Monica Peake. Monica is a general internist. She's an associate director of the McLean Center, and she's the faculty member at the McLean Center that's in charge of research and helping the fellows with their research. Monica is the world expert on improving shared decision-making between African-Americans with diabetes and their clinicians, and she has a really rare ability to basically bridge the worlds of academia, clicklnessum, and the African-American communities in a seamless way, sort of beloved by all these different communities. And so, Monica is going to be talking about the ethical responsibility of physicians to address health disparities. She's also a Greenwell fellow. Good morning. I am delighted to be here. I will not be talking about shared decision-making. I will not be talking about the grocery stores or our interventions. I actually did it at the last conference. I think it was the last conference. But what I am going to be talking about is the ethical responsibility of physicians to address health disparities. And I think about these conferences because it's a lot of us who come back every year as an ongoing conversation between myself and the group about some of the things that I'm interested in. So some of the slides you'll see are sort of repeated to welcome those that are new in the audience to this conversation that I consider myself having with all of you. All right. There we go. I'd like to just acknowledge the various places on campus that I sit, including the McLean Center, the Bucksbomb Institute, obviously the university, our diabetes center, and I'm currently funded through the Greenwell Foundation, one of the major bioethics foundations in the country. So part of the work that I'll be presenting today reflects my work as a Greenwell fellow. So for today, I'm going to talk a bit about health disparities, definitions and conceptual frameworks, some normative physician standards, the changing healthcare landscape, and then use two examples of studies of physicians, one of the physician organizations, and one that's currently being funded by the Greenwell Foundation that's underway. So I'll be presenting pilot data that's not yet been published about our ability as clinicians to try and address health disparities. All right. So health disparities in general, there are two kinds, disparities in the care that we deliver within hospital settings or healthcare settings, and disparities ultimately in the health that people have. These are obviously related. So one can lead to the other, but if we want to think about addressing the healthcare status in general, we have to think about both. This is just a reminder to us, and I'll come back to this in a second, that health care within this country is not equally distributed. And so there are different ways of thinking about disparities, and it's sort of, there are three different sort of buckets in which we think about differences. Two of those comprise how we think about disparities, disparities being sort of the bad version of a difference, either things that are happening within the healthcare system itself or things that are happening between people in healthcare settings. And so for interested in changing the health of people, a real people, then we need to think about changes in the healthcare system as well as changes outside of the healthcare system. And so last year, when I was here, I talked a fair bit about what's happening outside of the healthcare system in grocery stores and farmers markets and the work that we're doing to try and make bridges between what we're doing in care and what we're doing outside of care. And I had previously talked about shared decision making, particularly with the lens of what it means to have a marginalized social status, the race, sexual orientation, gender identity, any of those things, you know, those social identities that are marginalized, particularly if you have multiple of those identities and how that impacts, how patients and providers see each other, their communication, their ability to have common ground about making treatment decisions and ultimately health behaviors and health outcomes. I'm not talking about that today. So today, I'm going to be talking about healthcare systems and sort of broader macro level factors, and then particularly what we as physicians and all for the purposes of people in this room define physicians broadly. We can all be physicians today. If you're a healthcare provider, if you just sort of think about if you like to play one on TV, let's say. All right. I think I used this slide last time. I'm not sure, but just a reminder about the importance of distributive justice and what that means for existing disparities. And the tooth take home messages from Norm Daniels and Rawls are that disease and disability shouldn't impact our ability to live our lives and impact the range of opportunity that we have. And that the existing disease burden is disproportionately borne by marginalized populations. So some groups have disparities in healthcare and outcomes compared to others. And this is often the result of unequal distribution of societal resources. So it's not an accident that marginalized populations have worse healthcare and health outcomes. And so part of our job is to remedy the situation is to rethink how we are distributing resources and doing so in a way that's more just in order to ultimately address, reduce, and eliminate existing health disparities in our country. So as we're thinking about normative beliefs around physicians, so essentially what we should be doing as physicians to address health disparities, this is a paper that I like to read and reference periodically that had Mark Stegler as a key author. And they described several components of medical professionalism. And the one that I highlight in Maroon is the idea that part of being a professional clinician is to support policies to decrease health disparities. It's not just enough to take care of people that are marginalized, but we also work as individual physicians and as physician organizations to try and decrease the disparities that we see in healthcare and outcomes. This is normative. This is sort of the ideal. And this is a paper that was written by an ethics working group that had some people who have been trained here and have worked here at the McLean Center thinking specifically about ethics in practice, but there is a part of this that has specifically to do with health disparities. And this paper that was published in Annals in 2004, and they're talking about a number of factors. This paper was signed off on by a number of different national organizations of physicians. This is just a small listing of them. Oops. But what they said was that clinicians should advocate just as vigorously for the needs of their most vulnerable and disadvantaged as they do for their most articulate patients. So again, we have two examples where we are, we step forth our ideal goals of what we should be doing as physicians and as a profession to try and make sure that we are thinking about those who have the least resources and have the worst health outcomes among us and advocating just as vigorously for them and addressing these issues of disparities. So now I'm going to transition. And so talking about a paper that was written as part of a Disparities Task Force for the Society of General Internal Medicine.  