Accountability that outlasts leadership.
BOCA should remain accountable to the people it exists to serve—even as leadership, ownership, and economic pressures change.
The proposed governance would give patients and practices meaningful influence over the rules that affect them, place limits on concentrated power, and establish how those rules can improve with evidence and experience.
The opportunity is to give all participants a shared stake in building a system that works better for everyone who depends on it.
What prevents BOCA from becoming the system it was built to improve?
A system can begin with a clear purpose and gradually serve different interests. Founders leave. Companies change owners. Capital brings expectations, and financial pressures can reshape priorities. Decisions that appear reasonable individually can, over time, change whom the system primarily benefits. Cadmus itself is subject to those pressures.
BOCA needs to balance interests that will not always agree. Patients need affordable access to care and benefits they can rely on. Practices need sustainable compensation and the freedom to exercise professional judgment. The system needs sufficient resources to meet its commitments and keep operating. Preserving that balance requires limits on any one group’s ability to dictate the terms for everyone else.
The governance question is how to make those limits durable: which rights participants should retain, which powers require shared approval, and how important rules can be changed without quietly weakening the protections people joined under.
The principles behind BOCA have to hold up over time, through the decisions made in its name. Its governance should help preserve those principles even when doing so becomes inconvenient for those in control.
Participation should carry a meaningful voice.
Patients and practices experience the consequences of coverage rules every day. Their experience should help shape how those rules develop. BOCA’s proposed governance would create ways for participants to raise concerns, propose improvements, review the evidence behind a change, and exercise defined authority over decisions that affect them.
That requires clarity about what participation means. People should know when they are being consulted, when their representatives have approval rights, and when a decision is theirs to make. They should also be able to see how their input was considered and why a decision was reached.
Different interests will still produce difficult choices. Broader benefits may require higher contributions. Lower contributions may leave more costs with patients. Changes affecting practice compensation can influence providers’ willingness to participate. Making those tradeoffs understandable gives participants a basis for weighing options and proposing alternatives.
Over time, this could create a more responsive coverage system—one in which people have meaningful choices and practical ways to improve the arrangements they depend on. Those responsible for operating and sustaining BOCA would bring financial and operational evidence into that process, alongside the experience of patients and providers.
Meaningful participation also requires access to the information needed to make a decision. BOCA’s design includes plans for functions and features to run on a blockchain—a distributed ledger shared across a network of computers. One benefit is that selected system records, rule changes, and approvals could form a tamper-resistant public history that anyone can inspect. This would give participants a common source of evidence for evaluating proposals and checking the claims made in their support. Sensitive patient and business information would remain protected. The intention is to let people examine relevant evidence, understand its history, and negotiate from a more equal footing.
Rootprint could support verified participation without publicly exposing participants’ identities. Where one-person-one-vote is appropriate, it could help establish that each vote comes from a distinct, eligible participant. Governance would define which decisions use that approach and where representation or professional expertise calls for a different process.
Could participants share in the value they help create?
BOCA’s development would depend on contributions from across the ecosystem. Patients and practices bring experience. Professionals contribute expertise. Others build tools, evaluate proposals, or provide services that keep the network operating. Recognizing those contributions could give participants a stronger reason to stay involved and help the system improve.
A native BOCA token—a digital asset designed for use within the ecosystem—is one proposed way to connect useful participation with economic benefit. It could reward contributions, support access to services, and provide defined rights within the network. Participants could have a tangible stake in the value they help create as BOCA develops.
For example, a participant who contributes a rigorous review of a governance proposal could receive a reward for that work. A developer could be compensated for maintaining a useful tool. The design would need to establish what qualifies, how contributions are evaluated, and how rewards are funded. Incentives should recognize useful work and independent judgment, including contributions that challenge a proposal or identify a problem.
A common token could connect these incentives across BOCA’s services, allowing different forms of contribution to participate in a shared economic system. Its usefulness would depend on what people can actually do with it and whether the activities it rewards create lasting value.
The token could also support defined governance rights alongside verified identity and participant roles. Economic participation and governing authority would need explicit boundaries. Holding more tokens need not give someone greater authority over patient protections, clinical responsibilities, or every rule in the system.
The design work must establish which rights the token carries, how rewards remain sustainable, and how influence is protected from concentration. BOCA’s interest is in giving participants a meaningful stake in the ecosystem—and aligning the ways they benefit with the contributions that help it thrive.
Who can decide what—and whose approval is required?
A workable system needs people with the authority to act and clear responsibility for the decisions they make. Routine operations, clinical judgment, financial safeguards, and changes to participant rights call for different expertise and different forms of approval.
BOCA’s governance would define those responsibilities explicitly. Operational teams would need room to manage everyday services. Clinical decisions would remain with qualified professionals within their responsibilities. Cadmus and other accountable institutions would retain defined duties for the functions they operate. Changes affecting fundamental protections could require approval from more than one group, independent review, or advance notice before taking effect.
The scope of each role should be understandable: what it can decide, what requires additional approval, and how its decisions can be reviewed or challenged. Shared authority also needs clear accountability, so participants know who must explain a decision and who is responsible for addressing its consequences.
Capital has a legitimate role in funding development, supporting growth, and receiving returns. BOCA’s design would explore how those economic interests can coexist with boundaries that prevent investors from unilaterally changing important participant protections. The same scrutiny should apply to founders, management, providers, and any other group capable of concentrating influence.
