A coverage model has to stay balanced after it launches.
Prime gives patients and practices more visibility and flexibility than a tightly controlled network model. That can create healthier market behavior, but it also creates opportunities for people to exploit the rules.
Prime therefore cannot depend on one control, one algorithm, or everyone behaving perfectly. It needs ways to remain stable when real-world behavior puts the model under pressure—and to change course when evidence shows that something is no longer working as intended.
Alignment for good participants. Safeguards against bad actors.
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The practice sets its price. Prime defines the support it will provide.
Dental practices do not all operate under the same conditions. Costs vary by region. Staffing, technology, experience, overhead, service model, and the overall patient experience can vary substantially from one practice to another.
Prime’s design starts from the idea that the price of care and the amount coverage will support are two different decisions.
The practice submits the fee it actually charges for the recommended treatment. Prime does not replace that fee with a reimbursement schedule that participating practices are required to follow.
That preserves real market information. A higher fee may reflect a more expensive market, a different practice model, additional technology, greater service, or simply a different pricing decision by the practice. Patients should be able to see those differences rather than having them disappear behind a centrally imposed fee schedule.
But that freedom does not mean Prime accepts unlimited financial exposure.
Prime would set a regional limit for each procedure. Prime’s coverage percentage would apply to the practice’s fee up to that limit.
If the practice charges less than the regional limit, Prime would use the actual fee.
If the practice charges more, Prime would use the regional limit to calculate its contribution. The practice could still submit its actual fee, while any amount above Prime’s regional limit would remain outside Prime’s coverage calculation and would need to be handled according to the rules that ultimately apply.
This gives Prime a clear financial boundary without requiring every participating practice to follow the same fee schedule.
How those limits are calculated—and who can change them—is central to the proposed model. The aim is to make the methodology transparent and auditable, with changes governed by defined rules and, ultimately, community agreement. Cadmus would initially control these decisions while the longer-term governance structure is developed.
A regional limit establishes a financial boundary. Prime also needs ways to discourage people from exploiting the rules within and around that boundary.
What helps prevent gaming when practices remain free to set their own fees?
The first part of the answer is to make relative pricing and patient experience visible enough for patients and practices to act on that information.
WHAT HELPS KEEP PRICING ACCOUNTABLE?
Every time a practice submits a treatment fee to Prime, it provides information about what that practice charges for that procedure. Across participating practices, those submissions could help build a picture of what the same procedures cost throughout a region. As more practices and patients participate, that picture could become more complete.
Prime would use regional pricing information to help establish its coverage limits. That same information could also help patients compare practices.
For example, a patient looking for a dentist could see an indicator showing whether a practice’s fees are generally lower, similar to, or higher than those of other practices nearby. Individual treatment fees would remain private. The indicator would provide an overall comparison, with the method for making that comparison still to be developed and tested.
The planned patient-facing BOCA app would include a ratings and feedback component where patients could describe what receiving care at a practice was like. Did the dentist take time to explain treatment? Did patients feel listened to? Was the office organized? Was scheduling convenient?
Those ratings and reviews would appear alongside the practice’s relative-price indicator, so patients could consider both when choosing where to receive care.
Seeing price and patient experience together gives people something they can act on.
A practice with higher fees might offer longer appointments, additional technology, more convenient hours, or service its patients particularly appreciate. Someone who values those things could choose that practice knowing it is relatively expensive. Another person might prefer a lower-priced practice whose patients also report good experiences.
But if a practice charges substantially more than others nearby and its patients consistently describe disappointing experiences, prospective patients would have a reason to consider another office. The practice would have a reason to respond—by reconsidering its fees, improving its service, or addressing the problems patients describe.
Dentists could use the information too. A practice might discover that its fees are much higher than those of nearby offices, or that patients do not feel the experience justifies the price. That feedback could influence decisions the practice makes about both pricing and care delivery.
Think about how people choose a restaurant. A price indicator tells you roughly how expensive it is, while reviews help you decide whether the experience sounds worth paying for. An expensive restaurant with excellent food and service can attract people who happily pay more. An equally expensive restaurant with consistently poor reviews may struggle to persuade people to come through the door.
