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.

我国推行分级诊疗制度已十余年，但居民基层首诊意愿仍有待提高，有必要针对居民的首诊偏好影响因素进行系统分析。

探究分级诊疗各项举措对于提升居民基层首诊意愿的综合效用和相对效用。

于2024年5—6月，采用方便抽样和滚雪球抽样，利用社交平台对≥18岁成年人开展在线问卷调查。共发放问卷300份，回收有效问卷293份，有效回收率为97.7%。通过联合实验，模拟患者在组合政策情境下的决策过程。采用多层次线性回归模型，分析差异化医保报销比例、医疗联合体建设、家庭医生签约服务、基层医疗卫生机构服务提升对居民基层首诊意愿的影响，并估算不同资源条件对应的"意愿支付价格"。使用条件Logit回归模型，对结果进行稳健性分析。

基层医疗卫生机构的医保报销比例越高（P<0.010）、医疗技术水平越高（P<0.001）、距离受访者越近（P<0.050）、有三级甲等医院专家定期出诊（P<0.050），居民选择基层医疗卫生机构首诊的可能性明显提升。在受访者基本特征方面，自评健康状况越好的受访者越倾向于认为患者应该去基层医疗卫生机构首诊（P<0.001）。相对于低水平医疗技术，中等水平的基层医疗卫生机构医疗技术对于基层首诊意愿的刺激效果相当于医保报销比例增加42.50个百分点（P=0.010）。家庭医生签约服务和病历信息共享机制对首诊意愿的影响无统计学意义（P>0.05）。

在各项实验条件中，基层医疗卫生机构医疗技术水平提升具有最高的经济价值。研究结果为分级诊疗制度的优化提供了实证支持，强调改善基层医疗卫生机构服务质量的关键作用，揭示单纯依赖医保差异化支付难以实现引导患者合理就医的目标，同时指出进一步分析和增强家庭医生制度建设和信息共享机制可见性的潜在价值。