DaVita and Fresenius Control 74% of U.S. Dialysis: A Facility-Level Comparison of Chain and Independent Outcomes

DaVita and Fresenius Medical Care together operate 73.7% of the 7,557 Medicare-certified dialysis facilities in the United States. Chain-owned centers average 2.92 CMS stars versus 2.27 for independents. Independent facilities are 3.7× more likely to receive a 1-star rating. Correlation only — not causation.

Key findings

The dialysis duopoly

End-stage renal disease (ESRD) treatment in the United States is dominated by two corporations to a degree that has no parallel in any other medical specialty. DaVita operates 2,800 facilities across 47 states — a 37.1% national share. Fresenius Medical Care operates 2,772 across all 52 CMS-reporting jurisdictions — a 36.7% share. Together, the two chains claim 73.7% of the 7,557 Medicare-certified dialysis centers counted in the CMS Care Compare Dialysis Facility Listing snapshot dated 2026-05-07.

The remaining 26.299999999999997% is divided among smaller chains, hospital-based programs, and independent operators. US Renal Care ranks third nationally with 404 facilities (5.3%), followed by Dialysis Clinic, Inc. (DCI, a non-profit chain) with 242 (3.2%) and American Renal Associates with 220 (2.9%). True independents — facilities with no chain affiliation in the CMS data — account for only 9.8% of the market: 742 centers.

This concentration is the result of four decades of acquisition. ESRD patients require treatment three times per week for the rest of their lives, creating highly predictable Medicare revenue streams that made dialysis facilities attractive acquisition targets starting in the 1980s. Consolidation accelerated through the 1990s and 2000s, leaving the current duopoly structure. The Senate HELP Committee has recently examined pricing and care practices in the dialysis industry; see help.senate.gov for current activity.

Chain rankings by facility count and CMS five-star average

All ratings are CMS-published composites. Fonteum does not rate, inspect, verify, endorse, or guarantee any facility. Five-star averages exclude unrated facilities.

Chain-owned vs. independent: CMS five-star distribution

Among the 6,550 rated chain-owned facilities, the CMS five-star distribution peaks at 3 stars — consistent with the national average for the dialysis sector. Among the 522 rated independent facilities, 1-star is the single largest category, accounting for 36.2% of rated independents compared to 9.7% among chains.

This 3.7× difference in 1-star prevalence is the sharpest contrast in the data. Chain-owned facilities also produce 5-star ratings at a higher rate (8.3% vs 3.6% for independents), though the absolute number of 5-star independents is small (19) relative to the 543 5-star chain facilities.

DaVita + Fresenius market concentration by state

The big-two duopoly has penetrated most U.S. states deeply but not uniformly. West Virginia leads at 95.1% combined DaVita-Fresenius share — and also carries the lowest state-level average star rating at 1.87 stars. New Hampshire (95%), Kansas (91.5%), and Idaho (89.3%) also exceed 89% combined concentration. By contrast, South Dakota (15.4%), North Dakota (12.5%), and Vermont (12.5%) have the lowest big-2 concentration among states with at least 10 facilities, driven by cooperative and hospital-based programs.

The tile below shows the combined DaVita + Fresenius share for each state. Hover or tap a cell for the full breakdown. States with fewer than 5 facilities are shown without a percentage.

Top performers and underperformers

Highest-rated independent facilities (5 CMS stars)

A sample of independent facilities with 5-star CMS ratings in the snapshot. CMS ratings are published by CMS and reflect facility-level clinical data submissions.

Smaller chains with higher CMS ratings

Two non-profit chains stand out for performance well above the sector average. Satellite Healthcare, a California-based non-profit, operates 38 facilities across 5 states with a 3.79-star average — the highest of any chain with more than 10 facilities. Kaiser Permanente's integrated-care dialysis network (22 facilities, 5 states) averages 3.77 stars. Both are substantially smaller than DaVita and Fresenius, which may allow tighter clinical management; however, the non-profit organizational model and integrated care relationships are also plausible contributors.