Dental care involves more consequential decisions, and patient-experience ratings alone cannot establish clinical quality. The useful connection is that people can respond to what they learn, and businesses have a reason to pay attention to those choices.
Greater visibility into dental prices could also help participants understand what their contributions help fund. The cost of treatment affects how much money Prime needs to provide coverage. Making those costs easier to understand could give participants a clearer view of why the system needs contributions and why rising treatment costs matter.
This is one way Prime could encourage a more informed, fairer market while allowing practices to set their own fees. Whether it changes pricing and behavior as intended would need to be tested.
Of course, that depends on the information being trustworthy. What stops someone from buying positive reviews or creating fake patient accounts?
MAKING PARTICIPATION AND FEEDBACK CREDIBLE
A practice could buy positive reviews, ask employees or friends to post favorable comments, or use fake accounts to create the appearance of satisfied patients. Bots and accounts that are easily created and discarded could make that manipulation harder to recognize. Patients choosing a dentist would then be relying on a reputation that may not reflect what actual patients experienced.
For BOCA’s proposed ratings system to be useful, it needs a way to check that someone submitting a review actually received care at that practice.
BOCA already needs to answer related questions for the coverage system itself: Is this a real person? Are they participating as a patient or a dental provider? Do the records being submitted belong to the person receiving care?
Cadmus is developing Rootprint, a proprietary, patent-pending identity-verification system, to help answer those questions and automate the checks that support trustworthy participation.
When clinical records or participation history are used to support a request for coverage, the system needs confidence that those records belong to the person receiving care. Rootprint could help establish that connection, making it harder to pass off someone else’s records as one’s own or present the same person as several different participants.
These are some of Rootprint’s intended uses within Prime’s safeguards. Its broader design and applications are explained on the Rootprint page.
That same ability to verify participation could also help establish that a review came from an actual patient of the practice being reviewed. A review could be connected to a verified person and their relationship with the practice, giving patients a stronger reason to trust the source of the feedback.
That verification also needs to protect the person leaving the review. Patients may hesitate to describe a disappointing experience if doing so publicly identifies them or makes them feel uncomfortable returning for care.
The aim is to verify that the reviewer was a patient of the practice while keeping their identity private. Privacy-preserving methods could allow the system to confirm that relationship without publishing the patient’s name or necessarily revealing it to the dentist. The verification process would need to be designed carefully so that confirming a review’s legitimacy does not unnecessarily expose the person or their treatment information.
Verifying a patient relationship would still leave some questions to address. An employee or friend might also be a genuine patient. A real patient could be paid to post a favorable review. Confirming that someone received care cannot establish that every statement in their review is accurate. The ratings system would therefore also need rules for conflicts of interest, paid feedback, and other attempts to manipulate reviews.
The methods used to verify participation and protect privacy could ultimately be made available for independent inspection or audit, so their effectiveness can be evaluated.
Even when people and their records are genuine, some forms of manipulation only become apparent when pricing, treatment, reviews, or other activity are examined together. Prime would also need ways to recognize those patterns and bring concerns to human review.
DETECTING PATTERNS AND REVIEWING CONCERNS
Some attempts to exploit Prime could be difficult to detect when each submission is reviewed separately. A treatment record, a fee, or a patient review might appear legitimate on its own. Looking across many submissions could reveal repeated use of the same records under different identities, coordinated reviews, or patterns in treatment and pricing that warrant investigation.
As information comes into BOCA from participating practices and patients, it could become possible to recognize patterns that would be difficult to see from a single appointment or record.
DentAI is the AI component of BOCA’s design intended to help examine that information and identify activity that needs a closer look. Within Prime’s safeguards, it could look for unusual patterns in treatment fees, recommended or recorded procedures, how frequently coverage is used, patient reviews, and participation across the system.
Rootprint and DentAI would contribute different information to that process. Rootprint could help establish who a record belongs to and where it came from. DentAI could examine how that record relates to other activity. Together, they could help identify concerns that either approach alone might miss.
An unusual pattern would prompt investigation. Human review would determine what the available evidence actually shows.
For example, a practice might perform a particular procedure more frequently because it treats patients with more complex needs or receives referrals for that treatment. A higher fee might reflect additional time or resources required for a difficult case. Those circumstances matter when deciding whether a pattern has a legitimate explanation or points to possible misuse.
