#she made the decision amidst heightened situation

[isagrimorie]

Star Trek Voyager 5x11 - Latent Image

Seven: When you separated me from the Collective, I was an unknown risk to your crew, yet you kept me on board. You allowed me to evolve into an individual. Janeway: You're a human being. He's a hologram. Seven: And you allowed that hologram to evolve as well to exceed his original programming. And yet now you choose to abandon him. Janeway: Objection noted. Good night.

Latent Image Gifset series Part 1, 2, 3, 4, 5, 6, 7

[succinct-assbutt]

Ghosts From The Past.

Pairing: Sam x Reader, mentioned and potential Dean x Reader.

Request:  “Honestly you're my favorite writer on here and I'm surprised you aren't super popular. I was wondering if you could write something where the reader is one of Sam's college friends and they used to be a hunter and had a fling with Dean before they met Sam. If you don't want to that's cool. Have a great day!!!"

Warnings: none.

A/N: First time writing Sam and it came out not so horrible (..i hope?)

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She’s impossible to be around like this.

 For most of exam season it’s the same: late nights, the apartment reduced to a den of empty cans of monster and red-bull in every corner, worksheets askew the room and the only illumination being the robotic glow of her laptop screen onto her face.

 When Sam gets home from his lecture Thursday night, ruddy-faced and starved of sleep, he finds her on the couch in their living room, fingers clacking against the keys of her computer. The apartment is tiny. Only a few square meters and their kitchen is practically the same breathing space, separated only by a marble counter.

 Y/N’s eyes flick up at the sound of the door clicking open. He shrugs off his coat and dumps it on the table.

 “Hey.” She smiles at him, but it doesn’t meet her eyes; she’s just as tired he can see, the exhaustion written out in the dullness of the her skin and effort it takes just looking up from her screen, and he crosses the room in three long strides, settling down beside her with a sigh.

 Sam pulls her in, kissing the top of her head. “Working?”

 “Yeah.” Y/N sighs, gaze drifting to the opened tab before her. “Theology exam tomorrow.”

 “You know that whole last minute revision doesn’t work? Believe me, I know first-hand.”

 “It’s not last-minute.”

 Sam almost laughs at her stubbornness as she shuts her laptop and leans into him like it’s been an anticipation all day. She curls against his side, shutting her eyes as his hand swoops around her shoulder.

 “Do you think I’ll do well…”

 “I don’t know.” Sam’s voice just barely scratches the silence around them, hoarse and drenched in exhaustion. “With the way you’ve been studying I’m sure it’s nothing to be afraid of. Just relax.”

 “Kind of hard to do. It’s finals.”

 “It’s just an exam.”

 “Yeah, and my college fund is just money.”

 He knows how antsy she gets when it comes to school; for all the time they’ve known each other, wound together by fate, Sam’s witnessed all the breakdowns and bitten nails and ink stains on her skin, almost like, overwhelmed with knowledge, the words were diffusing themselves to the surface. And in a way he’s always envied her devotion because it’s talent just picking yourself up after a failure, he knows that much.

 Both of them have had a long day. Sam stands and leads them into the bedroom, the gentle lull of crickets and traffic acting as their lullaby as they lay down to sleep. Y/N attaches herself to his side and he lets her, feeling a warmth settle over them like a cloak. A comfort settles in his chest. Miles away from Kansas, but he can’t remember ever feeling more at home.

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He completely forgot to tell her Sam realizes. A little too late.

 It’s three weeks into April and he’s juggling lectures and assignments with what little time he has for himself spent studying when the thought strikes him. In the comfort of their kitchen, stirring a pot of noodles, the younger Winchester feels his muscles tense up. He glances back at Y/N—with the exams over she can finally put her feet up, and she lays sprawled out across the sofa, socked feet suspended in the air as the record-player buzzes.

 He’s not sure where to start.

 He got the call about a week ago. It was alarming and new and he’d just stepped out of one of Mr. Linley’s lectures, expecting anything but his phone to go off. Not to mention, before then, they hadn’t spoken for—what? Eight months? Brother or not, Dean wasn’t one for keeping in touch when he felt slighted.

 And that was the odd part.

 The call hadn’t been stilted and painful. Sam remembers it clearly: the baritone of his brother’s voice, the nonchalance that wafted between them like it hadn’t been ages since they talked. Like there was anything but poignant memories and resentments between them. And then Dean had dropped the bomb—a visit.

 When dinner’s ready Sam takes the pan off the stove and flicks the flame off. He carries it to the dining table, setting down their bowls, lobbing full ladles of stew into the dishes like this is the domestic life he was built for—he knows it’s a ruse. If second thoughts about his destiny weren’t already uprising thoughts then this whole situation has just set the freight-train on its tracks.

 Because there’s always been the stubborn inkling of doubt that tells him his hands are just too bloody, and his heart too heavy, and his past too dark to pretend he’s fit for anything other than hunting.

 “Pasta again,” Y/N looks up at him, a shimmer in her eyes and lips rested in a gentle smile. “Not that I’m complaining, but don’t you get tired of all the carbs?”

 Sam glances up at her, then laughs as he settles down. “Do you?”

 “Sometimes.” He picks at the skin of his palm and she teases, mouth curved like a Nike tick.  “It wouldn’t kill for us to try something fancier—bake turkey strips with potatoes? Fillet mignon?”

 “Peanut butter sandwiches—the possibilities are endless.”

 “Samuel…”

 “Y/n.”

 The coil in his chest finally snaps and Sam finds the courage to look up at her.

 His voice has turn solemn and low. Moonlight seeping in through the curtains paints the girl in front of him luminescent and glassy, like she’s a mirage, some wicked dream his mind’s conjured up to play a trick on him—and it sure feels like it.

 Swallowing, he pushes his food away and straightens out.

 Y/N’s waiting, her food untouched. It’s sudden and foreign and he can trace the worry in her lulled voiced.“What is it?”

 “I have something to tell you. Don’t worry, it’s not…” He shuts his eyes, breathes. The words come clumsy and jagged. “It’s not bad, just—maybe a little out of the blue? Y/N, you remember Dean, right?”

 “Your brother.”

 “Right. Well a few weeks ago…” Sam tells her everything; he tries not to come across as overbearing with the suggestion and laces his words with careful undertones he hopes will convince—law-school’s taught him the art of sweet-talking (maybe even manipulating?) and in the end he feels he’s made a decent enough argument.

 Because Y/N looks at him, lip tugged between her teeth and face twisted like she’s registering his words—not disregarding or judging. No. Just…understanding.

 His brother visiting?

 “I thought you guys had some sort of beef going on?” It’s a vague memory but she remembers Sam mentioning it: a hotheaded brother and the ties he’d severed just to come here. An absence of a father gave way for their relationship to root itself and flourish. Until law school came. Y/N and the life he built himself, Sam says, convincing himself more than anyone else. There was the decision to study and the stark difference between the people either of them had grown into. And then somewhere amidst the turmoil of their relationship she’d met his brother.

 Lime-green eyes and constellations on his cheeks and hands layered with thick callouses. Dean was everything she’d expected him to be—a little too much. A little too rough around the edges, a little too complicated and broken little boy and she’d welcomed him into their hole-in-the-wall-home because he was her friend’s brother.

 Neither of them knew what would come from it.

 There wasn’t any way that they could—Dean with his bright eyes and lopsided smiles he’d throw at any girl and her, taken up by school. No one would have guessed; not even Y/N, hungry hands clawing at the hem of his shirt one night, not six shots down and looming on the edge of bad decisions while Sam was out studying for a final.

 Y/N hasn’t told her boyfriend this.

 Not for the past couple of months. She’s not sure she can. Sam is kind and patient and nothing like her, and maybe that’s why she was so drawn to his brother—calloused from a life on the road, one scratch away from caving into himself. Y/N remembers Dean. Not that she wants to. It’s more of a guilt than a fondness.

 And it shows the next day when they’re at the airport, a pit yawning open in her stomach.

 In the distance they can the planes descend with a whistle, heightened by the chatter of intercoms and travelers moving through transit.

 With her arm looped through his, she keeps close to her boyfriend. There’s a sea of people blocking out the gate from the arrivals section, and, watching Sam stretch his neck for a better view, she tugs on his sleeve.

 He glances down at her and Y/N strains a smile. “Do you see him?”

 “Not yet.” He answers. His gaze shifts back to the gate and her own eyes follow his in wait of the elder Winchester.

 If she remembers right, Dean hates flying. Sam’s mentioned it before and she even got hear it right from the horse’s mouth that one time they were driving to Michigan for spring break, so it’s a wonder what got him on the plane here in the first place.

