Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
Department of Veterans’ Affairs
Analysis of
Submissions for the
Review of War Caused
Disabilities and
Pharmaceutical Costs
October 2010
This report contains 30 pages
Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
Contents
1 Executive Summary 3
2 Reason for the Review 4
2.1 Snapshot of the veteran community 4
2.1.1 Veteran culture 4
2.1.2 Veterans‟ health 5
2.1.3 DVA benefit recipients 6
2.2 Policy context 6
2.3 Services provided to veterans 8
2.4 Consultation paper 8
2.4.1 Policy and practical issues 8
2.4.2 Data quality and information management 8
2.4.3 Implications for prescribing doctors 9
2.5 Possible options to address the Government‟s commitment 9
2.5.1 Option 1 10
2.5.2 Option 2 11
3 Submissions analysis 13
3.1 Methodological approach 13
3.2 Summary analysis of respondents 13
3.3 Option and theme comments 15
3.3.1 Option 1 15
3.3.2 Option 2 16
3.3.3 Variations or alternative proposals/mechanisms 16
4 Summary 20
A Acronyms 21
B Definitions 22
C Coding Framework 24
D Summary statistics 25
D.1 Submission statistics 25
D.2 Option statistics 25
D.3 Theme statistics 26
E Veteran services relevant to the Review 27
E.1 Income support pensions 27
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
E.2 Disability compensation pensions 27
E.3 Health care 27
E.4 DVA Health care cards 28
E.5 Rehabilitation 28
E.6 Counselling 29
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
1 Executive Summary
This project forms part of the Australian Department of Veterans‟ Affairs (DVA) review (the
Review) into the cost of pharmaceuticals for war-caused disabilities. The focus of the Review
was to examine pharmaceutical usage, subsidy arrangements, and out-of-pocket costs for those
conditions which were caused by war, or linked to war-caused disabilities.
The Review was initiated as a result of a 2007 election promise by the Australian Government
to address the concerns of the veteran community, relating to the growing gap between the DVA
Pharmaceutical Allowance (PA) and the cost of the concessional pharmaceutical co-payment
paid by veterans for each prescribed medication available under the Repatriation Pharmaceutical
Benefits Scheme (RPBS).1 Many men and women who have served Australia in wars and
conflict zones have been placed at greater risk of particular diseases, exacerbated certain
conditions, or newly acquired physical or mental disabilities.2
The Review determined that a literal interpretation of the Government‟s commitment to directly
link veterans‟ pharmaceutical use to their war caused disabilities was not practical. This is due
to the implementation and operational difficulties that would be caused by data inconsistencies
and the need for supporting infrastructure, as well as the resource-intensive nature of the
process. The Review also highlighted a number of knowledge issues for prescribing doctors and
the dispensing pharmacists.
In response to the above concerns, the Government released the Consultation Paper for the
Review of War Caused Disabilities and Pharmaceutical Costs in May 2010 identifying two
options which are in keeping with the Government‟s commitment – with both options going
beyond the Government‟s commitment for many of the veterans affected. The veteran
community (individuals and organisations) was encouraged to consider the findings of the
Consultation Paper and to have their say by making a submission.
The analysis of public submissions indicate that of the two options put forward, Option 1 had
more support than Option 2 – particularly by Ex-Service Organisations. Option 1 was seen to
offer greater simplicity, ease of comprehension and possible cost savings to Government in the
long term.
Those respondents that did not directly support either Option either expressed a preference for
“free, up-front” pharmaceuticals and/or a relaxation of the eligibility requirements to all
veterans with disabilities; or offered an alternate proposal/mechanism.
1
Australian Government. Consultation Paper for the Review of War Caused Disabilities and Pharmaceutical Costs,
May 2010. Available from: ,
accessed July 2010
2
Australian Institute of Health and Welfare, Health care usage and costs: a comparison of veterans and war widows
and widowers with the rest of the community, December 2002. Available from:
, accessed July 2010.
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
2 Reason for the Review
The Australian Labor Party acknowledged the view in the ex-service community that
pharmaceuticals required for war-caused disabilities should be at no cost to the veteran, with a
2007 election commitment to:
“…review this matter in the first term of Government and to establishing, in consultation
with the ex-service community, a fair solution that relieves the burden on veterans of the
cost of medication to treat their war-caused disabilities.”
This section provides an overview of the veteran community, policy context and services
available to veterans. This is followed by a summary of the Consultation Paper for the Review
of War Caused Disabilities and Pharmaceutical Costs and an outline of the two options put
forward to address the Government‟s election commitment with worked examples of each.
2.1 Snapshot of the veteran community
Veterans often identify themselves as separate or different from the general community in
which they live. This is due to their personal experience with military service, their insights into
war and war-like situations; their changed knowledge of the world following their service and
the strength of their connection to the past.
2.1.1 Veteran culture
According to DVA, culture “profoundly affects the way we feel about ourselves, gives purpose
to our lives and provides essential characteristics and character for the group and individuals
who subscribe to the culture.”3 Veterans form their own distinctive cultural group, as the
hardship and history they have experienced serving overseas or in Australia was often a defining
experience in their lives. Cultural attributes often demonstrated in the veteran community
include:
bonds of mateship formed in times of danger;
commemoration of sacrifice of the fallen;
provision of welfare support for their mates and the wives and dependants of deceased
comrades;
high membership of ex-service organisations and other social groups; and
participation in commemorative activities, such as Anzac Day and Remembrance Day.4
3
Ibid.
4
Department of Veterans‟ Affairs website. Available from:
, accessed July 2010.
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
Veterans‟ worldviews are strongly influenced by these cultural influences, and affect the way
they live and the choices they make about their health and health cover.
2.1.2 Veterans’ health
Consistent with the findings from the 2002 Australian Institute of Health and Welfare (AIHW)
study5, veterans have higher rates of a wide range of health risk factors compared to their non-
veteran counterparts. According to DVA research findings,6 veterans are more likely to
experience a short or long-term illness, develop cancer or suffer from diseases of the digestive,
nervous, circulatory and musculoskeletal systems. Veterans are also prescribed more
medications than non-veterans, even allowing for disabilities.