Reviewers would need to consider the relevant records and circumstances and, where necessary, seek an explanation from the people involved before reaching a conclusion. An automated flag alone would not establish wrongdoing.
Prime’s design starts from the expectation that most patients and practices will participate honestly. It also needs to account for people who may test the rules, misrepresent information, or coordinate with others to exploit the system.
That is why several safeguards need to work together. Regional limits constrain how much Prime contributes toward a procedure. Pricing information and patient feedback help people make informed choices. Verification strengthens confidence in who is participating and whose records are being used. Monitoring and human review help address concerns that remain.
The system also needs to stay financially healthy when participants are acting legitimately. Treatment costs, demand for care, and the amount paid toward coverage can change over time. Prime therefore needs a way to see when those changes are putting the overall model under pressure.
MAKING SYSTEM HEALTH VISIBLE
Prime needs to track how much money comes into the system, how much it pays toward care, and whether the funds set aside for future obligations remain sufficient. Participants and those overseeing the system should also have ways to examine that information and understand when conditions are changing.
For example, treatment prices might rise across a region. Patients might need care more frequently than expected. Payments toward treatment might grow faster than contributions. Each could put pressure on the system even when everyone is following the rules.
Information gathered across participating practices and patients could help show whether Prime is operating as expected. That includes:
- Regional prices: what practices charge for procedures and how those prices change over time.
- Use of coverage: how often patients receive covered care, which treatments they receive, and how much Prime contributes toward that care.
- Coverage performance: whether Prime is providing the support its rules describe and meeting its payment obligations.
- Reserves: how much money is set aside, how those funds change, and whether they remain sufficient for expected obligations.
- Changes to the rules: adjustments to contribution levels, coverage percentages, regional limits, or other settings that affect participants and the system’s finances.
Comparing actual results with the assumptions used to design Prime could help identify problems early. Participants and reviewers should be able to understand how those comparisons are made, what information they rely on, and where that information may be incomplete.
The aim is to give people ways to check whether the system is doing what it says it is doing.
Publishing calculation methods and reporting rules would make it possible to examine how figures are produced. Independent audits could check those reports against the underlying records under appropriate access controls. Cryptographic verification could help confirm specific facts about records or calculations without exposing all the private information behind them.
Where useful, records on a blockchain could provide a shared history of approved rule changes or other system events, allowing reviewers to check what changed and when. Each method would serve a specific purpose within the wider process of making the system accountable.
Private patient transactions and clinical records would remain protected. Public reporting could describe patterns across groups of participants, while authorized reviewers receive access to the information needed for their work. The design would need to address who can access which records and how to prevent published statistics from revealing an individual’s care.
Together, these forms of reporting and verification could provide evidence for deciding when Prime needs to adjust—and help participants understand the reasons for those decisions.
Recognizing financial pressure is only part of the job. Prime also needs the funding, reserves, and financial policies to continue meeting its obligations when costs or demand for care change.
CAPITAL, RESERVES & TREASURY STRATEGY
Reducing the cost of administering coverage could leave more money available for care. Automating routine work and reducing unnecessary overhead are therefore important to Prime’s economics. But paying for treatment still requires money, including when patients need more care than expected.
Prime’s current design includes a 3% fee charged to participating dental practices to help fund system operations, build reserves, and support its treasury strategy. Those funds would help cover infrastructure, compliance, security, software development, and human review while strengthening the resources available to meet coverage obligations. The proposed 3% rate would be tested through financial modeling and could later be adjusted through Prime’s governance process.
Prime’s financial design would need to explain where that money comes from, how much is set aside, and how those funds are managed.
Different sources of funding and financial protections would serve different purposes.
Participant contributions would fund ongoing coverage. The amounts participants pay would need to reflect the support available under their plans, expected treatment costs, operating expenses, and the need to maintain reserves. Those assumptions would need to be tested against actual experience as the system grows.
Outside capital could help establish the system and build its initial reserves. Funding for software development and operations would need to be distinguished from money available to meet coverage obligations. Capital committed to reserves could provide a financial cushion while participation grows and the model develops an operating history. The amount available, its terms, and what investors receive in return would all affect the design.