 They stay close as travelers scud by. She clings onto Sam’s arm, more out of anxiety than fear of crowd and it only takes a few seconds before she feels the hammering in her chest halt at the sight of Dean.

 It’s a fraction of a second. She doesn’t have time to respond, anyway—Sam’s already tugging on her arm, moving towards the gates, and she swallows as they cross through the crowd. Dean hasn’t changed; he looks wilder, hair askew and stubble-jawed and there’s traces of fear still prominent in his green gaze, but it suddenly melts away once he sees his baby brother

 The younger Winchester’s face splits into a smile as he goes in for a hug, chuckling. “Finally.”

 “Tell me about it.” Dean pulls away, mouth quirked at the corner before his focus slides to her.

 Y/N tries not to stare, but it’s impossible. There’s a stiffness in her back. A reluctance running through her. The elder Winchester eyes rake over her like he’s trying to remember if he knows her and she can’t blame him considering how long it’s been.

 “Is this…”

 “You remember, Y/N, right?” Sam wraps an arm around her shoulder warmly, the skin on her arms prickling.

 “Y/N...” Dean draws out the name with his eyes narrowed; she’s sure he does, it reads in his green gaze, but the confirmation is a delayed ‘ah’ and nod. “Yeah—yeah, freshman year, let you stay at her dorm.” He finally smiles. “Hey.”

 “I didn’t tell you but we’ve been dating for a while.” Sam says and shrugs. “So…surprise.”

 “Dating?”

 “A lot’s happened in the past couple of years—don’t worry, we can catch up on the way to the dorm, but we should get going. Traffic and all.”

 “Rush hour.” Y/N supplements.

 Dean’s eyes shift to her briefly. She’s sure she catches a feint confusion swimming in bloodshot green, but if there’s anything to it, he doesn’t say. There’s not time to. A lot swimming in his head mixed with the panic from the flight and they’re trying to dodge the chaos on the roads, so instead she strains a smile and they begin moving.

Lugging his bag onto his back, he follows Sam out the airport, but as Y/N trails closely behind she can feel the pit in her stomach growing wider...

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It’s been over a month since this request was sent in and I’m an actual tool for posting this late, but I wanted to be as content with it as possible.

I hope you enjoyed this, anon! I’m still figuring out Part 2 and what comes next but feel free to message me and give some ideas of what you want to happen next.

Likes, reblogs and follows are greatly appreciated (a little less than 100 away from my next thousand so ayye); despite my irregular posting schedule I do take requests lol. My inbox is always open.

Thank you for reading!

[husna-reads]

Six of Crows by Leigh Bardugo

goodreads

rating: 4.75 / 5

i love everything about this book 

“six dangerous outcasts, one impossible heist. together they might just be unstoppable - if they don’t kill each other first.”

a story of mismatch people with haunting past, came together to do the impossible; infiltrate the impenetrable Ice Court and kidnap the scientist who created jurda parem, a stimulant that heightens a Grisha ability beyond their normal powers.

yes, this is a heist story.

the story sets in a universe called the Grishaverse. Grisha are people who practice Small Science; they can manipulate matter at its most fundamental level. basically, they have magic powers. example of Grisha are the Heartrenders, they can slow down your pulse, suck the air out of your lungs and sends you into a coma, all without touching you. the og series, the Shadow and Bones trilogy talks more about the Grishaverse and the world-building but i’m too lazy to read it huhu. 

the story is a character centered story. it is more on character building and exploring the characters’ upbringing and their view of the world they’re in. the plot of the story is not as fast paced as a normal heist story but the action is very detailed. the twists along the book also makes the story more engaging and not so monotonous. i don’t usually read heist related books but imagine how difficult it is to write an action packed and high risked heist in a book. so i think the author excel on making the story very thorough but still captivating. 

the story is told in alternate perspectives, mainly the main characters themselves: Kaz Brekker, Inej Ghafa, Jesper Fahey, Nina Zenik and Matthias Helvar. there’s no Wylan Van Eck's pov in the first book but there will be in the 2nd one. one of the reasons i like about the book was that the characters are so distinct from each other. often times when i read a book with multiple perspectives, i got so confused on whose thoughts am i reading. but this book has done a great job on differentiating the characters’ voices. 

“ a convict with a thirst for revenge, a sharpshooter who can’t walk away from a wager,  a runaway with privileged past,  a spy known as the Wraith,  a heartrender using her magic to survive the slums,  a thief with a gift for unlikely escapes.”

Kaz Brekker is a gang leader and a expert thief. people called him Dirtyhands. He’s selfish, greedy, manipulative and arrogant as hell but i am not shy to admit that i freaking love him. he’s smart, strong-willed but he’s broken. his dark past really took a toll on him and affects how he is in the present life. i wouldn’t say his past justifies his doings, but the traumatic events he experienced definitely messed him up. he’s also flawed, one of his leg is dead and he needs a cane to walk with. this imperfection really makes Kaz character seems very real. fun fact: the author has a bone illness called osteonecrosis which caused her to walk with a cane too! author representation, hell yeahh!!

Inej Ghafa is an acrobat and she often travels with her loving family to different cities to perform. but it all went down when she was taken by a slaver. i think you could guess what had happened to her before Kaz saves her from the hell she suffered through and gives her a job as a spy to collect information about his associates. i love Inej so much because she is so badass, brave and strong despite her emotional baggage. her desire to save people from going through the exact predicament she’d been through makes her so inspiring. 

Jesper Fahey is a university dropout who has gambling addiction. he’s witty and friendly but he’s reckless with his money. but he is not reckless with his pistols. his sharp aim makes him very valuable for the crew. amidst of his shortcomings, there’s more to him that what meets the eye. 

Nina Zenik is a heartrender and a former soldier recruiter for her country. on her journey to recruit her people, she was captured by a group of druskelle, Grisha hunters and was put in a cage of a ship with many other Grisha. along the way of her awaiting doom, a disaster struck and forced Nina and a certain druskelle (wink wink) to be stuck together. she’s fun, outspoken, beautiful and flirty but she once made a decision that caused her relationship. 

Matthias Helvar is a former druskelle that went to prison under a charge that he didn’t do. he’s been betrayed by a person that once meant something to him. now he wants to avenge himself to the person that sends him to the hellhole. he is a loyal Grisha hunter up until a situation that makes him questioned his loyalty and his believes. 

Wylan Van Eck is a powerful merchant’s son. he’s been raised in a wealthy and privileged life but he ran away from that life because of the weight of expectation. he’s talented, clever and a good demolition expert and an asset for the crew. i don’t much about him and his past but i am looking forward to read his thoughts. 

now can we talk about the romantic aspect of the story because it is so0oOo good !!!!

Kaz and Inej can have my soul.

“The ache in his lungs was unbearable. He needed to tell her ... what? That she was lovely and brave and better than anything he deserved. That he was twisted, crooked, wrong, but not so broken that he couldn’t pull himself together into some semblance of a man for her. That without meaning to, he’d begun to lean on her, to look for her, to need her near. He needed to thank her for his new hat.”

the romance wasn’t even a main aspect of the story pun. it was very subtle and not overbearing. that is what makes it so good. as the story is told in different perspectives, we can look into the characters’ mind on what their feelings for each other. the yearning and the wanting was written in such beautiful way that makes me soft for the pairings. 

“I will have you without armor, Kaz Brekker. Or I will not have you at all.”

my thoughts:

i now understand why this book was so famous and well loved, it truly deserved the hype. i personally LOVE this book, probably the best read of the year. i can’t wait to read the sequel but i am also scared to know what happen next, especially after the twist at the end of the book. there’s a third book in the making, so, i am definitely curious now. 

i'll be honest here, i tried to read the book back in 2018 but i only got to the first two chapters because i wasn’t feeling it and the terminologies of the Grishaverse was hard get through. i was lazy and dumb back then (still am though) and couldn’t just google the meanings. i am very disappointed on my past self.  

anyway, the reason why i didn't give it a 5/5 is really just a personal opinion. the story was great but i just wished the characters are older into their adulthood but in the story, they are just teenagers, 16 to 18 years old. there are some dark and traumatic scenes in the book that i wished a teen wouldn't go through. i know i could have just imagine that they're older in my head but still, it made me uncomfortable to read it. i just think the book is very dark for a teenage audience. if i were to read the book in 2015 when it first came out, i know would not liked it as much as i do now. 15 year old me would definitely not appreciate the concept, the character dynamics, the writing and the world-building as much as i do now. i was too uneducated and toya back then, so i am glad i read this in my 20s. 

all in all, it was perfect. i know for a fact that i will reread this book again again in the future. i would totally recommend this book to anyone who likes to read about the characters more that the plot. by the way, there will be a Netflix series adaptation on the Grishaverse!!!1 it’s called Shadow and Bones. it combines both the og series and Six of Crows series. i don’t know how that will work out but i can’t wait!!!!! god please let it be good. 