Further, the AIHW study found that health care costs for Gold Card veterans were higher than
for the rest of the community of similar age, and that this difference was entirely attributable to
service related disability. Additional analysis conducted as part of the Review confirmed that
pharmaceutical usage is particularly high for veterans on some of the higher rates of disability
pension.
Several research studies have been conducted by AIHW into the health of veterans since 1992
with consistent findings for veterans‟ overall health and wellbeing and health/social services
usage. For example, one study examined the incidence of cancer experienced by Australian
male veterans of the Korean War compared with that experienced in the Australian community
for the period 1982–1999. Results indicated that Korean veterans experienced a significantly
greater overall cancer risk than the Australian community, with an excess of between 13 percent
and 23 percent, and varying significantly in the pattern across services.7
Another study investigated mortality rates among Australian male veterans of the Korean War
from their last day of service in Korea to 31st December 2000, as compared to the corresponding
rates for the general Australian male population of the same age. The study demonstrated that
participation in the Korean War is associated with an overall increase in mortality of 21 and an
increase in cancer mortality of 31 percent.8
In terms of mental health, the veteran community experience increased rates of mental health
conditions compared to the general community. DVA statistics indicate that more than a quarter
of the treatment population have mental health issues, about half of which are accepted as being
due to military service.9 Veterans have much higher rates of conditions such as post-traumatic
stress disorder, although this diagnosis might not have been made in older veterans. War-related
5
Australian Institute of Health and Welfare (2002) Health care usage and costs: a comparison of veterans and war
widows and widowers with the rest of the community. Available from:
, accessed July 2010.
6
Department of Veterans‟ Affairs website. Available from:
, accessed July 2010.
7
Australian Institute of Health and Welfare (2003) Cancer incidence study: Australian veterans of the Korean War.
Available from: , accessed July 2010.
8
Department of Veteran Affairs (2003) Mortality study: Australian veterans of the Korean War. Available from:
, accessed July 2010.
9
Department of Veterans‟ Affairs website. Available from:
, accessed July 2010.
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
memories may have a negative effect on those with dementia, a critical issue in care planning
for older veterans.10
2.1.3 DVA benefit recipients
As of 30 June 2009, DVA beneficiaries numbered 394,810. Within this, veterans numbered
185,214 and war widows and widowers 104,760. The remainder comprise dependants (mostly
service pension spouses) and widows with children and orphans making up a small proportion.
A large majority of the DVA veteran population is comprised of older adults (65 years and
over). As of March 2010, there are approximately 260,000 veterans and war widow/widowers
with health cards (known as the Treatment Population), with 122,000 veterans receiving a DVA
disability pension.
The Treatment Population consists of eligible veterans, widow(er)s and dependants with
entitlement to medical and other treatment at DVA expense under the VEA. Depending on
eligibility, veterans are granted a Gold, White or Orange card to provide access to the RPBS
(these cards are described in further detail in section 2.3.4).11
2.2 Policy context
In recognition of the specific health concerns of veterans, the Repatriation Pharmaceutical
Benefits Scheme (RPBS) was established in 1919 to provide free pharmaceuticals to ex-service
men and women of the First World War and the Boer War.12
The RPBS has continued since, with the aim of providing a wide range of pharmaceuticals and
dressings at a concession rate for the treatment of eligible veterans, war widows/widowers, and
their dependants.13 It is managed by the Repatriation Commission under the Veterans‟
Entitlement Act 1986 (Cth).
The scheme has however progressively tightened over time with the two most significant
changes being:
restricting prescribing of medicines to those listed on the Pharmaceutical Benefits Scheme
(PBS) and a supplementary schedule of items tailored to the particular needs of the veterans
in March 1983; and
introducing a co-payment equivalent to the PBS concessional co-payment in 1991, and
including repatriation beneficiaries within the Safety Net (SN) provisions in January 1992.
10
Department of Veterans‟ Affairs website. Available from:
, accessed July 2010.
11
Ibid.
12
Parliament of Australia website. Available from: , accessed
July 2010.
13
Department of Veteran Affairs website. ,
accessed July 2010.
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
The reasons for the above changes were to ensure the sustainability of the PBS/RPBS, promote
the quality use of medicines, and to share the financial burden of the cost of medicines.14
The concessional co-payment to be paid by veterans was initially introduced at $2.50 per script
in 1991, and has since risen to $5.40 in 2010.
The Pharmaceutical Allowance (PA) was introduced at the same time as the co-payment, and
was initially introduced and indexed to offset the initial co-payment. From September 2009, the
PA was subsumed into both the Pension and Veterans Supplements and is currently at $6 per
fortnight. Although this amount is now not separately identified in the two Supplements, the
notional value of the PA is an important element in the reimbursement model proposed by the
Review. As such, the PA will continue to be referred to as a separate entity in this document.
Changes to the indexation method for the co-payment and one-off increases to it has meant that
the PA is no longer able to offset the cost of co-payments required to reach the Safety Net, with
a gap representing the out-of-pocket cost for veterans. In addition, the Safety Net for both
RPBS and PBS has since risen from the original 52 scripts in 1992 to 60 scripts in 2010.
The result of these policy changes since 1991 has been that veterans are facing increasing out-
of-pocket costs for pharmaceuticals, with this figure set to increase. Future projections indicate
that by 2016, the PA will only cover 40 percent of the maximum cost of co-payments, with
veterans facing out-of-pocket costs of up to $249 per year. This gradual upward trend is
captured in Figure 1 below.
