Matt Toothacre - Health Law Paper

The Globalization of Healthcare: Telemedicine Under the WTO Framework
Matt Toothacre
INTRODUCTION 2
TELEMEDICINE 3
APPLICABLE LAW – GENERAL AGREEMENT ON TRADE IN SERVICES 5
PRIMARY CLAUSES WITHIN GATS 7

MARKET ACCESS CLAUSES WITHIN GATS 8
ENFORCEMENT OF GATS PROVISIONS 11
TELEMEDICINE UNDER GATS FRAMEWORK 15
CONCLUSION 18
Introduction
A number of recent trends have led to the expansive growth of telemedicine in recent
years. There has been an improvement in the quality of care provided by developing countries,
which allows patients to obtain health care from professionals farther away. 1 The internet has
continued to advance in regards to medicine through both the number of users searching for
health information online and its increased use by patients, providers, and medical
professionals.2 Similarly, patients are no longer required to live in the same area as their medical
professionals because of the digitization of medical data and the advancement of
telecommunication.3 Further, there has been a trend towards globalization in the health care
industry as it is one of the fastest growing markets in the world.4 There has also been a trend
towards the privatization of health care sectors in foreign countries, meaning that non-citizens of
countries are able to obtain treatment.5 These trends have led to the advancement of
telemedicine, which is seen as a way to increase access and improve the quality and cost of
healthcare.6 This new demand for cheaper and more convenient medicine has stimulated the
growth of telemedicine.7 “As technology improves, and the ability to provide healthcare services
to remote areas through telemedicine increases, legal, policy, public health, and medical queries
arise and will have to be addressed.”8 This paper will address how Telemedicine is governed
pursuant to the World Trade Organization.
1
Article: Patients Without Borders: The Emerging Global Market for Patients and the Evolution of Modern Health
Care, 83 Ind. L.J. 71, 82.
2
Id. at 85.
3
Article: The Future Of Telemedicine & Its Faustian Reliance On Regulatory Trade Barriers For Protection, 16
Health Matrix 443, 443
4
Supra Cortez note 1, at 88.
5
Id. at 86.
6
Comment: A Piece Of The Puzzle: Telemedicine As An Instrument To Facilitate The Improvement Of Healthcare
In Developing Countries?, 18 Emory Int'l L. Rev. 151, 152.
7
Article: The Global Market For Health Care: Economics And Regulation, 26 Wis. Int'l L.J. 591, 604.
8
Supra Mendelsohn note 6, at 152.
Telemedicine
Telemedicine is defined by the United States government as being “the use of electronic
communication and information technologies to provide or support clinical care at a distance.”9
Telemedicine can also be broadly defined to refer to the transfer of a medical service to a patient
over a virtual network.10 The telemedicine system allows patients and medical professionals to
share information, technology, knowledge, and expertise in an instant.11 At its core, the system
allows a medical professional to deliver medical care, diagnoses, consultation, and treatment to
patients in a different location.12 Although telemedicine is a rather new concept13, it has received
large amounts of funding from state and federal governments in the United States and it has been
focused on providing healthcare to rural areas and populations with special needs. 14 The internet
has been a catalyst for the advancement of telemedicine as internet speeds have increased and an
increasing amount of people have gained access to the internet. 15 The increase in internet
technology has allowed telemedicine providers to bring less expensive and more convenient
health care to patients in other areas of the world from the provider.16 telemedicine is the
economic reality that health care services can be purchased substantially cheaper in developing
countries where the cost of physician labor is substantially less.17
There are four categories of categories of telemedicine, which include: doctor-to-doctor;
remote clinical, diagnostic, and monitoring services; remote provision of patient care; and claims
9
Articles: Distance Health Services Under the General Agreement on Trade in Services, Vol. 35, No. 1, HOSPLW
83.
10
Supra McLean note 7, at 592.
11
12
Id.
13
14
Supra Yeo note 9, at 83.
15
Id.
16
17
Id.
management and hospital administration from remote countries.18 Each of these categories can
be thought of the same as trading in goods and services because international trade in healthcare
services exists.19 In developing countries there tends to be a shortage of medical professionals to
staff facilities, less access to quality healthcare for patients when compared to those in western
countries, and limited or even no access to healthcare within a patient’s locality.20 The purpose
of having international trade in healthcare is to bring advanced technologies and individuals with
expertise to countries that have shortages.21 One way to prevent or counteract shortages in the
area of healthcare professionals is to have the have healthcare professionals travel from abroad
and provide health services.22 However, having individuals, whether it be the patient or the
healthcare professional, travel to another location can be time consuming and very expensive.
Telemedicine, on the other hand, allows local medical professionals to contact either patients or
other medical experts in order to diagnose, treat, or at the least to consult with about their
patients.23
In developing countries, there also tends to be a shortage high quality hospitals or