[wineanddinosaur]

Why It’s No Longer Politics as Usual in the Wine Business

As we approach one of the most contentious elections in recent memory, the politics of wine brands is taking on newly heightened importance. Now more than ever, it seems, consumers and trade buyers are viewing the actions of companies with increased scrutiny. Some report that they can no longer buy bottles without considering a brand’s politics.

One group of consumers that’s increasingly likely to do so are millennials. According to a research report from PR firm Weber Shandwick, “Half of Millennials (51 percent) say they would be more likely to buy from a company led by a CEO who speaks out on an issue they agree with.” In an industry where an owner or CEO’s name often appears on the product’s label, this is an especially important consideration. Of course, millennials are not the only age group to vote with their dollars, but the cohort’s influence is on the rise. Millennial spending in the U.S. will grow to $1.4 trillion in 2020, representing 30 percent of total retail sales, according to Accenture, an Ireland-based Fortune Global 500 professional services company.

The growing spending power of millennials combined with our politically charged reality could make some wine brands rethink their political practices. Those companies (and brand leaders) that do continue to make campaign contributions risk alienating their customer base and losing sales.

Why Wine Politics Matters

Wine Twitter was ignited two weeks ago after the American Association of Wine Economists (AAWE) shared lists of the wine industry’s “Top 20” contributors to President Trump, Bernie Sanders, Kamala Harris, and Elizabeth Warren. The AAWE stated that, according to its interpretation of the data, the wine industry “overwhelmingly” supports President Trump. (The methods used to arrive at this conclusion have since drawn criticism.)

Amidst a backdrop of high unemployment, a struggling economy, and civil tensions across the nation, the Trump post alone sparked a days-long debate. Some commenters defended the listed wine industry members, citing their rights to make campaign contributions. Others jumped in to fight for the industry, saying that a list of 20 winery owners, distributor CEOs, and a magazine publisher did not represent the entire wine community. Many said they would no longer buy wines from brands whose owners or employees donated to Trump.

As the debate raged on, industry professionals took action. “When that list came out, I was quite happy to see that in my shop, with 1,100 different placements, just three bottles had to go,” says Erin Palmer, owner of Oregon retailer The Wine Cellar.

Describing herself as a “total liberal,” Palmer says wine stores themselves are not the place for political debates. But retailers can practice politics when stocking their shelves, she says, adding, “I believe that every dollar you spend is a vote, so we try to represent our values with what’s on the shelf.”

Palmer isn’t the only retailer who plans to change their inventory because of the AAWE post. Darren Guillaume, owner of Hayward, Calif., wine store Doc’s Wine, says he understands why a brand might contribute for political influence. But Guillaume will not excuse anyone who’s donated to Trump because of the ongoing tariffs issue. “This is affecting my business,” he says. “I will not support any wine distributor or producer that supports Trump.”

How the Trade and Consumers Can Make Informed Decisions

Like retailers, sommeliers also hold significant influence over consumer purchasing. With that role comes a “responsibility,” says Master Sommelier June Rodil, partner at Houston-based restaurant group Goodnight Hospitality. “Rather than just saying ‘this juice is good,’ we’ve got to start asking more questions before we really stand up for a brand,” she says.

Rodil admits that this is no easy undertaking and says it can take years to build relationships with a brand. Many buyers may only come in contact with distributor representatives or sales managers, rather than the company’s leaders. In this scenario, it’s hard to get an accurate picture of a brand’s politics or values, Rodil says.

So how then can wine professionals make informed judgments?

A good first port of call is social media. In recent weeks, numerous brands have used platforms like Instagram to share statements about their values and to cite the actions they’re taking to create a more equitable society.

But these messages alone cannot always be taken at face value. Early last week, Oregon winery Domaine Serene shared an Instagram post supporting BIPOC communities and pledging to fight “systemic injustice.” The post appeared just days after Domaine Serene owner Grace Halsted featured in the AAWE list, showing a $50,000 donation toward President Trump’s election. Many Instagram users commented that there was a disparity between the statement and Halsted’s contribution, given President Trump’s well-documented history of racial bias.

Dozens of commenters lambasted the winery over Halsted’s donations, with one user writing: “Your contribution to Trump shows us what your values are. White words on a black background won’t change that.” Multiple users took to the comment section to make their own pledge: to cancel their membership to Domaine Serene’s wine club.

Another way consumers and trade can monitor brands’ values is to follow in the AAWE’s footsteps. The Federal Election Commission database is open to the public; anyone can use it to check if a winery owner has made political contributions to a candidate whose views and actions they deem problematic. But even this method is not entirely without flaws.

Russell Klenet is a Florida-based federal and state lobbyist who’s worked with the Distilled Spirits Council and the Wine Institute. Klenent warns against viewing all donations as being politically motivated and explains the point using a common scenario: A winery owner is approached by a distributor with significant influence over whether or not their products will get shelf space. The distributor says they’re hosting a fundraiser for a politician and asks the winery for their support. The winery can either turn them down, and risk losing shelf space, or write a check for a few thousand dollars. What should they do?

“You write the check,” Klenet says. “Honestly, that’s just business.” Then again, he adds, when a donation is made for $50,000 or above, “That’s no longer supporting someone’s business — that’s a whole different dynamic.”

But even donations of this magnitude may require further scrutiny. The third-highest contributor on the list of Trump contributors was Roger K. Bower, who donated a total $55,400 in 2016, per the AAWE data. At the time of the donation, Bower was the owner of California winery Westerly Wines. But in 2018, he sold that winery to Michael Speakman, who says he is “politically neutral.”

Still, Westerly has received online backlash because of the AAWE post. “People don’t care about Roger Bower,” Speakman says. “They see Westerly Wine [on the AAWE list] and they say ‘I’m not going to buy their wines anymore.’”

Why It’s No Longer “Business as Usual”

Regardless of whether Speakman was aware of Bower’s donations to Trump when he purchased Westerly Wines, he could not have foreseen the coming backlash. But there are lessons to be learned from his tale. Going forward, people buying businesses may wish to investigate the politics and donations of their sellers, prior to putting ink to paper.

Other business owners may think twice about continuing donations of any kind — even if it’s a “business” transaction toward a fundraiser. As soon as the donation is made, it becomes public knowledge. Any such transaction could see the winery land on a list similar to the AAWE’s top contributors to Trump, especially when five individuals on that list donated less than $3,500 each.

Those companies (and brand leaders) that do wish to continue making donations may wish to consider whether the political candidate they’re supporting contradicts their public-facing values. If that proves to be the case, they could receive significant pushback on social media — à la Domaine Serene — and a possible negative sales impact. In fact, California’s Cakebread Cellars found itself in a near-carbon copy situation, with Instagram users responding with criticism and calls to boycott.

All these scenarios present cautionary tales for wine brands and prove that trade buyers and consumers are watching. But both, in turn, must be careful to ensure that businesses don’t become victims of unwarranted criticism or “cancel culture.” In this highly politicized era, more due diligence is required on everyone’s part.

The article Why It’s No Longer Politics as Usual in the Wine Business appeared first on VinePair.

source https://vinepair.com/articles/trump-politics-winery-donations/

[johnboothus]

Why Its No Longer Politics as Usual in the Wine Business

As we approach one of the most contentious elections in recent memory, the politics of wine brands is taking on newly heightened importance. Now more than ever, it seems, consumers and trade buyers are viewing the actions of companies with increased scrutiny. Some report that they can no longer buy bottles without considering a brand’s politics.

One group of consumers that’s increasingly likely to do so are millennials. According to a research report from PR firm Weber Shandwick, “Half of Millennials (51 percent) say they would be more likely to buy from a company led by a CEO who speaks out on an issue they agree with.” In an industry where an owner or CEO’s name often appears on the product’s label, this is an especially important consideration. Of course, millennials are not the only age group to vote with their dollars, but the cohort’s influence is on the rise. Millennial spending in the U.S. will grow to $1.4 trillion in 2020, representing 30 percent of total retail sales, according to Accenture, an Ireland-based Fortune Global 500 professional services company.

The growing spending power of millennials combined with our politically charged reality could make some wine brands rethink their political practices. Those companies (and brand leaders) that do continue to make campaign contributions risk alienating their customer base and losing sales.

