{
  "study": {
    "slug": "dialysis-chains-vs-independents",
    "title": "DaVita vs Fresenius: The Two Chains Running 74% of US Dialysis",
    "url": "https://fonteum.com/research/dialysis-chains-vs-independents",
    "methodology_version": "dialysis-chains-vs-independents/v1"
  },
  "data_as_of": "2026-05-07",
  "temporal_coverage": "2024-01-01/2026-05-07",
  "sources": [
    {
      "name": "CMS Care Compare Dialysis Facility Listing",
      "publisher": "U.S. Centers for Medicare & Medicaid Services",
      "url": "https://data.cms.gov/provider-data/dataset/23ew-n7w9",
      "release_date": "2026-05-07",
      "retrieved_at": "2026-05-07",
      "license": "U.S. Government Works (17 U.S.C. §105)"
    }
  ],
  "headline": {
    "published": "2026-06-04",
    "total_facilities": 7557,
    "rated_facilities": 7072,
    "chain_owned_facilities": 6815,
    "chain_owned_pct": 90.2,
    "independent_facilities": 742,
    "independent_pct": 9.8,
    "davita_facilities": 2800,
    "davita_pct": 37.1,
    "fresenius_facilities": 2772,
    "fresenius_pct": 36.7,
    "big2_facilities": 5572,
    "big2_pct": 73.7,
    "chain_avg_star": 2.92,
    "independent_avg_star": 2.27,
    "star_delta": 0.65,
    "chain_avg_stations": 18.1,
    "independent_avg_stations": 13.6,
    "chain_rated_facilities": 6550,
    "chain_1star_pct_of_rated": 9.7,
    "chain_5star_pct_of_rated": 8.3,
    "independent_rated_facilities": 522,
    "independent_1star_pct_of_rated": 36.2,
    "independent_5star_pct_of_rated": 3.6
  },
  "sections": [
    {
      "id": "chain_star_distribution",
      "label": "Star-rating distribution — chain-owned facilities (rated only)",
      "columns": [
        "star",
        "facilities",
        "pct_of_rated_chain"
      ],
      "rows": [
        {
          "star": "1",
          "facilities": 634,
          "pct_of_rated_chain": 9.7
        },
        {
          "star": "2",
          "facilities": 1493,
          "pct_of_rated_chain": 22.8
        },
        {
          "star": "3",
          "facilities": 2722,
          "pct_of_rated_chain": 41.6
        },
        {
          "star": "4",
          "facilities": 1158,
          "pct_of_rated_chain": 17.7
        },
        {
          "star": "5",
          "facilities": 543,
          "pct_of_rated_chain": 8.3
        }
      ]
    },
    {
      "id": "independent_star_distribution",
      "label": "Star-rating distribution — independent facilities (rated only)",
      "columns": [
        "star",
        "facilities",
        "pct_of_rated_independent"
      ],
      "rows": [
        {
          "star": "1",
          "facilities": 189,
          "pct_of_rated_independent": 36.2
        },
        {
          "star": "2",
          "facilities": 102,
          "pct_of_rated_independent": 19.5
        },
        {
          "star": "3",
          "facilities": 150,
          "pct_of_rated_independent": 28.7
        },
        {
          "star": "4",
          "facilities": 62,
          "pct_of_rated_independent": 11.9
        },
        {
          "star": "5",
          "facilities": 19,
          "pct_of_rated_independent": 3.6
        }
      ]
    },
    {
      "id": "chains",
      "label": "Chains by facility count",
      "columns": [
        "chain",
        "facilities",
        "pct_of_national_total",
        "avg_star",
        "states",
        "ownership"
      ],
      "rows": [
        {
          "chain": "DaVita",
          "facilities": 2800,
          "pct_of_national_total": 37.1,
          "avg_star": 2.99,
          "states": 47,
          "ownership": "For-profit"
        },
        {
          "chain": "Fresenius Medical Care",
          "facilities": 2772,
          "pct_of_national_total": 36.7,
          "avg_star": 2.89,
          "states": 52,
          "ownership": "For-profit"
        },
        {
          "chain": "US Renal Care, Inc.",
          "facilities": 404,
          "pct_of_national_total": 5.3,
          "avg_star": 2.97,
          "states": 32,
          "ownership": "For-profit"