healthcare systems because they are usually located in urban centers in order to be as wide-
reaching as possible and the distribution of healthcare tends to be poor.24 Not only does the
advancement of telemedicine improve the treatments that a patient receives in an area with
shortage, but it also increases the doctors knowledge by allowing him to learn from an expert.25
Additionally, the advancement and increased use of telemedicine will make healthcare more
18
19
Id.
20
21
22
23
24
25
affordable to patients by giving them broader availability of providers, which increases
competition and in turn drives down costs.26
Infectious diseases are the leading cause of early death in developing countries.27 On the
other hand, developed countries, which used to have infectious disease as the leading cause of
early death, now deal with chronic diseases including heart and lung disease and cancer as the
greatest health risks to patients.28 In developing countries, it is common for infants, babies, and
children to be unvaccinated and without access to clean water, medicine, or any form of
healthcare.29 In developing countries, on the other hand, poverty has led to an increase in a
decrease in life expectancy, malnutrition, homelessness, mental illness, stress, suicide, family
disintegration, and substance abuse.30 Although developing and developed countries deal with
different problems, many of the issues they currently face can be helped through the use of
telemedicine. One main point is that telemedicine allows specialized doctors to consult with
patients in other countries or with the patient’s doctors in order to provide a specialized
treatment.
Applicable Law – General Agreement on Trade in Services
The WTO was created in 1995 and came from an international system of trade called the
General Agreement on Tariffs and Trade (GATT).31 The WTO has three essential functions: (1)
to provide a forum to negotiate, (2) to implement a set of rules, and (3) to settle disputes.32
26
Id.
27
28
Id.
29
Id.
30
Id. at 154-55.
31
The World Trade Organization in Brief, at 3.
32
See id. at 7.
Currently the WTO has 164 trading nations that are a part of the agreements.33 The WTO
agreements that arose from the GATT were negotiated by a majority of trading nations and were
eventually adopted by them.34 The WTO agreements essentially set forth a groundwork for how
international trade is governed and provide a dispute settlement system. 35 The agreements are
contracts that bind WTO member nations to implement trade policies that comport with the
negotiated language of the WTO agreements.36 Although the agreements were negotiated and
adopted by the member states, the main goal of the agreements is to “help producers of goods
and services, exporters, and importers conduct their business, while allowing governments to
meet social and environmental objectives.”37 The WTO is now the main venue for members to
resolve trade disputes, which has subsequently reduced and prevented trade wars.38
The purpose of the WTO is to enhance trade between countries by limiting or resolving
disputes between them and helping developing countries throughout the process.39 This involves
implementing rules for international trade that give rights to individual investors, corporations,
and member countries.40 The implementation of rules for international trade involves the creation
of rules that are clear and understandable.41
In the most recent round of WTO negotiations, the General Agreement on Trade in
Services (GATS) was adopted by the WTO.42 The GATS purpose was to protect international
commerce by prohibiting any discrimination based on nationality, which has increased the
33
https://www.wto.org/english/thewto_e/whatis_e/tif_e/org6_e.htm
34
Id. at 2.
35
See id.
36
Id.
37
https://www.wto.org/english/thewto_e/whatis_e/tif_e/fact1_e.htm
38
Shawn Donnan and Demetri Sevastopulo, Trump team looks to bypass WTO dispute system, FINANCIAL TIMES,
Feb. 27 2017, at 4-5.
39
See supra note 33, at 5.
40
Id.
41
See id.
42
globalization of the world since its inception.43 Medicine and insurance are specifically
stimulated by many clauses in the GATS that have increased free trade through the removal of
trade barriers.44 Further, the GATS requires member countries to take reasonable measure to
ensure that governments within the country are observing GATS provisions.45
Primary Clauses Within GATS
There are two primary clauses within the GATS that promote non-discrimination in trade
are the Most Favored Nation and National Treatment clauses46, which are derived from the
GATT.47 “The [Most Favored Nation] clause is a ‘favor one, favor all’ clause that mandates that
all WTO members must provide their best trade-in-service terms to all WTO members.”48 In
other words, the Most Favored Nation clause requires each country to treat each member country
equally.49 The National Treatment clause requires members of the WTO to regulate or treat
providers of foreign services the same way they regulate or treat providers of domestic
services.50 The Most Favored Nation and National Treatment clauses are both applied rather
broadly in that they may apply to regulations that are worded neutrally but which incidentally
discriminate against another country.51 However, each of these clauses have many exceptions
43
ARTICLE: International Law, Telemedicine & Health Insurance: China as a Case Study, 32 Am. J. L. and Med.
7, 39.
44
Id.
45
Donley Lecture Series: Health Care In America: Realizing The International Human Right To Health: The
Challenge Of For-Profit Health Care, 113 W. Va. L. Rev. 49, 58.
46
Supra note 43, 39-40.
47
48
Supra note 43, 39-40.
