INTRODUCTION
Since the onset of the COVID-19 pandemic, the healthcare system in Asia has shifted away from the traditional hierarchical pyramid to a new ecosystem. The new ecosystem is built around the demands of increased patient expectations, an aging population, lack of healthcare practitioners, increasing financial burden on the government, and technological advancements. These demands push governments, tax payers, insurance companies, and healthcare practitioners to reimagine systems for healthcare delivery and management. The emerging healthcare systems are designed to be more scalable, sustainable and individualized and are trending away from general practitioners being the only portal-of-entry practitioners available to patients. In response to these changes, patient-centric digital health ecosystems are growing at an unprecedented pace and scale across Asia. The chiropractic profession has had a golden opportunity in leading this transformation in changing the dynamic of the healthcare ecosystem.
DISCUSSION
5 Factors That Disrupt Traditional Healthcare and Build Demand for Chiropractors (Figure 1)
Increasing patient expectations: with the average income growing in many Asian countries, patients are spending more money on health and wellness while demanding increased value, service and convenience in the care they seek. During the pandemic, Chinese consumers spent more for health-branded products for increased peace of mind and reputable product quality. According to the World Economic Forum, 43.5% of Chinese consumers have increased their health spending in 2020, while 23.1% have increased their nutrition spending.1 Chiropractic has positioned itself to be able to meet the demands of patients by offering health and wellness services in convenient settings at a relatively inexpensive cost. Using the impact social media can have on society, chiropractic referrals also become viral within the region.
Aging population: By 2025, Asia will have 456 million senior citizens aged 65 and over, representing 10% of the total population.2 This represents a 14% increase from 2021, indicating a significant demographic shift that will increase demand for chiropractic services for rehabilitation and musculoskeletal management.
Lack of healthcare practitioners: Hong Kong has only an estimated 190 active chiropractors serving a population of 7.4 million. As the ideal chiropractor to population ratio is 1:2,588,3 Hong Kong alone has a strong demand for additional chiropractors. The World Health Organization currently estimates a shortage of 9 million nurses worldwide, with Asia being among the worst-affected regions.4 Asia’s average number of doctors per 1,000 inhabitants is lower than the OECD average, with the exception of three nations in the area.5 Increased utilization rates of chiropractic care can help ease the burden on an already stressed healthcare system to help meet Asia’s expanding health needs for musculoskeletal care.
Increasing financial burden: Currently, the Chinese government is the primary payment provider of healthcare in the country. Reducing the financial burden into a system providing more cost-effective services is difficult when delivery of health care is hindered by the current waste, inefficiencies, maldistribution and poor quality of workforce. Even while prioritizing quality and access for patients, finding strategies to curb the growth of healthcare spending remains a vital public issue.6 According to a speech presented by Kathleen Sebelius, Secretary of Health and Human Services, at the 2011 National Chiropractic Legislative Conference, chiropractic has proven to be cost-effective in the US healthcare system7 and the utilization of chiropractic becomes one of the keys to reducing the future healthcare-related financial burden in China.
Technological advancement: Asia has half of the world’s internet users and is already a global leader in digital innovation in a variety of fields.8 From venture capital and private equity investments into digital health in Asia, many healthcare companies are inventing new technologies such as AI diagnosis, to replace the traditional system. Chiropractic practice can apply the technology to raise the clinical skills and broaden the scope of conditions being treated and managed. For example, chiropractic clinics in Hong Kong are managing stroke risk and autism by using retinal photos with AI technology.9
The Rise of Health Ecosystems in Asia
In response to these fundamental factors affecting healthcare, the traditional medical system is being disrupted and new, patient-centric, digital ecosystems are forming worldwide.9 Such ecosystems are built to deliver the right care in the right setting at the right time by integrating 3 critical components: (a) a network of healthcare practitioners across multiple disciplines, (b) a system of intelligence that analyzes patients’ needs and selects the appropriate practitioner using behavioral, social, and health data, and (c) a technological backbone that allows data and insights to move freely between relevant healthcare providers.
While technology assists the health ecosystems, the system cannot be solely digital. It is important to incorporate both digital and physical health services together due to the diversity and complexity of these ecosystems. It also means that the ecosystem cannot be encapsulated by a single entity, but consist of multiple systems managing the care continuum anchored around a central orchestrator. They include investors, practitioners, healthtech start-ups, and IT vendors. The chiropractic industry can access health data as primary physicians and create the future of medicine, steering the development in preventive and precision treatment, drug discovery and health policy steering for governments.10
Future healthcare ecosystems will likely be patient driven, characterized by the demands of various patient populations and the effective care journeys that go with them. These ecosystems’ patient-centric character will also expand the number of healthcare touchpoints, with the goal of changing patient behavior and improving outcomes.11 The traditional doctor-centric model will be diminished if not excluded in the new system. Not only healthcare incumbents like insurance companies, practitioners, and governments, but also unconventional newcomers like consumer-technology behemoths, banks, telecommunication companies, real estate companies, and retail conglomerates are beginning to define their approach to healthcare ecosystems across Hong Kong and China.