Why Wine Politics Matters

Wine Twitter was ignited two weeks ago after the American Association of Wine Economists (AAWE) shared lists of the wine industry’s “Top 20” contributors to President Trump, Bernie Sanders, Kamala Harris, and Elizabeth Warren. The AAWE stated that, according to its interpretation of the data, the wine industry “overwhelmingly” supports President Trump. (The methods used to arrive at this conclusion have since drawn criticism.)

Amidst a backdrop of high unemployment, a struggling economy, and civil tensions across the nation, the Trump post alone sparked a days-long debate. Some commenters defended the listed wine industry members, citing their rights to make campaign contributions. Others jumped in to fight for the industry, saying that a list of 20 winery owners, distributor CEOs, and a magazine publisher did not represent the entire wine community. Many said they would no longer buy wines from brands whose owners or employees donated to Trump.

As the debate raged on, industry professionals took action. “When that list came out, I was quite happy to see that in my shop, with 1,100 different placements, just three bottles had to go,” says Erin Palmer, owner of Oregon retailer The Wine Cellar.

Describing herself as a “total liberal,” Palmer says wine stores themselves are not the place for political debates. But retailers can practice politics when stocking their shelves, she says, adding, “I believe that every dollar you spend is a vote, so we try to represent our values with what’s on the shelf.”

Palmer isn’t the only retailer who plans to change their inventory because of the AAWE post. Darren Guillaume, owner of Hayward, Calif., wine store Doc’s Wine, says he understands why a brand might contribute for political influence. But Guillaume will not excuse anyone who’s donated to Trump because of the ongoing tariffs issue. “This is affecting my business,” he says. “I will not support any wine distributor or producer that supports Trump.”

How the Trade and Consumers Can Make Informed Decisions

Like retailers, sommeliers also hold significant influence over consumer purchasing. With that role comes a “responsibility,” says Master Sommelier June Rodil, partner at Houston-based restaurant group Goodnight Hospitality. “Rather than just saying ‘this juice is good,’ we’ve got to start asking more questions before we really stand up for a brand,” she says.

Rodil admits that this is no easy undertaking and says it can take years to build relationships with a brand. Many buyers may only come in contact with distributor representatives or sales managers, rather than the company’s leaders. In this scenario, it’s hard to get an accurate picture of a brand’s politics or values, Rodil says.

So how then can wine professionals make informed judgments?

A good first port of call is social media. In recent weeks, numerous brands have used platforms like Instagram to share statements about their values and to cite the actions they’re taking to create a more equitable society.

But these messages alone cannot always be taken at face value. Early last week, Oregon winery Domaine Serene shared an Instagram post supporting BIPOC communities and pledging to fight “systemic injustice.” The post appeared just days after Domaine Serene owner Grace Halsted featured in the AAWE list, showing a $50,000 donation toward President Trump’s election. Many Instagram users commented that there was a disparity between the statement and Halsted’s contribution, given President Trump’s well-documented history of racial bias.

Dozens of commenters lambasted the winery over Halsted’s donations, with one user writing: “Your contribution to Trump shows us what your values are. White words on a black background won’t change that.” Multiple users took to the comment section to make their own pledge: to cancel their membership to Domaine Serene’s wine club.

Another way consumers and trade can monitor brands’ values is to follow in the AAWE’s footsteps. The Federal Election Commission database is open to the public; anyone can use it to check if a winery owner has made political contributions to a candidate whose views and actions they deem problematic. But even this method is not entirely without flaws.

Russell Klenet is a Florida-based federal and state lobbyist who’s worked with the Distilled Spirits Council and the Wine Institute. Klenent warns against viewing all donations as being politically motivated and explains the point using a common scenario: A winery owner is approached by a distributor with significant influence over whether or not their products will get shelf space. The distributor says they’re hosting a fundraiser for a politician and asks the winery for their support. The winery can either turn them down, and risk losing shelf space, or write a check for a few thousand dollars. What should they do?

“You write the check,” Klenet says. “Honestly, that’s just business.” Then again, he adds, when a donation is made for $50,000 or above, “That’s no longer supporting someone’s business — that’s a whole different dynamic.”

But even donations of this magnitude may require further scrutiny. The third-highest contributor on the list of Trump contributors was Roger K. Bower, who donated a total $55,400 in 2016, per the AAWE data. At the time of the donation, Bower was the owner of California winery Westerly Wines. But in 2018, he sold that winery to Michael Speakman, who says he is “politically neutral.”

Still, Westerly has received online backlash because of the AAWE post. “People don’t care about Roger Bower,” Speakman says. “They see Westerly Wine [on the AAWE list] and they say ‘I’m not going to buy their wines anymore.’”

Why It’s No Longer “Business as Usual”

Regardless of whether Speakman was aware of Bower’s donations to Trump when he purchased Westerly Wines, he could not have foreseen the coming backlash. But there are lessons to be learned from his tale. Going forward, people buying businesses may wish to investigate the politics and donations of their sellers, prior to putting ink to paper.

Other business owners may think twice about continuing donations of any kind — even if it’s a “business” transaction toward a fundraiser. As soon as the donation is made, it becomes public knowledge. Any such transaction could see the winery land on a list similar to the AAWE’s top contributors to Trump, especially when five individuals on that list donated less than $3,500 each.

Those companies (and brand leaders) that do wish to continue making donations may wish to consider whether the political candidate they’re supporting contradicts their public-facing values. If that proves to be the case, they could receive significant pushback on social media — à la Domaine Serene — and a possible negative sales impact. In fact, California’s Cakebread Cellars found itself in a near-carbon copy situation, with Instagram users responding with criticism and calls to boycott.

All these scenarios present cautionary tales for wine brands and prove that trade buyers and consumers are watching. But both, in turn, must be careful to ensure that businesses don’t become victims of unwarranted criticism or “cancel culture.” In this highly politicized era, more due diligence is required on everyone’s part.

The article Why It’s No Longer Politics as Usual in the Wine Business appeared first on VinePair.

Via https://vinepair.com/articles/trump-politics-winery-donations/

source https://vinology1.weebly.com/blog/why-its-no-longer-politics-as-usual-in-the-wine-business

[isaiahrippinus]

Why It’s No Longer Politics as Usual in the Wine Business

As we approach one of the most contentious elections in recent memory, the politics of wine brands is taking on newly heightened importance. Now more than ever, it seems, consumers and trade buyers are viewing the actions of companies with increased scrutiny. Some report that they can no longer buy bottles without considering a brand’s politics.

One group of consumers that’s increasingly likely to do so are millennials. According to a research report from PR firm Weber Shandwick, “Half of Millennials (51 percent) say they would be more likely to buy from a company led by a CEO who speaks out on an issue they agree with.” In an industry where an owner or CEO’s name often appears on the product’s label, this is an especially important consideration. Of course, millennials are not the only age group to vote with their dollars, but the cohort’s influence is on the rise. Millennial spending in the U.S. will grow to $1.4 trillion in 2020, representing 30 percent of total retail sales, according to Accenture, an Ireland-based Fortune Global 500 professional services company.

The growing spending power of millennials combined with our politically charged reality could make some wine brands rethink their political practices. Those companies (and brand leaders) that do continue to make campaign contributions risk alienating their customer base and losing sales.

Why Wine Politics Matters

Wine Twitter was ignited two weeks ago after the American Association of Wine Economists (AAWE) shared lists of the wine industry’s “Top 20” contributors to President Trump, Bernie Sanders, Kamala Harris, and Elizabeth Warren. The AAWE stated that, according to its interpretation of the data, the wine industry “overwhelmingly” supports President Trump. (The methods used to arrive at this conclusion have since drawn criticism.)

Amidst a backdrop of high unemployment, a struggling economy, and civil tensions across the nation, the Trump post alone sparked a days-long debate. Some commenters defended the listed wine industry members, citing their rights to make campaign contributions. Others jumped in to fight for the industry, saying that a list of 20 winery owners, distributor CEOs, and a magazine publisher did not represent the entire wine community. Many said they would no longer buy wines from brands whose owners or employees donated to Trump.

As the debate raged on, industry professionals took action. “When that list came out, I was quite happy to see that in my shop, with 1,100 different placements, just three bottles had to go,” says Erin Palmer, owner of Oregon retailer The Wine Cellar.

Describing herself as a “total liberal,” Palmer says wine stores themselves are not the place for political debates. But retailers can practice politics when stocking their shelves, she says, adding, “I believe that every dollar you spend is a vote, so we try to represent our values with what’s on the shelf.”