49
50
Supra note 43, 40.
51
Id.
that are somewhat ill-defined within in the GATS because they apply to all classes of services.52
For instance, the GATS “specifically excludes from coverage services provided in the ‘exercise
of governmental authority,’ which are services that have neither a commercial nor a competitive
basis.”53 This exception, however, is not expansive enough to allow countries to shelter their
involvement in telemedicine or the medical industry from the GATS provisions.54
Market Access Clauses Within GATS
GATS also contains three other clauses that essentially opens market access for other
countries.55 The first of these clauses is the market access clause, which is not found in any other
multilateral treaty.56 The market access clause prohibits WTO members from protecting a market
by limiting: (I) the number of suppliers; (2) the value of transactions; or (3) the number of
persons employed.57 Because the market access clause restrictions are framed in absolute terms,
they actually impose a greater degree of restriction than even the MFN and NT provisions do on
the ability of a government to regulate its economy.58 They allow countries to make market
access commitments for services that are reasonably tailored to the conditions of that country.59
Under the GATS, each member state enters into a "Schedule of Commitments" that sets forth,
for each service sector, the specific market access and National Treatment commitments that it is
prepared to make, if any.60 When a member state agrees to permit market access in a particular
52
53
Supra note 3, at 479.
54
Id.
55
Supra note 43, at 40; Supra note 3, at 484.
56
Supra note 43, at 40
57
Id.
58
Id.
59
60
Id.
service sector, it must avoid implementing a number of defined types of trade restrictions that
generally resemble quotas (e.g., limitations on the number of doctors or hospital beds).61 The
member state's National Treatment commitment for each sector defines the extent to which it
will treat foreign services and service suppliers in the same manner as national services and
service suppliers.62 In short, the market access restrictions clause of GATS could someday be
used as powerful leverage to open the domestic telemedi-cine market to foreign competition.63
The second clause is the proposed domestic regulation clause, which limits the criteria
that can be used to license, certify, or set technical production goals. 64 the proposed domestic
restrictions clause is of concern to the future of telemedicine because under this clause any
licensing, certification, and technical standards imposed by a nation on a particular sector of its
economy must not be "more burdensome than necessary to ensure the quality of the service."65
Under the domestic regulation clause, a country can only impose standards on an industry that
are no "more burdensome than necessary to ensure the quality of the service." 66 Accordingly, if
the WTO adopts the domestic restriction clause, many existing healthcare regulations would
become inconsistent with GATS, including: "(1) obligations on providers to accept all patients;
(2) limitations on fees so that access to healthcare is available to all; and (3) [guidelines that
mandate] disciplining providers with licensure revocation rather than using a scheme that fines
61
Id.
62
Id.
63
ARTICLE: THE FUTURE OF TELEMEDICINE & ITS FAUSTIAN RELIANCE ON REGULATORY TRADE
BARRIERS FOR PROTECTION, 16 Health Matrix 443, 485
64
7, 40
65
66
7, 40
or publishes wrong-doers' names in public forums."67 if GATS's domestic restrictions clause
should ever become applicable to the U.S. health care sector, this clause could seriously
undermine the authority of state boards of medical examiners by limiting the ability of these
governmental agencies to adjudicate and discipline provider's quality of care and professional
conduct.68
The third clause is the operational clause, which limits the provisions of the GATS to
certain sectors within a nation’s economy, not to its economy as a whole.69 It will be limited
based on the country’s commitments and the mode of commerce the specific sector is in. 70 But
even if a country commits its health care sector that does not necessarily mean the country has
opened its borders to foreign providers regardless of trade mode.71 Under GATS, each sector of a
nation's economy is further subdivided into modes based on how a particular service is
supplied.72 There are four supply modes based on the geographic relationship between the
service supplier and consumer.73 When a nation commits a sector of its economy under GATS,
that nation may only make a commitment for a particular mode.74 Accordingly, the mode by
which a service is supplied is a non-trivial matter under GATS because different aspects of a
sector of a nation's economy--like health care--may receive different degrees of commitment
67
7, 40
68
69
70
71
72
73
74
depending on the mode of the service's delivery.75 Within each service sector, the member state
can make different market access and National Treatment commitments across four different
"modes of supply," which encompass four different means by which a service provider in one
country might seek to export services to another country.76 These modes are: (1) "Cross-border,"
which would include, for example, the use of the Internet to provide health services across
national borders; (2) "Movement of Persons," which would entail, for example, a patient who
travels abroad to receive health services; (3) "Commercial Presence," which would include a
situation in which a company decides to construct a hospital in another country; and (4)