Underperforming single-state operators

Several smaller chains post notably low averages. Atlantis Healthcare Group (17 facilities, 1 state) averages 1.18 CMS stars — the lowest of any named chain in the dataset. Centers for Dialysis Care (18 facilities, 1 state) averages 1.61 stars. These entities operate at a fraction of the scale of DaVita or Fresenius and may face structurally different patient populations or operational constraints; causal interpretation requires clinical review beyond the scope of this dataset.

The independent sector: who remains

Of the 742 independent dialysis facilities, 220 are unrated or recently certified. Among the 522 that carry a CMS rating, performance spans the full range from 1 to 5 stars, but the distribution is heavily skewed toward lower ratings. A 1-star rating indicates that the facility scored below the CMS national threshold on the composite measure for four consecutive quarters.

New York hosts the largest independent dialysis sector in any single state with 112 independent facilities — 32.3% of the state's 347 total centers. This reflects New York's Certificate of Need laws and a historically fragmented hospital-based market that has resisted the level of chain consolidation seen in other large states. Florida (77 independents), Illinois (57), and California (85) also have significant independent populations, though their independence shares as a percentage of state total are considerably lower.

Independent facilities that carry 5-star ratings are typically hospital-based programs or integrated-care delivery systems (Mayo Clinic, Kaiser, Ochsner, Altru) rather than stand-alone community centers. This pattern suggests the independent facilities most likely to match or exceed chain-level quality ratings are embedded within larger health systems — not truly stand-alone operators competing on equal footing with national chains.

The average independent facility operates 14.3 dialysis stations, compared with 18.4 for chain-owned centers — a scale difference that may independently predict resource availability, staffing depth, and quality infrastructure.

How this analysis differs from USRDS and KFF reporting

The United States Renal Data System (USRDS) Annual Data Report publishes chain-level aggregates at the national level but does not provide facility-level chain attribution cross-tabulated against CMS five-star ratings in downloadable form. The Kaiser Family Foundation (KFF) has reported on dialysis industry concentration from a policy framing, focusing on prices and patient advocacy, but not on the CMS facility-level quality composite as the primary outcome variable.

This analysis is the first to apply Fonteum's 14-tuple field-level provenance standard to a facility-level CMS dialysis chain comparison — meaning every figure is anchored to a specific source row, a specific release date, a specific methodology version, and a specific snapshot attestation. The reproducible SQL below allows any journalist, policymaker, or researcher to regenerate every figure from the live database. USRDS aggregates are not used as a primary source; all figures derive directly from the CMS Care Compare Dialysis Facility Listing.

Methodology

Source: CMS Care Compare Dialysis Facility Listing, CMS Provider Data Catalog dataset 23ew-n7w9, bulk CSV (DFC_FACILITY.csv), snapshot fetched 2026-05-07. The dataset is a public-domain work of the U.S. government and is freely redistributable under the U.S. Government Works license.

Chain identification: CMS encodes chain affiliation directly in the dataset as two fields — chain_owned (boolean Yes/No) and chain_organization (text name). Facilities with chain_organization = 'Independent' and chain_owned = 'No' are classified as independent. All other chain names are taken verbatim from the CMS data without normalization or merging of related entities.

Star averages: Computed as the arithmetic mean of five_star across rated facilities only (facilities where five_star IS NOT NULL). Unrated facilities are excluded from averages. The five_star_data_availability_code field captures the reason a facility is unrated (e.g., too-recent certification, CMS data suppression). CMS publishes the composite measure using a rolling four-quarter window; methodology is available at the CMS Quality Measurement and Value-Based Incentives Group.

Methodology version: dialysis-chains-vs-independents/v1. Pinned at time of publish; changes to aggregation logic would require a new version tag and a refreshed snapshot.

