Dentistry has to work for the people providing the care.
Patients need dental care they can afford, understand, and feel confident pursuing. Dental practices need to provide that care in a way that supports their teams, their standards, and a sustainable business.
Those needs should not continually be placed in conflict. BOCA is being built around a different premise: the financial systems surrounding care should make the relationship between patients and practices easier to sustain—not add unnecessary friction, uncertainty, or pressure to it.
The cost of providing care keeps changing. What practices are paid has not kept pace.
An independent dental practice is, in many respects, a small healthcare facility. It employs a clinical and administrative team, maintains treatment rooms and sterilization systems, purchases specialized equipment and supplies, invests in technology, manages billing and compliance, and carries the continuing costs required to provide care safely.
But it does so on the economics of a small business—without the scale, purchasing power, institutional infrastructure, tax advantages, or forms of public support available to many larger healthcare organizations.
Those costs have been rising faster than reimbursement. The ADA Health Policy Institute describes the result as a continuing “fiscal squeeze” on dental practices. Over the past five years, prices for dental equipment and supplies and wages for dental staff rose 23%, while reimbursement across payor types rose 19%. Inflation-adjusted income for general-practice dentists has also been declining over the longer term.
A practice cannot absorb that pressure indefinitely. Fees may rise. Staffing and investment decisions change. Insurance contracts may become economically unworkable. Practices may try to see more patients or produce more care within the same number of working hours.
Those are understandable responses to financial pressure. But an environment that continually pushes practices to do more in less time can work against qualities patients and practitioners both value: careful diagnosis, time to explain treatment, personal attention, continuity, and a relationship in which the person receiving care feels like a person rather than another unit of production.
Sustainable practice economics are not separate from patient care. They are part of the conditions that make good care possible.
Sometimes the dentist and patient are responding to the same broken economics from opposite sides.
When the terms of an insurance contract no longer work for a practice, leaving the network can be a rational business decision. In an ADA Health Policy Institute survey of dentists who had dropped insurance networks, nearly all cited reimbursement amount as a reason, and more than half cited administrative burden.
WHY PRACTICES LEAVE
98.7%
Cited reimbursement amount.
57.3%
Cited administrative burden.
Source: American Dental Association Health Policy Institute.
For the patient, however, leaving the network can create a different set of problems.
A patient may receive dental coverage through work without having chosen the insurer, network, or benefit design themselves. If the dentist they know and trust is outside that network, using the coverage can become more complicated. Depending on the plan, the patient may face higher out-of-pocket costs, pay the practice upfront, submit the insurance claim themselves, and wait to be reimbursed.
That administrative difference alone can influence where someone receives care. Staying with a trusted dentist may mean taking on paperwork, payment, and reimbursement uncertainty that largely disappears when the patient chooses an in-network practice.
The practice has not done anything unreasonable by refusing terms it cannot sustain. The patient has not done anything unreasonable by wanting to use the coverage provided through their employer.
The patient can be left choosing between the dentist they want and the insurance network they have.
Patients should not have to choose between a dentist they trust and a financial arrangement they can practically use. Practices should not have to choose between sustainable economics and remaining accessible to those patients.
The system around care should support the patient–dentist relationship, not control it.
The dentist should remain responsible for diagnosis and treatment recommendations. The practice should establish what its care costs. Patients should be able to understand what financial support is available while that information can still help them decide how to proceed.
CLINICAL JUDGMENT
The dentist recommends the care they believe is appropriate.
PRACTICE AUTONOMY
The practice establishes its fees and decides how it operates.
FINANCIAL CLARITY
Patients and practices should be able to understand what support is available before uncertainty becomes an obstacle to care.
PATIENT CHOICE
The patient should be able to weigh the recommendation, the financial support available, and their remaining responsibility—and decide what is right for them.
A system that stands between patients and practices should earn that role by creating value, not merely extracting it.
BOCA SHOULD HAVE TO EARN ITS PLACE
- Reduce unnecessary administrative work.
- Make important information easier to understand.
- Coordinate responsibilities more reliably.
- Improve access to financial support.
- Make payment simpler.
- Remain accountable for the rules it applies.
BOCA should create more value than it consumes.
BOCA Direct is the first practical step.
Independent practices can create their own membership programs and establish a more direct financial relationship with patients.
BOCA Direct is being developed to make those programs easier to operate as participation grows—bringing recurring work such as payments, benefits, communication, renewals, and membership activity into one coordinated system.
Explore BOCA Direct →Coverage should support the treatment relationship without taking it over.
