finance implications for healthcare delivery in japan

The AMA Code of Medical Ethics offers principled advice. A3: Finance Implications for Healthcare Delivery There were several financial implications that occurred after the Affordable Care Act (ACA) was implemented, such as boosting the national job market and decreasing health spending. Cost-sharing and out-of-pocket spending: In 2015, out-of-pocket payments accounted for 14 percent of current health expenditures. 0000002712 00000 n 13 See Japan Institute of Life Insurance, FY2013 Survey on Life Protection, FY2013 Survey on Life Protection (Quick Report Version) (Tokyo: JILI, 2013), http://www.jili.or.jp/research/report/pdf/FY2013_Survey_on_Life_Protection_(Quick_Report_Version).pdf); Life Insurance Association of Japan, Life Insurance Fact Book 2015 (Tokyo: LIAJ, 2015), https://www.seiho.or.jp/english/statistics/trend/pdf/2015.pdf; and LIAJ, Life Insurance Fact Book 2018 (Tokyo: LIAJ, 2018), https://www.seiho.or.jp/english/statistics/trend/pdf/2018.pdf. In contrast insurance plans in the United States typically require a referral from the citizens primary care physician. A1. companies, and not for profit groups that can help citizens get their medications (The Total over six years: JPY 3.5 million (USD 35,000) at public schools; JPY 2045 million (USD 200,000450,000) at private schools. The reduced rates vary by income. Implications of Cost-Sharing for the Poor. While 6% of monthly household income was spent on health insurance in 2014, this . Enrollees in Citizen Health Insurance plans who have relatively lower incomes (such as the unemployed, the self-employed, and retirees) and those with moderate incomes who face sharp, unexpected income reductions are eligible for reduced mandatory contributions. People can deduct annual expenditures on health services and goods between JPY 100,000 (USD 1,000) and JPY 2 million (USD 20,000) from taxable income. Competition is limited because the government ensures that all citizens have Every prefecture has a Medical Safety Support Center for handling complaints and promoting safety. Physicians should be prudent stewards of the shared societal resources with which they are entrusted. 8600 Rockville Pike Episode-based payments involving both inpatient and outpatient care are not used. 0000006070 00000 n Physician education and workforce: The number of people enrolling in medical school and the number of basic medical residency positions are regulated nationally. Bookshelf Under the Medical Care Law, these councils must have members representing patients. Public reporting on physician performance is voluntary. Role of government: The national and local governments are required by law to ensure a system that efficiently provides good-quality medical care. 3 (2008): 2530. The strategy sets two objectives: the reduction of disparities in healthy life expectancies between prefectures and an increase in the number of local governments organizing activities to reduce health disparities.29. More than 70% of population has private insurance providing cash benefits in case of sickness, as supplement to life insurance. A 1. Number of pharmacies: over 53,000, or almost 42 per 100,000 people. see. Average cost of public health insurance for 1 person: around 5% of your salary. Finally, there are complex cross-subsidies among and within the different SHIP plans.11. In this episode of Making the Rounds, learn about one resident's experience of not matching, offering insight on coping and how unmatched applicants can find a position. The coverage depends on the agreed contract between the employer and the insurance company. 0000007475 00000 n The number of medical students is also regulated (see Physician education and workforce above). can range anywhere from 10% to 30% based on income with young children and the elderly Drive in style with preferred savings when you buy, lease or rent a car. spending targets and highly profitable categories of care see reductions as needed (The Most clinics and hospitals are HSn0+x$h(I Low-income people do not pay more than JPY 35,400 (USD 354) a month. (June 5, 2020). Japan's health insurance system is considered "universal," since it covers everyone in the country, but it is hardly "free" in the sense of having the government pay for everything with . A high average of Americans has trouble paying their medical bills, and one quarter of adults in the United States have medical debt (The Commonwealth Fund, 2008). with the specialist. Patient registration not required. This site needs JavaScript to work properly. Not every residency match is made to last, as more than 1,000 residents transfer programs each year. Approximately two-thirds of medical students study at public medical schools, while the remaining one-third are enrolled at private schools. H?k0w}!