Reproducible SQL

-- Chain vs. independent 5-star comparison
-- Source: cms_care_compare_dialysis (CMS dataset 23ew-n7w9, snapshot 2026-05-07)

SELECT
  CASE WHEN chain_owned THEN 'Chain-owned' ELSE 'Independent' END AS ownership_type,
  count(*)                                                          AS total_facilities,
  count(*) FILTER (WHERE five_star IS NOT NULL)                     AS rated_facilities,
  round(avg(five_star) FILTER (WHERE five_star IS NOT NULL), 2)     AS avg_five_star,
  count(*) FILTER (WHERE five_star = 1)                             AS one_star_count,
  count(*) FILTER (WHERE five_star = 5)                             AS five_star_count,
  round(
    100.0 * count(*) FILTER (WHERE five_star = 1) /
    nullif(count(*) FILTER (WHERE five_star IS NOT NULL), 0), 1
  )                                                                 AS one_star_pct_of_rated
FROM public.cms_care_compare_dialysis
GROUP BY ownership_type
ORDER BY ownership_type;

-- Chain-level breakdown (top 10 by facility count)
SELECT
  chain_organization,
  count(*)                                                          AS facility_count,
  round(100.0 * count(*) / 7557.0, 1)       AS national_share_pct,
  round(avg(five_star) FILTER (WHERE five_star IS NOT NULL), 2)     AS avg_five_star,
  count(DISTINCT state)                                             AS states_present
FROM public.cms_care_compare_dialysis
WHERE chain_owned IS TRUE
GROUP BY chain_organization
ORDER BY facility_count DESC
LIMIT 10;

-- State-level DaVita + Fresenius concentration
SELECT
  state,
  count(*)                                                                                   AS total,
  count(*) FILTER (WHERE chain_organization = 'DaVita')                                      AS davita,
  count(*) FILTER (WHERE chain_organization = 'Fresenius Medical Care')                      AS fresenius,
  round(
    100.0 * (
      count(*) FILTER (WHERE chain_organization IN ('DaVita','Fresenius Medical Care'))
    ) / count(*), 1
  )                                                                                          AS big2_pct,
  round(avg(five_star) FILTER (WHERE five_star IS NOT NULL), 2)                              AS avg_star
FROM public.cms_care_compare_dialysis
GROUP BY state
ORDER BY big2_pct DESC NULLS LAST;

Legislative context: Senate HELP Committee inquiry

The Senate Health, Education, Labor and Pensions (HELP) Committee has been active in examining the dialysis industry's pricing, consolidation, and patient care practices. The committee's oversight activity — available at help.senate.gov — focuses on the structural conditions that allow two corporations to control the majority of life-sustaining treatment for roughly 550,000 American patients dependent on dialysis.

The timing of this analysis — released during active congressional scrutiny — is intentional. Facility-level quality data, cross-tabulated against chain ownership, provides the kind of primary-source grounding that policy discussions about healthcare consolidation require. This study is not advocacy; it is a transparent presentation of publicly available CMS data using reproducible methodology. Fonteum does not take a position on what policy interventions, if any, are appropriate.

Limitations

• L1.The CMS five-star composite rating is a case-mix-adjusted aggregate measure, not a raw clinical outcome. CMS applies standardization for patient demographics and comorbidities, but the adjustment cannot fully account for all selection effects — facilities in harder markets or serving sicker populations may score lower for structural reasons unrelated to care quality.
• L2.Chain affiliation is taken verbatim from the CMS dataset. DaVita, Fresenius, and other chains operate through subsidiaries and joint-venture structures that may not be fully captured by the CMS chain_organization field. Some nominally 'independent' facilities may have affiliation agreements or management contracts with larger chains not reflected in this data.
• L3.This analysis does not include outcome measures beyond the CMS five-star composite. Mortality rates, hospitalization rates, and treatment adequacy (Kt/V) are components of the five-star score but are not individually analyzed here. Per-measure breakdowns would require parsing individual measure sub-scores not present in this dataset.
• L4.The snapshot date (2026-05-07) reflects a point-in-time view. Chain affiliations change through acquisitions; a facility that was independent in 2024 may be chain-owned by 2026, or vice versa. The analysis describes the state of the market as of the snapshot date.
• L5.Facilities with fewer than four rated quarters are excluded from the CMS star rating (shown as unrated). This exclusion disproportionately affects recently certified facilities, which may systematically differ from the rated population.
• L6.No causal inference should be drawn from this data alone. Observational facility-level data cannot establish whether chain ownership causes, prevents, or is unrelated to quality outcomes. Randomized or quasi-experimental designs are required to establish causal relationships.

Frequently asked questions