Palmer isn’t the only retailer who plans to change their inventory because of the AAWE post. Darren Guillaume, owner of Hayward, Calif., wine store Doc’s Wine, says he understands why a brand might contribute for political influence. But Guillaume will not excuse anyone who’s donated to Trump because of the ongoing tariffs issue. “This is affecting my business,” he says. “I will not support any wine distributor or producer that supports Trump.”

How the Trade and Consumers Can Make Informed Decisions

Like retailers, sommeliers also hold significant influence over consumer purchasing. With that role comes a “responsibility,” says Master Sommelier June Rodil, partner at Houston-based restaurant group Goodnight Hospitality. “Rather than just saying ‘this juice is good,’ we’ve got to start asking more questions before we really stand up for a brand,” she says.

Rodil admits that this is no easy undertaking and says it can take years to build relationships with a brand. Many buyers may only come in contact with distributor representatives or sales managers, rather than the company’s leaders. In this scenario, it’s hard to get an accurate picture of a brand’s politics or values, Rodil says.

So how then can wine professionals make informed judgments?

A good first port of call is social media. In recent weeks, numerous brands have used platforms like Instagram to share statements about their values and to cite the actions they’re taking to create a more equitable society.

But these messages alone cannot always be taken at face value. Early last week, Oregon winery Domaine Serene shared an Instagram post supporting BIPOC communities and pledging to fight “systemic injustice.” The post appeared just days after Domaine Serene owner Grace Halsted featured in the AAWE list, showing a $50,000 donation toward President Trump’s election. Many Instagram users commented that there was a disparity between the statement and Halsted’s contribution, given President Trump’s well-documented history of racial bias.

Dozens of commenters lambasted the winery over Halsted’s donations, with one user writing: “Your contribution to Trump shows us what your values are. White words on a black background won’t change that.” Multiple users took to the comment section to make their own pledge: to cancel their membership to Domaine Serene’s wine club.

Another way consumers and trade can monitor brands’ values is to follow in the AAWE’s footsteps. The Federal Election Commission database is open to the public; anyone can use it to check if a winery owner has made political contributions to a candidate whose views and actions they deem problematic. But even this method is not entirely without flaws.

Russell Klenet is a Florida-based federal and state lobbyist who’s worked with the Distilled Spirits Council and the Wine Institute. Klenent warns against viewing all donations as being politically motivated and explains the point using a common scenario: A winery owner is approached by a distributor with significant influence over whether or not their products will get shelf space. The distributor says they’re hosting a fundraiser for a politician and asks the winery for their support. The winery can either turn them down, and risk losing shelf space, or write a check for a few thousand dollars. What should they do?

“You write the check,” Klenet says. “Honestly, that’s just business.” Then again, he adds, when a donation is made for $50,000 or above, “That’s no longer supporting someone’s business — that’s a whole different dynamic.”

But even donations of this magnitude may require further scrutiny. The third-highest contributor on the list of Trump contributors was Roger K. Bower, who donated a total $55,400 in 2016, per the AAWE data. At the time of the donation, Bower was the owner of California winery Westerly Wines. But in 2018, he sold that winery to Michael Speakman, who says he is “politically neutral.”

Still, Westerly has received online backlash because of the AAWE post. “People don’t care about Roger Bower,” Speakman says. “They see Westerly Wine [on the AAWE list] and they say ‘I’m not going to buy their wines anymore.’”

Why It’s No Longer “Business as Usual”

Regardless of whether Speakman was aware of Bower’s donations to Trump when he purchased Westerly Wines, he could not have foreseen the coming backlash. But there are lessons to be learned from his tale. Going forward, people buying businesses may wish to investigate the politics and donations of their sellers, prior to putting ink to paper.

Other business owners may think twice about continuing donations of any kind — even if it’s a “business” transaction toward a fundraiser. As soon as the donation is made, it becomes public knowledge. Any such transaction could see the winery land on a list similar to the AAWE’s top contributors to Trump, especially when five individuals on that list donated less than $3,500 each.

Those companies (and brand leaders) that do wish to continue making donations may wish to consider whether the political candidate they’re supporting contradicts their public-facing values. If that proves to be the case, they could receive significant pushback on social media — à la Domaine Serene — and a possible negative sales impact. In fact, California’s Cakebread Cellars found itself in a near-carbon copy situation, with Instagram users responding with criticism and calls to boycott.

All these scenarios present cautionary tales for wine brands and prove that trade buyers and consumers are watching. But both, in turn, must be careful to ensure that businesses don’t become victims of unwarranted criticism or “cancel culture.” In this highly politicized era, more due diligence is required on everyone’s part.

The article Why It’s No Longer Politics as Usual in the Wine Business appeared first on VinePair.

source https://vinepair.com/articles/trump-politics-winery-donations/ source https://vinology1.tumblr.com/post/621000731995045888

[kristinsimmons]

Innovation Amidst the Crisis: Health IT and the Opioid Abuse Epidemic | Part 4 – Resource Allocation and Access

By COLIN KONSCHAK, FACHE and DAVE LEVIN, MD 

Dave Levin

Colin Konschak

The opioid crisis in the United States is having a devastating impact on individuals, their families, and the health care industry. This multi-part series will focus on the role technology can play in addressing this crisis. Part one of the series proposed a strategic framework for evaluating and pursuing technical solutions.

A Framework for Innovation

In part one of our series, we declared the opioid crisis an “All Hands-On Deck” moment and made the case that health IT (HIT) has a lot to offer. Given the many different possibilities, having a method for organizing and prioritizing potential IT innovations is an important starting point. We have proposed a framework that groups opportunities based on an abstract view of five types of functionality. In this article, with an assist from Dr. Marv Seppala, Chief Medical Officer at the Hazelden-Betty Ford Foundation and Dr. Krista Dobbie, Palliative Care physician at the Cleveland Clinic, we will explore allocation of resources and access to care and the role that technology can play.

Resource Allocation and Access for Opioid Management

Supply and Demand

There is almost always an imbalance between what we need (demand) what we have (supply) in healthcare. This ever-present imbalance between supply and demand inevitably and regularly leads us to grappling with how to wisely allocate precious resources. The opioid crisis is no exception and is a good window into the general challenge of resource allocation in healthcare. Fortunately, technology (both information tech and life sciences) can help navigate these challenges efficiently and effectively.

What exactly do we mean by “resources”? For the purposes of this paper we break this down into two groups: people and materials. As we will see, when it comes to people, this is mostly about access to care in a timely, effective and efficient manner. Materials can encompass many things, but we primarily will focus on drugs, testing and the like. In both cases, there are instances of underuse, overuse, shortages and misallocation which point towards ample opportunity for improvement.

Access to Care

Timely access to appropriate care is essential in dealing with the opioid abuse crisis – just as it is for many diseases. The vast majority of this care involves patients having access to and interacting with a variety of providers. “The first thing that comes to mind when I think about shortages and access is providers” says Dr. Seppala. This shortage includes primary & specialty care, physicians and other licensed professionals. There is a heavy emphasis on Medication Assisted Treatment (MAT) for addiction these days and this requires MD oversight. Physicians who specialize in addiction medicine are highly qualified to provide this oversight but are in short supply. Most primary care physicians, who could in theory provide this care, are reluctant to do so either due to lack of knowledge or concerns about the clinical and medical-legal consequences of bad outcomes like overdose or death. To make matters worse. Addiction specialists often have a personal preference for a broad-based practice that includes services besides MAT – services that could be provided by either primary care physicians or other clinical professionals. So, we have too few specialists practicing too broadly and too few primary care providers who are properly trained and confident in providing these services.

The potential solutions to these challenges can be drawn from similar ones in other areas of medicine:

Optimize and maximize the impact of experts like addiction medicine specialists.

Expand the capacity and capabilities of primary care providers.

Enhance the referral and consultation process in ways that maximize the collaboration and impact of a combined primary-specialty care approach. The mantra here should be: everyone at ‘top of licensure’ so each professional is mostly doing things that only they are qualified to do.

Obviously, some of these challenges are more “geopolitical” than technical. For example, tech likely has little to offer when it comes to a medical specialist’s preference to practice broadly. However, there are a number of promising health IT opportunities here:

Leverage analytics and scheduling applications to optimize scheduling to maximize access to the right provider at the right time.

Enhance communication between various providers to support provision of primary care and facilitate the timely identification and referral of patients who require higher levels of care.

Expand educational opportunities for all providers to “raise their game” and comfort level in caring for these patients.