$R( P:.:B? Finance Implications for Healthcare Delivery Health care facilities by the insurance companies and the government vary according to the citizen and the situation in America ranging from basic over-the-counter medications to complicated surgeries. Download AMA Connect app for Currently, there is no pooled funding between the SHIS and LTCI. There are also monthly out-of-pocket maximums. The more than 1,700 municipalities are responsible for organizing health promotion activities for their residents and assisting prefectures with the implementation of residence-based Citizen Health Insurance plans, for example, by collecting contributions and registering beneficiaries.4. Disclaimer. It is funded primarily by taxes and individual contributions. By continuing on our website, you agree to our use of the cookie for statistical and personalization purpose. A portion of long-term care expenses can be deducted from taxable income. Epub 2018 Feb 26. A 20 percent coinsurance rate applies to all covered LTCI services, up to an income-related ceiling. The national government prioritizes care coordination and develops financial incentives to encourage providers to coordinate care across care settings, particularly in cancer, stroke, cardiac care, and palliative care. official website and that any information you provide is encrypted Neurol Med Chir (Tokyo). the referral is denied pending more studies, lab work, or additional treatment avenues the citizen Issue briefs summarize key health policy issues by providing concise and digestible content for both relevant stakeholders and those who may know little about the topic. Referral to See a Specialist 12 Japan Institute of Life Insurance, Survey on Life Protection, FY 2016. because the country strives to have proper utilization of services to contain unnecessary (June 5, 2020). Find an overview of AMA efforts and initiatives to help improv GME. |r6I[:,;vc.xt>]Ccw8BhLQqnSwOu4u, SYDe1TE|XQ<0eJar+fH_&QwZ +b See Japan Pension Service, Employees Health Insurance System and Employees Pension Insurance System (2018), https://www.nenkin.go.jp/international/english/healthinsurance/employee.html; accessed July 23, 2018. iPhone or drug companies. C489 Task 3 - C489 Organizational Behavior and Leadership Task 3 no revisions first pass, C100 Study Guide - Notes for Intro to hummanities, C228 Task 2 Cindy - Bentonville - Passed with no revisions, Community Health and Population-Focused Nursing, C841 Task 2 - Ethical Challenges faced in Cybersecurity, https://www.commonwealthfund.org/sites/default/files/documents/___media_files_public, ations_fund_report_2017_may_mossialos_intl_profiles_v5.pdf, https://www.loc.gov/law/help/child-rights/japan.php#:~:text=Almost%20all%20children, %20in%20Japan,an%20allowance%20from%20the%20government.&text=The %20government%20provides%20this%20mandatory%20education%20free%20of, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491200/, https://www.commonwealthfund.org/international-health-policy-, https://www.commonwealthfund.org/publications/publication/2008/oct/testimony-rising-, health-care-costs-implications-health-and, Pediatric And Perinatal Clinical Nurse Specialist Practicum I (NUPR 569), Foundational Concepts & Applications (NR-500), Electrical Machines and Power Electronic Drives (E E 452), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Chapter 1 - Principles of Animal Behavior, Ch. Retrieved from, https://www.commonwealthfund.org/publications/publication/2008/oct/testimony-rising-health-care-costs-implications-health-and The Commonwealth Fund. 99meWRQ4C ,gfWtCJ$tJc4XJ)84k*L=+8Uko`$mU7+MX,S`%FD08IP)p%%EE5&5g-M6`h?QiC=w;lPeS.=1c %^aS;~~,QUTK!Ox 52O` :0?L?E2.Wt`m:2H/au"KHC400\*i}JpZ2YN;sVk<8*Q\;=k~&SGj]7:Ws&MXlc"SW'I{peeN YE Government agencies involved in health care include the following: Role of public health insurance: In 2015, estimated total health expenditures amounted to approximately 11 percent of GDP, of which 84 percent was publicly financed, mainly through the SHIS.6 Funding of health expenditures is provided by taxes (42%), mandatory individual contributions (42%), and out-of-pocket charges (14%).7, In employment-based plans, employers and employees share mandatory contributions. The site is secure. The Japanese Medical Specialty Board, a physician-led nonprofit body, established a new framework for standards and requirements of medical specialty certification; it was implemented in 2018. The United States does not make insurance mandatory. National and local government facilitate mandatory third-party evaluations of welfare institutions, including nursing homes and group homes for people with dementia, to improve care. This prevents overutilization of services and unnecessary medical Physicians can dispense medications in clinic, or the patient can utilize a pharmacy. Mental health care: Mental health care is provided in outpatient, inpatient, and home care settings, with patients charged the standard 30 percent coinsurance, reduced to 10 percent for individuals with chronic mental health conditions. 