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Goodwill | 9 Months Ended
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Sep. 30, 2021
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, 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 |
Acquisitions | 12,423 |  |  | 41,196 |  |  | 53,619 |
Divestitures | (623) |  |  | — |  |  | (623) |
Foreign currency and other adjustments | — |  |  | (31,438) |  |  | (31,438) |
Balance at September 30, 2021 | $ | 6,321,728 |  |  | $ | 618,939 |  |  | $ | 6,940,667 |
Balance at September 30, 2021: |  |  |  |  |
Goodwill | $ | 6,321,728 |  |  | $ | 747,933 |  |  | $ | 7,069,661 |
Accumulated impairment charges | — |  |  | (128,994) |  |  | (128,994) |
| $ | 6,321,728 |  |  | $ | 618,939 |  |  | $ | 6,940,667 |
The Company did not recognize any goodwill impairment charges during the nine months ended September 30, 2021 and 2020. As dialysis treatments are an essential, life-sustaining service for patients who depend on them, the Company's operations have continued 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 ultimate severity and duration of the pandemic, further spread or resurgence of the virus (including as a result of the emergence of new strains of the virus such as the Delta variant), 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 vaccines, treatments and therapies, the pandemic’s continuing impact on the U.S. and global economies, unemployment, labor market conditions, inflation and evolving monetary policies, the responses of the Company's competitors to the pandemic and related changes in the marketplace, and the timing, scope and effectiveness of federal, state and local 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.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, 2021. Except for the Company's Germany kidney care reporting unit as described further in Note 10 to the Company's consolidated financial statements included in the 2020 10-K, none of the Company's various other reporting units were considered at risk of significant goodwill impairment as of September 30, 2021.

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