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Goodwill | 9 Months Ended
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Sep. 30, 2019
Goodwill and Intangible Assets Disclosure [Abstract] |
Goodwill | Goodwill Changes in goodwill by reportable segment were as follows:
| U.S. dialysis and related lab services |  | Other-ancillary services and strategic initiatives |  | Consolidated total
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 |
Acquisitions | 18,089 |  |  | 59,149 |  |  | 77,238 |
Impairment charges | — |  |  | (124,892 | ) |  | (124,892 | )
Foreign currency and other adjustments | — |  |  | (28,647 | ) |  | (28,647 | )
Balance at September 30, 2019 | $ | 6,293,093 |  |  | $ | 472,566 |  |  | $ | 6,765,659 |
Balance at September 30, 2019 |  |  |  |  |
Goodwill | $ | 6,293,093 |  |  | $ | 622,307 |  |  | $ | 6,915,400 |
Accumulated impairment charges | — |  |  | (149,741 | ) |  | (149,741 | )
| $ | 6,293,093 |  |  | $ | 472,566 |  |  | $ | 6,765,659 |
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 were performed under this new guidance. During the three months ended March 31, 2019, the Company recognized a $41,037 goodwill impairment charge in its Germany kidney care business. This charge resulted primarily from a change in relevant discount rates, as well as a decline in current and expected future patient census and an increase in first quarter and expected future costs, principally due to wage increases expected to result from recently announced legislation. During the three months ended September 30, 2019, the Company completed additional goodwill impairment assessments of reporting units previously disclosed as at-risk of significant goodwill impairment, including its Germany kidney care business. As a result of these assessments, the Company recognized a further goodwill impairment charge of $78,439 in its Germany kidney care business and a $5,416 goodwill impairment charge in its German other health operations. The incremental charge recognized in the Germany kidney care business resulted from changes and developments in the Company's outlook for this business since its last assessment. These primarily concern developments in the business in response to evolving market conditions and changes in the Company's expected timing and ability to mitigate them, which was based on results of in-depth operating and strategic reviews completed by the Company’s new Germany management team during the third quarter. The impairment charges recognized in the third quarter of 2019 at the Company’s Germany kidney care business and its German other health operations include increases of $16,756 and $1,013, respectively, to the goodwill impairment charges, and reductions to deferred tax expense, related to deferred tax assets that the impairments themselves generated. The result is an $83,855 goodwill impairment charge to operating income and a $17,769 credit to tax expense, for a net $66,086 impact on net income. As of September 30, 2019, the Company's Germany kidney care business and its German other health operations remain at risk of further goodwill impairment. During the nine months ended September 30, 2019, the Company recognized total goodwill impairment charges of $124,892 consisting of the charges described above. Further changes in expected patient census, increases in operating costs, 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:
Reporting unit |  | Goodwill balance as of September 30, 2019 |  | Carrying amount coverage(1) |  | Sensitivities
Operating income(2) |  | Discount rate(3)
Germany Kidney Care |  | $ | 287,256 |  |  | —% |  | (1.3)% |  | (11.0)%
Brazil Kidney Care |  | $ | 72,461 |  |  | 4.4% |  | (2.8)% |  | (7.0)%
(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.
The Company did not recognize any goodwill impairment charges during the three months ended September 30, 2018 and recognized a goodwill impairment charge of $3,106 at its German other health operations during the nine months ended September 30, 2018. Except as described above, in Note 11 to the Company's consolidated financial statements included in the 10-K and in Note 7 to the Company’s condensed consolidated financial statements included in subsequent 10-Q filings, none of the Company's various other reporting units were considered at risk of significant goodwill impairment as of September 30, 2019. Since the dates of the Company's last annual goodwill impairment assessments there have been certain developments, events, changes in operating performance and other changes in key circumstances that have affected the Company's businesses. However, these changes 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 September 30, 2019.

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