The Qinghai-Tibet Plateau serves as an important ecological security shelter in China and across Asia. During the past two decades, the patterns of land development and conservation on the Qinghai-Tibet Plateau have undergone significant changes under the impacts of global climate change and human expansion. This paper analyzes the evolution of land development and conservation patterns and potential ecological implications on the Tibetan Plateau from 2000 to 2020 based on urbanization, agricultural and pastoral patterns with multi-source data, such as long-term time series land use data, ecological indices, environmental pollution, and population and economics. It was found that: (1) Coinciding with the agglomeration of population and economy, the urban development pattern on the Qinghai-Tibet Plateau has spatial-temporal differentiation. Urban development in the 2010s was more significant than that in the 2000s, with the intensity increased by 63.31%, and the development pattern varies spatially, which can be seen from the finding that central Tibet (the Yarlung Tsangpo, Lhasa river, and Nyangchu basins) and Huangshui River Basin in Qinghai Province were developed in a planar pattern, while other node cities and border towns in a dotted pattern. (2) The agricultural production pattern is relatively stable, the grain yields have increased by 34.68% in the past 20 years, but the total amount of arable land is shrinking, and the degree of fragmentation has increased. The pattern of pastoralism has changed greatly, showing a migration trend from west to east spatially, and there is a serious problem of pasture overload, with an increase of 18.4% in livestock products. Regardless of the pattern of urbanization or agricultural and livestock development, the intensity of human activities on the Qinghai-Tibet Plateau has shown an intensified trend in the past. (3) It shows that Lhasa City area and the middle and lower reaches of Huangshui show a trend of diffusion of atmospheric and water environmental pollution. The western part of the Ali region and the northern foothills of the Himalayas and other regions, under the combined impact of climate change and human activities, have undergone significant ecological degradation. Accordingly, this paper proposes policy recommendations for optimizing production and living space, advancing the establishment of national park clusters and nature reserve systems, and the integrated recovery of mountain, water, forest, lake, grass, sand, and ice with ecological value achievement.