        },
        {
          "chain": "Dialysis Clinic, Inc.",
          "facilities": 242,
          "pct_of_national_total": 3.2,
          "avg_star": 2.66,
          "states": 30,
          "ownership": "Non-profit"
        },
        {
          "chain": "American Renal Associates",
          "facilities": 220,
          "pct_of_national_total": 2.9,
          "avg_star": 2.97,
          "states": 27,
          "ownership": "For-profit"
        },
        {
          "chain": "Satellite Healthcare",
          "facilities": 38,
          "pct_of_national_total": 0.5,
          "avg_star": 3.79,
          "states": 5,
          "ownership": "Non-profit"
        },
        {
          "chain": "Northwest Kidney Centers",
          "facilities": 19,
          "pct_of_national_total": 0.3,
          "avg_star": 3.26,
          "states": 1,
          "ownership": "Non-profit"
        },
        {
          "chain": "Kaiser Permanente",
          "facilities": 22,
          "pct_of_national_total": 0.3,
          "avg_star": 3.77,
          "states": 5,
          "ownership": "Non-profit"
        },
        {
          "chain": "Wake Forest University",
          "facilities": 19,
          "pct_of_national_total": 0.3,
          "avg_star": 2.68,
          "states": 1,
          "ownership": "Non-profit"
        },
        {
          "chain": "Greenfield Health Systems",
          "facilities": 15,
          "pct_of_national_total": 0.2,
          "avg_star": 2.21,
          "states": 1,
          "ownership": "For-profit"
        }
      ]
    },
    {
      "id": "by_state",
      "label": "State market concentration",
      "columns": [
        "state",
        "total_facilities",
        "davita",
        "fresenius",
        "chain_owned",
        "independent",
        "big2_pct",
        "chain_pct",
        "avg_star"
      ],
      "rows": [
        {
          "state": "AL",
          "total_facilities": 178,
          "davita": 59,
          "fresenius": 98,
          "chain_owned": 176,
          "independent": 2,
          "big2_pct": 88.2,
          "chain_pct": 98.9,
          "avg_star": 2.73
        },
        {
          "state": "AK",
          "total_facilities": 7,
          "davita": 0,
          "fresenius": 4,
          "chain_owned": 7,
          "independent": 0,
          "big2_pct": 57.1,
          "chain_pct": 100,
          "avg_star": 4.14
        },
        {
          "state": "AZ",
          "total_facilities": 123,
          "davita": 46,
          "fresenius": 59,
          "chain_owned": 117,
          "independent": 6,
          "big2_pct": 85.4,
          "chain_pct": 95.1,
          "avg_star": 2.83
        },
        {
          "state": "AR",
          "total_facilities": 67,
          "davita": 34,
          "fresenius": 12,
          "chain_owned": 51,
          "independent": 16,
          "big2_pct": 68.7,
          "chain_pct": 76.1,
          "avg_star": 2.09
        },
        {
          "state": "CA",
          "total_facilities": 737,
          "davita": 354,
          "fresenius": 147,
          "chain_owned": 652,
          "independent": 85,
          "big2_pct": 68,
          "chain_pct": 88.5,
          "avg_star": 3.34
        },
        {
          "state": "CO",
          "total_facilities": 83,
          "davita": 37,
          "fresenius": 27,
          "chain_owned": 80,
          "independent": 3,
          "big2_pct": 77.1,
          "chain_pct": 96.4,
          "avg_star": 3.58
        },
        {
          "state": "CT",
          "total_facilities": 49,
          "davita": 28,
          "fresenius": 11,
          "chain_owned": 47,
          "independent": 2,
          "big2_pct": 79.6,
          "chain_pct": 95.9,
          "avg_star": 3.57
        },
        {
          "state": "DE",
          "total_facilities": 34,
          "davita": 1,
          "fresenius": 23,
          "chain_owned": 32,
          "independent": 2,
          "big2_pct": 70.6,
          "chain_pct": 94.1,
          "avg_star": 2.69
        },
