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Goodwill | 12 Months Ended
--- | ---
Dec. 31, 2018
Goodwill and Intangible Assets Disclosure [Abstract] |
Goodwill | Goodwill Changes in the carrying value of goodwill by reportable segments were as follows:
| U.S. dialysis and related lab services |  | Other ancillary services and strategic initiatives |  | Consolidated total
Balance at December 31, 2016 | $ | 5,691,587 |  |  | $ | 323,788 |  |  | $ | 6,015,375 |
Acquisitions | 485,434 |  |  | 131,598 |  |  | 617,032 |
Divestitures | (32,260 | ) |  | (126 | ) |  | (32,386 | )
Impairment charges | — |  |  | (36,196 | ) |  | (36,196 | )
Foreign currency and other adjustments | — |  |  | 46,454 |  |  | 46,454 |
Balance at December 31, 2017 | $ | 6,144,761 |  |  | $ | 465,518 |  |  | $ | 6,610,279 |
Acquisitions | 130,574 |  |  | 147,774 |  |  | 278,348 |
Divestitures | (331 | ) |  | (15,166 | ) |  | (15,497 | )
Impairment charges | — |  |  | (3,106 | ) |  | (3,106 | )
Foreign currency and other adjustments | — |  |  | (28,064 | ) |  | (28,064 | )
Balance at December 31, 2018 | $ | 6,275,004 |  |  | $ | 566,956 |  |  | $ | 6,841,960 |
Goodwill | $ | 6,275,004 |  |  | $ | 594,229 |  |  | $ | 6,869,233 |
Accumulated impairment charges | — |  |  | (27,273 | ) |  | (27,273 | )
| $ | 6,275,004 |  |  | $ | 566,956 |  |  | $ | 6,841,960 |
The Company elected to early adopt ASU No. 2017-04, Intangibles-Goodwill and Other (Topic 350): Simplifying the Test for Goodwill Impairment effective January 1, 2017. The amendments in this ASU simplify the test for goodwill impairment by eliminating the second step in the assessment. All goodwill impairment tests performed since adoption of this ASU were performed under this new guidance. Each of the Company’s operating segments described in Note 25 to these consolidated financial statements represents an individual reporting unit for goodwill impairment testing purposes and each sovereign jurisdiction within the Company’s international operating segments is considered a separate reporting unit. Within the U.S. dialysis and related lab services operating segment, the Company considers each of its dialysis centers to constitute an individual business for which discrete financial information is available. However, since these dialysis centers have similar operating and economic characteristics, and the allocation of resources and significant investment decisions concerning these businesses are highly centralized and the benefits broadly distributed, the Company has aggregated these centers and deemed them to constitute a single reporting unit. The Company has applied a similar aggregation to the vascular access service centers in its vascular access services reporting unit, to the physician practices in its physician services reporting units, and to the dialysis centers and other health operations within each international reporting unit. For the Company’s other operating segments, discrete business components below the operating segment level constitute individual reporting units. During the year ended December 31, 2018, the Company performed annual and other impairment assessments for various reporting units. As a result of these assessments, the Company recognized a goodwill impairment charge of $3,106 at its German other health operations during the year ended December 31, 2018. During the years ended December 31, 2017 and December 31, 2016 the Company recognized goodwill impairment charges of $34,696 and $28,415, respectively, at its vascular access reporting unit. These charges resulted primarily from changes in future governmental reimbursement rates for this business and the Company’s then-evolving plans and expected ability to mitigate them. As of December 31, 2017, there was no goodwill remaining at the Company's vascular access reporting unit. The Company also recognized a goodwill impairment charge of $1,500 at one of its international reporting units during the year ended December 31, 2017. Based on the most recent assessments, the Company determined that reductions in reimbursement rates, changes in actual or expected growth rates, or other significant adverse changes in expected future cash flows or valuation assumptions could result in goodwill impairment charges in the future for the following reporting units, which remain at risk of goodwill impairment as of December 31, 2018:
Reporting unit |  | Goodwill balance as of December 31, 2018 |  | Carrying amount coverage(1) |  | Sensitivities
Operating income(2) |  | Discount rate(3)
Germany Kidney Care |  | $ | 403,200 |  |  | 0.5 | % |  | (1.5 | )% |  | (10.3 | )%
Brazil Kidney Care |  | $ | 39,452 |  |  | 9.8 | % |  | (2.5 | )% |  | (7.3 | )%
Germany other health operations |  | $ | 12,646 |  |  | 8.1 | % |  | (2.2 | )% |  | (11.1 | )%
(1) | Excess of estimated fair value of the reporting unit over its carrying amount as of the latest assessment date.
(2) | Potential impact on estimated fair value of a sustained, long-term reduction of 3% in operating income as of the latest assessment date.
(3) | Potential impact on estimated fair value of an increase in discount rates of 100 basis points as of the latest assessment date.
There were no major changes in the business, prospects, or expected future results of these reporting units from their latest assessment date through December 31, 2018. Except as described above, none of the Company’s other reporting units were considered at risk of significant goodwill impairment as of December 31, 2018. Since the dates of the Company’s last annual goodwill impairment tests, there have been certain developments, events, changes in operating performance and other changes in key circumstances that have affected the Company’s businesses. However, except as further described above, these did not cause management to believe it is more likely than not that the fair values of any of the Company’s reporting units would be less than their respective carrying amounts as of December 31, 2018.

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