Figure 1: Veteran maximum out-of-pocket expenses over time15
Veteran out-of-pocket expenses over time
180
Veteran (max) out-of-pocket expense ($)
160
140
120
100
80
60
40
20
0
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
19
19
19
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
20
20
Year
14
Australian Government. Consultation Paper for the Review of War Caused Disabilities and Pharmaceutical Costs,
May 2010. Available from: ,
accessed July 2010.
15
Graphical representation of data provided in Consultation Paper for the Review of War Caused Disabilities and
Pharmaceutical Costs, May 2010, p7.)
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
2.3 Services provided to veterans
The DVA provides an extensive range of benefits and services to eligible veterans, current and
former serving members and their families. This report focuses on services provided through the
VEA, while still acknowledging entitlements provided under the MRCA. This is because the
former Act is the relevant legislation for the majority of potential beneficiaries under the
proposed two options. Detailed information on these services and benefits is provided in
Appendix E.
2.4 Consultation paper
The Consultation Paper for the Review of War Caused Disabilities and Pharmaceutical Costs
(the Consultation Paper) was a significant step in delivering on the Government‟s 2007 election
commitment to review the costs of pharmaceuticals required to treat war caused disabilities.
The Review determined that a literal interpretation of the Government‟ commitment to directly
link veteran‟s pharmaceutical use to their war caused disabilities is not practical. This is due to
the implementation and operational difficulties that would be caused by data inconsistencies and
the need for supporting infrastructure, as well as the resource-intensive nature of the process.
The Review also highlighted a number of knowledge issues for prescribing doctors and the
dispensing pharmacists.
These issues are described in further detail below.
2.4.1 Policy and practical issues
The processes and arrangements around subsidising pharmaceutical usage for all veterans with
Accepted Disabilities (ADs) creates a number of significant policy and practical issues for
prescribing doctors, dispensing pharmacists, DVA and Medicare Australia.
Prescribing doctors would require specific knowledge of the veteran‟s AD as recognised in the
DVA system; the ability to link pharmaceutical need to an AD; and prescribing arrangements
would need to be established so that prescriptions could be distinguished as AD or non-AD
related.
Dispensing pharmacists would also require dispensing arrangements which also recognise
prescriptions that are AD or non-AD related.
At an organisational level, both DVA and Medicare Australia would require data and processing
systems that are specifically designed to support doctors and pharmacists with the additional
decision making and administrative arrangements.
2.4.2 Data quality and information management
In order for prescribing doctors and dispensing pharmacists to differentiate between AD and
non-AD required pharmaceuticals, they would require specific knowledge of the veteran‟s AD
as recognised in DVA Information Technology (IT) system. This is problematic, as the DVA IT
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
system was not designed with this application in mind. The records date from the original
compensation claim, with many being manually entered, thus creating accuracy issues.
According to the DVA, analysis of DVA records on departmental databases indicates that all
records were entered into the information system in „free-text‟ and that there were 90,000
distinct values. DVA concluded that this non-standardised approach was due to the same
medical conditions being described in numerous ways.
Further, several ADs are coded according to the International Classification of Diseases (ICD)
format. The DVA noted several inconsistencies between the ICD and the text records, and that
discrepancy correction would be a time and resource exhaustive task. It is also not feasible to
store AD data on DVA treatment cards.
2.4.3 Implications for prescribing doctors
Beyond the policy and practical implications for subsidising pharmaceutical usage for all
veterans with ADs, prescribing doctors face the additional problem of accurately determining
whether a current condition is linked to an AD or not.
Discussions between DVA and GP representatives indicated that few practitioners were aware
of Gold Card veterans‟ recorded ADs. This is problematic as the majority of veterans are Gold
Card holders. The current issues associated with the existing AD data records would have to be
rectified so that GPs can accurately complete prescriptions. Further, GPs may be aware of their
patient‟s AD, however, they may require additional judgement to determine if a current
condition is linked to the AD.
2.5 Possible options to address the Government’s commitment
Due to the policy and practical considerations described above, the Consultation Paper put
forward two possible options to address the Government‟s commitment to respond to the
concerns of the veteran community.
The Government‟s commitment was to address pharmaceutical costs for war-caused disabilities.
This means that in order to be eligible for the two proposed options, veterans must have
Qualifying Service (QS), meaning war-like service. QS is linked to the concept of having
incurred danger from hostile forces, and as such, aligns with the Government‟s commitment.
A further qualification is that eligible veterans must also be in receipt of a disability pension
(DP). DP can result from disabilities obtained during service that is QS, but also as a result of
peacetime services. As such, DP in isolation is not a true indicator of war-like service and a
consequent need for pharmaceuticals for war-caused conditions. Similarly, QS may not have
resulted in an AD and related need for pharmaceuticals.
The target cohort for the two options proposed are therefore veterans with both QS and DP,
meaning those who have war-like service and also have one or more accepted disabilities. The
number of veterans eligible for the disability pension and with QS are estimated to be around
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
80,000 as at September 2010, and would be the beneficiaries under both Option 1 and 2 as
proposed in the Consultation Paper.16 These options are described in detail below.
2.5.1 Option 1
Option 1 is the broader of the two options. Under this option, all veterans with QS and any
percentage of DP would receive reimbursement for all out-of-pocket pharmaceutical costs.
These costs are based on the gap between the cost to individuals of pharmaceutical co-payments
and the value of the Pharmaceutical Allowance (now subsumed into the Pensions and Veterans
Supplements) in a calendar year.
This option does not distinguish pharmaceutical usage which is related to war-caused
disabilities, compared to usage for other health issues. It therefore extends additional assistance
beyond the scope of the Governments commitment.
A worked example of benefits is provided below.
John is a war veteran who actively served in Vietnam. As a result of his service, John now
suffers from depression. He also has severe arthritis which recently developed, and is on a
disability pension of 60 percent. John has significant pharmaceutical costs. He purchases three
scripts each fortnight for medication related to his arthritis and high blood pressure, and to treat
his depression. This means that every year, John requires 78 scripts.
Under Option 1, John will continue to receive the PA of $6 per fortnight, and will continue to
make the co-payment of $5.40 per script.