I had no idea there were so many. I probably wouldn't have undertaken the project had I know. But we identified them all and went and administered surveys to all of their organizational leaders. We checked out their websites. And we did as much reconnaissance as we could to try and really figure out what these organizations were doing to address disparities. And then we categorized them and looked at the overall numbers and did some predictive modeling to figure out which ones were more likely as physician organizations to be trying to do work to address health disparities. And so this figure is just our taxonomy that we came up both on we differentiated by organizational type. So what kinds of things people are doing as organizations. So we providing education, clinical care, advocacy, data monitoring, research, mentorship. And then the different kind of thematic domains. Are we specifically thinking about health disparities or things that impact health disparities like access to care, communication, health literacy, perceived discrimination, those kinds of things. So this is our taxonomy that we created to help sort of catalog all the various activities that we are identifying. And what we found is that the number of activities per organization range from zero to 22. About half 53 of the organizations fell into the zero or one category. So most organizations were not doing anything. And so we found 167 and half are basically doing little to nothing to try and reduce disparities. What we did find is that primary care organizations were more likely, although not statistically so, because the number was so small, there were only nine. But 89% is compared to 67% to have more than one activity. So two more activities to address health disparities. And we had to cut off at two or more because there were so few in general. So we looked at distribution curves and that's where the cut off sort of naturally lie. Large organizations, so that makes sense once they have more resources, both infrastructure, monetary resources, the ability to advocate, those were more likely to participate in, to have activities to address health disparities. Minority physician organizations, so the National Medical Association, Hispanic Medical Association, other organizations that were primarily comprised of underrepresented minorities were more likely to. And then organizations like my own, again this was a project from the Disparities Task Force of the Society of General Internal Medicine. So if an organization had a health disparities committee, that committee was probably doing something. And the doing something would be to try and address disparities. So that was a bit of a no-brainer that those organizations were much more likely, 95% of those are likely to have more than two or more activities to address disparities. So the conclusion that we came to from this one study was that we have a national priority to eliminate health disparities. Yet more than half of national physician organizations are doing little, if anything, to address this problem. That primary care and minority physician organizations and those with disparities committees can provide leadership and vision to the rest of us in thinking about how to try and from an organizational infrastructure and member organization perspective, think about trying to address some of these pernicious disparities. It's not enough for us to, I would submit, to think about the work that we can do individually or the work that we can do in small collectives at the University of Chicago. But we also need to band together and use our collective force in numbers, particularly in large physician organizations, like American College of Physicians, to really try and push a national agenda to try and really get towards equity. So that was one of the studies I'm going to talk about. And the other is sort of this reminder to just put this in context. So why am I talking about health disparities? That's because what I do, that's the focus of my research, but also to put that in the larger context of currently a current health policy implication. So Marshall had mentioned some, certainly Albert had talked a lot about healthcare policy, the long arc of health policy, and how challenging and difficult it is to actually make policy changes that have real impacts on people's lives. But one of the things that we're seeing as part of the Affordable Care Act is a shift in how organizations and physicians are being paid with a bigger priority on primary care and prevention, a bigger priority on care coordination, and on managing the health of a population. So population health management. And so what that encourages us to do is to think about not just those patients who have the wherewithal, and there are a number of reasons why they may or may not have that wherewithal, to find their way into my office and see me. We're actually thinking about all the patients in a giving population. And there's a little bit of debate about how we're defining population. I would argue that we should be defining it based on geographic area. Currently, for the most part, it's being defined based on payer mix. So you have patients that have a certain kind of insurance, and that insurance plan will consider themselves to be doing sort of management for that population of patients. The obvious downside for that is that when I see patients, it doesn't really matter to me what insurance they have. And I don't treat them differently. I don't look at their insurance card before I see them. And so we really need to be thinking about changing entire health systems and not just stratifying care within a given system based on payer mix. But the bigger picture is still one that we're thinking about entire populations of patients and that we're doing risk stratification. And so that we're thinking about those who are in greatest health need based on medical or social needs as a way of identifying resource allocation. So this gets back to my previous slide about distributive justice and the decisions, the tough decisions that we have to make around our limited healthcare dollars. And so part and parcel of population health management is thinking about these broader issues of inequities and providing additional resources to vulnerable populations, not less. And so it really encourages us to think about the underlying causes of health, because