It was hypothesized the increased number of hcbs

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increase the overall rate of public LTSS expenditures growth (Eiken, et al.). However, evidence shows the shift in Medicaid funding toward HCBS did not significantly alter overall Medicaid LTSS spending.Mental Model ChallengesGiven the magnitude of the challenge inherent to the Triple Aim, it has been argued on a conceptual level that new mental models need to be established. Mental models were first defined as a “psychological representation of some domain or situation that supports understanding, reasoning, and prediction (Storkholm, Mazzocato, Savage, & Savage, 2017).” Through contributions from cognitive psychology, pedagogy, and organizational science, our understanding of mental models has been expanded to recognize the role of past experiences.The management of mental models is a central tenant to the development of learning organizations able to adapt to societal trends, pressures, and demands. The Triple Aim forces together goals that traditionally have appealed to two competing logics: Managerialism and professionalism. Change efforts have been obstructed by this conflict; the two logics can learn from each other. Staff and managers understood the change imperative inherent to the Triple Aimmainly as a political requirement to become more efficient and reduce costs (Storkholm, et al.).Bending the Cost CurveEconomists have emphasized information asymmetries and institutions that defer decisions to providers as one reason for high healthcare costs. Moral hazard is the tendency to overconsume when third party insurance pays much of the cost. This is another oft cited explanation (Coyne, et al.). Triple Aim attempts to control costs by assuring that payment and
TRIPLE AIM IN HEALTHCARE11resource allocation support yearly initiatives to reduce waste, and rewarding providers for their contributions to better population health. The pursuit of this is still a challenge. Only 30% of cases have been able to improve quality, at the same time reducing costs (Hussey, Wertheimer, &Mehrotra, 2013). There is policy consensus that both cost containment and quality improvement are critical; however, the association between cost and quality is poorly understood. Deming described in his “chain reaction” model that by investing in quality improvement costs can be reduced (1985). Many have argued Deming's point. I tend to agree with him, but it takes a lot of work. With increasing costs, the quality benefits of additional resources may decline and eventually become negative (Hussey, et al.). However, economists agree there is evidence of a slowing in the rate of growth. Quietly over the last decade, large corporations have been on a slow and steady "buy-down" of benefits; this is benefit-consulting speak for "shift the financial burden to employees (Morrison, 2013)." Cost-sharing has been packaged as consumer empowerment, and delivered through the vehicle of consumer-directed health plans with health savings accounts.

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