With John requiring 78 scripts in the year, the first 60 (before reaching the Safety Net
Threshold) will require payment of the co-payment at $5.40, an amount of $324 in the year.
John will also be receiving the PA of $6 per fortnight, or $156 in the same year.
John is therefore out of pocket by an amount of $168 ($324 - $156).
Under Option 1 John will receive the full reimbursement of $168 for this amount.
The benefits of this option are that:
it recognises the view in the veteran community that war veterans should not be out of
pocket for any pharmaceutical costs;
the scheme would be relatively simple to administer; and
the scheme would be relatively easy to communicate to the veteran community.
16
Department of Veterans‟ Affairs (2010) Internal communication.
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
The disadvantage of this scheme is that it financially commits the Government beyond its
original commitment.
2.5.2 Option 2
Option 2 is the narrower of the two options. Although it also does not distinguish
pharmaceutical usage which is related to war-caused disabilities, it does recognise that some
pharmaceutical costs for veterans are for conditions or illnesses that are not war-related. The
level of reimbursement that veterans receive will therefore be adjusted using a proxy, to
take this factor into account.
This will be done by using the DP as a determinant for the amount of reimbursement. For
example, veterans on a DP rate of 50 percent would therefore receive reimbursement for 50
percent of their out-of-pocket costs. Similar to Option 1, veterans must have both QS and be in
receipt of DP to be eligible for this reimbursement.
A worked example of benefits is provided below, using the same scenario from Option 1.
John is a war veteran who actively served in Vietnam. As a result of his service, John now
suffers from depression. He also has severe arthritis which recently developed, and is on a
disability pension of 60 percent. John has significant pharmaceutical costs. He purchases three
scripts each fortnight for medication related to his arthritis and high blood pressure, and to treat
his depression. This means that every year, John requires 78 scripts.
Under Option 2, John will continue to receive the PA of $6 per fortnight, and will continue to
make the co-payment of $5.40 per script.
With John requiring 78 scripts in the year, the first 60 (before reaching the Safety Net
Threshold) will require payment of the co-payment at $5.40, an amount of $324 in the year.
John will also be receiving the PA of $6 per fortnight, or $156 in the same year.
John is therefore out of pocket by an amount of $168 ($324 - $156).
Under Option 2 John will receive a 60 percent reimbursement for his out-of-pocket costs,
being $100.80.
The advantages of this option are two-fold:
it recognises that some veterans‟ pharmaceutical costs are for illnesses or conditions that are
not war-caused; and
it is more cost-efficient for Government.
The disadvantages of this option are that:
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
it does not take into account the actual costs of pharmaceuticals, and assumes that
pharmaceutical costs are linked to DP rates – for example, it does not take into account the
fact that a person on a DP rate of 20 percent may have illnesses or conditions that require
more pharmaceuticals than someone on a DP rate of 60 percent;
the scheme may be harder to administer, involving the additional step of a proxy
adjustment; and
the scheme may be harder to explain to the veteran community.
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
3 Submissions analysis
This section provides an overview of the methodological approach taken to analyse the public
submission received by DVA, an analysis of submission statistics along with key themes and
emerging issues identified.
3.1 Methodological approach
The approach taken to register, code and analyse the submissions involved three key steps:
1 Registration: the registration process excluded any submissions that were not expressly
related to the topic of the Consultation Paper as well as any duplicate submissions.
2 Coding framework: a coding framework was developed (refer to Appendix C) to assist
with qualitative „coding‟ of the content of each submission against options chosen and
identified themes and sub-themes as well as recording any other comments and salient direct
quotes by using free text entries. The coding framework enabled consistency of coding and
analysis as well as quality control.
3 Validation: internal and external validation meetings were held to present and test the
preliminary findings of the analysis and to make adjustments where required. This included
counts on the key themes and issues raised in the submissions and the proportion of
submissions that raised these themes/issues.
3.2 Summary analysis of respondents
The Consultation Paper was released on 7 May 2010 and invited public submissions up to 18
June 2010. During this period, 72 submissions were received – 45 (63 percent) from individuals
and 27 (37 percent) from organisations (primarily Ex-Service Organisations or ESO‟s). The
majority of submissions were less than one page in length.
Of those 72 submissions received, 60 (83 percent) were coded as „valid‟. Most valid
submissions were classified as either „simple‟ (47 percent) or „moderate‟ (52 percent) in
complexity – that is, for simple submissions respondents either agreed or disagreed with Option
1 or Option 2 as presented in the Consultation Paper; with moderate submissions either
suggesting a variation to the presented options or offering alternate proposals/mechanisms
(which were later classified into two main themes).
„Complex‟ submissions were those in which respondents disagreed with both options but
incorporated other detailed information and/or provided several alternatives – only one
submission (2 percent) was classified as such.
Of the total valid submissions received:
Twenty eight percent (17 submissions) preferred Option 1;
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
Eighteen percent (11 submissions) preferred Option 2; while
Fifty-three percent (32 submissions) suggested variations to Option 1 or alternate
mechanisms‟
Of the total valid submissions received from Ex-Service Organisations, Option 1 was more
preferable than Option 2, For individuals, Option 1 was marginally more preferable than Option
2 with the majority proposing variations or alternative proposals These statistics are outlined in
the table below.
Variations or
Submission type Option 1 Option 2 alternative Total
proposals
ESOs 10 6 9 25 (42%)
Individuals 7 5 23 35 (58%)
All submissions 17 (28%) 11 (18%) 32 (53%) 60 (100%)17
Of all the submissions received without clear preference for either Option 1 or Option 2, two
broad themes were identified:
(1) Theme 1: Free pharmaceuticals (i.e. no out of pocket contribution) to veterans. This
theme encapsulates in the broadest sense those veterans who articulated a preference for not
paying for the pharmaceuticals they may need up-front. Submissions under this theme were
further categorised into two sub-themes which primarily concerned eligibility requirements
(scope) as outlined below.