Those boundaries must also apply to the power to change the governance arrangements themselves. A protection offers little durability if the party it constrains can remove it alone.
Governance would establish who is authorized to choose or change a rule and which approvals are required. The supporting architecture would carry out approved decisions and enforce applicable limits. Keeping those responsibilities explicit makes it possible to examine both whether a decision was properly authorized and whether the system implemented it correctly.
Which protections can be built into the system itself?
Some protections could become conditions the system requires before an action can take effect. BOCA could use blockchain-based rules and other technical controls to check permissions, require specified approvals, and enforce waiting periods before accepting a protected change.
For example, suppose BOCA’s rules require advance notice before reducing coverage benefits. Shortening that notice period could require approval from designated patient and provider representatives. The system could reject an attempt by the operator to shorten it without those approvals. A verifiable record could show exactly what changed, who approved it, and when it became effective.
The ability to modify those controls would need protections of its own. Whoever can upgrade the software, replace an approval requirement, or invoke an emergency override may hold substantial power. Those capabilities need defined limits, review, and a visible history of their use. Distributing the infrastructure across many computers does not, by itself, distribute those powers.
Encoded rules still depend on sound judgment. A rule can be enforced exactly as written and still produce an unacceptable result. BOCA would need authorized ways to correct mistakes, respond to changing conditions, and meet professional and legal responsibilities while preserving a record of what changed and why.
These protections would apply to the people and institutions responsible for BOCA itself. Important boundaries should continue to hold when those exercising authority would prefer to bypass them.
How does BOCA improve its rules without making its protections disposable?
BOCA’s rules should be capable of improving as experience reveals what works, what falls short, and what needs correction. Patients, practices, and those operating the system could bring proposals through a defined process, supported by evidence and open to review by the people affected.
A proposal should explain the problem, the evidence behind it, the alternatives considered, and the expected consequences. For example, if a regional procedure limit consistently leaves patients with higher costs than anticipated, a review could examine local pricing, patient balances, provider participation, and the financial effect of adjusting that limit. Patients and practices could contribute experience that the numbers alone may miss.
Where appropriate, a review could draw on independent pricing benchmarks, published research, or outside analysis alongside BOCA’s own records. Participants should be able to inspect where the evidence came from, when it was collected, and how it was calculated. If external data enters through an oracle—a service that supplies outside information to blockchain-based systems—its source and method should be open to scrutiny as well. Blockchain records could preserve a verifiable history of the evidence used in a decision, helping participants work from a common factual basis and identify where genuine uncertainty remains.
The proposed process would connect each decision to its rationale and results:
Evidenceproposalauthorized decision and approvalsimplementationvisible historymonitoring and correction.
Before a change takes effect, participants should be able to understand what was decided, why, how it affects them, and when it begins. Monitoring should then test whether the change delivered the expected benefit or created new problems. A decision’s approval should begin a period of accountability for its results.
Participants would also need ways to challenge errors and request a review of rules causing harm. Urgent situations may require faster action, with clear limits on who can intervene, what they can change, and how long temporary measures can remain in place. Subsequent review should explain the action taken and determine whether it should continue, change, or end.
The standard is a system that can explain its decisions, examine their consequences, and correct its course through an accountable process.
A credible path beyond dependence on one company.
Cadmus would initially carry substantial responsibility for developing BOCA, operating its services, and establishing the safeguards needed to support participants. The longer-term ambition is for patients, practices, and other participants to assume progressively greater authority over the shared rules and processes that govern the network.
That could begin with defined decision rights in specific areas and expand as participants demonstrate the ability to exercise them responsibly. Substantial or eventual full participant control over the protocol remains a possibility to investigate. Each transfer of authority would need clear responsibilities, accountable representation, tested safeguards, and evidence that the receiving governance arrangements can handle both ordinary decisions and difficult conditions.
Control over the protocol would be distinct from ownership of Cadmus. Participants could gain authority over shared network rules without acquiring ownership of the company, its products, or its intellectual property. Cadmus could continue earning its place through the technology, services, infrastructure, expertise, and innovation it contributes.
As authority evolves, participants should be able to see which decisions have become theirs, which remain with Cadmus or other responsible institutions, and what conditions govern further changes. The final allocation of authority, voting arrangements, and transition timetable would emerge through research, design, and testing.
The ambition is for BOCA to become less dependent on the continued judgment of any single company while preserving clear responsibility for the work required to keep it functioning.
Governance has to work under conflicting interests and real pressure.
The proposed approach needs to be tested against situations in which participants disagree, financial pressures intensify, or a powerful group seeks to change the rules in its favor. Research and testing would need to establish:
- Whether representation gives participants meaningful influence while protecting the process from capture by a powerful group.
- Whether important protections can survive changes in management, ownership, and funding.
- Whether participants can understand the choices, access relevant evidence, and realistically take part.
- Whether token incentives reward useful contributions and support shared value without concentrating control or rewarding manipulation.
- Whether decisions remain competent, timely, and accountable, including under urgent conditions.
- Whether mistakes can be corrected and rules improved without weakening the system’s purpose.
The planned research report Capital, Governance, and Institutional Capture will examine how ownership, funding, incentives, and decision rights shape whom an institution ultimately serves. That work would inform BOCA’s governance design, including the allocation of authority, protections against concentrated control, and procedures for authorized change.
The test is whether these arrangements preserve meaningful participant influence and clear accountability when exercising power becomes contentious—and whether they help BOCA remain worthy of the trust people place in it.