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Goodwill
 3 Months Ended
Mar. 31, 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
7,027

 
1,628

 
8,655

Impairment charges
—

 
(41,037
)
 
(41,037
)
Foreign currency and other adjustments
—

 
(10,210
)
 
(10,210
)
Balance at March 31, 2019
$
6,282,031

 
$
517,337

 
$
6,799,368

 
 
 
 
 
 
Balance at March 31, 2019:
 
 
 
 
 
Goodwill
$
6,282,031

 
$
585,347

 
$
6,867,378

Accumulated impairment charges
—

 
(68,010
)
 
(68,010
)
 
$
6,282,031

 
$
517,337

 
$
6,799,368


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 performed goodwill impairment assessments of certain reporting units previously disclosed as at-risk of significant goodwill impairment. As a result of these assessments, the Company recognized a $41,037 goodwill impairment charge in its Germany kidney care business during the three months ended March 31, 2019. This charge resulted primarily from a change in relevant discount rates, a decline in current and expected patient census in the quarter and higher than expected current and future costs, primarily due to newly announced legislation that is expected to increase wages in that market.
This impairment charge includes an $8,865 increase to the goodwill impairment charge, and reduction to deferred tax expense, related to deferred tax assets that the impairment itself generates. The effect is a $41,037 goodwill impairment charge to operating income and an $8,865 credit to tax expense, for a net $32,172 impact on net income.
As of March 31, 2019, the Company's Germany kidney care business remains at-risk of further goodwill impairment. Further change 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 additional goodwill impairment charges in our Germany kidney care business.
Reporting unit
 
Goodwill balance as
of March 31, 2019
 
Carrying amount
coverage(1)
 
Sensitivities
Operating income(2)
 
Discount rate(3)
Germany Kidney Care
 
$
354,182

 
—%
 
(1.4)%
 
(9.3)%
 
 
(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 March 31, 2018.
Except as described above and in Note 11 to the Company's consolidated financial statements included in the 10-K, none of the Company's various other reporting units were considered at risk of significant goodwill impairment as of March 31, 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 March 31, 2019.