There are 2 types of health ecosystems evolving, each type has its places in the new system:
Improving primary care access: During the pandemic, many of Asia’s top health ecosystem firms have adapted to combine telemedicine and e-pharmacy services. In China, Ping An Good Doctor’s initial value proposition was to allow consumers to see a doctor online in minutes rather than waiting in a hospital line for hours. Patients requiring an in-person follow-up might then be able to receive an appointment at a more hospital quickly. Ping An Good Doctor later moved into e-commerce, offering consumer health products, generic supplements, and health exam kits through their website. EC Healthcare, as the largest chiropractic service provider and non-hospital medical provider in Hong Kong, established new avenues of provider partnerships for offering telehealth consultations, e-rehabilitation prescription, appointment booking, e-payment, pre-vaccination health assessment, and nutritional supplement distribution.12
Improving health and wellness: Some governments and insurance companies are experimenting with digital technology to encourage consumers to track their health and reduce long-term healthcare costs. The Singapore Health Promotion Board (HPB) has been running the Healthy 365 initiative since 2015, which gamifies wellbeing by granting redeemable “Healthpoints” based on daily step counts, healthy food purchases, health tests, and other factors.13 The HPB expanded its program in 2020 by working with Apple to launch LumiHealth, which adds more exercise and wellness challenges for Apple Watch users.14 Similarly, private insurance companies like AIA15 and Bank of China Life16 have relied on EC Healthcare chiropractors to actively engage their policyholders and direct them to proper health and wellness.
The capital market has rewarded healthcare entrepreneurs expanding into this new healthcare ecosystem. Tencent’s WeDoctor is valued at the $6.8 billion USD in March 2021, which is 24 times the price-to-revenue ratio, 12 times the ratio of Ping An Good Doctor, and significantly higher than the average price-to-revenue ratio of brick-and-mortar health providers in Asia, which is around tenfold.17 Chiropractic leaders at EC Healthcare are learning from the promising principles and market trends and are thus capitalizing on future growth opportunities. Therefore, even as a smaller but rapidly growing health company, its valuation had risen with leading investors and billionaires18 in 2021. EC Healthcare created a successful ecosystem with chiropractic at its core, aligning interests and connecting multiple stakeholders (government, insurance companies, healthcare providers, and patients) within its health systems, and in-depth resolution of each party’s operational pain points is critical to uncovering opportunities. Its digital ecosystem is not solely an online strategy, but a successful model integrating both online and offline resources to establish a care continuum and obtain the best patient results.
How Chiropractors are Involved in the future of Healthcare
Despite the fast moving health ecosystem companies are transforming, chiropractors have the opportunity to increase the scope of healthcare ecosystems across Asia.19 The winner-take-all dynamics of ecosystem-based markets significantly favor first movers or rapid followers; therefore, speed is crucial to extracting value in this emerging sector. As a result, possible chiropractic leaders should consider the following 2 questions:
Know your advantage and resources: Successful leaders usually begin by starting base. Consumer technology behemoths like Tencent’s WeChat and Alibaba’s Tmall use their current consumer platforms as a launching pad for health-related services. Chiropractic group like Chiropractic First Singapore, use their massive distribution networks and access to claims data from patients to create service offers. They aligned with local department stores in providing spinal screenings to the public.
Strategic capacities and collaborations: Chiropractic leaders need to be able to form agreements quickly if they want to develop their services beyond their original capabilities. For example, BOC Life collaborates with EC Healthcare to use EC’s extensive IT system to deliver Covid-Tests to customers’ homes across Hong Kong—a service that would be too expensive for the firm to build on its own.12 Tencent collaborates with EC Healthcare to create Tencent Doctorwork, or invests directly in healthtech startups. Chiropractors who work at the Tencent Doctorwork enjoy the patient flow from the Tencent system.
Conclusion
Though there is a growing consensus that technology will improve healthcare delivery in Asia, there are still considerable obstacles to its implementation and expansion in the new ecosystem. As with all disruptive transformations, those who design and benefit from the current medical system may resist or reject the changes despite the promise of better quality care for the patient. The new ecosystem will shift the power between healthcare practitioners and patients, leading to the patient-centric system with both government and insurance companies. Chiropractors, health incumbents, and new entrants can design what our future roles will be in the new ecosystems. Hong Kong chiropractic leaders stepped up by taking bold, strategic moves, thereby helping ecosystem orchestrators in building a digital health ecosystem that focused on patients’ needs.
Conflict of Interest
We declare that we have no conflict of interest relate to the subject matter or materials discussed in the article.