Abstract
I used to have this impression that very few people could live to their seventies and that people in their fifties and sixties have already entered the twilight of their lives. It was hard for me to imagine what a person would look like when he or she is over one hundred years old. In 2010, I led the Board of Directors of Taikang Life Insurance to visit an elderly community in the United States, and it was the first time I met a centenarian in my life.
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What Should a Centenarian Look like?
I used to have this impression that very few people could live to their seventies and that people in their fifties and sixties have already entered the twilight of their lives. It was hard for me to imagine what a person would look like when he or she is over one hundred years old. In 2010, I led the Board of Directors of Taikang Life Insurance to visit an elderly community in the United States, and it was the first time I met a centenarian in my life. She was wearing a nurse hat—I guess she was a nurse in World War II. Holding her hands, I felt they were warm and strong. She was exactly one hundred years old at the time, very outgoing and quick-thinking. She shared with us the glory of her youth and laughed out loud. Her cheerfulness lit up everyone around her. I was feeling many things at the time, and the biggest one was that I didn’t know a 100-year-old person’s life could be so vigorous and dignified, even toward the end of life. I cannot help but think of the daily living conditions of older people in China. Is it possible for older people in China to laugh and talk lively and energetically just like that?
We see that the life expectancy of human beings is getting longer, but does that mean people are getting healthier? In that extended life expectancy in old age, are people healthy, strong and at ease? Or are they sick, disabled and bedridden? Unlike young people, the health status among older people varies greatly. Some people, even in their eighties, may still have almost the same physical strength and intelligence as young people do, while others are more or less affected by diseases or even loss of capacity. For the latter, they suffer not only from the declining ability to take care of themselves in daily life but also from a reduced positive life experience, as they could hardly gain value through participation in social life, sharing experience and imparting knowledge. The widely diverse health conditions of senior citizens also result in significantly different family care needs and financial burdens. It is safe to say that a happy and dignified life in old age is impossible without health. As the World Health Organization highlighted in its 1997 World Health Report, increased longevity does not equal improved quality of life; healthy longevity is more important than increased longevity. The essence of the Era of Longevity lies in the pursuit of a high-quality life in old age and healthy longevity.
The advent of the Era of Longevity provides us more possibilities in both the breadth and depth of our lives, but it has also brought about completely different health challenges. Health has become a more urgent and long-term demand that will grow more diversified. This demand will become a strong driving force for the growth of the health industry, ushering in the Era of Health.
2.1 As Modern Medicine Progresses, Chronic Diseases Have Become the Main Health Threat
Humankind has been fighting against diseases for thousands of years. Facing birth, aging, illness and death, human beings’ fear, anxiety, longing and yearning have been driving us to constantly explore the real nature of life.
In early human development, mortality was mainly caused by deadly diseases and infections from pathogenic microorganisms in the external environment, especially infectious pathogens. Severe infectious diseases such as plague, cholera, smallpox, tuberculosis and syphilis raged and killed countless people. The Black Death struck at the end of the Middle Ages and killed one-third of Europe’s population. Cholera was the worldly disease of the nineteenth century: seven global cholera pandemics broke out within 200 years. Another major challenge was pregnancy and childbirth: the process of childbirth is extremely dangerous for humans. Women faced severe pain and death risks when giving birth, and neonatal deaths were also very common.
Human beings’ hands had been tied fast in the face of all these risks until the last 200 years, when the technological achievement of modern medicine grew exponentially, which changed the balance of forces between man and nature. First, preventive medicine and public health strategies came into play and made an essential contribution. As mentioned in the previous chapter, drawing from the experience of controlling deadly infectious diseases such as cholera and plague, human beings gradually established a relatively complete system of preventive medicine, both in theory and in practice. With public health strategies such as maintaining clean water sources and improving the living environment, people were able to reduce the prevalence of epidemic diseases in general. Even so, the help such an improved public health system could offer individuals against specific diseases was still very limited.
The rapid rise of industrial pharmaceutical manufacturing and the leaping development of surgical technology have enabled medicine practitioners to comprehensively improve the disease treatment of individual patients. The earliest drugs came mainly from plants, such as various Chinese herbs, pain-relieving opium poppies and cinchona tree (also known as quinine) bark, which was used to treat malaria. From this perspective, Chinese medicine and the earliest Western medicine are basically of the same origin. It is worth mentioning that Tu Youyou, China’s first Nobel Prize laureate in Physiology or Medicine, who discovered artemisinin, was also inspired by Ge Hong’s Handbook of Prescriptions for Emergencies in China’s Eastern Jin Dynasty. In the nineteenth century, with prosperous industrial development, Western chemists gradually mastered the methods of extraction and purification, which directed Western medicine onto a fast track. In 1897, researchers from the German company Bayer succeeded in synthesizing pure stable acetylsalicylic acid, which was later known as the world’s most popular fever-reducing and pain-relieving drug, aspirin. The birth of aspirin set off a wave of chemical synthesis of pharmaceuticals.
Industrial production of drugs does not always happen overnight immediately after its discovery. In human beings’ fight against bacterial infections, Sir Alexander Fleming’s discovery of penicillin in 1928 was definitely a milestone. However, further extraction, concentration and purification were needed to put penicillin into medical use. These procedures were completed in 1938 by Howard Florey and Ernst Chain, two scientists from Oxford University. As the demands of penicillin swelled in wartime, pharmaceutical companies finally realized scaled industrial manufacturing of penicillin in 1943. Fleming, Florey and Chain were awarded the Nobel Prize in Physiology or Medicine together in 1945 for their contribution to the penicillin project. Inspired by the discovery of penicillin, scientists began collecting samples in the natural environment to look for new drugs, and consequently, a large number of antibiotics were discovered and produced. Streptomycin was discovered in 1943 and it cured tuberculosis. Cephalosporin was discovered in 1948. The discovery and widespread use of many antibiotics significantly reduced the incidence of bacterial infections in the second half of the twentieth century. At the same time, vaccines for common diseases such as smallpox, rabies, tuberculosis and poliomyelitis were invented and quickly applied, greatly reducing the fatality of infectious diseases. Antibiotics and vaccines have become two powerful tools for doctors to fight diseases; they not only greatly reduce the incidence and mortality of infectious diseases but also prolong human survival. As technologies in drug screening, synthesis and manufacturing continue to progress, the spectrum of human diseases changes over time. The most important category in the pharmaceutical market has gradually shifted from anti-infection drugs to drugs for chronic diseases. Today, the global pharmaceutical industry has reached a scale of more than one trillion US dollars, supporting medicine and health care as an important foundation. The pharmaceutical industry has been further subdivided into pharmaceutical manufacturing, distribution, retail and other subindustries.
