小李飞刀不能乱发

转贴

1、

2018年12月，齐齐哈尔医学院附属三院因收受患者家属给外院专家的5000元会诊费，被患方以“索要红包”举报。

2、

2019年1月，一网友向甘肃省卫健委投诉，镇原县第一人民医院外请陕西省人民医院专家会诊，院方收取5000元会诊费，没有开票。

3、

2019年4月，徐州沛县中医院骨科医生因向要实施椎间孔镜手术的患者收取了1.1万元外请专家的会诊金及设备耗材费用，被患者家属当成“索要红包”进行了举报。

4、

2019年5月，柳州市人民医院发函为患者请广东省人民医院两位医生前来做心脏瓣膜手术，医院向患方收取了3.5万专家会诊费，没有提供医院的收据。术后家属公开发帖质疑3.5万元会诊费。

……

在外科领域有一个专门的暗语：“飞刀”，形容医生在休息时间飞到其他医院主刀手术的医疗行为。《医师报》记者调查发现，近年来，“飞刀”医生收取的劳务会诊费成为医患纠纷的焦点之一。柳州市人民医院、镇原县第一人民医院、齐齐哈尔医学院附属三院、徐州沛县中医院等多家医院因收取会诊费且未开具收据或发票，被患方以医生“索要红包”为由举报，被举报的医生和涉事医院均被主管部门给予不同程度的处罚。以致于大V@温柔医刀在网上委屈地发声：行善积德的院外会诊，医生为什么像做贼一样偷偷摸摸？

前不久，发生在山西省洪洞县人民医院医生手术室收万元“红包”的事件引发社会的广泛热议，最终调查结果显示，所谓的“红包”是给前来主刀的北京天坛医院专家的会诊费，是经患方同意后收取的。尽管在舆论上，网友对“飞刀”医生一边倒地支持，但由于收取的会诊费并没有经过医院财务科，程序涉嫌违规，该院负责收钱的科主任和北京天坛医院的“飞刀”医生受到不同程度的处罚。令人困惑的是，看起来合情合理的“飞刀”医生会诊费，为什么会被患方以“索要红包”一告一个准？颇受争议的会诊费，到底该怎么收才算合法呢？

现状

政策不少 “飞刀”依然盛行

中国非公立医疗机构协会皮肤专业委员会主任委员、复旦大学附属华山医院郑志忠教授告诉《医师报》记者：“根据《医师外出会诊管理暂行规定》，这种外出会诊手术应该由当地医院对会诊医院发出会诊邀请函，会诊费统一支付给会诊医院，医院在根据单位的管理规定按比例支付给外出会诊的医生。如果未经单位批准会诊或者未在目标医院登记备案多点执业，私自‘飞刀’并向患方收取会诊费，不仅违规还涉嫌非法行医。”

一位不愿透露姓名的骨科副主任反问《医师报》记者：“《医师外出会诊管理暂行规定》出台十几年，多点执业政策也推行好几年，为什么‘飞刀’现象依然盛行？这说明政策没有可操作性。按照规定，医生外出会诊需要经过医院批准，会诊费少的可怜，只有一两百块钱，还要跟医院分。而现在一个三甲医院专家的会诊费少则三五千，多则过万，政策和现实差距太大了。且不说钱多少的问题，院长会同意你往外跑吗？向医院报备太麻烦了。如果能多点执业、医院同意外出会诊最好，可以免除医生的后顾之忧。就算没有也无所谓，该怎么‘飞’还怎么‘飞’，毕竟大多数患者还是通情达理的。”

仅3.2%医师参与多点执业

官方数据显示，目前全国多点执业的医师为11万余名，仅占全国执业医师总人数（339万）的3.2%。然而，相较之下，“飞刀”直到今天依然大行其道。丁香园网站一项3000多名医生参与的调查显示，55％的医生称“所在医院的医生‘飞刀’现象普遍”，近三成医生表示自己曾经“飞刀”过。

华医心诚医生集团董事长、北京大学第一医院霍勇教授认为，多点执业落地难主要是医院管理方面的问题。“因为医生隶属于医院，医院为医生提供奖金、工资、养老保险等，所以医院很难同意医生多点执业。”霍勇建议，国家应完善公立医院人事制度，比如取消编制内外的待遇差别等，只有这样才能真正地推动医生多点执业取得实质性进展。

全国政协委员、中国中医科学院望京医院温建民教授一直呼吁让医生们的外出执业行为“阳光化”，不再陷于“飞刀”的灰色地带。他指出，我国古代的名医就是多点执业，扁鹊在秦国治病、也在齐国治病；当今国际上的医生很多也在多点执业。但在我国当今的各个医院，推行多点执业就像一拳打在棉花上，不抵抗、不执行。私立医院的院长欢迎多点执业，公立医院院长却用各类“土政策”百般阻挠。因此，政府各级行政主管部门应该清查各个医院的有悖国家多点执业政策的“土政策”，加以清理。