Telehealth

Telehealth is a proven way to extend access to care and holds great promise in addressing this crisis. According to Dr. Seppala, “Telehealth definitely helps but is limited to 1-to-1 interactions between the provide and patient. What we need now is a 1-to-many solution that supports group visits. “ This is a major tech gap that, assuming it is HIPPA and CFR Part 42 compliant, could have a major positive impact that goes beyond simply expanding capacity.  As Dr. Seppala pointed out, “There is a proven, special value in group visits. This disease undermines brain’s ability to recognize that one has the disease. This goes far beyond simple denial and is a function of the disease itself. But these patients can recognize it in other people in the group and that can lead to the important breakthrough of self-recognition.”

Efficient Use of Material Resources

Material resources refers to things like drugs, diagnostic testing, etc. They are the non-people part of our resources and they too are subject to misallocation, overuse and underuse. As in many other industries, enhanced supply chain management applications can play a transformative role in allocation of materials. But that’s just the tip of the iceberg in this area.

Fortunately, with rare exceptions, the main drugs used to treat opioid addiction are readily available and covered by insurance. However, as is often the case, newer drugs tend to be in shorter supply and much more expensive. They are also subject to stricter control by insurance companies and usual require prior authorization. Lack of insurance coverage or self-pay situations can place these drugs out of reach. This isn’t unique to the opioid crisis. Regardless, more efficient authorization processes, easier access to drug payment programs and provider adherence to best-practice treatment protocols backed up by clinical decision support – all of which can be IT-enabled – provide opportunities for further improvement.

The Other Side of the Coin: A Palliative Care Perspective

It’s important to remember that opioids do have an important and valid place in patient care. To learn more about this perspective, we spoke with Dr. Krista Dobbie an experienced palliative care physician at the Cleveland Clinic. Dr. Dobbie of course is concerned about the opioid abuse epidemic but also pointed out that use of opioids is a mainstay of effective pain management in palliative and end-of-life (EOL) care. As is often the case, it’s about context, clinical knowledge and the specific patient and their needs; In a word: judgement.

When it comes to access and allocation, she notes a couple of challenges that have arisen in providing palliative care as a result of well-intended attempts to address opioid abuse. For example, it has become more difficult to get cancer and other palliative care patients the medications they need.

Some of the new hurtles are administrative. For example, morphine for cancer patients previously did not require prior authorization since this it is considered first-line treatment in this population. Some payers now require prior authorization which increases administrative burden and can result in delays in care. In addition to the direct clinical impact on the patient, this can lead to extended hospital stays as inpatients wait for prior-authorization of these vital medications before they can be discharged. Dr. Dobbie states there are, “More hoops than ever – even with cancer patients” and notes that pharmacists and some insurance companies refuse to fill prescriptions out of, in these cases, misguided concerns about dose, duration, or amount dispensed.

From a materials perspective, there have also been reports of outright shortages of vital pain drugs due to production issues. Dr. Dobbie recalled previous periods of time when there were shortages of intravenous pain meds for hospitalized patients which forced providers into tight restrictions and careful allocation of the limited supply.

Heightened concerns about opioid abuse may be leading to increased resistance of clinicians and others to engage palliative medicine services because of undifferentiated concerns about addiction and misuse. This, in turn, may result in under-treatment of pain in vulnerable patients with terminal illness.

On the plus side, Dr. Dobbie sees that heightened awareness has increased screening for palliative medicine patients who may be at high risk for misusing or abusing opiates. Most patients are signing treatment contracts outlining opiate risks. These contracts also state that there must not be any misuse or diversion of drugs. Routine drug screening is utilized to ensure patients are using medications appropriately. If the clinician is concerned, the situation can be investigated further, and team conferences can be leveraged to evaluate and plan interventions.

Another resource to consider is diagnostic testing. Dr. Seppala pointed to urine drug screening (UDS) as an area ripe for improvement. To start with, UDS tests have known limits. Lower cost, urine screening can only detect some drugs for a short time after they’ve been used leading to false negative results. Other UDS methods only test for prescription drugs missing a major cause of the opioid crisis – the migration use of street drugs like heroin. More sophisticated tests can overcome these limits, but are more expensive and time consuming. Adopting a tiered approach based on evidence is best. Better education, distribution of best-practice protocols coupled with decision support are potential avenues where health IT can contribute. Advances in clinical testing hold out hope as well.

According to Dr. Seppala, UDS also provides an interesting window into overuse, another form of inefficient allocation. This is mostly a story of unscrupulous providers taking advantage of patients and arguably, committing insurance fraud. The typical scenario plays out in low cost, “sober housing” settings. In a kind of bait-and-switch, these providers set low base fees to attract patients. They then overuse tests like UDS by ordering too many and directing the samples to their owned labs where they charge high fees. Dr. Seppla says insurance companies and State attorneys general have woken up to this and are beginning to pursue.

In the face of deliberate fraud, testing protocols and CDS will be of limited value. Of course, in value-based reimbursement models the incentive is to avoid wasteful overuse since that decreases provider profits.

Big data analytics may hold some answers to these behavior-based challenges. It is not hard to envision a future where the same AI techniques that look for potentially “bad” credit card charges and flag them for further attention could be applied to many of the challenges outlined above. This kind of profiling has the potential to find unusual or suspicious patterns while also recognizing legitimate differences in practice between say, an advance pain expert like Dr. Dobbie and the garden variety primary care physician.

What’s Next

The next article in this series will look at the role technology can play in supporting and enhancing medical research into opioid abuse and addiction. For those with even greater interest, we have published a white paper that provides a more in-depth perspective on clinical, sociological and technical factors impacting the opioid abuse epidemic.

Download White Paper

Dave Levin, MD is the Chief Medical Officer for Sansoro Health where he focuses on bringing true interoperability to health care. Dave is a nationally recognized speaker, author and the former CMIO for the Cleveland Clinic. He has served in a variety of leadership and advisory roles for health IT companies, health systems and investors. 

Colin Konschak, RPh, MBA, FACHE is the Chief Executive Officer at Divurgent. Colin is a Registered Pharmacist and is a highly accomplished executive with over 20 years of experience with extensive experience in health care operations, P&L management, account management, strategic planning and alliance management. 

  Innovation Amidst the Crisis: Health IT and the Opioid Abuse Epidemic | Part 4 – Resource Allocation and Access published first on https://wittooth.tumblr.com/

[isaacscrawford]

Innovation Amidst the Crisis: Health IT and the Opioid Abuse Epidemic | Part 4 – Resource Allocation and Access

By COLIN KONSCHAK, FACHE and DAVE LEVIN, MD 

Dave Levin

Colin Konschak

The opioid crisis in the United States is having a devastating impact on individuals, their families, and the health care industry. This multi-part series will focus on the role technology can play in addressing this crisis. Part one of the series proposed a strategic framework for evaluating and pursuing technical solutions.

A Framework for Innovation

In part one of our series, we declared the opioid crisis an “All Hands-On Deck” moment and made the case that health IT (HIT) has a lot to offer. Given the many different possibilities, having a method for organizing and prioritizing potential IT innovations is an important starting point. We have proposed a framework that groups opportunities based on an abstract view of five types of functionality. In this article, with an assist from Dr. Marv Seppala, Chief Medical Officer at the Hazelden-Betty Ford Foundation and Dr. Krista Dobbie, Palliative Care physician at the Cleveland Clinic, we will explore allocation of resources and access to care and the role that technology can play.

Resource Allocation and Access for Opioid Management

Supply and Demand

There is almost always an imbalance between what we need (demand) what we have (supply) in healthcare. This ever-present imbalance between supply and demand inevitably and regularly leads us to grappling with how to wisely allocate precious resources. The opioid crisis is no exception and is a good window into the general challenge of resource allocation in healthcare. Fortunately, technology (both information tech and life sciences) can help navigate these challenges efficiently and effectively.

What exactly do we mean by “resources”? For the purposes of this paper we break this down into two groups: people and materials. As we will see, when it comes to people, this is mostly about access to care in a timely, effective and efficient manner. Materials can encompass many things, but we primarily will focus on drugs, testing and the like. In both cases, there are instances of underuse, overuse, shortages and misallocation which point towards ample opportunity for improvement.

Access to Care

Timely access to appropriate care is essential in dealing with the opioid abuse crisis – just as it is for many diseases. The vast majority of this care involves patients having access to and interacting with a variety of providers. “The first thing that comes to mind when I think about shortages and access is providers” says Dr. Seppala. This shortage includes primary & specialty care, physicians and other licensed professionals. There is a heavy emphasis on Medication Assisted Treatment (MAT) for addiction these days and this requires MD oversight. Physicians who specialize in addiction medicine are highly qualified to provide this oversight but are in short supply. Most primary care physicians, who could in theory provide this care, are reluctant to do so either due to lack of knowledge or concerns about the clinical and medical-legal consequences of bad outcomes like overdose or death. To make matters worse. Addiction specialists often have a personal preference for a broad-based practice that includes services besides MAT – services that could be provided by either primary care physicians or other clinical professionals. So, we have too few specialists practicing too broadly and too few primary care providers who are properly trained and confident in providing these services.