"Movement of Service Providers," which would include a situation in which a physician moves
to another country to provide services.77 Each member state's Schedule of Commitments is,
therefore, a matrix that is defined by the different types of services on one axis, and the four
different modes of supply on the other. Within each of the resulting boxes, the member states
make either no commitment (in trade parlance, that box is "unbound"), or it makes a market
access and National Treatment commitment subject to whatever conditions and qualifications it
has imposed.78
Enforcement of GATS Provisions
GATS contains two enforcement mechanisms for dealing with regulations promulgated
by WTO members that are inconsistent with the principle of non-discrimination. First, there is
75
76
77
Id.
78
Id.
the "liberalization" provision.79 Under GATS, during each round of trade negotiations WTO
members are expected to lower trade barriers for services. 80 The purpose of this clause is to
move the world's trading community progressively towards truly free trade. As the liberalization
clause is applied to each successive round of WTO negotiations, it will tend to standardize the
laws and regulations around the world, thereby making the laws of all nations consistent with
each other and eliminating trade barriers.81
Second, GATS provides a forum for WTO members to arbitrate trade disputes.82 To the
extent that one nation feels that the laws or regulations of another country are inconsistent with
GATS, a country may arbitrate the dispute before the WTO.83 In the event that a nation's laws or
regulations are found to frustrate free trade, the WTO has authority to impose trade sanctions
against that nation unless the nation enacts remedial legislation.84 A recent dramatic application
of the WTO's arbitration process played out over steel commerce. 85 In March 2002, the U.S.
enacted a protective steel tariff, to which the E.U. immediately objected. After preliminary
discussions to modify the tariff failed, the E.U. sought to arbitrate the dispute before the WTO. 86
The WTO concluded that the U.S. steel regulations amounted to an attempt to unreasonably
protect the U.S. steel market from foreign competition, and authorized a $ 3 billion trade
79
7, 40
80
7, 40
81
7, 40-41
82
7, 41
83
7, 41
84
7, 41
85
7, 41
86
7, 41
sanction in the form of an E.U. boycott of Florida citrus fruits.87 Faced with a significant trade
sanction, the U.S. repealed the steel tariff.88 In short, GATS makes it very difficult for a WTO
member to protect its economy from foreign invasion.89 In particular, GATS has the potential to
make it difficult for a nation to protect its healthcare sector with regulations that: (1) impose
certificate-of-needs requirements; (2) use a regional licensure system or a licensure system that
limits the total number of licenses that will be issued; or (3) cap the total value of healthcare
services to be reimbursed.90 This means that as WTO members progressively open their markets
with each round of negotiation, by 2018 China may be encouraged to open its healthcare market
to free trade.91 If China were to do so, nothing would stop an underemployed American cardiac
surgeon from opening cybersurgical facilities in Beijing to capture Chinese healthcare dollars.92
The WTO’s dispute settlement system is the forum created by the WTO in order to
resolve trade disputes between member countries and is essentially a high court that determines
whether a country is in violation of WTO rules and resolves the dispute.93 This dispute
settlement system of the WTO was created pursuant to the Dispute Settlement Understanding
(DSU) and it enables member countries to bring a lawsuit against another member when they
claim there has been a WTO violation.94 The lawsuit is then decided and resolved by a WTO
87
7, 41
88
7, 41
89
7, 41
90
7, 41
91
7, 41
92
7, 41
93
See Daniel C.K. Chow, How China Promotes Its State-Owned Enterprises at the Expense of Multinational
Companies in China and Other Countries, 41 N.C.J. Int'l L. & Com. Reg. 455, 462.
94
Id. at 464.
panel.95 Further, the U.S. and China have been in many WTO disputes independently and against
one another.96
First, the WTO has implemented rules for trade that involves goods.97 The trade rules that
apply to goods are enumerated under the Agreement on Trade Related Investment Measures
(TRIMs).98 The TRIMs agreement does not allow any member country to implement a trade
related investment measure that goes against Article III (national treatment) or Article XI
(quantitative restrictions) as set forth in GATT 1994. Section two of the Annex from the TRIMs
Agreement gives an “illustrative list” of TRIMs that do not comport with the GATT 1994. One
such example is a restriction on “the importation by an enterprise of products used in or related
to its local production by restricting its access to foreign exchange to an amount related to the
foreign exchange inflows attributable to the enterprise.”99 Second, the WTO and thus its member
countries have adopted treaties and agreements that govern how foreign corporations and
investors should be treated by member countries.100
Some worry that GATS could be used to force developing countries to align their health
policies at the expense of domestic needs. For example, GATS encourages WTO members to
liberalize free trade by requiring each WTO country to treat all countries alike (so-called "most
favored nation" status) and to treat foreign companies as if they were domestic ("national
treatment"). As a result, local health care providers may struggle to compete with foreign
