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Goodwill | 9 Months Ended
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Sep. 30, 2020
Goodwill and Intangible Assets Disclosure [Abstract] |
Goodwill | Goodwill Changes in goodwill by reportable segments were as follows:
| U.S. dialysis |  | Other - Ancillary services |  | Consolidated
Balance at December 31, 2018 | $ | 6,275,004 |  |  | $ | 566,956 |  |  | $ | 6,841,960 |
Acquisitions | 18,089 |  |  | 72,137 |  |  | 90,226 |
Impairment charges | — |  |  | (124,892 | ) |  | (124,892 | )
Foreign currency and other adjustments | (5,993 | ) |  | (13,666 | ) |  | (19,659 | )
Balance at December 31, 2019 | $ | 6,287,100 |  |  | $ | 500,535 |  |  | $ | 6,787,635 |
Acquisitions | 24,377 |  |  | 85,871 |  |  | 110,248 |
Divestitures | (1,549 | ) |  | (6,744 | ) |  | (8,293 | )
Foreign currency and other adjustments | — |  |  | (21,213 | ) |  | (21,213 | )
Balance at September 30, 2020 | $ | 6,309,928 |  |  | $ | 558,449 |  |  | $ | 6,868,377 |
Balance at September 30, 2020 |  |  |  |  |
Goodwill | $ | 6,309,928 |  |  | $ | 688,881 |  |  | $ | 6,998,809 |
Accumulated impairment charges | — |  |  | (130,432 | ) |  | (130,432 | )
| $ | 6,309,928 |  |  | $ | 558,449 |  |  | $ | 6,868,377 |
The Company did not recognize any goodwill impairment charges during the nine months ended September 30, 2020. As dialysis treatments are an essential, life-sustaining service for patients who depend on them, the Company's operations have continued and are currently expected to continue throughout the novel coronavirus (COVID-19) pandemic. However, the ultimate impact of the dynamic and evolving COVID-19 pandemic on the Company will depend on future developments that are highly uncertain and difficult to predict, including among other things the severity and duration of the pandemic, further spread or resurgence of the virus, its impact on the chronic kidney disease (CKD) patient population and the Company's patient population, the availability, impact or efficacy of COVID-19 treatments, therapies or vaccines, the pandemic’s continuing impact on the U.S. and global economies and unemployment, the responses of the Company's competitors to the pandemic and related changes in the marketplace, and the timing, scope and effectiveness of governmental responses. While the Company does not currently expect a material adverse impact to its business as a result of this public health crisis, there can be no assurance that the COVID-19 pandemic will not have a material adverse impact on one or more of the Company's businesses. During the nine months ended September 30, 2019, the Company recognized goodwill impairment charges of $119,476 in its Germany kidney care business. Of this amount, $41,037 was recognized in the first quarter of 2019 and resulted primarily from a change in relevant discount rates, a decline in then current and expected future patient census and an increase in then current and expected future costs, principally due to wage increases expected to result from legislation announced at that time. An incremental charge of $78,439 was recognized during the third quarter of 2019 and resulted from changes and developments in the Company's outlook for this business since its last assessment at that time. These primarily concerned 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 of 2019. During the nine months ended September 30, 2019, the Company also recognized a goodwill impairment charge of $5,416 in its German other health operations. Developments, events, changes in operating performance and other changes in circumstances since the dates of the Company’s last annual goodwill impairment assessments have not caused 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, 2020. Except for the Company's Germany kidney care reporting unit as described further in Note 10 to the 10-K, none of the Company's various other reporting units were considered at risk of significant goodwill impairment as of September 30, 2020.

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