浙江省卫生计生委医政处副处长俞新乐表示，医师多点执业虽然在当下受制度、观念、惰性等因素的限制，推进过程中困难重重，但他仍坚信多点执业取代“飞刀”是未来的大势所趋。“只有让制度在阳光下运行，才能最大程度地保障各方的利益。”

甩不掉的“红包”污名

尽管患者便捷地获得了外地大专家提供的优质医疗服务，“飞刀”医生也获得了相对合理的劳动收入。但是因为费用是由主管医生个人代收，自然不可能向患方出具收据或发票；因为劳务报酬是邀请医生私自转交给“飞刀”医生个人，自然也不合乎规定，这就注定了会诊费洗脱不掉“红包”的污名，甚至成为医患关系恶化的导火索之一。一旦患方举报，无论是发出邀请的医院还是医生、或是“飞刀”医生毫无疑问都成了过错方，一告一个准自然毫不稀奇了。

建议

医生自由执业的呼唤


对于如何扭转“飞刀”会诊费身上“红包”的污名，安徽省东至县第三人民医院叶正松认为：“正确的做法是把市场的还给市场，将会诊这一块放开医疗服务的价格管制，拟定一个符合市场价值的会诊价格。同时，进一步打断优质医疗资源垄断、开放医生执业自由大门。”他同时对相关部门处罚“飞刀”医生和基层主管医生的做法表示担忧：如果这条路今后彻底掐死，而暂时又没有开辟一条新的“公路”，可以想象，接下来基层优质医疗资源的下沉，将会真的沦为一句口号。基层患者想获得优质的医疗资源将会付出更大的代价。

那么，是否有能体现医生劳动价值，又合理合法的办法呢？对此，卓壮超声医生集团创始人张梁平认为，私下收会诊费的问题很麻烦，专家会诊，以及医生多点自由执业，可以选择合适的医疗机构平台，医生集团可以出一份账单，开服务费发票给患者，就可以解决这一尴尬困境。

澳大利亚 College of Intensive Care 注册医生Gigi介绍，在世界上多数发达国家，医生都是真正的自由执业者，解决国内“飞刀”医生会诊费合法的问题关键是让医生成为自由执业者。澳大利亚有Locum 医生（临床替班的医生）制度，Locum医生都是正式在澳洲AHPRA 注册的医生，有外科主刀医生、麻醉医生、ICU、急诊科专家，还有很多的主治医生帮忙去各个医院查房。他们利用假期到其他医院工作。比如，一位毕业于中山医科大学的师兄，他的正式工作是政府雇佣的高级毒理药理科学顾问，圣诞节期间去偏远的小镇做急诊科住院值班医生，薪水比正常上班的要高2~3倍。Locum医生制度不仅让医生实现自我价值与经济收入的双赢，也使得患者365天都能享有高质量的服务。

 

 

The state pension is likely to be a key feature of your retirement income, so knowing what it is and how much you will get can help you plan better for the future.

The new full state pension is worth £175.20 a week (or £9,110.40 a year) for the current tax year

The age at which you can claim your state pension rose from 65 to 66 for both men and women in October 2020. It will increase again to 67, and then to 68, over the next few decades. While you may have to wait longer to receive your pension, the good news is that the chancellor recently confirmed that it will keep the generous state pension triple lock – the current system under which pensioners are promised a rise each year in line with the cost of living, average earnings growth or 2.5%, whichever is higher. Maintaining the triple lock is a Conservative party manifesto pledge, but the government had come under pressure to scrap it to save money.

What is the state pension?

This is a regular payment from the government that you can claim when you reach state pension age. But before you think that means your retirement funding is all sorted and paying into a private pension is a waste of money, there are a few things to remember. First, depending on the sort of lifestyle you want to lead, the state pension is unlikely to offer anything more than covering the basics – if that. Even then, not everyone will receive the full amount – currently about £9,000 a year –  and, contrary to popular belief, not everyone gets a state pension.

Who is entitled to it and how much you will be paid depends on how many “qualifying” years of national insurance contributions (NICs) you have built up during your working life. If you have been unable to work for periods of time – perhaps if you had caring responsibilities – or if you have been claiming employment and support allowance or jobseeker’s allowance, you will receive credits instead. 