we're trying to save money by keeping people healthy. And the biggest driver of health is not actually what we do in healthcare systems. It's what's happening when people are living in our communities outside of healthcare systems, these social determinants of health. And so there is an increased interest currently in thinking about how can we wrap our hands around these social determinants as healthcare organizations, either because we think it's the right and moral thing to do like me or because we're trying to save money like many others. But for whatever reason, we are trying now as a country to figure out how to do this. And so it makes these issues of equity and the operationalization, I haven't had them actually, much more important currently. And so then again, so I've been talking about the reorganizing the delivery of healthcare, but it also has implications for individual clinicians and that we're thinking about more team based care and care that for me is great. That means that the onus isn't on me to remember all of those vaccinations and if there's a whole team behind me who can sort of do some of these things, it is less physician centric, which I think is the way that life should be. But that does mean that there's less power, that physicians are going to be giving some of our turf away to others to try and deliver better care for patients. So are we ready for that? Who knows? I hope to find out with the survey that I'm doing. So that then brings us to this very busy slide, which I'm just going to walk us through a little bit. And so we asked, so this is a result of one, two, three, six questions that we asked on a Likert scale for physicians to comment on. Item C has to do, or let's take item D, sort of start in the middle. It's unfair in principle for patients to have a different quality in healthcare for the same medical condition. And purple and green are basically agree, red and blue or disagree. And so for question D, almost everyone strongly agree that it's unfair that health disparities exist. Now, when it comes to E and F, who should be addressing those issues, should it be healthcare systems or should it be physicians? These are physicians who responded. They were more likely to say that it should be the healthcare systems responsibility rather than our individual physician responsibilities to address these disparities. But they did say that we should be partially responsible. And some of this issue around how we choose to make these choices in the clinical encounter comes down to what's more important. The patient that's sitting in front of me or all the patients that I'm taking care of or all the patients that are part of this population. And so we asked about some of that tension between the individual versus the community of patients. And so that's sort of what A, B, and C are about. So a physician's main responsibility is to his or her individual patients more so than the overall patient population. Most physicians said, yes, I'm here for this patient. And then for population health and thinking about that tension, so item C, population health management versus individual patient care, we'll see that there's a little more of a tempering of that effect so that we can understand the importance of balance between these two constructs, but we still as physicians are leaning towards taking care of the very person that I'm looking at in the room at that time, which makes sense. And then last, that clinicians should make, we should consider how the allocation of resources when making clinical decisions. And most physicians did agree to some degree with that. The next slide is also very busy. That's my last one, almost my last one. And it's about addressing non-healthcare needs within the healthcare systems. And so the first two, the top two slides have to do with screening and addressing social needs, such as safety and family support. And the second asks physicians about who is doing and who should be doing screening for material needs like food and housing. And what physicians largely said is that, so in the maroon, that they are 40% of the time screening for social needs. And a quarter of the time screening for material needs. And that, but when you combine them together, someone in the clinical practice, either themselves or a non-physician, is screening for medical and social needs. We just know that that's not true. That's not happening. And so that for me is, I think that's an important sort of reality check for us as clinicians. The other has to do with addressing a social needs and who should be doing that. And what physicians are saying is that I'm doing a fair bit of this screening and addressing, but I really wish someone else would be doing that. I really rather task shift more of that to non-physicians. And so we have not looked at this in any detail, adjusting for various social demographic variables. This is sort of our first pass at our preliminary data. But the early conclusions that we have from that is our physicians believe that health disparities are unfair and that resource allocation considerations should be a factor in clinical decisions that our physicians and our sample anyway are prioritizing individual care over population health goals. The physicians may be overestimating the extent to which healthcare systems are addressing underlying causes of health disparities and systems meaning systems and themselves, that physicians believe that non-physicians as opposed to clinicians should be responsible for addressing health disparities. And they're more likely to support that healthcare systems more than individual physicians should be responsible for addressing health disparities. So in wrapping up, my final thoughts are that I think that physicians believe that health disparities are unfair, but we aren't really willing to sufficiently follow up with actions to address such disparities. And so that the goals of population health management and achieving health equity are at risk, these issues are not sufficiently addressed. So for me, this is a time to take a good long look in the mirror as a physician and at my colleagues nationally and think about what we can be doing to change systems and change hearts from our peers to try and sort of promote health equity. I'll end again with thanks to everyone who supports me and that makes my work possible. And also a picture of me and Paul Farmer last night where I did this ridiculous late last-minute party crash and he was so generous and hugged me like he knew me. And so I just wanted to say thank you and to, I always cry, this is so embarrassing, but just to say that he is the reason that I started on this work. That it's people like Paul Farmer and others that were like him that made me see that social justice is something that we should all be working for and something that I could actually do as well. So I just really wanted to