Surgical operation, on the other hand, has played an irreplaceable role in the treatment of trauma, deformities, tumors and other conditions, especially dystocia. The main driving force for the development of surgery was the physical trauma of people caused by all kinds of cold and hot weapons in turbulent times of war. There were very few systematic surgical theories before the sixteenth century, when human anatomy was first developed. It was not until the eighteenth century that surgery became a specialty based on the development of human anatomy. Surgical pain was one of the core obstacles to the technical progress of surgical operation back then. Surgeries were almost torture, and the focus of surgeons was getting the operation done as quickly as possible. At that time, there was even an appalling case where Robert Liston, who was known as “the Fastest Knife of the West End”, set a record of a 300% death rate in a single operation: the doctor’s assistant was accidentally injured by the sharp blade during the operation, an audience died of fright on the spot, and the patient and the doctor’s assistant both died of postop infections. It was not until 1846 when ether anesthesia was introduced into surgery, allowing patients to be operated on while being put in a controlled sleep. The time of surgery was remarkably extended, allowing surgeons to perform more complex and delicate procedures. Another major problem that restricted the development of surgical techniques was infection, which could cause more than 50% of postop mortality. In the mid-nineteenth century, Hungarian obstetricians found that washing hands with disinfectant before performing a cesarean section significantly reduced the incidence and mortality of “puerperal fever”. As the germ theory of infectious disease matured in the late nineteenth century, aseptic operation became the norm practice of medicine and markedly increased the success rate of surgeries and invasive procedures. Due to the popularization of anesthesia and aseptic operations, surgical techniques were liberated from previous limitations, and the scope of surgery began to extend to the heart, brain, abdominal cavity, joint and other parts of the human body. Today’s surgeries can even be performed remotely by a robot controlled by doctors. To a certain extent, the development of surgery has propelled hospitals to become the true place for disease treatment rather than a place for patients to receive hospice care. The medical equipment industry has also prospered along and has grown globally into an enormous market of nearly 500 billion US dollars.
With the molecular model of the double helix structure of human DNA being discovered in 1953, the era of molecular biology began. More medicine findings at the molecular level interpret the origin, development and decline of life from a whole new perspective, and humans, for the first time, were able to look at diseases at the molecular level. Molecular biology has a profound impact on disease diagnosis and treatment. Before, drugs were only used to kill external microbes invading human bodies, but now, drugs can work directly in human bodies targeting specific conditions, such as cardiovascular drugs, psychotropic drugs, immunosuppressants and diabetes drugs. In addition, the development of molecular diagnostic technologies, such as nucleic acid testing and gene chips, and the commercialization of targeted drugs and gene therapy drugs have started the refined and individualized development of drug use.
Since the end of the nineteenth century, many leaping medical achievements have been made (Fig. 2.1), and human life expectancy has increased dramatically. More importantly, people are full of confidence in the technological power of medicine, and they certainly expect to rely on medicine to solve life-related problems much more than before. As this trend continues, it appears that human beings are getting closer to ultimately conquering diseases and taking full control of our health. With emerging new drugs, advanced surgical techniques and the popularization and application of cutting-edge technology, many diseases that were once deadly can now be cured. Some diseases that used to cause acute deaths have become manageable chronic diseases now. As mentioned in the first chapter of this book, cancer, which has long been considered incurable, is also becoming a chronic disease: the five-year survival rates for cancer patients are rising worldwide in general. According to 2019 statistics from the American Cancer Society, the overall five-year survival rate for cancer patients in the US increased to 69% from 49% in the 1970s. Research data from China’s National Cancer Center in 2018 show that China’s overall five-year cancer survival rate was 40.5%, which was a 10% increase compared with that of 10 years ago. There is still much room for China to improve in the application and popularization of new cancer treatment technologies, cancer prevention and cancer screening. Diseases that were once undefeatable, such as cancer, have gradually become treatable, delayable and controllable through early diagnosis and intervention.
Source Studies by Costa (2015), collated by the author
Human life expectancy, height and public health and medicine milestones.
With medical progress, human attention has also begun to shift from the traditional treatment of diseases to the control of aging for an eternal life. The immortal HeLa cell line was discovered in 1951. It was taken from cancer cells of a patient named Henrietta Lacks and could reproduce infinitely in cell culture, given the right environment. HeLa was the first “immortal” cell that can reproduce infinitely in human history. The first human kidney transplant surgery was carried out in Boston in 1954. Until now, except for brain transplants, which have not been thoroughly studied due to huge ethical issues, other human organs, such as the heart, liver, lung and kidney, can also be transplanted or even replaced by 3D printing with the support of powerful medical technology. After the birth of Dolly, the world’s first cloned sheep, in 1996, people began to envisage growing vital organs such as hearts, livers and kidneys directly from our own cells in the future. With these remarkable achievements, humans are also imagining a world where aging no longer exists. The 2005 DreamWorks Film The Island tells such a story: rich people keep cloned humans on an island to provide harvestable organs and body parts when the rich need to cure diseases or even achieve immortality.
However, there is still a considerable distance between humans’ dream of immortality and the reality of having to live with disease. When faced with real health challenges in the Era of Longevity, such as chronic degenerative diseases, aging and gradual loss of physical functions, we find that we are only just beginning to understand and explore longevity and aging. Aging will cause abnormal genetic expression and cell damage, which will gradually accumulate and develop into chronic degenerative diseases under behavioral and environmental stimulation. To date, such diseases can only be mitigated but not reversed. They certainly cannot be cured completely. After being found to be suffering from progressive lung disease, Dolly the Sheep was euthanized in 2003 at the age of six. Her life expectancy was only half that of a normal sheep. It seems that in the Era of Longevity the law of life would be “gradually suffering from chronic diseases, living with chronic diseases for a long time, and eventually dying from chronic diseases”. Among chronic diseases, cardiovascular and cerebrovascular diseases, cancer and Alzheimer’s disease have become the three that have drawn the most attention.
Cardiovascular and cerebrovascular diseases generally refer to diseases related to heart vessels and brain vessels. They are commonly seen in forms such as coronary heart disease, stroke, heart failure, and arrhythmia. What these diseases have in common is the buildup of lipids within blood vessels, which may have already appeared when patients are young. With age, the lipid buildup would grow and oxidize to form plaques. Mild cases include narrowing of vessels and organ hypoxia, while severe cases include myocardial infarction and cerebral infarction where ruptured plaques fall off vascular walls and cause death. The progression is multifactored: hyperlipidemia, hypertension, diabetes, obesity and smoking could all contribute to an increased prevalence at a younger age. According to the 2019 Annual Report on Cardiovascular Health and Diseases in China, the prevalence of cardiovascular diseases in China is on a continuous rise, and the number of people suffering from cardiovascular diseases is estimated to have reached 330 million, ranking first among the causes of death total of urban and rural residents.
Cancer is also age-related. Most types of cancer are the result of long-term accumulation of genetic damage and changes in human cells under the long-term influence of external factors. Cancer is a multifactored, multi-staged, complex and progressive process that often takes more than a decade to several decades. Advances in medical technology have slowed down the progression of cancer and turned it into a chronic disease, cancer remains the second leading cause of death globally as the number of older people grows. The latest Global Cancer Data released by the WHO’s International Agency for Research on Cancer (IARC) in 2020 shows that for the first time, breast cancer has surpassed lung cancer to become the world’s most commonly diagnosed cancer, and that China, due to its large population, has the most cases of newly diagnosed cancer in the world.
Alzheimer’s disease is a neurodegenerative disease with insidious onset that progresses with age. The incidence of Alzheimer’s disease is considerably high in older people, reaching 20–30% in people over 85 years old. The prevalence of Alzheimer’s disease account for 60–70% of all types of dementia. Alzheimer’s disease is caused by degenerative changes of the brain nervous system, leading to loss or disorder of cognition, language and memory accompanied by mood swings. However, the pathogenesis of Alzheimer’s disease is not clear, and no effective treatment has been found. Statistics from the World Health Organization show that the number of dementia patients was 47 million in 2015 and is estimated to grow to 75 million in 2030 and 132 million in 2050, which is almost 3 times that of 2015. According to WHO’s 2019 Global Health Estimates, dementia, including Alzheimer’s disease, has become one of the 10 top-ranking causes of death globally.
