Reimbursement rules, not cost or technology, often decide whether offshoring happens.

Evidence

Under these programs, the government essentially does not reimburse providers for services rendered outside of the United States. So, a hospital that finds it economically, technically, and institutionally feasible to contract for offshore telemedical modular services may ultimately not be able to do so if it will not be compensated for these services by one if its largest reimbursers. — Georg Schreyögg and Jörg Sydow, The Hidden Dynamics of Path Dependence, 588