express my excitement that he's winning this award and my delight that he hugged me like he knew me. And to say thank you and thank you all. I'll take this one of you. I know you're not looking. Hey Dr. Peake, how are you? Thank you. I'm Ben Brown. I'm one of the current Ethics Fellows and an OBGYN and a family planner here at UFC. And this question probably could have gone to really anybody in this block of talks, but I'm excited. I think it interfaces well with your talk about the ecology of the health system in particular. I wonder what you think about the challenge of addressing care for patients when the patient for whatever reason may be marginalized and the care itself may be marginalized or stigmatized. And so I think about trans care. I think about physician aid and dying. I think based on where I come from about abortion and birth control. And I think a really important growth in the discussion of intersectionality in caring for patients who continue to suffer historical marginalization. And so I wonder how you think that interfaces with when the care itself is not stigmatized or marginalized even within the health system? Yeah, no, that's a very important point that I've primarily been talking about social identity and how that can marginalize people. But even for people who are not otherwise marginalized or maybe they can be experiencing health conditions or medical treatments that will have that have socialist stigma attached to them. I think when any time you are at the intersection of marginalization, it's more than a doubling impact on that person in their health. And that makes them particularly vulnerable. And that it's our job as stewards of health care resources as clinicians to really try and be more empathetic to providing care for vulnerable patients no matter how they're being defined. And to make sure that they have the full range of access to care knowing that they have disproportionately been historically denied such access. And that's our job today and tomorrow and in perpetuity until we see equity to disproportionately reallocate resources until we see equal numbers in outcomes. Thank you. Hi, I'm Candice Hindley with the Blue Hat Foundation. And one of the things that I'm thank you so much about your slide for health care disparities because it's definitely with spot on. It's a lot of times that it's not addressed properly and it was I mean everything that you had on your side was spot on. One of the things I always like to ask doctors when they're prescribing treatments is to take the moment and look at your patient and ask themselves does the treatment match the life? Because a lot of times patients especially low income patients they don't have the opportunity to take off work. They don't have the opportunity to have treatments that may cause more harm than good. So is that something that you think would be feasible that can be added in the questions that were added in when doctors are evaluating patients or treatment? Does this treatment match the life and can they alter the treatment so the patient is still able to maintain a lifestyle that's not going to impair them? Absolutely. That's the other hat that I wear is thinking about this very thing how culture, race, class, socioeconomic position and social identities impact people's ability to share in treatment decisions. And for those communities or populations that have traditionally had less of a voice it's hard for them to articulate the reasons why it's more challenging for them to be adherent to a plan of care or to voice their preferences about plans of care that may reflect either personal preferences or lifestyle barriers. And so how can we as physicians and as health systems try and change ourselves to meet the needs of patients where they are? And certainly I'm thinking about those considerations is a core part of how we should be addressing marginalized populations in shared decision making and clinical care delivery. Absolutely. So this is the second year in a row that I've cried in front of this audience and so I just have to apologize. But thank you again for your patience and for your very engaging questions.


From the Cosmopolitan Hotel in Las Vegas, Nevada, it's theCUBE, covering Coupa Inspire 2019. Brought to you by Coupa. Welcome to theCUBE at Coupa Inspire 19. I'm Lisa Martin on the ground at the Cosmopolitan in Las Vegas, and we're pleased to welcome to theCUBE Michael Van Keulen, Global Percument Director of Lululemon Athletica. Michael, welcome to theCUBE. Thank you. I'm a big Lulule fan, have been for many, many years. If anybody doesn't know Lululemon, this is a three plus billion dollar designer, distributor and retailer of really cool technical athletic apparel. You've been there for a few years now, came from a finance background. One of the things that I love about Lululemon is the inspirational messages on the bags.  Talk to us about just one of the examples of this procurement transformation that you've helped initiate when you came in and found something really interesting about this iconic brand, this iconic bag. Sure. Yeah, so when I joined the company, we, you know, you start to do your basic spent cube analysis and trying to figure out where the big spent items are. And given that the bag is so visible for everybody, I figured like that's really like a big volume, lots of spent, very visible, and very important to our business. So I started to dig into our shopping bag as a category and I uncovered that it was single-sourced with one factory in Cambodia with a nine-month lead time. But nobody in the company really knew that. So when I was put in front of our senior executive to talk about like, you know, where do I feel there's opportunity, there was some pushback on me digging into our shopper and that there was even perspective in the senior executive teams that I didn't really understand how important our shopper is. And then when I asked the question, where does the shopper come from? Where is it made? How is it made? What's the lead time? What's the cost? There were lots of unknowns. And when I threw that on the table and said, well, it's single-sourced, one factory in Cambodia, you can immediately see a lot of people going like, wow, that's very interesting. And I started to realize that procurement is not just about saving money, which we also did, but it's also about de-risking our supply chain, being more nimble and more agile. Yes, I was going to say that what you discovered was a massive risk to the brand. I think the bag is what is the number one brand asset. Totally. It's very visible. But that was really the tip of the iceberg of some of the things you came in saying, you know, as procurement, there is a massive, many massive impact elements that it can have on the business. So going from sort of a tactical to a strategic approach, how was the bag, as an example, able to start helping