The potential solutions to these challenges can be drawn from similar ones in other areas of medicine:

Optimize and maximize the impact of experts like addiction medicine specialists.

Expand the capacity and capabilities of primary care providers.

Enhance the referral and consultation process in ways that maximize the collaboration and impact of a combined primary-specialty care approach. The mantra here should be: everyone at ‘top of licensure’ so each professional is mostly doing things that only they are qualified to do.

Obviously, some of these challenges are more “geopolitical” than technical. For example, tech likely has little to offer when it comes to a medical specialist’s preference to practice broadly. However, there are a number of promising health IT opportunities here:

Leverage analytics and scheduling applications to optimize scheduling to maximize access to the right provider at the right time.

Enhance communication between various providers to support provision of primary care and facilitate the timely identification and referral of patients who require higher levels of care.

Expand educational opportunities for all providers to “raise their game” and comfort level in caring for these patients.

Telehealth

Telehealth is a proven way to extend access to care and holds great promise in addressing this crisis. According to Dr. Seppala, “Telehealth definitely helps but is limited to 1-to-1 interactions between the provide and patient. What we need now is a 1-to-many solution that supports group visits. “ This is a major tech gap that, assuming it is HIPPA and CFR Part 42 compliant, could have a major positive impact that goes beyond simply expanding capacity.  As Dr. Seppala pointed out, “There is a proven, special value in group visits. This disease undermines brain’s ability to recognize that one has the disease. This goes far beyond simple denial and is a function of the disease itself. But these patients can recognize it in other people in the group and that can lead to the important breakthrough of self-recognition.”

Efficient Use of Material Resources

Material resources refers to things like drugs, diagnostic testing, etc. They are the non-people part of our resources and they too are subject to misallocation, overuse and underuse. As in many other industries, enhanced supply chain management applications can play a transformative role in allocation of materials. But that’s just the tip of the iceberg in this area.

Fortunately, with rare exceptions, the main drugs used to treat opioid addiction are readily available and covered by insurance. However, as is often the case, newer drugs tend to be in shorter supply and much more expensive. They are also subject to stricter control by insurance companies and usual require prior authorization. Lack of insurance coverage or self-pay situations can place these drugs out of reach. This isn’t unique to the opioid crisis. Regardless, more efficient authorization processes, easier access to drug payment programs and provider adherence to best-practice treatment protocols backed up by clinical decision support – all of which can be IT-enabled – provide opportunities for further improvement.

The Other Side of the Coin: A Palliative Care Perspective

It’s important to remember that opioids do have an important and valid place in patient care. To learn more about this perspective, we spoke with Dr. Krista Dobbie an experienced palliative care physician at the Cleveland Clinic. Dr. Dobbie of course is concerned about the opioid abuse epidemic but also pointed out that use of opioids is a mainstay of effective pain management in palliative and end-of-life (EOL) care. As is often the case, it’s about context, clinical knowledge and the specific patient and their needs; In a word: judgement.

When it comes to access and allocation, she notes a couple of challenges that have arisen in providing palliative care as a result of well-intended attempts to address opioid abuse. For example, it has become more difficult to get cancer and other palliative care patients the medications they need.

Some of the new hurtles are administrative. For example, morphine for cancer patients previously did not require prior authorization since this it is considered first-line treatment in this population. Some payers now require prior authorization which increases administrative burden and can result in delays in care. In addition to the direct clinical impact on the patient, this can lead to extended hospital stays as inpatients wait for prior-authorization of these vital medications before they can be discharged. Dr. Dobbie states there are, “More hoops than ever – even with cancer patients” and notes that pharmacists and some insurance companies refuse to fill prescriptions out of, in these cases, misguided concerns about dose, duration, or amount dispensed.

From a materials perspective, there have also been reports of outright shortages of vital pain drugs due to production issues. Dr. Dobbie recalled previous periods of time when there were shortages of intravenous pain meds for hospitalized patients which forced providers into tight restrictions and careful allocation of the limited supply.

Heightened concerns about opioid abuse may be leading to increased resistance of clinicians and others to engage palliative medicine services because of undifferentiated concerns about addiction and misuse. This, in turn, may result in under-treatment of pain in vulnerable patients with terminal illness.

On the plus side, Dr. Dobbie sees that heightened awareness has increased screening for palliative medicine patients who may be at high risk for misusing or abusing opiates. Most patients are signing treatment contracts outlining opiate risks. These contracts also state that there must not be any misuse or diversion of drugs. Routine drug screening is utilized to ensure patients are using medications appropriately. If the clinician is concerned, the situation can be investigated further, and team conferences can be leveraged to evaluate and plan interventions.

Another resource to consider is diagnostic testing. Dr. Seppala pointed to urine drug screening (UDS) as an area ripe for improvement. To start with, UDS tests have known limits. Lower cost, urine screening can only detect some drugs for a short time after they’ve been used leading to false negative results. Other UDS methods only test for prescription drugs missing a major cause of the opioid crisis – the migration use of street drugs like heroin. More sophisticated tests can overcome these limits, but are more expensive and time consuming. Adopting a tiered approach based on evidence is best. Better education, distribution of best-practice protocols coupled with decision support are potential avenues where health IT can contribute. Advances in clinical testing hold out hope as well.

According to Dr. Seppala, UDS also provides an interesting window into overuse, another form of inefficient allocation. This is mostly a story of unscrupulous providers taking advantage of patients and arguably, committing insurance fraud. The typical scenario plays out in low cost, “sober housing” settings. In a kind of bait-and-switch, these providers set low base fees to attract patients. They then overuse tests like UDS by ordering too many and directing the samples to their owned labs where they charge high fees. Dr. Seppla says insurance companies and State attorneys general have woken up to this and are beginning to pursue.

In the face of deliberate fraud, testing protocols and CDS will be of limited value. Of course, in value-based reimbursement models the incentive is to avoid wasteful overuse since that decreases provider profits.

Big data analytics may hold some answers to these behavior-based challenges. It is not hard to envision a future where the same AI techniques that look for potentially “bad” credit card charges and flag them for further attention could be applied to many of the challenges outlined above. This kind of profiling has the potential to find unusual or suspicious patterns while also recognizing legitimate differences in practice between say, an advance pain expert like Dr. Dobbie and the garden variety primary care physician.

What’s Next

The next article in this series will look at the role technology can play in supporting and enhancing medical research into opioid abuse and addiction. For those with even greater interest, we have published a white paper that provides a more in-depth perspective on clinical, sociological and technical factors impacting the opioid abuse epidemic.

Download White Paper

Dave Levin, MD is the Chief Medical Officer for Sansoro Health where he focuses on bringing true interoperability to health care. Dave is a nationally recognized speaker, author and the former CMIO for the Cleveland Clinic. He has served in a variety of leadership and advisory roles for health IT companies, health systems and investors. 

Colin Konschak, RPh, MBA, FACHE is the Chief Executive Officer at Divurgent. Colin is a Registered Pharmacist and is a highly accomplished executive with over 20 years of experience with extensive experience in health care operations, P&L management, account management, strategic planning and alliance management. 

  Article source:The Health Care Blog

[kristinsimmons]

Innovation Amidst the Crisis: Health IT and the Opioid Abuse Epidemic | Part 4 – Resource Allocation and Access

By COLIN KONSCHAK, FACHE and DAVE LEVIN, MD 

Dave Levin

Colin Konschak

The opioid crisis in the United States is having a devastating impact on individuals, their families, and the health care industry. This multi-part series will focus on the role technology can play in addressing this crisis. Part one of the series proposed a strategic framework for evaluating and pursuing technical solutions.

A Framework for Innovation

In part one of our series, we declared the opioid crisis an “All Hands-On Deck” moment and made the case that health IT (HIT) has a lot to offer. Given the many different possibilities, having a method for organizing and prioritizing potential IT innovations is an important starting point. We have proposed a framework that groups opportunities based on an abstract view of five types of functionality. In this article, with an assist from Dr. Marv Seppala, Chief Medical Officer at the Hazelden-Betty Ford Foundation and Dr. Krista Dobbie, Palliative Care physician at the Cleveland Clinic, we will explore allocation of resources and access to care and the role that technology can play.