In general, the shift in epidemiology of human disease types has coincided with the arrival of the Era of Longevity. The main diseases limiting the increase in the average human lifespan are no longer acute infectious diseases but chronic noncommunicable and degenerative diseases. A 2017 study of 195 countries by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington also shows that, 30 years ago (1990), the leading causes of death globally were neonatal diseases, intestinal infections, respiratory infections, tuberculosis and other infectious diseases, while in 2017, the leading causes of death globally were chronic diseases such as ischemic heart disease, stroke, chronic obstructive pulmonary disease (see Table 2.1). In developed countries, diabetes and Alzheimer’s disease also rank among the top 10 causes of death.
It is a common phenomenon for older people to survive with diseases. According to the survey data in the Report on the Development of Life Quality of Older People in China (2019), more than 85% of people over 70 years old in China suffer from chronic diseases, and nearly 50% suffer from two or more chronic diseases at the same time. In the age of longevity, more diseases will coexist with elderly individuals, and long-term survival with diseases will become more common. This has led us to wonder whether longevity increases our risk of disease and how we can reduce the health hazards of living with disease and embrace the era of longevity more positively.
2.2 Can Longevity Be Healthier?
Longevity is only a good thing when it is healthy. According to the WHO’s definition, “health” means not only free of disease or physical weakness but also a physical and mental status of well-being, content and adaptability. If the increase in life expectancy is related to the time of death, then health status is closely related to the quality of life prior to death. When picturing a serene life at an old age, we cannot help but ask the following question: as possible future centenarian life comes, will our health status improve with the increase in longevity?
To better evaluate the relationship between increased life expectancy and health, the world usually uses a new concept, health-adjusted life expectancy (HALE), to measure and statistically analyze people’s health status. Individual diseases include long-term and short-term subhealth conditions, such as physical dysfunction and pain, which affect individual health and reduce longevity to varying degrees. The expected life years of individuals are adjusted and converted based on the weighting of diseases, and the sum is equivalent to the years of healthy survival, which is the health-adjusted life expectancy. A longer health-adjusted life expectancy reflects a healthier longevity (Fig. 2.2).
Source: Global Burden of Disease (2019), IHME, the University of Washington
Increase in life expectancy and health-adjusted life expectancy (HALE) in the world, Japan, US and China, 1990–2019.
We see that life expectancy and HALE both increased, but the gap between the two has not narrowed; instead, it has widened. In other words, older people today may seem healthier than before, but the reality is far from optimistic. A 2015 study published in the Lancet pointed out that as life expectancy increases, the gap between life expectancy and HALE widens year by year. The gap even exceeded 10 years of time, which means that 11.5–15% of life expectancy is lost during weighting and adjustment due to poor health.
What is worth noticing is that diseases do not always appear in middle-aged and older people, which means that the gap could widen even further. Under the influence of growing unhealthy behaviors and the environment, the prevalence of hypertension, hyperlipidemia, hyperglycemia, hyperuricemia, cardiovascular and cerebrovascular diseases, cancer and other chronic symptoms or diseases in young people tends to increase. Data from the Global Burden of Disease by the IHME show that in the past 30 years, in Chinese people aged between 15 and 49 years old, the incidence of ischemic heart disease increased by 44.6%, the incidence of Type II Diabetes increased by 60.3%, and the incidence of colorectal cancer and female breast cancer increased by more than 200%. Moreover, individuals age physically at different rates, and premature aging may also appear in young people. Some young and middle-aged adults have shown signs of cognitive function decline and brain aging and may also have poor physiques. In other words, today’s younger generation is likely to be less healthy than the older generation at the same age. Therefore, some people propose the concept of “biological age”, using biological indicators related to physical aging to reflect a person’s real age, rather than simply using the chronological age of social identity.
Health is influenced by a combination of factors. One’s health condition is not only about whether a person is sick but also about whether he or she has the ability to maintain a normal life. Chronic degenerative diseases are often accompanied by varying degrees of long-term or short-term loss of capacity, especially vision and hearing impairment, stroke, osteoarthritis, diabetes, chronic obstructive pulmonary disease, Alzheimer’s disease, and other age-related conditions. Loss of capacity is reflected not only in the decline of motor function and perceptive and cognitive ability but also in the limitation of activities of daily living (ADL), such as the autonomy to handle going out, shopping, and financial management. More importantly, it may lead to a low sense of social participation, depression, anxiety, loneliness and other psychological changes. According to the Fourth Sampling Survey on the Living Conditions of Older People in China’s Urban and Rural Areas conducted in 2015, the number of older people in complete loss or semi-loss of capacity in China exceeded 40 million. According to the Research Report on Long-term Care in China 2018—2019, approximately a quarter of older people are in need of multidimensional care (Fig. 2.3).
Source: The Research Report on Long-term Care in China 2018—2019, by Insurance Association of China and Institute of Population and Labor at China Academy of Social Sciences
Loss of capacity in age groups in China.
Of all capacity losses, senile dementia is a special kind. Cognitive abilities will decline with age, but this kind of decline varies from person to person as it is influenced by a variety of factors, including lifestyle, socioeconomic status, chronic diseases and medication. A decline in cognitive ability may appear earlier or more severely in certain senior citizens, who suffer from mild cognitive impairment, Alzheimer’s disease, or other types of dementia. A study by Japanese scholars in 2012 proposed that for every 5 years of increase in age, the risk of older people developing dementia doubles. The research institute of Japan’s Ministry of Health, Labor and Welfare estimated that by 2050, one in every five Japanese citizens aged 65 and older will have dementia. Psychiatric conditions such as anxiety, depression, hallucinations, delusions, restlessness and aggression are also seen in the elderly population. This also means that disabled older people need longer-term and more professional care, which would be a huge burden. According to 2020 data from the US Alzheimer’s Association, dementia patients may have had to live with diseases for over 10 years, and their average medical care costs in 2019 were more than three times those of nondementia patients.
We are entering the Era of Longevity, but not the Era of Health at the same pace. Growth in HALE has not yet caught up with the increase in life expectancy. The number of people living with chronic diseases continues to grow, and the number of disabled elderly people is increasing. How to live long and healthy has become an important topic for us to think about in the Era of Longevity.
Aging and death remain inevitable for all of us. As we age, our physical and mental functions decline, disease and death risks increase, and that is the process of natural aging everyone has to go through. People may age physically at different rates and on different trajectories. An optimal healthy aging process is shown as Trajectory A in Fig. 2.4: people remain strong and stable for a long time in their lives, and the occurrence of decline or loss of functions and capacities is postponed. For different groups, changes caused by aging also show different patterns in different social environments. In China, with the increase in age, the HALE proportion of life expectancy of older people generally declines rapidly at first and then remains dynamically stable, very much alike to Trajectory B. This also indicates that the aging process of older people in China is often less than healthy or ideal.
Source: World Report on Aging and Health, World Health Organization
Trajectories of aging.
How can healthy aging of the elderly individuals be achieved? The World Health Organization proposed a “sugar cube” model in 2015 as a possible solution (Fig. 2.5). Generally, in regard to health, we pay more attention to the quantifiable biological indicators such as genetic inheritance, personal behaviors and physical and organ metabolism, which are individual factors inside the “sugar cube”. What we often ignore are the external influence of social environmental factors outside the “sugar cube” on healthy aging.
Source: World Report on Aging and Health, World Health Organization
Healthy aging model.
External environmental factors include all the factors in the extrinsic world provided by society—from the microlevel to the macrolevel—home, communities, the built environment, people and their relationships, attitudes and values, health and social policies, and the systems that support them. These factors may have a greater impact on our health than we think. Research shows that light labor workers, people who live in economically developed areas/cities, and those with higher education, higher income or assets tend to have better health in old age. It is not hard to understand, as these groups have greater access to health services. However, it reflects an influence of public policies and the unequal allocation of resources. In addition, the quality of life is also largely influenced by micro-factors and individual factors such as education level, medical insurance, social participation, mental health and disease status. Macro regional factors play an essential role as well: the availability of community medical services and the medical supply resources in the region are both important factors.