you transform the culture of Lulu to be more strategic and start looking at all of the other ways in which this business can derive value from a number of the other elements besides the bag? Yeah, and so we started to identify, like what are some of our core principles when it comes to how we source and how we procure? Those are things to me, like fact-based decision-making, analytics, knowing what you buy, how you buy, where you buy, competitive pressure, making sure the suppliers realize that we have options in the marketplace. I mean, those are some of the key components of running a competitive department that drives a competitive advantage. And that's really what we focus on at Lulu Lemon in procurement. Some of the disruptors that we see in procurement and finance today are consumerization. Rob Bernstein talked about it this morning with some of the things that Koopa is now doing with the Amazon marketplace. But as consumers, whether we're consuming Lulu Lemon products or software, we have choice. We also have this expectation that we can go somewhere and find anybody that's selling this particular product, I can see the prices, I can see the pricing pressures put on, I can see all the different suppliers. So the consumerization sort of disruptor is really interesting to every industry. How are you leveraging that to really drive much more value, not just saving costs, but even things like impacting shareholder value for a little bit? Yeah, I think table stakes today is just managing spend, right? Knowing where your money goes and trying to make sure that we stretch the dollars as much as we can, I think is what every procurement function does. I think what distinguishes the world class from the let's say the middle of the pack is are you able to contribute to top line growth? How are you able to innovate? Are you able to innovate through your suppliers? And so one example is how we implemented third party gift cards at many grocers across North America. That was an idea generating from procurement, tying into gift cards that we already sourced and that we now have third party gift cards at the Kroger's and the likes that just drive more traffic to our stores. And that's just a really exciting, cool idea that wouldn't necessarily come from a procurement, traditional procurement function, but one that really wants to contribute to future growth. One that wants to contribute to future growth that has a strategic vision, when we look at the Cooper community, there's now $1.2 trillion of transactions going through that there's a tremendous amount of data. And we go to so many conferences at theCUBE every year and we hear very commonly, data is the new oil, data is gold, it is those things. If you have the right, if you have visibility and the opportunity to extract value from it and act on it immediately. Talk to me a little bit more about the third party gift card approach and was that something that you said we have so much more visibility into our data, into our consumers, into our suppliers? There's an obvious low-hanging fruit opportunity here. How did the data help you make that decision? Now this was more an idea where you start to look at like what value can procurement drive other than just managing and reducing costs. And every other big apparel retailer is already in this third party space and Lululemon is not. And the power of our companies, we are vertically integrated. You can only buy our product at Lululemon and some select strategic partners. But opening up the doors for people to be experiencing our brand in a different way through purchasing a gift card or being gifted a gift card, I should say. And that audience that now comes into our store, it just could potentially be a completely new guest. And that is what is super exciting. So let's talk about some of the business impact of that. So I would like to be on the receiving end of the Lululemon gift card for anybody who's watching my birthdays in March. And, but in terms of like what are some of the things that you've seen map back to top-line impact from that? Increase in new customers acquired, increase in customer lifetime value. What are some of those big impacts that procurement has made with what seems like, and, aha, this is a simple idea. We should be doing this too. I think what Lululemon does better than any retailer on the planet is our educators, right? Our educators in our stores. And so it's my job is how do I set these guys up for success? So I think one way we're now doing and leveraging the Koopa platform is taking away administrative complexity. So the lesser the administrative burden is on our stores and our educators, the better they are with engaging with our guests and educating them on our product, why we make it, what it does, so that our consumers that we call guests ultimately not just make the transaction but also by the right product, they know what the product is supposed to do for them and how it's supposed to fit and how it's supposed to help them in their daily lives. And so what procurement really does is just take away that complexity that they have today so that they can focus on what they do best. So walk me through who within, so one of the things that Koopa does is more than I think any other competitors is it's procurement, it's invoices, expenses, payments. Tell me about all the different ways in which Lululemon is leveraging Koopa and walk me through kind of an average user experience. Is this somebody like an individual contributor in marketing or finance? Give me a little bit of a taste of that. Yeah, so we use Koopa for sourcing, contracting, requisitioning, purchase orders and then flip that P.O. into pay. So we use the full suite of solution. The biggest focus for us is on the downstream as we call procure to pay. So it's a lot of people placing requisitions and that can be in marketing, it could be in the store, it could be in any part of our business really. And the downstream is the most important element because that's where the visibility comes and then from a procurement standpoint we use the sourcing and the CLM platform but the downstream is where the magic happens. So is every business unit within Lululemon on the Koopa platform? So we launched North America on February 4th. We're live in 18 stores as a pilot and we're going to roll out all of North America the entire fleet in August. So just February of 2019, so just what five months or so ago and the impact to the business that you've seen with just these first 18 stores? Yeah, it's not just the 18 stores, it's inclusive of our head office and our distribution centers in North America. We just now focus on supplier enablement. More suppliers on the platform, more spent through the portal and with the stores it's a pilot. It's going really well and if the stores are going to get it I'm pretty sure they will be very pleased. So we talked about