providers for scarce resources. Other critics of GATS worry that market-driven health care
systems reduce widespread access to health care, as observed in the United States and in many
95
See id.
96
See id. at 464-65.
97
Agreement Establishing The World Trade Organization, at 9.
98
Agreement on Trade-Related Investment Measures, page 139.
99
See id.
100
Monika C.E. Heymann, International Lawand The Settlement Of Investment Disputes Relating To China, 11(3) J.
Int’l. Econ. L. 507, 508-09.
Latin American countries. In fact, several international observers worry that these market
reforms will create international convergence towards the U.S. health care system, which is
dominated by for-profit, private sector companies. It is easy to understand the cause for concern.
The U.S. health care system is famous for its spending, accounting for roughly half of the $ 4
trillion spent on health care each year worldwide. But by most estimates, Americans are neither
healthier nor happier with their health care system than citizens in peer countries.
ARTICLE: INTERNATIONAL HEALTH CARE CONVERGENCE: THE BENEFITS
AND BURDENS OF MARKET-DRIVEN STANDARDIZATION, 26 Wis. Int'l L.J. 646, 699-
700
Telemedicine Under GATS Framework
Whether GATS is applicable to a particular market depends upon the delivery mode and
whether a country has committed a particular sector of its economy to free trade.101 GATS views
services as being delivered by one of four methods or modes.102 Mode I transactions occur when
services and capital flow freely and bidirectionally across an international border; Telemedicine
falls in to this category.103 a Mode II transaction occurs when a service is consumed while a
person is abroad.104 Under Mode III delivery, rather than having the consumer traveling to
receive a service, a supplier sets up a commercial presence in a foreign country.105 Mode IV
101
ARTICLE: THE GLOBAL MARKET FOR HEALTH CARE: ECONOMICS AND REGULATION, 26 Wis.
Int'l L.J. 591, 626
102
Int'l L.J. 591, 626-627
103
Int'l L.J. 591, 627
104
Int'l L.J. 591, 627
105
Int'l L.J. 591, 627
services are delivered by the movement of natural persons, which in health care means services
provided by physician immigration.106
Most examples of telemedicine services would fall under the classification of "Medical &
Dental Services" on a GATS schedule of commitments. To the extent that the services are
provided to inpatients, they could also be classified as "Hospital Services." Telemedicine
services are services that are provided overwhelmingly, if not exclusively, in "Mode 1." This
means that they are provided by remote means across national borders without the movement of
the patient (Mode 2) or of the service provider (Mode 4). The provision of telemedicine services
to a particular country may or may not entail the establishment of a commercial presence in that
country (Mode 3), but in most cases it probably would not.
After a service mode is selected, unless a country has made a commitment, GATS does
not attach.107 A commitment is a sector and mode specific schedule "made by individual
countries allowing specific foreign products or service providers access to their markets." By
making a commitment, a WTO member creates a legally enforceable guarantee that its sector is
stable with respect to market conditions; and that its sector is not a target for further regulations
that would undermine an investor's interests. After a WTO member commits a sector of its
economy to free trade, the country is obligated to economically administer that sector with (1)
"reasonable, objective, and impartial manner"; (2) provide "adequate procedures to verify the
competence of professional or any other member"; and (3) any further regulations should be
made to conform to "common international standards" for services. Once a country makes a
106
Int'l L.J. 591, 627
107
Int'l L.J. 591, 627
commitment to free trade, all of GATS' rules come into play. The general structure of GATS is
that of a "top-down" treaty; meaning that, unless a country makes a specific reservation, all
aspects of GATS are applicable to that sector and mode of delivery. Under GATS, after a
commitment is made, countries are also expected to progressively remove any barriers to trade
for that mode and sector of service. The importance of GATS trade liberalizing provisions
becomes clear when it is juxtaposed with the domestic restrictions clause, which states that any
licensing, certification and technical standards [*629] imposed by a nation on a particular sector
must not be "more burdensome than necessary to ensure the quality of the service."
ARTICLE: THE GLOBAL MARKET FOR HEALTH CARE: ECONOMICS AND
REGULATION, 26 Wis. Int'l L.J. 591, 628-629 *
The truest measure of how much work remains to be done in the area of health services
liberalization is the fact that, of all the service sectors covered by the GATS, only the educational
sector has received fewer national commitments than the health sector. It is, in other words, the
second most trade-restricted service sector in the global economy, despite the fact that health
services account for a very significant portion of the gross domestic product of many countries,
especially economically advanced countries. In one recent study of healthcare commitments
under the GATS, only 54 WTO member states had made any sort of commitment for medical
and dental services, in any mode of supply. By contrast, over 100 WTO member states have
made commitments in the area of financial services, and close to 100 WTO member states have
made commitments in the area of telecommunications.