 

Unlike a personal pension, which you can take at 55 (rising to 57 in 2028), when you can claim your state pension depends on when you were born. The official state pension age is currently 66 for both men and women – and as we all live longer, the age will gradually increase further to ease the burden on government finances.

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The new state pension

In April 2016 a new flat-rate state pension was introduced to make it simpler to understand, but the changes only affect those reaching retirement age on or after April 6, 2016. As a result, there are now two systems to navigate. 

For the new system, you need 35 years of NICs or credits to claim the full state pension and 10 years to get anything at all. For years where you have not been receiving credits or working, you may be able to make voluntary contributions in order to be eligible for the full amount. 

As the new system only went live in 2016, most current retirees are still being paid under the old one. This is divided into two parts: a basic state pension and an additional state pension, also known as the state second pension. Both are based on your previous NICs but the additional state pension also considers your earnings, whether you contracted out of the scheme, and whether you topped up your basic state pension. To get the full basic state pension, you need to have 30 years of NICs. If you have less, you get 1/30th of the full state pension amount for each year of contributions.

The state pension system is run by the Pension Service, which is part of the Department for Work and Pensions. It can help with any questions you have about your pension. 

 

You can check your state pension age and get an estimate of how much you are entitled to by checking your state pension forecast on the gov.uk website.

How much is the state pension?

For those reaching state pension age on or after April 6, 2016, the new single-tier “full level” of state pension is £175.20 a week (or £9,110.40 a year) for 2020-21. If you retired before this date, then the full basic state pension is £134.25 a week. 

How much state pension you’ll actually receive depends on your national insurance record. To claim your state pension at the full rate, you will need 35 years of national insurance contributions by the time you reach state pension age under the new system, or 30 years under the old one. Many people will have built up some additional state pension, based on their earnings during their career, so will get more than the basic state pension. You could also get more if you have deferred your state pension. These amounts go up every year under the triple lock system – more on this shortly – but in April 2020, both increased by 3.9% in line with average earnings. 

It is important to have an idea of how much your pension pots will be worth to help plan for retirement. To check your state pension and get a pension forecast, visit the Pension Service. 

What is the state pension age?

The age at which you can start to claim your state pension from the government is currently 66 for both men and women, but may be different depending on when you were born. When you will reach state pension age involves working it out from the year and month you were born. You can check your state pension age on the gov.uk website.

The age at which you can draw the pension will rise to 67 between 2026 and 2028. It is expected that between 2037 and 2039, the age will increase further to 68 – a government review in 2017 brought these dates forward by seven years. 

Women born in the 1950s have seen the biggest rise in their state pension age, from 60 to 66. Critics say the women were treated unfairly as the government gave them little notice about the change in their state pension age.

How is the state pension calculated?

The state pension is calculated using a formula that takes into account your national insurance contributions and credits when you reach state pension age, and any periods that you were contracted out of the additional state pension – paying less in the way of NICs if you were part of a workplace or personal pension scheme – as well as any additional state pension you may have accrued. 

The state pension is horribly complicated – partly because we have two different systems – but if you want to know the full workings (deep breath), here goes…

Your “starting amount” is based on your national insurance record before April 6, 2016 and is the higher of either what you would receive under the old rules, including your basic state pension and state second pension, or what you’d get from the new state pension.

If your starting amount is less than the full new state pension, you can add more qualifying years to your national insurance record after April 5, 2016, up until you reach the full amount or you reach your state pension age – whichever is first. Each qualifying year will add about £5 a week to your retirement income. 

To achieve the full state pension, you need 35 qualifying years, so the exact amount you will get is calculated by dividing £175.20 by 35 and then multiplying by the number of qualifying years after April 5, 2016.

For example:

• Your starting amount before April 6, 2016 was £120 based on your NIC record.
• You pay for another six qualifying years, adding £30 a week.
• Your state pension will be about £150 a week, though this figure may change once inflation is taken into account.

If your starting amount is more than the full new state pension, the excess is called your “protected payment” and is paid on top. Any qualifying years added after 5 April, 2016 will not provide you with any more state pension.

You usually need at least 10 years of NICs to get any money or 35 years to be eligible for the full state pension, so what you receive will be a proportion of the new state benefit between 10 and 35 years.

For example:

• You have 20 qualifying years
• You divide £175.20 by 35 and then multiply by 20
• Your new state pension will be £100.11 per week.

State pensions currently rise each year in line with the triple lock system. If you receive a protected payment, that will increase only by the consumer prices index (CPI) measure of inflation. 

If you aren’t sure how much you are likely to receive, it takes only 2 minutes to use a pensions calculator to check. It is important to have an idea of what your pension pot is likely to look like when you reach retirement age so you can plan effectively now for the future.