kind of the consumer, the guest experience, supplier centricity. What have you achieved with respect to supplier centricity using Koopa and how is that affecting everybody up to the C-suite in your organization in terms of wow procurement is really a business engine here we do invest in? Yeah, I think our, if you look at our journey when we started three years ago where we literally had no real procurement as it is described today, we're still in that journey of maximizing our supplier relationships and through our supplier relationship to really drive innovation. I think we're not entirely there yet. I think that is one of the next iterations is how do we take procurement to the next level? And if you look back the last few years what surprises you about coming from a finance background now being in charge of procurement for a major global brand? Where are, what are some of the things that surprise you about this future of procurement and where Lululemon is set up to be successful? I think the biggest surprise is that people never intentionally do business with a company that we may or may not be, we should be doing business with. People never intentionally do that. It's just because they don't ask the right questions around ownership structure and risk and sustainability and reputational risk and environmental risk and just cost aside. And what I think what procurement helps to do is to actually ask all those questions so that we end up with the right company with the right pricing, the right quality, the right specs, the right everything. I think that's what surprised me is that that missing link that procurement brings to the table. So if you had to give your peers in any industry some advice, would it be, first of all, help establish a culture that is willing to ask questions? Because there's that whole thing too, right? We always think, well, maybe it's a dumb question. Have that culture that is no question as a dumb question ask, ask, ask? Yeah, and Lulule is fortunate enough, it's such a young company. So I had a lot of great stakeholders. I still have them today that are highly supportive. It's never just me or my team. It is collaboration, it's cross-functional. Everybody has to have something in it, right? So Lulule is a very young company.  There it required more convincing. Then maybe at Lululemen where, again, like people were just, the population is much younger and we were just, we needed more structure and people recognized that. The appetite was there. The appetite was there, for sure. Last question for you, Michael. Some of the things that are being announced this week at Inspire, we heard this morning about, we mentioned a minute ago about the size of the Coupa community, the amount of data, the value that it's driving for customers and for suppliers. Also, they talked about this Amazon marketplace that they're expanding this relationship so that IT folks can have this full-sweeted visibility. What excites you most about the direction that Coupa is going in? Yeah, I mean, it's the data, it's the native integrations with Amazon and the likes, absolutely. What excites me the most in terms of the different modules is CoupaPay. I've been wanting to go after dynamic discounting. That's what CoupaPay is going to enable us to do. Virtual pay is not a big opportunity where we can start flowing a lot of our payments through a virtual payment system, our payment cards. That excites me, but it's the data. And it's how do we, as a community, start to leverage our spend, I think will be absolutely awesome. Yeah, that collaborative, yes, and that collaborative spirit this morning was really palpable. Well, Michael, it's been a pleasure to have you on theCUBE today.  Thank you. For Michael Vankeel and I'm Lisa Martin. You're watching theCUBE from CoupaInspire19. Thanks for watching.


here to close out our week wrap up our day here this Friday afternoon shortly after 2.30 PM Eastern time. Nice trade here taking us into the afternoon. This APLD still holding right near the highs made a really strong backup once again today. But I agree to see all of our students members alike inside our live trading room Felix, Michael, Rovina just before Patrick just a moment ago. A few more of us still with us here right like Nicholas just before Bell and Mike see perfect. All right. So hey, we got a few of us here we got a few of us in social media all of our social media streams, Facebook Live, LinkedIn, Twitter, YouTube, the works for right now APLD will start with this on the screen like I just said up big once again today. The stock came out with news earlier this week in relation to you know some AI contract. I think it was like $180 million you know contractor so to say led to a nice pop but you don't necessarily expect such a good swing on this day over day over day. So you know we didn't recommend it as a swing trade it was recommended as a day trade and has worked out phenomenally as a day trade. So you know going into the afternoon we're going to definitely put this on our watch list just to begin. How could we not you know just right within our price range still it's extremely liquid that is the part that I'm most excited about you know anytime you trade a stock for the first time you know pops up on a given day you know if it doesn't have good liquidity then I'm not going to really like try and trade a day over day. If it does have good liquidity then at least you're telling me there's a chance where maybe it can make another sort of move the following day for me to take part in for me to take advantage of well with that I mean really since Tuesday this week not only up days but it's retained its liquidity here pretty well and that is what's made this really tradable. So love to see it gonna put this on our watch list just to begin this APLD. Now this is moving up markets seem to be pushing much lower heading into the close. I ended up breaking above historical level 415 roughly on the spy you know the spy does not trade exactly with the SPX with the ES right with the S&P futures you could say. So hey ES ended up breaking above a pretty big resistance historically just yesterday as well but now at the way back down that we're seeing here today I'm sure that ES level is getting tested that 415 levels a little ways away on the spy chart there but for right now lower high should look to equate to a lower low. So there could be a couple of good shorts to work with heading into the market close folks you know hey for all this inside the live trading room I'd said this just you know a few times before this meeting started FL footlocker it is down big today it was on our watch list to begin this morning and with that I mean I was kind of scanning through I'm actually recording my other monitor for a trade station video that CT will be coming out with soon. So be on the lookout for that on your YouTube channel but with that though