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Goodwill | 12 Months Ended
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Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract] |
Goodwill | Goodwill Changes in the carrying value of goodwill by reportable segment 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 |  |  | 105,680 |  |  | 130,057 |
Divestitures | (1,549) |  |  | (6,744) |  |  | (8,293) |
Foreign currency and other adjustments | — |  |  | 9,710 |  |  | 9,710 |
Balance at December 31, 2020 | $ | 6,309,928 |  |  | $ | 609,181 |  |  | $ | 6,919,109 |
Balance at December 31, 2020: |  |  |  |  |
Goodwill | $ | 6,309,928 |  |  | $ | 745,732 |  |  | $ | 7,055,660 |
Accumulated impairment charges | — |  |  | (136,551) |  |  | (136,551) |
| $ | 6,309,928 |  |  | $ | 609,181 |  |  | $ | 6,919,109 |
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, including as a result of the emergence of the new strains of the virus, its impact on the chronic kidney disease (CKD) patient population and the Company's patient population, the availability, acceptance, impact and efficacy of COVID-19 treatments, therapies and 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 marketplaces, 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. Each of the Company’s operating segments described in Note 25 to these consolidated financial statements represents an individual reporting unit for goodwill impairment assessment purposes. Within the U.S. dialysis 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 physician practices in its physician services reporting units, to the dialysis centers and other health operations within each international reporting unit, and to the vascular access service centers in its former vascular access services reporting unit. For the Company’s other operating segments, discrete business components below the operating segment level constitute individual reporting units. When performing quantitative goodwill impairment assessments, the Company estimates fair value using either appraisals developed with an independent third party valuation firm which consider both discounted cash flow estimates for the subject business and observed market multiples for similar businesses, or offer prices received for the subject business that would be acceptable to the Company. During the year ended December 31, 2019, the Company recognized goodwill impairment charges of $119,476 in its Germany kidney care business. These charges resulted primarily from a decline in then current and expected future patient census and an increase in then current and expected future costs, including due to wage increases expected to result from legislation announced at that time. The changes in the Company's expectations were informed by developments in the business in response to evolving market conditions, including changes in the Company's expected timing and ability to mitigate them, and based on in-depth operating and strategic reviews completed by the Company's new Germany management team. During the year ended December 31, 2019 the Company also recognized a goodwill impairment charge of $5,416 in its German other health operations. Based on its most recent assessments, the Company determined that 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 unit, which remains at risk of goodwill impairment as of December 31, 2020:
Reporting unit |  | Goodwill balance |  | Carrying amount coverage(1) |  | Sensitivities
Operating income(2) |  | Discount rate(3)
Germany kidney care |  | $ | 322,736 |  |  | 2.3 | % |  | (1.5) | % |  | (10.1) | %
(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. Except as described above, none of the Company’s other reporting units were considered at risk of significant goodwill impairment as of December 31, 2020. 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 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 December 31, 2020.

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