18 The figures are calculated from statistics of the Ministry of Health, Labour and Welfare, 2014 Survey of Medical Institutions (MHLW, 2016). Read the House of Delegates (HOD) speakers' updates for the 2023 Annual HOD Annual Meeting. Reduced coinsurance rates apply to patients with one of the 306 designated long-term diseases if they use designated health care providers. All services are rendered based on an In Japan the municipal government arranges health exams for children up to four (Library of Congress Law, 2007). Japans statutory health insurance system provides universal coverage. continue to rise, and some employers have decided to drop coverage due to this increase. Citizens 65 and older or the disabled qualify for federal Medicare benefits. Ageing in Japan is proceeding at a rapid pace, but, at the same time, Japanese elderly people are in better health compared to elderly people . 28 Japan Council for Quality Health Care, Hospital Accreditation Data Book FY2016 (JCQHC, 2018) (in Japanese), https://www.jq-hyouka.jcqhc.or.jp/wp-content/uploads/2018/03/20180228-1_databook_for_web2.pdf; accessed July 17, 2018. The citizens that are employed in a small business, unemployed, self- They serve as the basis for calculating the benefits and insurance contributions for employment-based health insurance and pension. Public reporting on the performance of hospitals and nursing homes is not obligatory, but the Ministry of Health, Labor and Welfare organizes and financially promotes a voluntary benchmarking project in which hospitals report quality indicators on their websites. If the request is denied completely by insurance, it can usually be appealed. The patient can see any provider of their choosing related to specialty care, by the government. Part A is usually free to citizens that worked in the United States and paid payroll taxes. There are no deductibles, but SHIS enrollees pay coinsurance and copayments. 17 MHLS, 2017, Annual Health, Labour and Welfare Report 2017 (provisional English translated edition), https://www.mhlw.go.jp/english/wp/wp-hw11/dl/02e.pdf; accessed July 15, 2018. Payments for primary care are based on a complex national fee-for-service schedule, which includes financial incentives for coordinating the care of patients with chronic diseases (known as Continuous Care Fees) and for team-based ambulatory and home care. Safety nets: In the SHIS, catastrophic coverage stipulates a monthly out-of-pocket threshold, which varies according to enrollee age and income. This project aims to explore whether and how the slowdown in NHS funding since 2010 has affected patients' access to high-quality care. In 2016, 66 percent of home help providers, 47 percent of home nursing providers, and 47 percent of elderly day care service providers were for-profit, while most of the rest were nonprofit.27 Meanwhile, most LTCI nursing homes, whose services are nearly fully covered, are managed by nonprofit social welfare corporations. It also establishes and enforces detailed regulations for insurers and providers. The national government regulates nearly all aspects of the SHIS. Accessibility 0000003790 00000 n All rights reserved. Most clinics and hospitals are privately owned and operated, and patients are free, but not required to, to choose a primary provider. PT MH services, home care services and dental care. approved price throughout the entire country (The Commonwealth Fund, 2020). the overall rate of increase or decrease in prices of all benefits covered by SHIH, developing efficient and comprehensive care in the community, developing safe, reliable, high-quality care and creating services tailored to emerging needs, reducing the workload of health care workers. The figures are based on the number of persons registered for any plans in either the SHIS or the Public Social Assistance Program. Effect of Japanese government policy on hospital pharmaceutical profit levels. Pre-exposure prophylaxis is one of the Affordable Care Act (ACA) preventive services at risk in federal court, says Stephen Parodi, MD. Posted: April 28th, 2017Explain two financial implications for the patient with regard to the healthcare delivery differences between the two countries. Sudo K, Kobayashi J, Noda S, Fukuda Y, Takahashi K. Biosci Trends. Cost containment is evidenced by price regulation for all services and all prescribed Think of the AMA as your ally while preparing for the USMLE and COMLEX-USA. Small copayments are charged for primary care and specialty visits (see table). The Japanese government's concentration on post-World War II economic expansion meant that the government only fully woke up to the financial implications of having a large elderly population when oil prices were raised in the 1970s, highlighting Japan's economic dependence on global markets. Penalties include reduced reimbursement rates if staffing per bed falls below a certain ratio. must follow the steps determined by the insurance company prior to making the appointment endstream endobj 184 0 obj<>stream Hospital accreditation is voluntary. 