小李飛刀不能亂發

轉貼

1、

2018年12月，齊齊哈爾醫學院附屬三院因收受患者家屬給外院專家的5000元會診費，被患方以“索要紅包”舉報。

2、

2019年1月，一網友向甘肅省衛健委投訴，鎮原縣第一人民醫院外請陝西省人民醫院專家會診，院方收取5000元會診費，沒有開票。

3、

2019年4月，徐州沛縣中醫院骨科醫生因向要實施椎間孔鏡手術的患者收取了1.1萬元外請專家的會診金及設備耗材費用，被患者家屬當成“索要紅包”進行了舉報。

4、

2019年5月，柳州市人民醫院發函為患者請廣東省人民醫院兩位醫生前來做心髒瓣膜手術，醫院向患方收取了3.5萬專家會診費，沒有提供醫院的收據。術後家屬公開發帖質疑3.5萬元會診費。

……

在外科領域有一個專門的暗語：“飛刀”，形容醫生在休息時間飛到其他醫院主刀手術的醫療行為。《醫師報》記者調查發現，近年來，“飛刀”醫生收取的勞務會診費成為醫患糾紛的焦點之一。柳州市人民醫院、鎮原縣第一人民醫院、齊齊哈爾醫學院附屬三院、徐州沛縣中醫院等多家醫院因收取會診費且未開具收據或發票，被患方以醫生“索要紅包”為由舉報，被舉報的醫生和涉事醫院均被主管部門給予不同程度的處罰。以致於大V@溫柔醫刀在網上委屈地發聲：行善積德的院外會診，醫生為什麽像做賊一樣偷偷摸摸？

前不久，發生在山西省洪洞縣人民醫院醫生手術室收萬元“紅包”的事件引發社會的廣泛熱議，最終調查結果顯示，所謂的“紅包”是給前來主刀的北京天壇醫院專家的會診費，是經患方同意後收取的。盡管在輿論上，網友對“飛刀”醫生一邊倒地支持，但由於收取的會診費並沒有經過醫院財務科，程序涉嫌違規，該院負責收錢的科主任和北京天壇醫院的“飛刀”醫生受到不同程度的處罰。令人困惑的是，看起來合情合理的“飛刀”醫生會診費，為什麽會被患方以“索要紅包”一告一個準？頗受爭議的會診費，到底該怎麽收才算合法呢？

現狀

政策不少 “飛刀”依然盛行

中國非公立醫療機構協會皮膚專業委員會主任委員、複旦大學附屬華山醫院鄭誌忠教授告訴《醫師報》記者：“根據《醫師外出會診管理暫行規定》，這種外出會診手術應該由當地醫院對會診醫院發出會診邀請函，會診費統一支付給會診醫院，醫院在根據單位的管理規定按比例支付給外出會診的醫生。如果未經單位批準會診或者未在目標醫院登記備案多點執業，私自‘飛刀’並向患方收取會診費，不僅違規還涉嫌非法行醫。”

一位不願透露姓名的骨科副主任反問《醫師報》記者：“《醫師外出會診管理暫行規定》出台十幾年，多點執業政策也推行好幾年，為什麽‘飛刀’現象依然盛行？這說明政策沒有可操作性。按照規定，醫生外出會診需要經過醫院批準，會診費少的可憐，隻有一兩百塊錢，還要跟醫院分。而現在一個三甲醫院專家的會診費少則三五千，多則過萬，政策和現實差距太大了。且不說錢多少的問題，院長會同意你往外跑嗎？向醫院報備太麻煩了。如果能多點執業、醫院同意外出會診最好，可以免除醫生的後顧之憂。就算沒有也無所謂，該怎麽‘飛’還怎麽‘飛’，畢竟大多數患者還是通情達理的。”

僅3.2%醫師參與多點執業

官方數據顯示，目前全國多點執業的醫師為11萬餘名，僅占全國執業醫師總人數（339萬）的3.2%。然而，相較之下，“飛刀”直到今天依然大行其道。丁香園網站一項3000多名醫生參與的調查顯示，55％的醫生稱“所在醫院的醫生‘飛刀’現象普遍”，近三成醫生表示自己曾經“飛刀”過。