Resource Allocation and Access for Opioid Management

Supply and Demand

There is almost always an imbalance between what we need (demand) what we have (supply) in healthcare. This ever-present imbalance between supply and demand inevitably and regularly leads us to grappling with how to wisely allocate precious resources. The opioid crisis is no exception and is a good window into the general challenge of resource allocation in healthcare. Fortunately, technology (both information tech and life sciences) can help navigate these challenges efficiently and effectively.

What exactly do we mean by “resources”? For the purposes of this paper we break this down into two groups: people and materials. As we will see, when it comes to people, this is mostly about access to care in a timely, effective and efficient manner. Materials can encompass many things, but we primarily will focus on drugs, testing and the like. In both cases, there are instances of underuse, overuse, shortages and misallocation which point towards ample opportunity for improvement.

Access to Care

Timely access to appropriate care is essential in dealing with the opioid abuse crisis – just as it is for many diseases. The vast majority of this care involves patients having access to and interacting with a variety of providers. “The first thing that comes to mind when I think about shortages and access is providers” says Dr. Seppala. This shortage includes primary & specialty care, physicians and other licensed professionals. There is a heavy emphasis on Medication Assisted Treatment (MAT) for addiction these days and this requires MD oversight. Physicians who specialize in addiction medicine are highly qualified to provide this oversight but are in short supply. Most primary care physicians, who could in theory provide this care, are reluctant to do so either due to lack of knowledge or concerns about the clinical and medical-legal consequences of bad outcomes like overdose or death. To make matters worse. Addiction specialists often have a personal preference for a broad-based practice that includes services besides MAT – services that could be provided by either primary care physicians or other clinical professionals. So, we have too few specialists practicing too broadly and too few primary care providers who are properly trained and confident in providing these services.

The potential solutions to these challenges can be drawn from similar ones in other areas of medicine:

Optimize and maximize the impact of experts like addiction medicine specialists.

Expand the capacity and capabilities of primary care providers.

Enhance the referral and consultation process in ways that maximize the collaboration and impact of a combined primary-specialty care approach. The mantra here should be: everyone at ‘top of licensure’ so each professional is mostly doing things that only they are qualified to do.

Obviously, some of these challenges are more “geopolitical” than technical. For example, tech likely has little to offer when it comes to a medical specialist’s preference to practice broadly. However, there are a number of promising health IT opportunities here:

Leverage analytics and scheduling applications to optimize scheduling to maximize access to the right provider at the right time.

Enhance communication between various providers to support provision of primary care and facilitate the timely identification and referral of patients who require higher levels of care.

Expand educational opportunities for all providers to “raise their game” and comfort level in caring for these patients.

Telehealth

Telehealth is a proven way to extend access to care and holds great promise in addressing this crisis. According to Dr. Seppala, “Telehealth definitely helps but is limited to 1-to-1 interactions between the provide and patient. What we need now is a 1-to-many solution that supports group visits. “ This is a major tech gap that, assuming it is HIPPA and CFR Part 42 compliant, could have a major positive impact that goes beyond simply expanding capacity.  As Dr. Seppala pointed out, “There is a proven, special value in group visits. This disease undermines brain’s ability to recognize that one has the disease. This goes far beyond simple denial and is a function of the disease itself. But these patients can recognize it in other people in the group and that can lead to the important breakthrough of self-recognition.”

Efficient Use of Material Resources

Material resources refers to things like drugs, diagnostic testing, etc. They are the non-people part of our resources and they too are subject to misallocation, overuse and underuse. As in many other industries, enhanced supply chain management applications can play a transformative role in allocation of materials. But that’s just the tip of the iceberg in this area.

Fortunately, with rare exceptions, the main drugs used to treat opioid addiction are readily available and covered by insurance. However, as is often the case, newer drugs tend to be in shorter supply and much more expensive. They are also subject to stricter control by insurance companies and usual require prior authorization. Lack of insurance coverage or self-pay situations can place these drugs out of reach. This isn’t unique to the opioid crisis. Regardless, more efficient authorization processes, easier access to drug payment programs and provider adherence to best-practice treatment protocols backed up by clinical decision support – all of which can be IT-enabled – provide opportunities for further improvement.

The Other Side of the Coin: A Palliative Care Perspective

It’s important to remember that opioids do have an important and valid place in patient care. To learn more about this perspective, we spoke with Dr. Krista Dobbie an experienced palliative care physician at the Cleveland Clinic. Dr. Dobbie of course is concerned about the opioid abuse epidemic but also pointed out that use of opioids is a mainstay of effective pain management in palliative and end-of-life (EOL) care. As is often the case, it’s about context, clinical knowledge and the specific patient and their needs; In a word: judgement.

When it comes to access and allocation, she notes a couple of challenges that have arisen in providing palliative care as a result of well-intended attempts to address opioid abuse. For example, it has become more difficult to get cancer and other palliative care patients the medications they need.

Some of the new hurtles are administrative. For example, morphine for cancer patients previously did not require prior authorization since this it is considered first-line treatment in this population. Some payers now require prior authorization which increases administrative burden and can result in delays in care. In addition to the direct clinical impact on the patient, this can lead to extended hospital stays as inpatients wait for prior-authorization of these vital medications before they can be discharged. Dr. Dobbie states there are, “More hoops than ever – even with cancer patients” and notes that pharmacists and some insurance companies refuse to fill prescriptions out of, in these cases, misguided concerns about dose, duration, or amount dispensed.

From a materials perspective, there have also been reports of outright shortages of vital pain drugs due to production issues. Dr. Dobbie recalled previous periods of time when there were shortages of intravenous pain meds for hospitalized patients which forced providers into tight restrictions and careful allocation of the limited supply.

Heightened concerns about opioid abuse may be leading to increased resistance of clinicians and others to engage palliative medicine services because of undifferentiated concerns about addiction and misuse. This, in turn, may result in under-treatment of pain in vulnerable patients with terminal illness.

On the plus side, Dr. Dobbie sees that heightened awareness has increased screening for palliative medicine patients who may be at high risk for misusing or abusing opiates. Most patients are signing treatment contracts outlining opiate risks. These contracts also state that there must not be any misuse or diversion of drugs. Routine drug screening is utilized to ensure patients are using medications appropriately. If the clinician is concerned, the situation can be investigated further, and team conferences can be leveraged to evaluate and plan interventions.

Another resource to consider is diagnostic testing. Dr. Seppala pointed to urine drug screening (UDS) as an area ripe for improvement. To start with, UDS tests have known limits. Lower cost, urine screening can only detect some drugs for a short time after they’ve been used leading to false negative results. Other UDS methods only test for prescription drugs missing a major cause of the opioid crisis – the migration use of street drugs like heroin. More sophisticated tests can overcome these limits, but are more expensive and time consuming. Adopting a tiered approach based on evidence is best. Better education, distribution of best-practice protocols coupled with decision support are potential avenues where health IT can contribute. Advances in clinical testing hold out hope as well.

According to Dr. Seppala, UDS also provides an interesting window into overuse, another form of inefficient allocation. This is mostly a story of unscrupulous providers taking advantage of patients and arguably, committing insurance fraud. The typical scenario plays out in low cost, “sober housing” settings. In a kind of bait-and-switch, these providers set low base fees to attract patients. They then overuse tests like UDS by ordering too many and directing the samples to their owned labs where they charge high fees. Dr. Seppla says insurance companies and State attorneys general have woken up to this and are beginning to pursue.

In the face of deliberate fraud, testing protocols and CDS will be of limited value. Of course, in value-based reimbursement models the incentive is to avoid wasteful overuse since that decreases provider profits.

Big data analytics may hold some answers to these behavior-based challenges. It is not hard to envision a future where the same AI techniques that look for potentially “bad” credit card charges and flag them for further attention could be applied to many of the challenges outlined above. This kind of profiling has the potential to find unusual or suspicious patterns while also recognizing legitimate differences in practice between say, an advance pain expert like Dr. Dobbie and the garden variety primary care physician.

What’s Next

The next article in this series will look at the role technology can play in supporting and enhancing medical research into opioid abuse and addiction. For those with even greater interest, we have published a white paper that provides a more in-depth perspective on clinical, sociological and technical factors impacting the opioid abuse epidemic.

Download White Paper

Dave Levin, MD is the Chief Medical Officer for Sansoro Health where he focuses on bringing true interoperability to health care. Dave is a nationally recognized speaker, author and the former CMIO for the Cleveland Clinic. He has served in a variety of leadership and advisory roles for health IT companies, health systems and investors. 

Colin Konschak, RPh, MBA, FACHE is the Chief Executive Officer at Divurgent. Colin is a Registered Pharmacist and is a highly accomplished executive with over 20 years of experience with extensive experience in health care operations, P&L management, account management, strategic planning and alliance management. 

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