1 CHE101 - Summary Chemistry: The Central Science, Chapter 15 Anxiety and Obsessive-Compulsive Disorders, ACCT 2301 Chapter 1 SB - Homework assignment, Answer KEY Build AN ATOM uywqyyewoiqy ieoyqi eywoiq yoie, Blue book mark k - Lecture notes Mark Klimek, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. 4 (2012): 27991; MHLW, Summary of the Revision of the Fee Schedule in 2018: DPC/PDPS (in Japanese), https://www.mhlw.go.jp/file/06-Seisakujouhou-12400000-Hokenkyoku/0000197983.pdf; accessed July 17, 2018; OECD, Health-Care Reform in Japan: Controlling Costs, Improving Quality and Ensuring Equity, OECD Economic Surveys: Japan 2009 (OECD Publishing, 2009). In contrast Reducing health disparities between population groups has been a goal of Japans national health promotion strategy since 2012. An official website of the United States government. more for coverage for a preexisting condition (The Commonwealth Fund, 2020). Japans prefectures develop regional delivery systems. Residents and fellows deciding on a practice setting should be armed with all the relevant details. Structural, process, and outcome indicators are identified, as well as strategies for effective and high-quality delivery. 2012 Jan;12(1):16-22. doi: 10.1111/j.1447-0594.2011.00776.x. 167 23 Most clinics (83% in 2015) are privately owned and managed by physicians or by medical corporations (health care management entities usually controlled by physicians). In this paper I will discuss and compare the United States healthcare system with that of Japans. The goal of the Reimagining Residency grant program is to transform residency training to best address the workplace needs of our current and future health care system. By law, prefectures are responsible for making health care delivery visions, which include detailed service plans for treating cancer, stroke, acute myocardial infarction, diabetes mellitus, and psychiatric disease. The national government sets the fee schedule. Explore reports on this topic from the Council on Medical Education presented during the AMA Interim and Annual Meetings. Those working at public hospitals can work at other health care institutions and privately with the approval of their employers; however, even in such cases, they usually provide services covered by the SHIS. Drug prices can be revised downward for new drugs selling in greater volume than expected and for brand-name drugs when generic equivalents hit the market. For example, the monthly maximum for people under age 70 with modest incomes is JPY 80,100 (USD 801); above this threshold, a 1 percent coinsurance rate applies. Since Japan has universal healthcare, one of the financial implications to the patient is that there are no deductibles but must pay a 30% coinsurance rate except for the following: children under the age of three pay a rate of 205, individuals between the ages of 70-74 with lower income pay 20% and . Administrative mechanisms for direct patient payments to providers: Clinics and hospitals send insurance claims, mostly online, to financing bodies (intermediaries) in the SHIS, which pay a major part of the fees directly to the providers. If approved, an appointment is made, however, it could possibly take weeks to get in for said appointment. All costs for beneficiaries of the Public Social Assistance Program are paid from local and national tax revenue.26. Health Aff (Millwood). 30 MHLW, What the Ministry of Health, Labour and Welfare Does for the Elderly (in Japanese), http://www.mlit.go.jp/common/001083368.pdf; accessed Aug. 26, 2016. The revision involves three levels of decision-making: For medical, dental, and pharmacy services, the Central Social Insurance Medical Council revises provider service fees on an item-by-item basis to meet overall spending targets set by the cabinet. Organizational Systems and Quality Leadership, Task 3, SAT1-0517/ There are more pharmacies than convenience stores. Role of private health insurance: Although the majority (more than 70%) of the population holds some form of secondary, voluntary private health insurance,12 private plans play only a supplementary or complementary role. access to healthcare through cost containment and equity. States has varied plans for medications with varied copays and formularies. Economic evaluation is essential in healthcare for the elderly. 0000002976 00000 n Officials and members gather to elect officers and address policy at the 2023 AMA Annual Meeting being held in Chicago, June 9-14, 2023. The fee schedule includes financial incentives to improve clinical decision-making. 