Why do patients bypass primary care? Trust, resource concentration, and risk in China's tiered healthcare system: A comparative policy perspective

China's tiered healthcare system seeks to direct patients to clinically appropriate levels of care, and yet many patients continue to seek care directly at higher-level hospitals. This Policy Forum proposes a conceptual explanation linking resource and capability concentration, perceived institutional trust differentials, risk-avoidant choice of providers, and the amplification of reputation through family and social networks. Illustrative comparisons with the United Kingdom, the United States, Japan, and South Korea reveal related but non-equivalent forms of alternative healthcare access under different arrangements. The framework does not treat bypassing a tier as inherently irrational or claim that the proposed pathways have been causally established. Instead, it suggests that credible primary care, reliable referral benefits, continuity of care, risk-sensitive rules on access, aligned financial incentives, and trustworthy quality information must be developed together. The proposed framework is intended to guide empirical testing and policy evaluation rather than to rank healthcare systems or estimate the prevalence with which care is bypassed.