A defined share of system revenue could help strengthen reserves over time. Prime would need rules for allocating money among payments for care, operating expenses, reserves, reinvestment, and any distributions or rewards. Those decisions would determine how much financial strength the system retains as it grows.
Reserves would provide funds for obligations that ongoing income alone may not cover when they fall due. The amount set aside would need to account for expected payments, uncertainty, and periods of higher demand. Reserve targets would need regular review as participation, treatment costs, and use of coverage change.
Treasury management would determine how those funds are held and made available. Money needed for upcoming treatment payments must be accessible when those payments are due. Decisions about where funds are held would need to consider safety, access, and investment risk. Rebalancing would mean adjusting those holdings as payment needs and financial conditions change.
Future services within the broader BOCA ecosystem could potentially generate additional revenue. Where appropriate, some of that revenue could support reserves or other system needs. Its contribution would depend on those services producing revenue and on defined arrangements for directing it toward Prime.
Risk-transfer arrangements could provide another form of protection. Prime could explore paying another organization to take responsibility for a defined portion of unusually high costs. The value of such an arrangement would depend on its price, exclusions, limits, and the financial strength of the organization accepting that responsibility.
The purpose of building financial capacity is to sustain a system that creates value for patients, providers, investors, and Cadmus.
Patients need support the system can continue to provide. Practices need terms that make participation worthwhile. Investors need a credible basis for committing capital, and Cadmus needs resources to develop and operate the system.
The model therefore needs to examine how benefits and burdens are distributed. Financial gains should not depend on continually squeezing providers, simply shifting more costs onto patients, promising patients benefits the system cannot sustain, or allowing Cadmus to absorb a disproportionate share of the value created.
The required capital, reserve targets, revenue allocations, treasury policies, and risk-transfer arrangements remain subjects for financial modeling and validation. Together, they would need to demonstrate that Prime can meet its obligations through changing conditions.
Alongside those financial resources, Prime could give participants a meaningful stake in the system’s continued health—and a reason to help protect it.
GIVING PARTICIPANTS A STAKE IN SYSTEM HEALTH
Patients, providers, investors, and other participants could have stronger reasons to support Prime’s continued success if participating in a healthy system creates something valuable for them. A useful reward or an opportunity to help shape decisions could make the system’s future matter more directly to the people involved.
Prime’s design includes exploring a digital asset called a token. A token is a digitally recorded unit that someone can own and hold. A useful starting comparison is reward points: a person can accumulate a balance and use it for benefits defined by the program.
For Prime, participants could earn tokens through qualifying activities and use them to access defined benefits or take part in certain decisions about the system.
The value would depend on what the token actually allows someone to do or receive. The design would need to explain why people would want to earn or hold it, how rewards are funded, and how participation benefits both the recipient and the broader system.
Potential uses include:
- Prevention: rewarding participation in appropriate preventive care that supports oral health and could reduce future treatment needs.
- Long-term participation: recognizing patients and practices that remain involved over time, helping build continuity and a more stable participant base.
- Unused benefits: exploring whether participants who use less of their available coverage could receive some form of value while preserving funds for those who need care. This would require careful design so that people have no incentive to postpone necessary treatment.
- Strong provider performance: recognizing practices that meet clearly defined, evidence-based standards. The measures would need to account for differences in the patients and conditions those practices treat.
- Governance participation: recognizing useful contributions to reviewing proposals, evaluating evidence, or making decisions about the system.
- Other contributions to system health: rewarding activities that produce a demonstrable benefit for participants or improve how the system operates.
Credit-card rewards offer a familiar example of how a useful benefit can influence behavior. Someone may repeatedly choose a particular card because the points, cash back, or travel benefits are worth something to them. Those benefits give the person a reason to keep participating.
Prime would explore whether rewards could create a similar reason to remain involved while encouraging activities that help the system work well. If participants receive benefits they value from a healthy ecosystem, they may have more reason to care about its financial stability, the integrity of its records, and the decisions that affect its future.
Those rewards would need a sustainable source of value. Distributing tokens does not by itself create the money needed to pay for care or deliver a benefit. Any rewards would need to fit within the allocation of revenue, reserves, and other resources described in Prime’s financial strategy.