- Sub-theme 1a: Free pharmaceuticals (i.e. no out of pocket contribution) to veterans
with war caused disabilities with Qualifying Service.
This class of submission preferred pharmaceuticals to be free at the time of purchase
at the chemist (that is, no copayment requirement and therefore no need for
reimbursement). This is a preference for a return to the pre-1991 situation when there
was no pharmaceutical copayment requirement for veterans.
- Sub-theme 1b: Extended eligibility together with free pharmaceuticals with no out
of pocket contribution requirements.
This class of submission favoured pharmaceuticals to be free at the time of purchase
at the chemist (that is, no co-payment requirement and therefore no need for
reimbursement) and indicated a preference for the eligibility requirements to be
extended to all veterans with or without QS (i.e. including veterans without war
caused but with service related disabilities). This theme encompassed those veterans
that worked in a serving operational capacity in Australia or overseas, participated in
17
Note: percentages were rounded up or down to the nearest whole percentage (e.g. 53.33% has been rounded to
53%).
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
simulated war exercises, and/or other service related activities; and, in a small number
of submissions, to non-veterans such as war widows, orphans and dependants.
Some 62 percent of those submissions proposing a variation were categorised as Theme 1.
(2) Theme 2: Alternative proposals/mechanisms. This class of submission provided new
proposals/mechanisms. The new proposals/mechanisms covered a range of alternative
suggestions to the two options proposed in the Consultation Paper, including broad changes
to the Pharmaceutical Allowance, the Safety Net Threshold and Treatment Card
entitlements.
Some 38 percent of those submissions proposing alternative approaches were categorised as
Theme 2.
3.3 Option and theme comments
3.3.1 Option 1
For those respondents that selected Option 1, some highlighted the simplicity, ease of
comprehension and possible cost savings to Government over time of this option compared
with Option 2.
“Simplicity is paramount. The complications of option 2 would lead to much more
confusion and trouble than any monetary savings might be worth.”
“We acknowledge that (Option 1) would extend additional assistance beyond the scope of
the Government's commitment, but in view of its simplicity it may actually result in
savings over Option 2.”
However, there were respondents who selected Option 1, believing that this Option only goes
some way in addressing pharmaceutical needs of eligible veterans.
“Option 1 offers the better outcome for those eligible and meets the criteria of the
government commitment however neither option solves the long standing problem of the
erosion of an entitlement that ex-servicemen and women and war widows once had.”
Some respondents noted what they thought were shortcomings with the alternate option (Option
2), when selecting Option 1. For example, one respondent noted that:
“Option 2 is administratively cumbersome and is less fair in that DP recipients below
those on 100% do not get the full flow on. There will also be many veterans on lower
rates of DP who have conditions requiring high volumes of medication.”
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
3.3.2 Option 2
For those respondents that selected Option 2, some highlighted the perceived „fairness‟ of this
option as it was thought to take into account a veteran‟s level of disability that most accurately
reflects the degree of need.
“After reading the Consultation Paper for the Review of War Caused Disabilities and
Pharmaceutical Costs and giving deep and thorough consideration to both Options, I
believe that the second option is the fairest. The weighting of this option by percentage of
disability ensures that those most affected by their Qualifying Service are justly
recompensed for the cost of Pharmaceuticals required to treat their related
injuries/conditions.”
“I think both Option 1 and Option 2 defined in the Review Paper have merits, but if the
costs for administering either are similar, then Option 2 would be the one I would
personally adopt as most accurately meeting the need.”
3.3.3 Variations or alternative proposals/mechanisms
A greater proportion of total valid submissions suggested variations to Option 1 or alternative
mechanisms for consideration. Analysis of this group of submissions identified two high level
themes. Theme One‟s underlying premise was for modifying the benefits scheme – both in
terms of the payment model and eligibility criteria. Theme 2 explores the alternate
proposals/mechanisms suggested. These themes are detailed further below.
Theme 1a
Those submissions highlighting the preference for free pharmaceuticals (i.e. no out of pocket
contribution) to veterans with war caused disabilities with Qualifying Service were classified
as Theme 1a.
Respondent views supporting this theme included the following.
"Of critical importance is that the Government move to a position where its policy and
administration are based on a return to the clear undertaking of successive Governments
since the inception of the Repatriation system is to provide full treatment of war-caused
disabilities to Veterans at no cost to them."
"The most simple, effective and equitable option to restore a commitment to full treatment
of Veterans' war-caused disabilities at no cost to the Veteran is simply to abolish the
requirement for payment of any amount at all for medicines prescribed for Veterans in
receipt of a disability pension."
“If injuries/illness are verified by the relevant Government Authorities as being service
related, then doctors should be able to issue pharmaceutical scripts which allow the
injured person to receive medication free from Pharmacies, and those Pharmacies then
forward to DVA/MCRS for payment.”
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
The significant difference between Theme 1a and Option 1 as proposed in the Consultation
Paper is that the former is not based on a reimbursement model. For this option to be fully
implemented, the co-payment and the PA would have to be abolished, and pharmaceuticals
would be provided free of charge in the first instance.
Theme 1b
Those submissions highlighting the preference for „uncapped‟, „unlimited‟, „free‟
pharmaceuticals to all veterans with service related disabilities with or without QS were
classified as Theme 1b.
This theme encompasses an extension of veteran eligibility to those that worked in a serving
operational capacity in Australia or overseas, participated in simulated war exercises, and/or
other service related activities; and to non-Veterans. Ethical and just responses by Government
were also highlighted in submissions categorised under this theme with a strong suggestion that
Government has a moral duty to care for the veteran community, which extends to veterans not
incurring any out-of-pocket pharmaceutical costs due to their service.
"I suggest that the allowance of $5.80 per fortnight be discontinued and all medications
required for war caused/related conditions be provided at no cost to the veteran.”
