and Surgeons General, we are glad to have you here. I have to say that it has been a real pleasure working with you and your predecessors on some of the medical questions relative to the active duty Armed Services.

I know we have worked directly with you on the issue of fleet hospitals. We ended up building two hospital ships. Then there is the program that the Chairman mentioned, the bone marrow program. I have to tell you that without the DOD, and more specifically the United States Navy and Navy medicine, I don't think we would have a national marrow donor program today like we have. It is a miracle. No doubt about that.

The answer to it is people who are willing to be donors, and without the ability to determine who those donors are and to determine their tissue types to enable them to go into the registry to be a potential donor, people are going to die without a transplant. We worked long and hard to try to find a home for the registry and the United States Navy was very receptive and cooperative, and without them we wouldn't have the program we have today.

With them we have reached over a half million Americans in our registry. We have done over a thousand bone marrow transplants, and the DOD has been extremely cooperative because you have been doing recruiting at various military installations throughout the country.

We work with Dr. Bob Hartzman of the Navy directly and he deserves a lot of credit. He tells me there is a waiting list up through September to get to the various military bases that want to do recruiting drives. I think that is a tremendous testimony to the willingness of the United States military men and women to do something for their fellow Americans. This program has become international and we are trading marrow donations and patients across international lines. Without the cooperation of the DOD, I don't think it would have happened because other agencies in the Federal Government didn't really want to get involved with it. They thought it was too risky.

I think that you deserve that credit and I can't say enough about Dr. Hartzman because of the many long hours that he has devoted to this program and the tremendous help he has given us.

DISABLED BENEFICIARIES

I want to go back to the issue Chairman Murtha raised about the witness who was here this morning, Terry Cox and her husband Andy. They are my constituents. We have tried to help them work out their problems and we hit a brick wall every time we turned around. That is the reason that I asked the Committee to approve the language they did last year during our markup, language that you say you will be implementing within a week?

Dr. MENDEZ. Yes, sir.

Mr. YOUNG. That is good news. I would like to ask a couple of questions about that case. It may relate to the other 9,000 people that find themselves in the same category. That has to do with a major question of what is custodial care and what is skilled care. I understand that your department determined that Andy Cox, who served in the military honorably for 22 years, only needed custodial care. In other words, put him in a warehouse someplace and forget about him until he dies. We think he has shown considerable improvement since his injury.

He was bedridden, unable to communicate or do anything. Today Andy Cox is able to be in Washington, D.C. and has been in this room off and on all day long. So he has improved, and there is hope that he will continue improving.

One of your nurses visited Mr. Cox and was astonished that it had been determined that he was only worth custodial care, because in her opinion skilled care would be appropriate. Have you seen a report from this nurse?

Dr. MENDEZ. I have not seen the report from the nurse. I am aware of the case. Would you like me to comment?

Mr. YOUNG. Please.

Dr. MENDEZ. The Cox case represents to me, on the question of custodial care, truly a great problem. The problem is not purely CHAMPUS, it is also Medicare. It is a problem with chronic health care of all people. Although they may not get better or their medical requirements are low, these people nevertheless have a requirement to maintain a quality of life, and, that speaks to health from a different perspective.

Definitionally, you ask what I understand custodial care to be. It is basically when a person is mentally or physically disabled and the disability is expected to be prolonged. Besides being prolonged, it is expected to continue. It is when that individual requires a monitored or a protected or a controlled environment, requires assistance for the essentials of daily living, bathing, and so on; and is not under active medical or surgical or psychiatric treatment that will reduce his or her disability. When the determination, therefore, is that there is no further reduction of disability with medical therapy, then that individual is considered an individual under custodial care. That is a definition. The definition sounds almost bureaucratic, but that is my understanding of the definition.

The question, you see, as we look at the law and my attempt at trying to implement it is the question of custodial care. That question also comes up with Medicare. There is Veterans Administration support that offers nursing home care but, in general, commercial health plans have not followed the thrust of the VA in terms of custodial care.

I too believe that is a problem. The answer is yes in terms of resolution. I believe that the CHAMPUS definition to that effect is probably no different than other definitions of custodial care.

Mr. YOUNG. If your department determines that a patient is a custodial care patient, does that mean you have written him off? Dr. MENDEZ. No. CHAMPUS continues to cover all necessary and appropriate medical prescriptions. They will pay occasional skilled nursing services-occasional means a visit per day of one hour. It also pays for some physician visits for appropriate monitoring of

the patient's condition, but it is restricted to medical care as it sits

now.

Mr. YOUNG. In the case of Andy Cox, there is no question that he benefits from therapy, but I understand that under custodial care he is not eligible for therapy, but that under skilled care he would be eligible for therapy. Do you see that as a problem in the way the rules are written?

Dr. MENDEZ. Under custodial care, he would be eligible for therapy.

Mr. YOUNG. We understand that is not the case.

Dr. MENDEZ. I would be happy to recheck it also, Mr. Young.

Mr. YOUNG. We can't proceed if the regulations are different. We would like to have a clarification because it is our understanding and the Coxs' understanding that under custodial care he is not eligible for therapy.

[The information follows:]

With the custodial care exclusion in law, when a patient has been defined as custodial, services such as physical, occupational and speech therapies are no longer covered under the CHAMPUS basic program. The only services covered under this program for custodial patients are prescription drugs, medical supplies and equipment, one hour per day of skilled nursing services, and monthly physician visits. The basic program is cited because a broader range of therapies and non-medical services, such as institutionalization are available for custodial patients under the Program for the Handicapped. This special program is limited by law to the dependents of active duty members and the maximum government payment is generally $1,000 a month.

A patient is defined as a custodial care patient when the patient is disabled mentally or physically and the disability is expected to be prolonged; when the patient requires a protected, monitored or controlled environment in an institution or at home; when the patient needs help with the activities of daily living, such as bathing, eating and dressing; and, when the patient is not receiving active and specific treatment to reduce the disability to the extent necessary to permit the patient to function outside the protected, monitored or controlled environment.

Custodial patients are those who require long-term maintenance, assistance and support. Given the advance in trauma care, many of these patients require elaborate, expensive and high intensity life-support and similar services. Obviously, the long-term care patient bears a considerable degree of the cost of care.

The question of long-term care benefits is not unique to CHAMPUS or the Department of Defense. Exclusion of custodial care is virtually universal in health insurance, including Medicare and Federal Employees Health Benefits Plans. Specific long-term care health insurance policies have only recently begun to be marketed but they are expensive, with annual premiums of up to $5,000. Medicaid covers some custodial care, but only for those whose income and assets are low enough to meet Medicaid eligibility requirements, which vary by state. We have found through our CHAMPUS case management demonstration that, even if CHAMPUS cannot provide significant financial relief directly to custodial patients, we are sometimes able to identify public or private, community-based sources of services or funding that can assist patients to a considerable degree. We are planning to expand case management services nationwide.

Mr. YOUNG. The language we put in our bill last year we thought pretty much solved the problem for some 9,000 people who fit into Andy Cox's category. The authorizing committee's was a little different. They used the phrase "benefits less benefits". Can you explain what that means?

Dr. MENDEZ. I can't. My understanding was that one of the things that led to the tardiness-at least that is my word-of implementation was, indeed, the differences between the two Acts. One spoke to October 1, the other spoke to a time subsequent to that.