In working toward healthy aging, we should pay attention to the maintenance of intrinsic capacity of the elderly, such as the physical and mental functions. Moreover, sufficient active assistance from the extrinsic social environment should be provided. Many high-quality elderly care communities in China and abroad are built in consideration of both. These communities are often located in places with beautiful natural scenery. While enjoying an interactive experience of education and entertainment and a variety of social activities, residents also have an easy access to medical services, hospitals and third-party payments of medical insurance.
Healthy aging is not an easy goal to achieve. The key is changing people’s awareness. Past generations underestimated the increase in life expectancy in the future, and we are underestimating the maximum health expectancy achievable for older people. Today, most people are probably not adequately prepared for their long life ahead. The currently available health resources are only focused on treating diseases regardless of age. Services covering a full life cycle to aim at promoting overall health are not being provided. Therefore, a serious mismatch between health resources and health needs is formed. The real challenge is how to shift people’s awareness from “focusing on treatment” to “focusing on health”. Let us aim for healthy aging and be best prepared to meet the unprecedented Era of Health.
2.3 The Era of Health Calls for a New Model
Can Healthy Aging Be Achieved Through Medicine?
When picturing the future in the Era of Health, people often hold high expectations for modern medicine. The development of modern medicine has helped mankind fend off a large number of acute, infectious and fatal diseases and saved lives from severe injuries. It addressed human’s most pressing survival needs, and extended life span to a maximum. Currently, survival-extending treatment measures have been developed even for with cancer and AIDS, which used to be considered incurable, to maximize the life span of patients. However, except for relieving life-threatening crises, medical treatment cannot guarantee that people will stay healthy, nor can it completely cure diseases or reverse aging.
Health is influenced by a combination of multiple factors, and medical factors account for only 11%. However, the other 89%, such as individual behavior, social environment and genetic factors (Fig. 2.6), do not receive as much attention as medical factors. With that said, almost half of the factors influencing an individual’s health are determined by his or her “birth” and “origin”. The biological diversity of individuals will also be reflected in the diverse health conditions of different people. The factor weighing the most is individual behaviors, and they could be effectively improved by efforts people make on their own. Individual behaviors should also be the main direction for general health maintenance promotion and disease prevention in senile age groups.
Source: Determinants of Health (2018), Edwin Choi, Juhan Sonin, collated by the author
Factors influencing individual health.
Health conditions are not completely determined by medical factors. The choice of medical treatment itself reflects a balancing process of benefits and costs. Medical treatment is hardly completely harmless. Although the benefits of most medical treatments far outweigh the costs, we should not ignore the side effects of drugs, surgical complications and sequelae. Therefore, the focus of medical research is also shifting to the early prevention of diseases.
Medical services are often considered a kind of social resource, but all resources are limited, and the consumption of resources requires more rational consideration of cost and health benefits. People’s traditional belief of medical services is “focusing on treatment”. As a result, most medical expenditure is spent after diseases occur. As more advanced medical technology and treatment are developed, medical costs keep increasing. Additionally, chronic degenerative diseases are usually difficult to cure completely and these patients may require years of increasingly expensive medical support. Living with multiple diseases means that patients have to be put on multiple medications, which are often expensive and ineffective. Therefore, medical models have also been under constant reforms.
Medical Model Reform
If we look back on human history, the first thing that came along the rapid progress of medical technology was the constant renewal of human awareness. As people have different understandings of diseases and health, their attitudes and methods also differ in treating diseases and dealing with health problems.
For a long time in ancient times, people believed that life and health were bestowed by gods, and diseases and disasters were either divine punishment or mishaps caused by ghost possession. Such early concepts of disease and health were considered the spiritualism medical model. At that time, maintenance of health and treatment of disease mainly relied on psychical inquiries, fortune-telling, and prayers to gods. At that time, medicine and witchcraft were often intertwined.
Later, naive dialectical holistic medical views emerged one after another in both Ancient Greece in the West and China in the East. These views drove out the spiritual elements in the spiritualism medical model, and people began to integrate and organize scattered fragmented pieces of medical knowledge. Empirical medicine gained major development, forming the Natural Philosophy medical model. Its examples include theories such as Yin, Yang and the Five Elements in traditional Chinese medicine and the ancient Greek physician Hippocrates’ theory of the Four Bodily Humors.Footnote 1 Doctors carried out medical activities based on experience, intuition or speculative reasoning, and they accumulated valuable first-hand materials on diagnosis methods, treatment methods and drug efficacy in their practice.
In the sixteenth century, the scientific revolution flourished in various fields during the Renaissance. Medical development began to break through ideological shackles and technical barriers. With the establishment of Newton’s classical mechanics theory system, the metaphysical mechanistic materialistic conception of nature came into being. It explains all natural phenomena with “force” and “mechanical movement”. The Mechanistic medical model that emerged at roughly the same time believed that “motions of living creatures are mechanical movements” and explained all of human’s physical phenomena from a mechanical view. It compared a healthy body to a well-oiled machine running in harmony and compared diseases to failures of certain parts of that machine. This model overlooked the biological and social complexity of life, but it did greatly accelerate the development of anatomy and biology. Many outstanding figures in the history of medicine emerged during this period, who also promoted the development of medicine to a certain extent. Vesalius, the founder and practitioner of modern human anatomy, is among the most famous. He enjoyed equal fame as Copernicus, and they are considered to be the two major representatives of the Scientific Revolution. Vesalius wrote the great medical books De Humani Corporis Fabrica Libri Septem (on the fabric of the human body in seven books). More importantly, he refuted the so-called authoritative ideas, which were impractical and wrong, broke away from religion’s control over scientific research, and defended the scientific truths. His contributions to anatomy also paved the way for William Harvey, an English physician, to establish his theory of blood circulation with his work De Motu Cordis et Sanguinis (On the Motion of the Heart and Blood) published in 1628. Many great achievements and discoveries were made in physiological science in this period.
Entering the nineteenth century, in the process of western industrialization, three great discoveries were made in natural science, namely, the Law of Conservation of Energy, Cytology and the Theory of Evolution. These discoveries further propelled the development of biology and medicine. Scientific methods are widely used in medical practice, and people’s awareness of health has been greatly updated. A biomedical model of health was built on the basis of biological sciences, breaking medicine completely free from the shackles of religious theology and idealism. Thorough research was performed on the morphological structure of the human body, physiological pathology, etiology and pathogenesis, and a relatively complete scientific system was formed in medicine. At the same time, William Osler, known as the “Father of Modern Medicine”, co-founded the globally top-ranking Johns Hopkins School of Medicine. Osler established the earliest residency system of doctors and published the famous textbook The Principles and Practice of Medicine. By his “bedside clinical training”, the idea of learning from practice has been sealed deeply in medical education, profoundly influencing not only medical practitioners at his time but also generations to come.
In fact, biomedicine alone cannot solve the problems people have in the prevention, incidence or prevalence of diseases, such as tuberculosis and sexually transmitted diseases, especially AIDS. Nor can it solve obesity and drug abuse, which are becoming increasingly common. The reason is that these conditions are the results of people’s lifestyles and individual behaviors, as well as social factors such as economic conditions and education levels. In 1977, George Engel, an American doctor, proposed the “Biopsychosocial Model”. Engel’s model expanded treatment from only focusing on the physical cause of disease to an integrated approach incorporating prevention, maintenance, treatment and rehabilitation, targeting biology, psychology, and socioenvironmental factors. This approach improved the efficacy of treatment more comprehensively. The biopsychosocial model interconnects biology, psychology, and socioenvironmental factors. It is a new multidimensional medical model that meets modern human needs in healthy aging.