Many respondents commented on the entitlement between those with war service (QS) and
those without within the veteran community. A range of views were expressed on this eligibility
definition with common themes of belonging to a „unified military force‟ which should include
those without QS with minimisation/elimination of out-of-pocket expenses. Examples of these
views include the following.
“… [the Consultation Paper deals] with war caused injuries or diseases only. The
[organisation‟s] policy is that all accepted disabilities, not just war caused, should have
a no cost pharmaceutical entitlement."
“the Government is breaching their contract with former ADF members, for whom they
agreed to provide lifelong support should they be injured as a result of their service,
without distinguishing between „war-caused injuries‟ and otherwise.”
It was also noted that many training injuries have been sustained while performing tasks within
a simulated combat environment. The concept of the training simulation at this level is to be as
realistic as possible, and as such, the risk of personal injury is as high as if the task was real.
"...consideration of the medical and pharmacological treatment needs for those members
that have been injured within a pre-deployment environment (e.g. during peace time
and/or non-war like service) including the normal Special Forces training regime."
Expansion of the eligibility criteria to those who are not veterans was also highlighted by some
respondents to include war widows, orphans and dependants, who by definition are not
veterans.
“…. that war widows and orphans must be included, together with veterans.”
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
For example, one respondent endorsed Option 1 but proposed an extension of the target
population to include dependents with the rationale that war widows and orphans were
considered to be unfairly excluded, given that there is some evidence that utilisation rates
(including pharmaceutical needs) for war widows and veterans who hold Gold Cards are
similar. It was also thought that Option 2 would not be amenable to allowing widows and
dependants to be included and would be harder to administer; and in the longer term, it may
mean that Option 2's potential costs savings to Government could be eroded.
“It is submitted that the death of a veteran is the ultimate war-caused disability (for the
dependent)…finally, the treatment for all conditions with the Gold Card has never been
differentiated between veterans and dependents…to introduce a difference in eligibility
for pharmaceutical benefits would be discriminatory and unfair”
Theme 1b is ultimately the broadest possible variation as it does not distinguish between those
with and without QS. It is again similar to Option 1, although with the expansion of veteran
eligibility; and as with Theme 1a, it is not based on a reimbursement model.
Theme 2
Those submissions suggesting an alternative option(s)/proposal(s) to that of Option 1 or Option
2 were classified as Theme 2. These alternate options/proposals encapsulated the different ideas
offered, whether as a simple statement of intention, or a considered alternative. The alternative
options/proposals covered a range of suggestions to the two options proposed, including broad
changes to the Pharmaceutical Allowance, the Safety Net Threshold and Treatment Card
entitlements.
Distinguishing between different veteran card holders
It was suggested that all disabled Gold Card holders receive a total exemption for all
pharmaceutical costs, with no distinguishing between those with QS and those without. It was
thought that veterans with disability with White Cards and war widows should be granted an
annual reimbursement co-payment, on a percentage basis, pro rata, paid into their fortnightly
pension. Further, the respondent did not agree with QS being a condition of the two options.
Another suggestion indicated that the PA should be removed and that all Gold and White Card
holders should receive prescription medicine free of charge. The respondent added that all other
cardholders and war widows should still pay a capped co-payment, with a reduced Safety Net
threshold.
Changes to the current benefits scheme
The following points highlight suggestions made by respondents that involve changes to the
current benefits scheme. These suggestions were primarily clustered around the PA amount,
Safety Net Threshold and the nature of payment mechanisms – prospective versus retrospective
and additional payments to cover more costly illnesses. Suggestions included the following.
One respondent contended that the current PA is insufficient to meet pharmaceutical costs
for veterans and should be increased.
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
“The PA should be increased to either $25 or $30 (the figure to be subject to subsequent
indexation) per fortnight in order to offset rising medication costs.”
Another respondent suggested capping the current co-payment per script at $5.40 and
reducing the Safety Net Threshold to 52 scripts per year.
“Illnesses, disabilities and disease that are currently not counted as ADs but that may be
a „follow-on‟ should also be included within the scheme.”
Another respondent noted that the current Safety Net presented challenges for some
veterans, with repeat prescriptions within 20 days not currently counting towards the Safety
Net, or free if the Safety Net has been reached. The respondent indicated that the current
configuration of the Safety Net presents problems for veterans in remote areas who cannot
access a chemist regularly, or for those who travel to remote areas where chemists do not
carry a full range of pharmaceuticals.
Another suggested alternative was for veterans to receive excess payments above the
general allowance if they have a 'costly' condition/illness. It was thought that the
introduction of ongoing single-issue prescriptions that cover multiple subscriptions, to
reduce the costs of seeing a doctor for single prescriptions would be beneficial.
One respondent suggested that all veterans should receive a prospective lump sum payment
on the 1st of January each year that is equal to the maximum out-of-pocket expenses for the
coming calendar year, and that the payment be adjusted each year. In addition, it was
suggested that all veterans should receive a one off ex-gratia payment that is to be made
prior to 1 January 2011 to recognise the unintended consequences of previous legislation.
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
4 Summary
The findings from the analysis of public submissions indicate that a majority would prefer a
return to the PBS/RPBS policy arrangements that were in place before 1991 (that is, prior to the
introduction of the pharmaceutical copayment, when pharmaceuticals were free for all
concessional beneficiaries).
Given this, of the two options provided, there was more support for Option 1 (28 percent).
This option was seen to offer greater simplicity, ease of comprehension and possible cost
savings to Government in the long term. Submissions in support of Option 2 (18 percent)
highlighted the perceived ‘fairness’ of this option.
Of submissions received from ESO‟s, there was clearer support for Option 1, although a number
indicated that this choice was made „reluctantly‟ – a qualification that represents a belief in the
veteran community of a broader Government responsibility for the health needs of all veterans.
Of the submissions from individuals, a significant number of respondents preferred a return to
the pre 1991 arrangements.
