Health plans offered on state and federal marketplaces known as exchanges mean higher deductibles and higher out-of-pocket costs for consumers and potentially less business for hospitals under the Affordable Care Act.

A parade of reports out this week looks at the repercussions for consumers who choose high deductible plans to get a lower priced premium and health facilities, which are being pushed further away from fee-for-service medicine to an era when they are paid based on the value of medical care that they provide.

“The increasing shift to high deductible health plans meaningfully impacted patient volumes in 2013,” said Jim LeBuhn, senior director and sector head at Fitch Ratings, which said in a report this week that such plans and “rising consumerism” would negatively impact hospital financial ratings. “We expect the growing popularity of these plans to further challenge utilization rates going forward.”

When deductibles and co-payments are high, patients tend to think twice about their health care purchases, making them more likely to shop around for the best deal. Fitch sees this impacting hospital patient volumes with choosier patients more likely to demand “price and quality information,” the New York based financial ratings firm said in its report.

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