Although the new medical model was put forward in the 1970s, the actual transformation was very slow in clinical practice. This was partly due to limited technical conditions: a fragmented healthcare system could not sustain continuous health management services. The full transformation was also hindered by utilitarian mindsets and the lack of interactions between segregated specialties. In the Era of Longevity, factors such as individual genetics, environment, behavior style, psychology, and society will have an amplified influence on people’s health within the full life cycle. Individuals and society’s demands for healthy aging will create challenges. These needs and challenges will accelerate the medical model transformation from sole disease treatment to a comprehensive package of health maintenance services covering the full life cycle.
Innovation Will Lead Human Beings to a Healthier Longevity
Welcoming the Era of Health, we still have a long way to go. Fortunately, human beings are making extraordinary technological breakthroughs in various fields. We are looking forward to harnessing that technological potential in disease prevention, rehabilitation, chronic disease management, sociopsychological health, etc. Through health intervention to individuals’ full life cycle and to the environment, people expect to age healthily in our finite lives.
First, we should minimize the risks of disease by prevention. The extensive application of vaccines is a classical example of disease prevention. New vaccination technology is showing huge potential: significant progress gained in molecular biology and molecular immunology, and genetic engineering is being utilized. The commercialization prospects of vaccination are extended, especially to rare or difficult diseases that have never been completely conquered, for example, the prevention and treatment of cancer. No one could have foreseen that the global pandemic of COVID-19 would draw unprecedented attention to the new mRNA vaccine. Before COVID-19, the prevention and treatment of cancer was one of the targeted applications of mRNA vaccines R&D. The pandemic expedited the fast application of mRNA vaccines and added one more powerful piece of weaponry to the human arsenal in the fight against diseases. The Internet of Things, AI, machine learning and other emerging new technologies have also contributed to vaccine R&D by improving the speed and coverage of data collection and data analysis.
The development of Life Sciences has proven that there is a correlation between many commonly seen yet seriously damaging diseases and individual genetic inheritance. By taking genetic screening tests early, people have the option to take targeted preventive measures in advance to minimize the risks of catching certain diseases in the future. With “Test Tube Baby” technology and genetic testing, couples carrying thalassemia genes now have a chance to have a healthy baby. Through genetic screening tests, the famous Hollywood star Angelina Jolie found that she carries the hereditary gene BRCA1, which gave her an 87% chance of developing breast cancer and a 50% chance of developing ovarian cancer. She then underwent a voluntary double mastectomy, and her ovaries and fallopian tubes were surgically removed. The “extreme” measures Angelina Jolie took to reduce risks were not approved by all people, but her choices showed an alternative path. By understanding their own disease risks, people can manage the possibility of getting certain diseases in the future by adjusting individual behaviors, lifestyles and dietary habits. This proactive approach has become an important part of disease prevention.
Aside from the prevention of disease, scientists are also actively exploring the prevention of aging and death. With their efforts, the “immortal” HeLa cell line was discovered; old rats could get young by exchanging blood with young rats; lab rat’s life can be extended by controlling caloric intake in its diets; mutant DNA, which causes aging, could be cleansed by cell programming; R&D of telomerase inhibitors could delay telomere shortening; gene editing is being combined with stem cell therapy, etc. As for application, antiaging drugs (rapamycin, metformin, spermidine, NAD + precursor supplement, etc.) have shown possible antiaging effects in experiments and have become a very popular R&D direction, but their effect on the human body still needs further experimental validation.
Precision medicine makes treatment safer and more effective. Precision medicine was developed based on personalized medicine. By integrating methods and techniques of modern scientific disciplines (genetics, molecular imaging, bioinformatics, etc.), precision medicine provides customized treatment for patients based on differentiated individual genetic inheritance, environment and living habits. Customized treatment has the best clinical results, lowest medical cost and highest social health benefit, and the most classic example is the treatment of cancer patients. Due to the biological diversity of individuals, patients may have various degrees of sensitivity and resistance to chemotherapeutic drugs, and many patients have received unnecessary or even damaging treatments with strong side effects. In recent years, targeted medicine has been carried out in many hospitals, especially in tumors that have been proven to be associated with genes. In targeted gene therapy, cancer cells will be tested genetically, and mutated genes, which are the targets, will be detected and treated. Because of their small molecular size, nanomaterials are used as drug carriers to improve absorption and utilization, and extend the biologic half-life of medications. After entering the body, they will only combine with molecular targets without acting on the normal tissues surrounding cancer cells, efficiently delivering targeted medication and reducing unnecessary physical burden and loss of health for patients.
In addition, the popularization of surgical robots has improved traditional surgery in accuracy, duration, visual field angle and other aspects. In the treatment of certain diseases, surgical robots have gained common recognition of doctors and patients. Surgical nanobots are designed following principles of molecular biology and can precisely kill cancer cells, remove clots and lipid buildup in arteries, clean wounds, crush stones, etc. Other robotic technologies for medical use, such as robotic radiosurgery, capsule robots, and robotic assisted ultrasound/imaging, are also in research and development.
For people who are already suffering from degeneration or loss of physical capacity due to aging or diseases, attention should be given to the timely prevention of further decline of physical ability and cognitive ability so that patients can recover as much as possible. Human body tissues and organs are self-healing to a certain extent. For example, stroke patients who go through a standardized rehabilitation program within 6 months after stroke have a 78.6% probability of improving ADL ability and minimizing loss of capacity. Our skin will heal by itself after being cut, and a cast can help bones “grow” after fracturing. However, chronic diseases, such as heart disease, diabetes and osteoarthritis, take a long time to progress and can only be alleviated rather than self-healed. If we can “learn” more about the principles of self-healing and methods to help self-healing, we can better cope with aging, diseases, injuries and infections.
Based on tissue engineering and life sciences, multiangled interdisciplinary research has been carried out in regenerative medicine. Examples include the fabrication of tissues and regeneration of organs using directive differentiated stem cells or progenitor cellsFootnote 2 (cell therapy), organ regeneration in vitro, transplant of tissue and organ (tissue engineering), reconstructing the microenvironment to induce and activate cell regeneration (immunoregulatory therapy) through infusion of cell-active substances and growth factors, etc. Shinya Yamanaka, laureate of the 2012 Nobel Prize in Physiology or Medicine, discovered and successfully cultured iPS cells (induced pluripotent stem cells). The differentiation potential of iPS cells can be used in many fields, such as retinal tissue culturing, knee cartilage regeneration, and treatment of damaged hearts. The emergence of regenerative medicine has undoubtedly brought new hope to solving many medical problems currently faced by human beings. However, regenerative medicine is still in the stage of fundamental research and needs to be standardized and restrained due to ethical considerations.
Another observation is that the overcrossing of many new cutting-edge technologies has presented the possibility for humans to gain “external assistance” to our physical functions. The brain-computer interface (BCI) is one of the most eye-catching research directions in brain science and neuroscience. With electrodes implanted in the visual cortex of the brain, a blind patient in Spain wearing glasses equipped with a tiny camera was once again able to “see” letters and patterns on a piece of paper. Parkinson’s disease can also be contained to a certain extent by deep brain stimulation. By building a direct new pathway for neural directives, BCI can help stroke patients and those suffering from language dysfunction establish cross-language communications. People also have very high expectations for BCI in treating depression and Alzheimer’s disease. Machine science research is expected to reach a new height to substitute for certain physical functions of the human body, especially for disabled, elderly, and mobility-impaired people.
