I think clearer numerical standards could help, but they might not fully solve the overlapping problem. Even if the industry set strict limits, for example, a maximum dollar amount for meals or travel, companies would still need to interpret what qualifies as “educational,” “necessary,” or “reasonable.” Those subjective elements are often where questionable practices slip through.

What might be more effective is a combination of numerical thresholds and transparent justification requirements. For instance, a meal could have a capped value, but companies would also need to document the educational purpose and attendees. That way, the emphasis is not just on cost, but on the intent behind the interaction. Another possible angle is to focus on standardizing training formats rather than enforcing strict monetary restrictions. If professional training is delivered in controlled environments the opportunity for lavish perks decreases.

I’m curious how others feel: would tighter financial caps actually improve compliance, or would companies just find new loopholes?

I believe that tighter financial caps on physician gifts could improve compliance, but they do not guarantee that companies won’t adapt and find loopholes. With stricter limits, companies might increasingly rely on consulting agreements, research grants, or educational events. They could also reframe marketing gifts as educational, training, or research materials. While these approaches may appear legitimate on paper under the AdvaMed Code, companies could still legally justify them if the wording aligns with the Code. Another potential loophole is focusing on volume rather than the value of individual gifts. Even if gift amounts are reduced, a higher frequency of interactions with physicians could still become influential over time. Without additional restrictions beyond financial caps, lowering gift amounts may shift company strategies rather than eliminate them.

I agree that clearer limits might help, but one thing that hasn’t been mentioned is how inconsistent a single numerical cap would be across regions. A $100 meal can be modest in one city and unrealistic in another, so even strict limits could still feel ambiguous in practice.

Because of that, I think standardizing processes (like pre-approved venues or required documentation) might reduce gray areas more effectively than trying to force a universal number.

Do you think clearer rules about how expenses are handled would work better than strict dollar caps?

I think the real issue with defining what “modest” means is about how the gifts to the physicians are functioning on a psychological level. Something less expensive can still affect the physician’s mindset, leading to obligation or influence depending on the timing of the gift, how useful it is, and how often a gift is given to the physician. A $30 lunch is not extravagant, but with frequent visits or having lunch right before any major decisions with the physician, they can be influenced. This is not modest in the behavioral sense, even if it is financially modest. 

Thus, the “modest and educational value” of a gift according to AdvaMed is very gray since an engraved $90 stethoscope has a completely different impact than a regular $40 textbook to a physician. They both comply, but they influence the physician in different ways. I think that other guardrails need to be included, such as frequency of gift-giving, the context, and how the physician perceives the gift. This should all be documented, as Naomi mentioned, which would give regulators a better understanding of the full situation. 

The power imbalance between physicians and a big company can also play a role. A gift coming from a large device company that controls access to training, clinical trials, and future contracts would seem huge to a physician. The gift does not sit in a vacuum, as it is given in the broader context of the situation. The psychological effect this could have is immense. 

Lastly, when gifts are substituted for actual training and proper meetings, there is a red flag. If training events are used as a pretext to give gifts, then the intent is clearly skewed and should be investigated further. This is where physician honesty and proper documentation would come into play. 

Do you think gifts should be evaluated based on their psychological impact as opposed to their price? How would this be measured accurately? Would the frequency of gift-giving and interactions provide better insight than the price? Is looking at too many factors putting too many burdens and restrictions on company and physician interactions?

Loopholes will always exist in every area where there are restrictions. As mentioned, the cost of a "gift" is a bit irrelevant if the intent behind the gift stays the same. If the goal of implementing this limit is to reduce physician loyalty to specific companies, it certainly is not the optimal way to do it. A recurring smaller gift can be the same, if not more influential, than a single expensive gift. The best way to eliminate loyalty acquired through gifting is transparency and oversight. Companies have a significant amount of influence when it comes to clinical areas which is done usually through sales representatives. Providing clear structures for gifting and providing transparency for what happens between the company and physician could be a good step for the development of an organic relationship between a physician and a company.

I find the $100 dollar a gift limitation to be extremely futile, considering there is no period in which a gift cannot be provided. Even if there was a cool down period for these gifts, I'm sure bad actors will find a way to take advantage of a loophole. I believe in order for a gift to be considered acceptable, the gift should be a physical object like providing better equipment for the physicians office, however even that creates a situation in which physicians can be bought out by companies. In order to truly limit gifting, there must be a proper avenue to go through which can accept or deny a gift before it's seen by a physician. Or another system that could be implemented is transparency by the physician for who is providing their company with gifts, similar to how sponsors work.