What does ‘contracting out’ mean?

Under the old pensions system, employees could elect to be “contracted out” of the additional state pension, also known as the state second pension, or Serps, in return for a bigger private pension pot: a worker and their employer paid lower national insurance contributions, with extra money going into their personal pension, or an employer-sponsored money purchase scheme, instead. Contracting out ended in April 2016, but it can still affect your state pension entitlement. 

Those who were contracted out for many years might find they get less pension income than they had expected. People qualifying for a state pension under the old system will receive less or no additional state pension if they spent time contracted out, while those reaching state pension age on or after April 6, 2016 will receive a lower “starting amount”.

What is the state pension triple lock?

Back in 2010, the coalition government introduced the state pension triple lock guarantee. The aim was to ensure that pensioners would not see the cost of living or the average wage growth of workers overtake what they received in retirement. The state pension is therefore increased each year in line with whichever is the highest of: 

1. The consumer prices index measure of the rate of inflation
2. Earnings growth (the increase in average wages)
3. 2.5%

The government uses September’s figure of inflation to increase the state pension the following April. In April 2020, the new and older basic state pension both increased by 3.9% in line with average earnings. The state pension is expected to rise 2.5% in April 2021, due to September 2020’s inflation reading of 0.5% and average earnings being lower than a year earlier. This should mean the new flat-rate state pension goes up by £4.40 a week to £179.60 a week next April, while the old basic state pension rises by £3.35 to £137.60 a week.

How do I get a state pension forecast?

A state pension forecast is an estimate of what you are likely to get when you reach state pension age based on your national insurance record. It is not a guarantee of what you will receive and doesn’t factor in the triple lock, but it is still useful for retirement planning. You can check your state pension online using the government’s Pension Service. If you will reach your state pension age in more than 30 days, you can call the Future Pension Centre for a statement or you can fill in a paper application form from the Department for Work and Pensions and send it in the post.

Your forecast will show the number of qualifying years on your national insurance record, including any gaps where you have not made national insurance contributions or received national insurance credits. The forecast will also show an estimate for any contracted-out pension equivalent. Again this is only an estimate, as the exact amount your scheme will pay if you contracted out depends on the rules of your private pension scheme and any investment choices.

Can I carry on working and claim the state pension?

Yes, you can carry on working either full-time or part-time, or doing freelance work, while claiming state pension. 

If you want to work for as long as you can, you could consider deferring your state pension. That way, you will boost the amount you receive each week when you do eventually stop working. For someone reaching state pension age after April 2016, every nine weeks you defer lifts that weekly payment by 1%. That’s a 5.8% boost If you hold off for 12 months. So if you’re entitled to the full £175.20 flat-rate pension, deferring by a year means you’ll get an extra £10.15 a week

Bear in mind that you won’t pay national insurance contributions on your wages if you continue to work past state pension age, but you could end up paying tax on your weekly state pension depending on how much you earn.

Can I boost my state pension?

There are a number of ways to boost your state pension and increase your retirement income.

1. You can choose to make voluntary lump sum contributions to fill any gaps that you might have in your NIC record. It might be you had a job that paid too little to qualify, or your profits were too small as a self-employed person, or you were unemployed and didn’t claim benefits, or you were living abroad, but any gaps will mean you can’t claim the full amount of state pension. For the full basic state pension – for those who reached retirement age before April 2016 – 30 years of NICs are needed; under the new system, 35 full years is the requirement. You have until April 5, 2023 to cover the tax years from 2006-7 to 2015-16, after HM Revenue & Customs (HMRC) extended the usual deadlines. To check your national insurance record, have a look at the HMRC website, where you can also find out if you are able to pay voluntary national insurance contributions and how much this will cost you.  Contact the National Insurance helpline on 0300 200 3500 for more information. You may also be eligible for national insurance credits if you claim benefits because you cannot work, are unemployed or caring for someone full time.
2. Another way to increase the amount you receive in retirement is postponing or deferring your state pension. The longer you can leave it, the higher the payout you will receive when you do eventually claim. For those reaching state pension age on or after April 6, 2016, the payout increases every week that it is deferred, as long as you hold off for at least nine weeks. For each nine weeks deferred, the pension increases by 1%. This means that for every year you delay taking the state pension, it rises by just under 5.8%. 
3. You may also be able to boost your pension if you’re married, divorced, widowed or in a civil partnership. You may be eligible to increase your basic state pension to £80.45 per week as a result of the contributions made by your current or former spouse or civil partner. You might also qualify for the additional state pension or, if you’re on a low income, pension credit.

The Pensions Advisory Service is a free, independent and impartial service that can help you if you are reaching state pension age and have any questions.