Having to live with diseases creates a need for chronic disease management. Scientific development enabled the “patient-oriented” healthcare to be reconstructed both in time and space. For a long time, medical resources lack integration, and older people living with multiple diseases at the same time often have to travel back and forth between different levels and types of medical facilities many times. The lack of synergy between facilities usually results in poor recovery and relapses of patients. Older people are often on multiple medications at the same time, which leads to an increase in adverse drug reactions. Currently, we do not have a well-established chronic disease management system in place that could offer multidimensional, proactive and continuous services. Therefore, it is difficult to delay the progression of chronic diseases, prevent complications, lower disabilities, improve quality of life and reduce medical costs. As more people will have to live with diseases, the social medical burden will also continue to grow.
With the rapid development of testing, diagnostic technology and information technology, healthcare services may be extended to more occasions: in addition to in-between facilities, they could also reach beyond hospitals to communities and families. Medical information and data will no longer be stored in isolation. It can be shared, compared and used to inform the self-management of chronic diseases. Patients with heart failure risks will be able to monitor their own vitals in real time through sensors in their watches, wristbands or wearable devices. Diabetic patients on long-term medication can monitor biological recognition indicators through on-skin wearable devices for precise medication. All these data could be uploaded to medical facilities or even larger platforms through the Internet. It will save time for both doctors and patients and allow patients stronger control over their own conditions. With the development of digital medicine, the process of medical services will be further optimized, and the quality and efficiency of medical services will be improved. Digital medicine will enable medical facilities to communicate, share information, and provide personalized treatment protocols to patients based on big data analysis. The ultimate goal is for patients to enjoy better medical experiences and treatment results.
Aside from physical diseases, factors such as mental state, individual behaviors and social environment are affecting people’s health as well, directly or indirectly. With the accelerating pace of life and increasingly intensified competition in the modern society, it is highly possible for people who lack sufficient socialization experience to present a series of psychological symptoms, such as fear, anxiety, tension and despair. These psychological symptoms are important pathogenic factors for cardiovascular diseases, hypertension, malignant tumors and mental disorders. According to statistics released by the World Health Organization in 2017, more than 300 million people worldwide suffer from depression, of which over 95 million are in China. Depression has become the third leading cause of disability, ranking only after heart disease and respiratory disease. New technologies could aid treatment of psychological conditions too. Internet big data can be used to study, explore and quantify the behavioral characteristics of psychological diseases and establish a quantitative model of psychological disease. Artificial intelligence can analyze users’ facial expressions, voices and texts, and establish a common analysis basis of the three to identify and screen psychological problems. Online consultation, diagnosis and treatment have created new space for patients who are suffering from psychological conditions but too shy to see a doctor.
In terms of the social environment, intelligent home systems have been constantly developing. A intelligent home system could cover many housing needs: it could monitor individual health status, such as sleep monitoring, body temperature and respiration sensors; it could monitor indoor environment and coordinate air purification, intelligent environmental control of room temperature and humidity, noise cancellation and water purification; it can even intelligently interact with home owners, providing companionship, daily interactions and daily reminders. Hardware wise, special equipment with enhanced user convenience is introduced to help maintain people’s physical vigor and functions, such as walking assistance devices, hearing aids, and home elevators designed for elderly individuals. More sites are being designed and constructed for older people to do physical exercises and participate in social events. Senior colleges, senior societies, social network sites, volunteer work and jobs for retirees are becoming more common, and senior citizens’ needs for continuous personal study, social contribution and realization of personal value are accommodated. In 2010, the Department of Psychology at Brigham Young University conducted a systematic analysis on the correlation between social connections and death risk. According to their findings, individuals with good interpersonal relationships had a 50% increased likelihood to live longer than those lacking social contact. Further analysis by a 2016 study from the Department of Sociology at the University of North Carolina found that social inactivity had an even greater impact on the incidence of hypertension in older adults than diabetes, and that higher levels of social involvement would reduce the incidence of hypertension in older people by 13% and slow disease progression by 54%. Internet has shortened the social distance between one another, and people gather for their shared hobbies or sports, exchange ideas and have fun together. These gatherings not only help maintain and improve their physical capacity and functions but also bring them to a healthier mental state.
For a long time, scientific progress was believed to be the solution to disease treatment. Today, we hold the same expectation for scientific progress to present a solution to achieving healthy aging. Many scientists and thinkers have openly declared that the ultimate question to modern science is how to defeat death and achieve eternal youth. Benefitting from the development of life sciences and information technology, such as the Internet, big data, cloud computing, AI and 5G, the sharing of resources and integration of functions will contribute great value to the ecology of health industry. We will need a brand-new point of view in welcoming the Era of Health. We look forward to new models and new technologies, which will enable us to cope with noncommunicable chronic diseases more effectively and lead us to a healthy long life.
2.4 Blue Ocean of the Big Health Industry
The Big Health Industry Harbors the Largest Business Opportunities
In the Era of Longevity, huge demands for all aspects of health will boost the development of the Big Health Industry. A crucial component of the Big Health Industry will be to provide people with healthy living solutions targeted at healthy aging. The Big Health Industry will harbor the largest business opportunities, and it will be a substantial force driving society to the Era of Health.
As of now, the Big Health Industry is already one of the largest industries worldwide. In developed countries such as the US, Switzerland, Germany and France, medical expenditure accounted for over 10% of their national GDP in 2019. Statistics from US medical insurance and Center for Medicare & Medicaid Services (CMS) show that the US spent 17.7% of its 2019 GDP on medicine and health. China’s health expenditure in 2019 was approximately 650 million RMB, which is approximately 6.6% of its GDP in the same year. Compared with developed countries, there is still considerable room for growth for China’s Big Health Industry. According to the “Healthy China 2030” Blueprint, the size of China’s Big Health Industry will grow to 1.6 billion RMB by 2030. China’s Big Health Industry has an immense potential and room for optimization in its industrial structure. With the boost of favorable policies and market prosperity, it is expected to become one of the pillar industries of China’s national economy.
As a new and steadily developing industrial cluster, the Big Health Industry looks much alike medical care services in a narrow sense. But in a broader sense, the scope of the Big Health Industry is reaching beyond fields that are directly related to medical care services, and it will extend to incorporate a package of health services covering the full life cycle and all age groups. The application of new technologies such as AI, big data, and the Internet of Things will become more mature and infiltrate into medicine and health care. Their interactions with conventional healthcare industry components will hasten new businesses, new models, new scenarios and new growth of the Big Health Industry.
The Big Health industry is extensive. It has a large number of subindustries, such as biological pharmaceutical manufacturing, medical equipment, elderly care, sports and fitness, health management, nutrition, medical cosmetology and Internet Medicare. These subindustries are already showing great market potential, and they have been attracting much investment. The Big Health industry is also intensive and concentrated. From scale and structure of business, pharmaceutical companies, health insurance companies and medical facilities are the three main drivers of the Big Health Industry’s prosperous development. In 1996, 11 companies in the Big Health Industry made the Fortune 500 list, and this number had grown to 28 in 2020, which is a 255% of “explosion” in 24 years. Pharmaceutical companies such as Johnson & Johnson and Pfizer and retail companies such as McKesson and Sinopharm took half of the Big Health Industry market. The market value of Johnson & Johnson alone was over 400 billion US dollars in 2021. Commercial health insurance companies are also great contributors. The United Health Group in the US is the largest commercial health insurance corporation in the world, and its market value in 2021 was 380 billion US dollars. HCA, the world’s largest hospital chain group, was valued at 70 billion US dollars in 2021. The “money-making” power of the Big Healthy Industry and its major players was astonishing.