The design would also need to examine who receives rewards, how much they receive, and whether the incentives produce the intended behavior. A reward that can be easily exploited, disproportionately benefits one group, or consumes resources needed for coverage could weaken the system it is meant to support.
Token utility, funding, distribution, governance rights, and behavioral effects therefore remain questions for development and testing. Incentives would work alongside verification, monitoring, human review, and financial safeguards.
As evidence accumulates, reward rules and other parts of Prime’s design may need to change. Who would have the authority to make those changes, what evidence would guide them, and how would participants have a say?
HOW THE RULES COULD CHANGE
If treatment costs rise or more patients need care than expected, Prime would need to respond. Increasing participant contributions would be one option. Depending on the circumstances and the resources available, other adjustments could help restore financial stability.
The mature design could allow changes to:
- Contribution levels and tiers: how much participants pay and the coverage options available to them.
- Practice fee rate: the percentage charged to participating dental practices to help fund operations, reserves, and treasury needs, currently proposed at 3%.
- Coverage percentages: the share of eligible treatment costs Prime contributes.
- Regional procedure limits: the maximum fee used when calculating Prime’s contribution toward a procedure.
- Reserve targets: how much money the system aims to keep available for future obligations and unexpected costs.
- Reward rates: how much value is allocated to participation incentives.
- Treasury policies: how funds are held, how much remains readily accessible, and what financial risks are permitted.
- Other defined mechanisms: additional adjustments established through the system’s governance process.
Each choice would have consequences. Higher contributions affect affordability. Lower coverage percentages can leave patients paying more toward treatment. Changes to rewards or reserve targets affect how resources are distributed between benefits available today and financial protection for the future.
Participants should be able to understand why a change is being considered, what evidence supports it, and who has the authority to approve it.
The reporting described earlier could help show where pressure is developing. Proposals could then explain the available responses, their expected effects, and the tradeoffs for patients, practices, and other participants. Results would need to be monitored after a change to see whether it worked as intended.
Measures of inflation and changes in the cost of providing dental care could also inform those reviews. They would provide evidence for considering an adjustment without automatically triggering changes to contributions or coverage.
This is central to the kind of institution BOCA aims to build. Important rules should be open to inspection, and the power to change them should be subject to defined limits. Those limits would apply to the organization operating the system as well as to its participants.
Where appropriate, software could enforce those limits by requiring specified approvals before a rule change takes effect. That could make it harder for an operator or another powerful participant to change important terms simply because doing so serves its own interests.
Cadmus would initially control these decisions while the system is developed and tested. The longer-term aim is to move toward community-authorized governance, giving participants a defined role in decisions that affect the system. The structure and conditions for that transition remain to be developed.
Community governance would need to specify which decisions require participant approval, which can be delegated, and who is responsible for carrying them out. Routine operations would not require everyone to vote on every action.
For decisions organized around one person, one vote, Rootprint could help verify that each eligible participant is counted only once, making it harder for someone to gain extra votes by creating additional accounts. Under those voting rules, holding more tokens would not give someone additional votes.
The code and the governance process would also need to work together. Rules must be enforceable, while allowing necessary corrections through an authorized process. Both would require testing to establish whether they protect participants, resist misuse, and allow the system to respond when circumstances change.
The aim is a system whose important decisions can be examined, whose decision-makers have defined responsibilities, and whose rules can be changed through a process participants understand.
WHAT STILL HAS TO BE PROVEN
Prime’s design brings these mechanisms together to test whether a coverage system can reduce administrative overhead, direct more resources toward care, give patients and practices greater freedom, and remain financially sustainable—with transparent rules and defined ways to adjust as conditions change.
Work remains to develop and test regional pricing methods, relative-cost indicators and ratings, Rootprint verification and privacy protections, DentAI’s criteria for flagging concerns, and human-review processes. Financial modeling must evaluate reserve assumptions, capital and treasury strategy, token incentives, and risk-transfer arrangements. Governance must establish how decisions are authorized and how those rules are enforced.
The mechanisms also need to be tested together to understand how changes in one part affect the people and resources elsewhere in the system.
The safeguards are part of the design. Their performance still has to be proven.
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