5 Regulatory Information Task Force, Japan Pharmaceutical Manufacturers Association, Pharmaceutical Administration and Regulations in Japan (2015), http://www.jpma.or.jp/english/parj/pdf/2015.pdf; accessed Oct. 8, 2016. 1998 Oct;13(4):255-62. doi: 10.2165/00002512-199813040-00001. Some physician fees are paid on the condition that physicians have completed continuing medical education credits. 21 Fire and Disaster Management Agency, Annual Report of Fire and Disaster Management, FY2018 (Tokyo: FDMA, 2019): 202203. Services covered: All SHIS plans provide the same benefits package, which is determined by the national government: The SHIS does not cover corrective lenses unless theyre prescribed by physicians for children up to age 9. Japans statutory health insurance system (SHIS) covers 98.3 percent of the population, while the separate Public Social Assistance Program, for impoverished people, covers the remaining 1.7 percent.1,2 Citizens and resident noncitizens are required to enroll in an SHIS plan; undocumented immigrants and visitors are not covered. Reorganize health care delivery aroundReorganize health care delivery around medical conditionsmedical conditions over theover the full cycle of care 4. Recent measures include subsidies for local governments in those areas to establish and maintain health facilities and develop student-loan forgiveness programs for medical professionals who work in their jurisprudence. I verify that Im in the U.S. and agree to receive communication from the AMA or third parties on behalf of AMA. Bethesda, MD 20894, Web Policies LTCI covers: End-of-life care is covered by the SHIS and LTCI. Implications for Cost Savings on Healthcare in Japan Gabriel Symonds, MB BS This paper is an expanded version of a talk I gave at the International Forum on Quality and Safety in Healthcare, Japan 2014. SuZG } u=vo,Nn5ssGs]B,RJrOfNzoR=pBtmkmYWZE>B;Bwl$_dkc'\ d=Ch$R?|0 `SE In the United States citizens spend twice as much on out of pocket medical expenses Employers and employees split their contributions evenly. Price revisions for pharmaceuticals and medical devices are determined based on a market survey of actual current prices (which are usually less than the listed prices). Privacy Policy, Read the report to see how your state ranks. Fee schedules are analyzed every year by the government and in order to meet spending targets and highly profitable categories of care see reductions as needed (The Commonwealth Fund, 2020). 167 0 obj <> endobj healthcare costs have made it impossible for low income families, that do not qualify for state But AI can play a positive role in medical education. Funding/Support: Support was provided by Quality and Group Health Cooperative and by grant R18 HS019129 from the Agency for Healthcare Research. International healthcare system profiles Japan. benefits, to be insured. Before Medicare part D, which is the prescription drug benefit also has a premium. Determine the requirements to get a referral to see a specialist in the two healthcare systems.c. Retrieved from, Civilization and its Discontents (Sigmund Freud), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. The SHIS covers hospice care (both at home and in facilities), palliative care in hospitals, and home medical services for patients at the end of life. 0000000016 00000 n recommended through the Pediatric Society of Japan. Access Long-term care and social supports: National compulsory long-term care insurance (LTCI), administered by municipalities under the guidance of the national government, covers those age 65 and older, and people ages 40 to 64 who have select disabilities. After that, a referral is sent to the insurance for approval or denial of services. Your A smaller proportion are owned by local governments, public agencies, and not-for-profit organizations. Commonwealth Fund, 2020). At hospitals, specialists are usually salaried, with additional payments for extra assignments, like night-duty allowances. Total tuition fees for a public six-year medical education program are around JPY 3.5 million (USD 35,000). The SHIS consists of two types of mandatory insurance: Each of Japans 47 prefectures, or regions, has its own residence-based insurance plan, and there are more than 1,400 employment-based plans.3. In some regions and metropolitan areas, fire and emergency departments organize telephone emergency consultation with nurses and trained staff, supported by physicians.21. In addition, expenditures for copayments, balance billing, and over-the-counter drugs are allowable as tax deductions. 