The Era of Longevity Drives Structural Changes in the Big Health Industry
Older people are the main consumers of medical and health services. Noncommunicable chronic diseases have become a medical resource-consuming “black hole”, and the demands and cost of medical services are both increasing further. The growth of the elderly population and the development of chronic diseases have brought unprecedented challenges to the current medical and health industry. According to investigations carried out in the US by the Medical Expenditure Panel Survey (MEPS) in 2006, 84% of healthcare expenditure was spent on chronic disease management. The China Development Report 2020 titled “Population Aging: China’s Development Trend and Policy Options” also points out that the treatment costs of chronic diseases (such as circulatory system diseases, respiratory diseases, malignant tumors, etc.) have been rising, accounting for approximately 80% of the elderly’s medical expenditure.
Various studies have also found that another major factor for the rising medical costs is the advancement of medical technology. In 2000, the United States Social Security Administration reviewed several studies on the contribution of different indicators to the increase in per capita medical service cost from 1940 to 1990. They found that medical technological advancement contributed 38–62% to the increase in medical cost. Some reports even pointed out that the contribution may be more than 65%. Research in Japan also shows that the continuous rise of medical and health expenditures was caused by many factors, including medical technology progress, economic wealth growth, an aged population and the changing structure of human disease spectrum, among which the primary factor is technological progress, accounting for 40% of contribution. The above findings are highly related with the fact a that the current mainstream medical services are still concentrated on treating acute and major diseases, which require costly high technologies and equipment, resulting in the constant climbing of medical expenditure.
In the past, scientific research and medical resources were focused more on acute or fatal diseases and less on eliminating or delaying chronic and degenerative age-related diseases. This is largely because life expectancy was short back then, and medical research naturally focused more on deadly diseases. At that time, there were not as many people having to live with disease long term as today, thus they were more likely to be neglected by the society. The growing imbalance between the health demands and medical resource distribution is occurring not only in China but also in the US and other developed economies. The medical system itself also has problems such as weak prevention, strong treatment, fragmentation, inefficiency and abuse of medical resources. Excessive medical treatment, repeated hospitalization, and increasingly heavy medical burden on both the government and the patients are the most commonly seen manifestations. As the demographic structure changes, more people will have to live with chronic diseases for a long time. Health becomes people’s largest demand, and it will cause structural changes to the industry.
On the one hand, the pressure on treatment should be relieved by strengthening disease prevention and health management. With the changes in the industrial structure and the guidance and support of governmental policies, patients with common diseases and chronic diseases and outpatients could be redirected from costly and inefficient general hospitals to community medical facilities, where more economical treatment and procedures will be applied. For example, nail-clipping services could be provided to diabetic patients to reduce the risk of foot infections, gangrene and potential amputations, and better management of pregnancy would reduce infant hospitalization and NICU cases. These efforts will not only benefit the patients’ health but also play a role in curbing the rapidly rising medical costs.
On the other hand, integrated healthcare services should be created and provided. Medical institutions should be vertically integrated: closely connected medical associations should be established to provide continuous and active medical and health services for patients. There should also be horizontal integration between institutions and facilities of subindustries, such as obstetric services, physical examinations, health management, sports rehabilitation, elderly care, etc. With the boost of information technology, integrated services centering on health needs can improve operational efficiency and service accuracy of the health industry, optimize medical expenditure composition, and expedite industrial structure transformation. In a sense, the traditional extensive medical service model is being replaced by an inclusive package of medical and health services centering on individual health needs with the purpose of quality, efficiency, efficacy and value.
As the elderly population’s compound demands for medical treatment, health, nursing, elderly care and other services grow gradually, integrated services are becoming customized with more features, and the service model is being constantly innovated. Health services such as home visit and home care for the elderly and the disabled are growing popular. In recent years, exploration of home visit medical services and professional support in caretaking and rehabilitation have begun in Japan, the United States, China and other countries. Older people face many practical problems in getting healthcare: they have difficulty in mobility and often have unpleasant experiences at the hospital. Home visits and home care can solve those problems and reduce the overall medical costs greatly. Integrated eldercare communities are also developing vigorously in the United States. For example, the CCRC model, which is Continuing Care Retirement Community, provides a variety of service options based on different health statuses and social needs of residents in the community. The options include independent living, assisted living, professional 24-h nursing, etc. Thousands of elderly care communities in the United States have adopted the CCRC model: the housing designs of these communities are customized for elderly individuals, leisure facilities are built within, and residents have an easy access to professional medical and health services.
The CCRC model has also been introduced into Taikang’s longevity communities. We established a “1 + N” service team model to implement the CCRC concept. “1” here refers to “1 case manager” in each team, who is usually the community housekeeper or care giver. “N” refers to a multidisciplinary professional team made of more than 15 specialists in nursing, rehabilitation, medicine and other specialties. The “1 + N” teams support the residents in maintaining and improving their physical, psychological and social functions, while ensuring their health, comfort and pleasure. We were pleasantly surprised to see that some of our residents, who were too weak to even get out of bed at admission, recovered well enough to live a healthy and happy life independently after two years in Taikang’s longevity communities.
Considering that medical care is one of the necessities of our residents, we also equipped each of our elderly communities with a rehabilitation hospital to create a “one community, one hospital” model. With this model, we have built a triple-layered medical service mechanism for the residents, namely, “first aid—chronic disease management—rehabilitation”. This mechanism provides comprehensive and sustainable medical and health services focusing on rehab and diseases commonly seen in older people. At the same time, we maintain close cooperation with surrounding top graded hospitals to ensure that residents receive public medical services when needed in a timely manner. By the combination of maintenance and medical care, we want to make sure there is “a top hospital close by, and doctors by the side” so that our residents have access to both sufficient daily care from community hospitals and effective timely public medical services. In the future, we will further develop a new five-in-one business model in locations with mature conditions. Medical care, elderly care, rehabilitation, health management and insurance will be seamlessly integrated to provide our residents with comprehensive medical services including health consultation, health management, diagnosis and treatment so that residents can truly enjoy a healthy longevity.
Commercial Health Insurance Companies Became Levers of Revolution
In the Big Health Industry, insurance companies, as third-party payers of medical and health services, are extremely important participants and naturally have overlapping business with elderly care and healthcare industries. In fact, in the entire business world, there is no other industry like the medical industry: with the participation of third-party payers, customers only have to pay a very small amount of money but they can enjoy a great number of high-quality medical services. More importantly, third-party insurance institutions negotiate for better quality and lower price of medical services with medical facilities on behalf of customers. This position gives them unique advantages in optimizing the allocation of medical resources, and adding value to the industry and extending the industrial value chain. With these unique advantages, commercial health insurance companies became the levers of revolution.
In the Era of Longevity, people need more inclusive insurance services to provide protection for a longer and healthier life. On top of the basic social medical insurance system, commercial health insurance can provide stronger and wider protection and has a positive influence on improving people’s overall health. Commercial health insurance developed best in the US. US commercial health insurance companies offer a large variety of health insurance products and a wide coverage of protection. According to the US Census Bureau of the Department of Commerce, approximately 68% of the US population was covered by commercial insurance already in 2019. Data from the US Centers for Medicare and Medicaid Services also showed that commercial health insurance accounted for 31% of healthcare funding in the US in 2019. Commercial health insurance has become an important component of the financial insurance system and social security system in the US. In other developed countries, commercial health insurance also plays an important role in medical and health systems. Germany also adopts a social medical insurance system. According to the data from the German Federal Statistics Office, commercial health insurance expenditure accounted for 8% of the country’s total health expenditure in 2019, more than double that of China.