華醫心誠醫生集團董事長、北京大學第一醫院霍勇教授認為，多點執業落地難主要是醫院管理方麵的問題。“因為醫生隸屬於醫院，醫院為醫生提供獎金、工資、養老保險等，所以醫院很難同意醫生多點執業。”霍勇建議，國家應完善公立醫院人事製度，比如取消編製內外的待遇差別等，隻有這樣才能真正地推動醫生多點執業取得實質性進展。

全國政協委員、中國中醫科學院望京醫院溫建民教授一直呼籲讓醫生們的外出執業行為“陽光化”，不再陷於“飛刀”的灰色地帶。他指出，我國古代的名醫就是多點執業，扁鵲在秦國治病、也在齊國治病；當今國際上的醫生很多也在多點執業。但在我國當今的各個醫院，推行多點執業就像一拳打在棉花上，不抵抗、不執行。私立醫院的院長歡迎多點執業，公立醫院院長卻用各類“土政策”百般阻撓。因此，政府各級行政主管部門應該清查各個醫院的有悖國家多點執業政策的“土政策”，加以清理。

浙江省衛生計生委醫政處副處長俞新樂表示，醫師多點執業雖然在當下受製度、觀念、惰性等因素的限製，推進過程中困難重重，但他仍堅信多點執業取代“飛刀”是未來的大勢所趨。“隻有讓製度在陽光下運行，才能最大程度地保障各方的利益。”

甩不掉的“紅包”汙名

盡管患者便捷地獲得了外地大專家提供的優質醫療服務，“飛刀”醫生也獲得了相對合理的勞動收入。但是因為費用是由主管醫生個人代收，自然不可能向患方出具收據或發票；因為勞務報酬是邀請醫生私自轉交給“飛刀”醫生個人，自然也不合乎規定，這就注定了會診費洗脫不掉“紅包”的汙名，甚至成為醫患關係惡化的導火索之一。一旦患方舉報，無論是發出邀請的醫院還是醫生、或是“飛刀”醫生毫無疑問都成了過錯方，一告一個準自然毫不稀奇了。

建議

醫生自由執業的呼喚


對於如何扭轉“飛刀”會診費身上“紅包”的汙名，安徽省東至縣第三人民醫院葉正鬆認為：“正確的做法是把市場的還給市場，將會診這一塊放開醫療服務的價格管製，擬定一個符合市場價值的會診價格。同時，進一步打斷優質醫療資源壟斷、開放醫生執業自由大門。”他同時對相關部門處罰“飛刀”醫生和基層主管醫生的做法表示擔憂：如果這條路今後徹底掐死，而暫時又沒有開辟一條新的“公路”，可以想象，接下來基層優質醫療資源的下沉，將會真的淪為一句口號。基層患者想獲得優質的醫療資源將會付出更大的代價。

那麽，是否有能體現醫生勞動價值，又合理合法的辦法呢？對此，卓壯超聲醫生集團創始人張梁平認為，私下收會診費的問題很麻煩，專家會診，以及醫生多點自由執業，可以選擇合適的醫療機構平台，醫生集團可以出一份賬單，開服務費發票給患者，就可以解決這一尷尬困境。

澳大利亞 College of Intensive Care 注冊醫生Gigi介紹，在世界上多數發達國家，醫生都是真正的自由執業者，解決國內“飛刀”醫生會診費合法的問題關鍵是讓醫生成為自由執業者。澳大利亞有Locum 醫生（臨床替班的醫生）製度，Locum醫生都是正式在澳洲AHPRA 注冊的醫生，有外科主刀醫生、麻醉醫生、ICU、急診科專家，還有很多的主治醫生幫忙去各個醫院查房。他們利用假期到其他醫院工作。比如，一位畢業於中山醫科大學的師兄，他的正式工作是政府雇傭的高級毒理藥理科學顧問，聖誕節期間去偏遠的小鎮做急診科住院值班醫生，薪水比正常上班的要高2~3倍。Locum醫生製度不僅讓醫生實現自我價值與經濟收入的雙贏，也使得患者365天都能享有高質量的服務。

 

 

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.