BOCA Prime is a proposed coverage model built around clearer roles for the dentist, the practice, the patient, and the coverage system.
For participating practices, the relationship is intended to be more straightforward:
YOU RECOMMEND THE CARE
Diagnosis and treatment recommendations remain professional responsibilities.
YOU ESTABLISH YOUR FEE
The practice sets what it charges. Prime does not impose a mandatory fee schedule.
PRIME ESTABLISHES ITS SUPPORT
Prime applies its coverage and financial rules to determine what it will contribute.
PATIENT AND PRACTICE SEE THE FINANCIAL PICTURE
The aim is to make the expected Prime contribution and remaining patient responsibility understandable while that information can still help determine what happens next—and to provide it promptly enough to be useful in that decision.
AN ESTABLISHED OBLIGATION SHOULD MOVE TOWARD PAYMENT
If Prime has already determined what it will contribute, and the treatment and relevant conditions do not change, that determination should lead toward payment rather than another complete round of administrative interpretation.
This is the relationship Prime is trying to create: the dentist remains responsible for care, the practice retains control over its fees, the patient can see the financial picture more clearly, and the coverage system performs its role without unnecessarily taking over the relationship.
If that model is worth building, it will need dentists willing to challenge it, improve it, and help determine whether it works in real practice.
Explore BOCA Prime →The practice should experience the benefit, not the complexity underneath it.
New technology only helps if it makes the work easier.
A practice should not need to understand the financial rail underneath a payment simply to get paid. It should not need to become an expert in digital identity to verify who is participating, or understand the technical architecture behind an automated task before that task can be useful.
The same principle should apply to coverage administration. Dental teams should not have to become specialists in complicated billing rules, submission strategies, follow-up processes, and reimbursement rules simply to move legitimate care from recommendation to payment. Necessary checks and safeguards still matter. The system should carry as much of that coordination as it reasonably can.
At its simplest, the relationship should remain understandable: a patient needs care, the dentist recommends and provides it, the coverage system applies its rules, and established financial obligations move toward payment.
THE PRACTICE SHOULD SEE THE RESULT
- Less duplicate entry.
- Clearer coverage requirements.
- Less routine administrative follow-up.
- Practical, reliable payment.
- Human attention when judgment or an exception is actually needed.
- New capabilities that fit around the practice rather than forcing the practice to reorganize around them.
Over time, that could extend to other everyday work. An authorized agent, for example, might help prepare a routine supply order, compare approved vendors, or follow up on an administrative request within limits the practice establishes.
The point is not to add more technology to dentistry. It is to give time back to the people providing care.
A better system should give practices reasons to want it to succeed.
Participation should create value for the practice as well as for the patients, institutions, and capital supporting the system around it.
Dentists should not simply be providers receiving whatever terms the system establishes. They can also be customers, contributors, research participants where they choose to take part, users helping evaluate new tools, participants in future governance, and beneficiaries of value the ecosystem succeeds in creating.
Patients, practices, Cadmus, and the capital supporting the system all depend on one another. Patients need practices willing and able to provide care. Practices need patients, workable economics, and reliable payment. Cadmus needs both sides to find enough value to participate. Capital has to see a credible reason to support the system over time.
That interdependence should be reflected in what each participant receives from the relationship.
FOR PRACTICES
Sustainable economics, professional autonomy, less unnecessary administrative work, reliable payment, useful tools, and opportunities to benefit from the value they help create.
FOR PATIENTS
Meaningful financial support, clearer information, greater choice, and a meaningful voice in decisions that affect them.
FOR THE SYSTEM
Enough resources, safeguards, and accountability to meet its commitments and remain financially healthy.
FOR CADMUS AND CAPITAL
A viable business and credible returns for building and supporting infrastructure and services people choose to use.
Those interests will not always point in the same direction. But BOCA is being designed around the possibility that more of the value created by the system can be shared among the people who help create it, with clearer pathways for that value to return to patients, practices, and other participants instead of simply accumulating within the institution.
That could eventually include rewards for useful participation and defined ways for patients and practices to influence important rules. Dentists who want to engage more deeply should have opportunities to do so. Those who simply want a system that works should not need to become experts in how it is governed.
The larger ambition is straightforward: build something patients want to use, practices want to participate in, and everyone involved has a reason to help keep healthy.
Connect with Cadmus.
Independent practices interested in BOCA Direct, BOCA Prime, future research or pilots, or simply sharing their experience with the problems this work is trying to address are welcome to connect.
Talk with Cadmus →Explore the Research →