In recent years, Chinese consumers’ demands for commercial insurance have expanded from life insurance to health insurance, such as sickness insurance, commercial medical insurance and long-term care insurance. According to the data from the China Banking and Insurance Regulatory Commission, health insurance premium income continued to grow from 2011 to 2019 at rate of 30%, much higher than that of any other insurance product, making it the fastest-growing market segment in the insurance industry. In 2020, the premium income of commercial health insurance in China reached 820 billion RMB and is expected to maintain rapid growth in the next 5–10 years to reach 2 trillion RMB in 2025.
People’s demands for medical care and eldercare are growing rigid in China. These rigid demands are creating huge potential for health insurance products. There have been vigorous innovations in health insurance products, which have invigorated scientific and technological progress and boosted the development of the pharmaceutical industry. The development of innovative insurance products, such as chronic disease treatment insurance, specialty drug insurance, rehabilitation and nursing risks, aims to better compensate medical costs and help alleviate patients’ financial burden. These new insurance products have improved the accessibility to medical services, high value drugs, new drugs and specialty drugs to a certain extent, driven sustainable development of relevant industries and contributed to the optimization of social welfare. China’s health insurance market is rapidly maturing, and health insurance products in China are being continuously optimized. A more well-rounded “umbrella of protection” will be held up for people’s health.
As the main consumer interest in commercial insurance products shifted from life insurance to health insurance, the insurance industry also develops a trend of integration: segments throughout the health industrial chain from upstream to downstream are integrated, such as medical care, pharmaceuticals, health management, elderly care and nursing. The operation of health insurance is to operate the health value chain through the insurance lever. In the US, commercial health insurance policy holders had to pay medical costs out of their own pockets first, and then go to commercial health insurance companies for “reimbursement”. As the commercial health insurance market continues to grow in size, the industry experiences increasing marketization and policy holders no longer need to do that. Commercial health insurance in the US has transitioned into a “managed health care” model, where insurance companies become directly involved in the management of the health service system. This new model reasonably controls medical expense growth and ensure that customers obtain medical services of higher quality.
Founded in 1945, in California, Kaiser Permanente (KP) is a nonprofit healthcare group and one of the largest health maintenance organizations in the United States. KP built a lever through the integration of insurance and services, and its core business is the innovative integration of health plans, hospitals and physicians into one organization through a prepaid insurance model (see Fig. 2.7). Through a series of measures taken in finance, systems and incentives, KP became the first to unify insurance payers and medical service providers with common interests, forming a closed commercial loop where medical services are provided and paid for within the integrated system. Its profit model is that the risks are shared by the insurance end and the physician end, and the medical expenses are controlled through measures such as the strict patient guidance system and health management of its members. In KP’s model, the Health Plan is responsible for premium collection and regional promotion; Kaiser Foundation Hospitals, as independent entities, receive their budget from the insurance end and are responsible for investing in their own medical facilities or managing facilities in cooperation with other local facilities. As an independent for-profit organization, the KP group has an exclusive cooperation agreement with the payment terminal, and its physicians are only responsible for providing services to KP members. By 2020, KP had more than 12.4 million members, 39 hospitals, 723 clinics, over 24,000 doctors and more than 64,000 nurses in 9 states of US. In 2020, its revenue reached 88.7 billion US dollars, with a compound annual growth rate (CAGR) of 7.2% in the past 10 years and an average profit rate of 3.1%, which all reflected its stable operational capability. The emergence of the “Kaiser Model” brought more attention to the efficiency of medical and health services and showed that medical care is needed and can be controlled by value, which indirectly promoted the development of managed health care in the United States.
Source Collated by the author
Kaiser medical care model.
Another representative of the US commercial health insurance industry is the United Health Group (UHG), which leverages bargaining power with health care services by pooling payment ability and business scale. UHG pooled payment ability through aggressive acquisitions, entering the government healthcare market and building a strong distribution of health services. With the payment ability, UHG combines its two business segments, United Healthcare, which is the health insurance business, and Optum, UHG’s health services business, to achieve two-way synergies and profitability. United Healthcare is responsible for providing various types of health insurance and diverting clients to Optum, the health services business segment. While providing back-end health, medical and nursing services, Optum is also responsible for developing cooperation with hospitals, pharmacies and other related companies. This model enables UHG to control cost of the whole process of data and health services, reduce the indemnity cost of the insurance end, and achieve double spiral business growth. United Healthcare and Optum contributed 64.4% and 35.6% to UHG’s operating revenue and 52.5% and 47.5% to its operating profit, respectively. Since its establishment in 1974, UHG has grown to be the largest commercial health insurance company in the United States, providing health insurance-related services to more than 70 million people in the United States. In 2020, UHG’s business revenue was more than 250 billion US dollars, and its profit exceeded 15 billion US dollars. For over a decade, the CAGR of UHG’s revenues and profits have reached 13% and 10%, respectively. As of May 2021, UHG’s market value exceeded 380 billion US dollars, and is, without a doubt, one of the leading health insurance companies in the United States.
In general, all kinds of insurance companies are making efforts to involve themselves deeply into the Big Health ecology in their own ways. In addition to providing patients more cost-effective protection of finance and service, insurance companies have also gradually grown to become investors of the health industry and participants in medical services, disease prevention and disease management. Insurance companies are an emerging force of the Big Health Industry: they add value to the industry, and extend the length of the industrial chain. As an increasing number of people will have to live with diseases over the long term, people will seek out solutions to prolong health-adjusted life expectancy. Under such circumstances, industries that would directly or indirectly affect health, including the insurance industry, will become part of the Big Health Industry and be welcomed in a blue ocean of development driven by huge demand.
The Era of Longevity is the result of the continuous progress of material civilization, creation of abundant social wealth and the constant development of medical technology. This unprecedented experience is both an opportunity and a challenge. The explosion of medical and health demands will place a heavier burden on social resources. It is not only about the elderly but also a social issue, and it needs to be addressed by several generations to come. In the Era of Longevity, health is the largest livelihood and the largest industry. Facing such epoch-making social changes, enterprises, as the main participants of market economic activities, must also gain a deep understanding of these changes, wield the power of business in innovation and exploration, and provide much more efficient corporate solutions to the health needs and challenges. Taikang started as a traditional life insurance company, dug deep into life insurance business and its entire industrial chain, and redirected itself to the path of building a grand Big Health ecology. We realized that we are facing great opportunities in the health industry in the Era of Longevity. From our experience, we also see in practice the powerful synergies between the insurance, health care and elderly care industry, and believe Taikang can make a great contribution to the Big Health ecology and to the society. Our determination was boosted and we aim to become a leading enterprise in the Big Health Industry. We will persist in expanding health insurance payments, establish services such as health care and eldercare to change people’s lives, and serve human’s goal of healthy aging in the Era of Longevity and Health.
Notes
- 1.
Theory of the Four Bodily Humors: it was believed by Hippocrates and his followers that diseases were caused by dyscrasia of the four bodily humors (blood, black bile, yellow bile and phlegm). They also believed that people of ideal health should have equal amounts of the four bodily humors, and people get sick when there is imbalance between the four bodily humors and will not recover until that balance is restored.
- 2.
Stem cells are primitive and unspecialized cells that have the potential function of regenerating various tissues and organs. They exist in various cell tissues and have different types with differentiation in ability. Hematopoietic stem cells, for example, can differentiate into blood cells; embryonic stem cells appear before zygotes and have the potential to differentiate into a whole living organism. Progenitor cells are intermediate cells before differentiation, similar to stem cells, but with limited ability to differentiate, replicate and divide.
Reference
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Chen, D. (2023). The Era of Health: A Healthier Longevity. In: The Era of Longevity. Springer, Singapore. https://doi.org/10.1007/978-981-19-6784-9_2
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