Of the remaining submissions, 53 percent suggested variations to Option 1 or offered alternate
proposals/mechanisms. Analysis of this group of submissions identified two high level themes.
Theme 1: Free pharmaceuticals (i.e. no out of pocket contribution) to all disabled veterans
(62 percent); and
Theme 2: Alternative proposals/mechanisms (38 percent).
Theme 1 was expressed primarily in two sub-themes identified from the submissions;
Those highlighting the preference for free pharmaceuticals (i.e. no out of pocket
contribution) to veterans with war caused disabilities with QS (sub Theme 1a); and
Those highlighting the preference for „uncapped‟, „unlimited‟, „free‟ pharmaceuticals to all
veterans with service related disabilities with or without QS (sub Theme 1b).
Theme 2 were those submissions that encapsulated different ideas, whether as a simple
statement of intention, or a considered alternative. Alternate proposals/mechanisms included:
distinguishing between different veteran cardholders to determine appropriate benefits; and
amending the current scheme around the PA amount, Safety Net Threshold and the nature of
payment mechanisms – prospective versus retrospective and additional payments to cover
more costly illnesses.
In summary, of the two options proposed, 28 percent of all submissions selected Option 1
while 18 per cent selected Option 2 as the more preferable option. Fifty three percent of
submissions suggested variations or alternative proposals. The analysis identified Theme 1 as
variations to Option 1, with Theme 2 identified as support for a range of alternative methods of
reducing pharmaceutical costs to veterans.
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
A Acronyms
AD Accepted Disabilities
CPI Consumer Price Index
DP Disability Pension
DVA Department of Veterans‟ Affairs
EDA Extreme Disablement Adjustment
ESO Ex-Service Organisations
GP General Practitioner
INT Intermediate Disability Allowance
ISS Income Support Supplement
LMO Local Medical Officer
MBS Medicare Benefits Scheme
MRCA Military Rehabilitation and Compensation Act (2004)
PA Pharmaceutical Allowance
PBS Pharmaceutical Benefits Scheme
QS Qualifying Service
RPBS Repatriation Pharmaceutical Benefits Scheme
SN Safety Net
SNT Safety Net Threshold
TPI Totally and Permanently Incapacitated
TPOP Treatment Population (DVA specific)
TTI Temporarily Totally Incapacitated
VEA Veterans‟ Entitlements Act (1986)
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
B Definitions
TERM DEFINITION / DESCRIPTION
The Repatriation Gold Health Card is issued to Australian Defence
Force Veterans, their widows/widowers and dependents. Gold
Cardholders receive treatment for all medical conditions, access to
the RPBS, assessment for services through Veteran‟s Home Care,
Gold Card
and they receive a Seniors Concession Allowance. Eligibility
criteria are exhaustive, for example, WW1 veterans and nurses,
EDA pensioners, and veterans receiving a disability pension of
100% or more of the general rate.
The Repatriation White Health Card is issued to veterans or
mariners of Australia‟s Defence Force with an accepted war or
serviced caused injury or disease, as well as other specific
White Card diseases, whether war caused or not. For example, post traumatic
stress disorder. White Card Holders receive free treatment for the
specific accepted condition, and they are eligible for assessment
for services through Veteran‟s Home Care.
The Repatriation Orange Health Card is issued to Commonwealth
and Allied veterans and mariners, who have Qualifying Service
from WW1 or WW2, are over 70 years of age, or who have been
Orange Card an Australian resident for over 10 years. Orange Card holders
receive prescribed medications at a concessional rate per item, and
free prescriptions once the annual safety net threshold has been
reached.
In line with the Veterans' Entitlements Act 1986 (VEA), war
caused conditions include injuries or diseases caused or aggravated
War Caused Conditions
by war service or certain defence service rendered on behalf of
Australia before 1 July 2004.
Qualifying service is defined in the VEA and is one of the criteria
used to determine if you are eligible for a service pension. Defence
Force members have rendered qualifying service if they:
rendered service during World War 1 or World War 2 and
incurred danger from a hostile force; or
Qualifying Service
served in an operational area after WW2 and were allotted
duty, or were a member of a unit that was allotted duty in that
operational area; or
have warlike service; or
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
TERM DEFINITION / DESCRIPTION
are being paid a pension in respect of injury or death resulting
from an occurrence on or after 31 July 1962 as a result of
action by hostile forces or warlike operations against hostile
forces, outside Australia; or
have been awarded, or were eligible to be awarded, a
medal/clasp listed in the „Bomb Clearance or Minesweeping
Clasp‟.
The Safety Net 20 Day Rule supports the responsible use of PBS
entitlements by discouraging people from obtaining supplies of
medicines earlier than they are needed.
This rule was designed to assist in reducing the “stockpiling” of
PBS medicines that occurred towards the end of each calendar
year when many people reach the Safety Net, and promote the
quality use of medicines (QUM).
Safety Net 20 Day Rule
If a medicine is resupplied within 20 days of a previous supply of
the same medicine:
the co-payment will not count towards the Safety Net
Threshold tally; and
if the threshold has been reached, the usual copayment amount,
not the reduced Safety Net co-payment amount, will apply.
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
C Coding Framework
CODING
DEFINITION
CATEGORY
Respondent agrees with Option 1 or 2 as presented in the Consultation
Simple Paper; or disagrees with both options with no other alternative
suggested. (Coded 1).
Respondent does not agree with either option as presented, but suggests
Moderate
variations or alternative approaches (Coded 2).
Respondent does not agree with either option as presented, incorporates
Complex other detailed information and/or suggests variations or alternative
approaches (Coded 3).
Respondent‟s submission does not specifically address the issues and/or
Invalid options raised by the Consultation Paper and/or provides insufficient
information for analysis. (Coded 0).
CODING THEMES DEFINITION
Theme 1 Free pharmaceuticals (i.e. no out of pocket contribution) to veterans.
Free pharmaceuticals (no out of pocket contribution) to veterans with
war caused disabilities with Qualifying Service.