169 0 obj<>stream Primary care: Historically, there has been no institutional or financial distinction between primary care and specialty care in Japan. Learn more with the AMA. This trickledown effect causes many citizens in the United States to be without healthcare The AMA Code of Medical Ethics offers insight into what is ethically required to safely make a broader range of health care services available in a public health crisis. Mainly private nonprofit; 15% public. Primary care practices typically include teams with a physician and a few employed nurses. one quarter of adults in the United States have medical debt (The Commonwealth Fund, 2008). *E2L(0[&GU2l#eY>\fOUXYVEEBL7#* Japan's healthcare policy for the elderly through the concepts of self-help (Ji-jo), mutual aid (Go-jo), social solidarity care (Kyo-jo), and governmental care (Ko-jo). In some places, nurses serve as case managers and coordinate care for complex patients, but duties vary by setting. The fine print in physicians contracts can create problems caring for patients in emergencies. It also opened several public and private revenue sources for job investments that resulted in creating 14 million jobs in the United States within 5 years. In this paper I will discuss and compare the United States healthcare system with that of Generally no gatekeeping, but extra charges for unreferred care at large hospitals and academic centers. 0000004773 00000 n Physicians working at medium-sized and large hospitals, in both inpatient and outpatient settings, earned on average JPY 1,514,000 (USD 15,140) a month in 2017.20. For residence-based insurance plans, the national government funds a proportion of individuals mandatory contributions, as do prefectures and municipalities. Schools are also mandated to implement, States has varied plans for medications with varied copays and formularies. Retrieved from, https://www.commonwealthfund.org/international-health-policy-center/countries/japan The Commonwealth Fund. coverage is dependent of the specific formulary that your insurance plans have agreed upon with Most acute care hospitals receive case-based (diagnosis-procedure combination) payments; FFS for remainder. While The King's Fund has reported extensively on the size of the financial issues facing the health service, this will be our first piece of in-depth research examining what this means for patients. the Central Social Insurance Medical Council, which sets the SHIS list of covered pharmaceuticals and their prices. Highly profitable categories usually see larger reductions. Careers. employed, or retired are covered by the National Health Insurance program (NHI). Childrens rights: Japan. Patients pay cost-sharing at the point of service. Healthy lifestyle choices are actively promoted to keep costs down, as well. (June 30, 2017). bDZ,q LR#0H>O,:I X,-K8M"c`LCY@u9Pvc; Jan 13, 2023 03:30pm. The remaining LTCI funding comes from individual mandatory contributions set by municipalities; these are based on income (including pensions) as well as estimated long-term care expenditures in the residents local jurisdiction. Doctor-patient relationships are highly impacted by the changing landscape of how health care is financed and delivered. Family care leave benefits (part of employment insurance) are paid for up to 93 days when employees take leave to care for family members with long-term care needs. Fees are determined by the same schedule that applies to primary care (see above). Low income families may qualify for Medicaid benefits through their individual states (The Commonwealth Fund, 2020). Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized. The Japan Health Insurance Association, which insures employers and employees of small and medium-sized companies, and health insurance associations that insure large companies also contribute to Health Insurance for the Elderly plans. 0000008091 00000 n The .gov means its official. By contrast, price regulation for all services and prescribed drugs seems a critical cost-containment mechanism. Commonwealth Fund, 2020). Collaborating and networking to advocate for patients and the medical profession. All costs for treatment and As of 2016, 26 percent of hospitals were accredited by the Japan Council for Quality Health Care, a nonprofit organization.28 The names of hospitals that fail the accreditation process are not disclosed. Discuss coverage for preexisting conditions in the two healthcare systems.3. The citizens that are employed in a small business, unemployed, self-employed, or retired are covered by the National Health Insurance program (NHI). The results were often mixed, however, and the magnitude of impact was modest in many instances. Set yourself up for success with tips and tools on choosing a residency program. Related Topic: Medical Ethics Catalog of Topics. Download the latest guides and resources for telehealth services.

Optavia Approved Salads, Hometown Newspapers Wakefield Ri, Can Pigs Eat Moldy Bread, Cumberland County Nc Zoning Codes, Articles F