Within Mode 1, which is the mode of supply most relevant to telemedicine, only 27
WTO member states have made either a full or partial market access commitment for Medical &
Dental Services, and only 15 member states have made market access commitments in the area
of Hospital Services. This means that there are very few countries that have in any way opened
their markets to remote health services from other countries. Interestingly, the absence of
specific commitments in Mode 1 may reflect the fact that many countries did not believe that it
was technically possible to provide health services in this mode of supply: several member states
noted "technical unfeasibility" as the reason for the absence of Mode 1 commitments in health
services, particularly Hospital Services. This perception may have been somewhat more justified
in the mid-1990s, when most countries prepared their schedules of commitments, but it
undoubtedly also reflects the fact that national health authorities who understood the potential
applications of telemedicine played little or no role in the preparation of these schedules.
Conclusion
Under the WTO framework, there are many rules countries must abide by in order to
participate in the international trade of telemedicine, however, at the same time, there are
remedies a country may use in order to deal with countries they think are violating the rules.
Countries under the GATS framework must abide by the two main clauses of the GATS, the
Most Favored Nation and the National Treatment clauses. This means a country must provide
the same trade-in-services terms to each country without discrimination and to treat foreign
service providers the same as domestic service providers.

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The Globalization of Healthcare: Telemedicine Under the WTO Framework

