Despite a decade of promoting a hierarchical medical system in China, residents' willingness to seek initial care at primary healthcare settings remains low. An analysis of the factors influencing residents' first-contact preferences is therefore warranted.

To investigate the overall and relative utility of various measures within the hierarchical medical system on enhancing residents' willingness to choose primary healthcare institutions for their first visits.

A conjoint analysis experiment was conducted via an online questionnaire distributed on social media platforms between May and June 2024. Using convenience and snowball sampling, we recruited 300 adults aged 18 and above, yielding 293 valid responses (a 97.7% effective response rate). The experiment simulated patients' decision-making processes in various policy-mix scenarios. A multilevel linear regression model was employed to analyze the effects of differentiated insurance reimbursement rates, the development of medical consortia, family doctor contract services, and improvements of service capacity of primary healthcare institutions on residents' first-contact decisions. Willingness-to-pay (WTP) was estimated for different resource configurations. A conditional Logit regression model was used for robustness checks.

The likelihood of residents choosing a primary healthcare institution for their first visits was significantly higher with increased insurance reimbursement rates (P<0.010), a higher level of medical technology (P<0.001), closer proximity (P<0.050), and the regular presence of visiting specialists from Grade 3A hospitals (P<0.050). Regarding patient characteristics, healthier respondents were significantly more inclined to choose primary healthcare institution for their initial diagnosis (P<0.001). Compared to a low level of medical technology, a medium level at primary healthcare institutions was equivalent to a 42.50 percentage point increase in the insurance reimbursement rate (P=0.010) in terms of its effect on patient preference. The impacts of family doctor contract services and case information sharing mechanisms were not statistically significant (P>0.05).

Among all experimental attributes, enhancing the healthcare service level of primary healthcare institutions holds the highest economic value. These findings provide empirical support for optimizing the hierarchical medical system, underscoring the critical role of improving service quality at the primary level. The study reveals that relying solely on differentiated insurance payments is insufficient to guide patient flow effectively and highlights the potential value of increasing the visibility and efficacy of the family doctor system and information-sharing mechanisms.