I've been kind of hawking a few different trades APLD being one of them and FL being another and with that it was moving back up and up towards its opening print perhaps you can call this good timing it took maybe a few minutes about three to five minutes before it truly made the break but I was looking for this to break over and under over and under it was down big already if it didn't make that move then I wouldn't have been as interested in it at all I don't know if I'd be interested in any sort of dead cat bounce unless it was down even that much more. So yeah I missed out on the bounce from 30 so far but I was more bearish and with the break under the opening print price here 30.65 it has been smooth running is all the way down towards the low there again 29.90 actually is like a historical level two to complement that 30 if you look on the daily chart back from 22 that is you know just it was kind of lingering off of 29.90 actually have to go back more than that it was 21 I was on a coaching call the student earlier and just a couple of different close prices right around this 29.86 29.93 29.92 from here so it just leads me to say like that could complement the 30 and it has so far but you know hey lower highs equals lower lows and the more times that support level gets poked at I'd be led to think that that could be a really good continuation Michael shorted 10 shares of footlocker before the market closed yesterday there you go Mike nice job for right now I think that there could still be some room on the way down perhaps I mean it's got a really obviously continue to make lower highs but very good start on the short from the opening print this morning here just at the 30.65 level so I'll put this on our watch list too at the APLD on the way up FL on the way down let's see what else we can get though going from top to bottom here this MNK you know Felix was asking here earlier like you know is this volatile enough like you think right so it ended up pushing up came back down pushed up came back down and with that it's not really something like to entertain by you know if it's going to break higher than do it if not then I don't want to be stuck just with a pop and drop type of move so I actually took my eyes off this trade recently when it wrapped back up again I thought this would have been game over after this last shake uh hey it's near the highs this stock I think hmm I don't know if this is newly listed on to the American American exchange Amex because prior to today this stock was trading like next to no volume so maybe it was OTC before today and finally got listed on a major exchange like the Amex is that big today let's see where historical level could be if not right from like right around five 20 ish should really pop that much higher you know pretty much where it dipped off back in april time here 460 ish 465 so that could still still be ahead level to watch out for here coming up uh you know what hey it hasn't dove off just yet right if it did I wouldn't really look at it here so uh for now it makes the cut if it tanks during this meeting then hey always subject to change all right we keep it going though otherwise sda done for w key it's kind of looking like that mnk trade a little bit just trying to tease us make more of a little afternoon move here for right now uh pretty thin volume out there on the order book for such a cheap stock three dollar stock like this so you know comparing apld liquidity to this apld definitely seems more tradable in that regard I guess if I add mnk I got to add the other one this w key for for right now we'll come back to him at least this amtx this was a sneaky one from earlier wow I was calling this out with one of our students poplo and a coaching call earlier today off 302 as a key resistance and we were looking for a push up to 325 so you could see I left some money on the table on this trade good entry it took a little while for it to churn up so I wasn't like really happy with the pace of it got the job done took the money and ran but man this thing really blew the roof off this you know resistance unfortunately there was a poppin drop and been very lackluster since all right you know hey for right now like I said you know just to jump back really briefly apld no need to build up a big list no need to try and look at this stock that stock when stock that we should be trading is the one that we've been trading the whole time this apld here so obviously you could say that on a few different trades but with trend there's no better place to start right like that's what we were talking about to begin apld just breaking a new high right now we're looking to break the highs right now it's moving back above big volume here off of 824 823 822 so perhaps this could lead to a nice squeeze here coming up right I kind of lost my spot there actually in the meantime there amtx atnf here we go all right so we'll keep it going though for right now atnf pretty slow dead for right now that trade bioc this stock is like just I don't even know this probably this probably has had so many different reverse stock splits now at this point yeah you could tell back from 2019 so I just remember in the past a couple of our students you know calling us out as a day trade like years ago years ago they're not in this room right now I could see but you know hey it was a good day trade back then it was a good day trade back then actually but you can tell what happened to this stock over time since just by looking at the daily chart here so you know had to have done a couple of reverse splits over time not looking too good there either way for right now today uh keep it going got it cheapy here ARQQ you know it's up right now moving up pretty nicely see if there's anything looking better you know hey I appreciate when students you know newly enrolled students or any student of that matter just kind of ask what my thoughts are on a stock had a private chat from one of our students here and uh you know they're asking about what are your thoughts on FTCH you know I think it's done for right now just you know this already made a move up and down I don't know you know if this is going to be any sort of good play here heading into the final hour you know maybe it could be a good short should this break below 510 and it seems like that's the better direction for right now I absolutely would not be looking for a bounce back up on this trade at this point yeah and otherwise I want to follow a stock that's much closer to the highs or near the lows this could be near the lows but you know what I mean I'm talking about a stock down percentage wise perhaps going with the market maybe off a news footlocker all right what else we got though here otherwise we got the MVIS Bell asking about that right now and we get to adhere on the gainers list so up about 17 percent actually just popped before the the meeting