APPLICABLE LAW – GENERAL AGREEMENT ON TRADE IN SERVICES 5

PRIMARY CLAUSES WITHIN GATS 7

TELEMEDICINE UNDER GATS FRAMEWORK 15

professionals because of the digitization of medical data and the advancement of

pursuant to the World Trade Organization.

communication and information technologies to provide or support clinical care at a distance.”9

countries where the cost of physician labor is substantially less.17

There are four categories of categories of telemedicine, which include: doctor-to-doctor;

services exists.19 In developing countries there tends to be a shortage of medical professionals to

In developing countries, there also tends to be a shortage high quality hospitals or

competition and in turn drives down costs.26

Applicable Law – General Agreement on Trade in Services

of rules that are clear and understandable.41

Primary Clauses Within GATS

involvement in telemedicine or the medical industry from the GATS provisions.54

Market Access Clauses Within GATS

sector of a nation's economy--like health care--may receive different degrees of commitment

Enforcement of GATS Provisions

each other and eliminating trade barriers.81

such example is a restriction on “the importation by an enterprise of products used in or related

investors should be treated by member countries.100

ARTICLE: INTERNATIONAL HEALTH CARE CONVERGENCE: THE BENEFITS

AND BURDENS OF MARKET-DRIVEN STANDARDIZATION, 26 Wis. Int'l L.J. 646, 699-

Telemedicine Under GATS Framework

receive a service, a supplier sets up a commercial presence in a foreign country.105 Mode IV

provided by physician immigration.106

provided to inpatients, they could also be classified as "Hospital Services." Telemedicine

country (Mode 3), but in most cases it probably would not.

ARTICLE: THE GLOBAL MARKET FOR HEALTH CARE: ECONOMICS AND

REGULATION, 26 Wis. Int'l L.J. 591, 628-629 *

especially economically advanced countries. In one recent study of healthcare commitments

made commitments in the area of telecommunications.

applications of telemedicine played little or no role in the preparation of these schedules.

Supra Yeo note 9, at 83.

service providers the same as domestic service providers.

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