Theme 1a
(That is, „uncapped‟, „unlimited‟, „free‟ pharmaceuticals to veterans
with war caused disabilities with QS.)
Extended eligibility together with free pharmaceuticals with no out of
pocket contribution requirements. (That is, „uncapped‟, „unlimited‟,
„free‟ pharmaceuticals to all veterans with service related disabilities
with or without QS).
Theme 1b
This theme encompasses those that worked in a serving operational
capacity in Australia or overseas, participated in simulated war
exercises, and/or other service related activities; and to non-veterans.)
Theme 2 Alternate proposals/mechanisms suggested (free text).
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
D Summary statistics
D.1 Submission statistics
DESCRIPTION NUMBER PERCENTAGE
Total number of submissions received 72 100%
Number of submissions received from individuals 45 63%
Number of submissions received from organisations 27 38%
Number of valid submissions received 60 83%
Number of invalid submissions received 12 17%
Number of „simple‟ submissions received 28 47%
Number of „moderate‟ submissions received 31 52%
Number of „complex‟ submissions received 1 2%
D.2 Option statistics
DESCRIPTION NUMBER PERCENTAGE
Option 1 chosen 17 28%
Option 2 chosen 11 18%
Neither Option 1 or Option 2 chosen (but variations or
32 53%
alternative proposals/mechanisms suggested).
TOTAL 60 100%
Note: percentages were rounded up or down to the nearest whole percentage (e.g. 28.33% has been rounded to 28%)
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
D.3 Theme statistics
DESCRIPTION NUMBER PERCENTAGE
Theme 1 – Free pharmaceuticals (i.e. no out of pocket
20 62%
contribution) to veterans.
Sub-theme 1a: with QS 5
Sub-theme 1b: with or without QS 15
Theme 2 – New option/proposal provided (free text) 12 38%
TOTAL 32 100%
Note: percentages were rounded up or down to the nearest whole percentage (e.g. 21.66% would be rounded to 22%)
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
E Veteran services relevant to the Review
E.1 Income support pensions
There are a variety of income support payments available to the ex-service community. The
service pension provides a regular income for people with limited means. A service pension can
be paid to veterans on the grounds of age or invalidity, and to eligible partners, widows and
widowers. It is subject to income and assets tests. Service pensions are available at an earlier
age than the age pension paid by Centrelink, in recognition of the intangible effects of war that
may result in premature ageing of the veteran and/or loss of earning power.
Income Support Supplement (ISS) provides a regular income in addition to the war widow‟s or
widower‟s pension for Australian war widows and widowers with limited means. The payment
is subject to income and assets tests.
Supplements and allowances which may be paid in association with service pension and ISS
include pension supplement, rent assistance and remote area allowance.
E.2 Disability compensation pensions
The disability pension is a tax-free benefit paid to Australian veterans who have had an illness
or injury accepted by the DVA as being caused by their service. The DP rate depends upon the
severity of the illness or injury, and veterans who are unable to work solely because of the
effects of their service related disability may receive the pension at a special rate (also known as
Totally and Permanently Incapacitated (TPI)).
Supplements and allowances, which can be paid in associated with the disability pension,
include clothing allowance, attendant allowance, recreational transport allowance, and
recognition of certain medals and decorations.
E.3 Health care
A broad range of health care and support services are available to eligible veterans and
dependents. Various health service providers provide services on behalf of DVA. Aside from
pharmaceuticals available through the RPBS, other Health care and support services include:
general practitioner (GP) services;
specialist services including pathology and radiology;
podiatry, physiotherapy and other allied health services;
dental care;
community nursing;
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Department of Veterans’ Affairs
Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
spectacles and hearing aids;
care in public and private hospitals;
home support services;
optometric;
aids and appliances; and
transport assistance.
E.4 DVA Health care cards
There are a number of different levels of health care entitlement, represented in the form of
different DVA-issued treatment cards.
Gold Card holders (the Repatriation Health Card – For All Conditions) are entitled to all
health care services as well as assistance aids and appliances, at the expense of DVA.
White Card holders (the Repatriation Health Card – For Specific Conditions) are entitled to
the full range of health care services at DVA expense for any disability or illness that is
accepted as service related. A White Card can also be issued for treatment of certain non-
service related diseases and illnesses, such as post-traumatic stress disorder or cancer.
Orange Card holders (Repatriation Pharmaceutical Benefits Card) are entitled to obtain
prescribed medications at a concessional rate per item (currently $5.40 per item) and free
prescriptions once they reach the annual safety net limit (currently $324 or 60 prescriptions
for a calendar year).18
E.5 Rehabilitation
The DVA provides rehabilitation services for any illness or injury resulting from Australian
Defence Force service that has been accepted under the SRCA or the MRCA. Rehabilitation
services might include medical treatment, the provision of special equipment, or vocational
rehabilitation for employment purposes.
The Veterans‟ Vocational Rehabilitation Scheme (VVRS)19 provided under the VEA is
voluntary vocational rehabilitation scheme which assists eligible veterans who require
assistance in returning to paid work, to increase work hours, or for those who are finding it
difficult to maintain or seek employment.
18
Department of Veterans‟ Affairs. Overview of cards available to veterans and their dependants. DVA Factsheet
IS160.
19
Department of Veterans‟ Affairs. Veterans Vocational Rehabilitation Scheme. Available from:
, accessed July 2010.
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Analysis of Submissions for the Review of War Caused Disabilities and Pharmaceutical Costs
October 2010
E.6 Counselling
The Veterans and Veterans Families Counselling Service (VVCS)20 is a free and confidential
counselling service available to veterans of all conflicts and peacekeeping operations, as well as
their partners and dependents. The service provides individual, couple and family counselling,
lifestyle management programs, information and education.
20
Department of Veterans‟ Affairs. Veterans and Veterans‟ Families Counselling Service. Available from:
, accessed July 2010.
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