started I didn't realize that so more of an afternoon little pop right now I mean it was up all morning but just now breaking above the highs 373 ish you know up over 380 so it still looks pretty strong I mean just pull back a brief amount but otherwise actually I like this one here Bell MVIS I'll add it it's a stock that we are really familiar with here too micro vision mavis we kind of nickname it as back in 2021 pandemic time popped up did really well did really well on it back then all right what else we got APLD we talked about I mean there's definitely enough that's up percentage wise still even with the market slumping off right now TO TIO backup but once again today let me go back to the daily chart here it's getting pretty close to the high that we had back from just yesterday I mean the open price the high price there oh no there we go this part I was wondering that the numbers on this box here that popped up or throwing me off right here so 538 the open price from yesterday 540 the high it is pretty much right there now so yet TIO TTOs as Fauston nicknames here we'll have to put back on our list looking pretty strong all right not a bad list to begin folks and again we have a couple will jump back to already on there perhaps if they tank will kind of scrap them but uh let's see if there's anything looking even better from the loser side footlocker of course we talked about just going to skip over that at this point already on our list and DLS technically shortable technically at the lows of the day too you know what let me just check here it's on good spread it's on good liquidity not really treating a whole lot of volume per minute but check this I mean this is pretty close to all-time lows here beautiful rounded bottom back in 17 316 the low there this big wick 314 the low so look at that pretty strong you know what more for kind of just studying and just to kind of see what it does eventually not to like really put this on the top of our list you know it's tradable if you want to practice like a potential short on a level one stock this could be it for you and you know the all-time lows aspect of it I kind of just am interested in so you know I add it to our watch list notice how we phrase it as the watch list not the CTU you must trade this list so you know we want our students to start with this watch list to begin you know personally I'm probably going to start on APLD and Foot Locker and then I'll probably move around to Tito's and the Mavis and then eventually work my way down to that and DLS KSS down big tier today it's not exactly at the lows but you know pulling back perhaps it has more room to drop towards there now and showing decent direction doesn't hurt us to I guess add this but looks like retail is taking a bit of a hit right now American Eagle also down I mean the clothing stores I mean like KSS, AEO I don't know Macy's yeah down big today all right folks I don't know if there's anything else looking good I'll take a look at some sideless stocks while I'm at it here just really briefly like Shopify at the low of the day Square is a nice short early this morning AMD a little expensive there oh be careful APLD making a bit of a reversal there a bit of a head fake it failed to continue to make that pop and instead it smashed back under that big volume there off of E22 E23 where's my friend Felix here in this chat board right now I can only imagine what he's up to on this trade here so yeah if you had your eye on this year this could have triggered an interesting short opportunity on the flip side so like saying W has been a good short for him today well if you got in from the morning definitely treating you well but for a $35 stock looking a little little slow little little like watching the grass go right now so for this afternoon we'll pass on and happy the mics up on it let me know if there's anything else that could be a good day trade from this point at least I mean MNK there's higher risk with you know following this still it hasn't tanked though right well actually I'll tell you what I actually did tank briefly but even then from there pulled back up this is pretty chaotic stock here so I'll keep this on our list since it hasn't totally dove off and in fact it pushed back up once again and same with W key wow both of these actually it's kind of reluctant of put them on the list at least to begin but yeah still looking pretty strong for the meantime both of them jith got out on the APLD trade at $8.33 there you go nice nice exit from jith there good all right so let me know if there's anything else folks I'm going to actually just check Benzinga before you wrap up here right now so I had that on this monitor here brief second there we go all right so what do we got here we got MNK W key and that's really it and then on the loser side for right now AI if you could short it beyond meat dropping off there if you could short it Carvana if you could short it no hey don't get me wrong those you know clothing store stocks like Kohl's Macy's American Eagle you know those are all really tradable you definitely put them on your personal watch list if anything all right let me jump to that CVMA let me jump to that beyond meat none of what you're really looking too good at this point all right so you know what actually out of all those different clothing stocks if I were to add one of them if anything I'll just kind of pick through I'll tell you what it's kind of like a tie between American Eagle Macy's here um you know I'll go Macy's I'll go Macy's I feel like Macy's probably trade a little bit more volume both are very liquid but I'll just kind of shoot from hip and go that one Sam's saying anyone know what Powell and Bernanke said that crashed the market I do not but if maybe Rich can pull up something just coming up there in the bit he may have posted earlier in the chat board Sam so you could probably just use the search tab up top on the chat little setting icon gear button that you press and you could search really any term in the chat board probably pull that up there all right for all of a social media facebook live linked in twitter youtube the works etc hey we appreciate you folks sticking with us each and every day each and every afternoon for myself if you have any questions or trades in which you'd like to go over feel free to shoot me over a quick email josh at c2trading.com is the handle but we got a lot to work with you're going into the close folks for the end of this week so for Jeth and Michael Leda Grant and Kathleen and Ravina and Bill and all of our students alike inside the chat board I'll be with you folks pretty much all the way until the market closed today I got a coaching call up until 330 and if we're in a healthy market if I'm in a trade really after 330 I'm probably sticking around to the close so I look forward to it folks a lot of work to cover here talk to you soon