        {
          "state": "FL",
          "total_facilities": 536,
          "davita": 209,
          "fresenius": 174,
          "chain_owned": 459,
          "independent": 77,
          "big2_pct": 71.5,
          "chain_pct": 85.6,
          "avg_star": 2.33
        },
        {
          "state": "GA",
          "total_facilities": 361,
          "davita": 139,
          "fresenius": 111,
          "chain_owned": 337,
          "independent": 24,
          "big2_pct": 69.3,
          "chain_pct": 93.4,
          "avg_star": 2.47
        },
        {
          "state": "HI",
          "total_facilities": 41,
          "davita": 0,
          "fresenius": 21,
          "chain_owned": 39,
          "independent": 2,
          "big2_pct": 51.2,
          "chain_pct": 95.1,
          "avg_star": 3.48
        },
        {
          "state": "ID",
          "total_facilities": 28,
          "davita": 9,
          "fresenius": 16,
          "chain_owned": 27,
          "independent": 1,
          "big2_pct": 89.3,
          "chain_pct": 96.4,
          "avg_star": 3.08
        },
        {
          "state": "IL",
          "total_facilities": 340,
          "davita": 127,
          "fresenius": 143,
          "chain_owned": 283,
          "independent": 57,
          "big2_pct": 79.4,
          "chain_pct": 83.2,
          "avg_star": 2.81
        },
        {
          "state": "IN",
          "total_facilities": 158,
          "davita": 61,
          "fresenius": 67,
          "chain_owned": 152,
          "independent": 6,
          "big2_pct": 81,
          "chain_pct": 96.2,
          "avg_star": 2.76
        },
        {
          "state": "IA",
          "total_facilities": 61,
          "davita": 28,
          "fresenius": 13,
          "chain_owned": 43,
          "independent": 18,
          "big2_pct": 67.2,
          "chain_pct": 70.5,
          "avg_star": 3.17
        },
        {
          "state": "KS",
          "total_facilities": 59,
          "davita": 34,
          "fresenius": 20,
          "chain_owned": 54,
          "independent": 5,
          "big2_pct": 91.5,
          "chain_pct": 91.5,
          "avg_star": 3.33
        },
        {
          "state": "KY",
          "total_facilities": 122,
          "davita": 39,
          "fresenius": 60,
          "chain_owned": 116,
          "independent": 6,
          "big2_pct": 81.1,
          "chain_pct": 95.1,
          "avg_star": 2.66
        },
        {
          "state": "LA",
          "total_facilities": 171,
          "davita": 28,
          "fresenius": 112,
          "chain_owned": 155,
          "independent": 16,
          "big2_pct": 81.9,
          "chain_pct": 90.6,
          "avg_star": 2.86
        },
        {
          "state": "ME",
          "total_facilities": 21,
          "davita": 4,
          "fresenius": 13,
          "chain_owned": 20,
          "independent": 1,
          "big2_pct": 81,
          "chain_pct": 95.2,
          "avg_star": 3.55
        },
        {
          "state": "MD",
          "total_facilities": 169,
          "davita": 84,
          "fresenius": 48,
          "chain_owned": 153,
          "independent": 16,
          "big2_pct": 78.1,
          "chain_pct": 90.5,
          "avg_star": 3.09
        },
        {
          "state": "MA",
          "total_facilities": 85,
          "davita": 13,
          "fresenius": 38,
          "chain_owned": 73,
          "independent": 12,
          "big2_pct": 60,
          "chain_pct": 85.9,
          "avg_star": 3.71
        },
        {
          "state": "MI",
          "total_facilities": 222,
          "davita": 95,
          "fresenius": 86,
          "chain_owned": 205,
          "independent": 17,
          "big2_pct": 81.5,
          "chain_pct": 92.3,
          "avg_star": 2.71
        },
        {
          "state": "MN",
          "total_facilities": 114,
          "davita": 45,
          "fresenius": 48,
          "chain_owned": 107,
          "independent": 7,
          "big2_pct": 81.6,
          "chain_pct": 93.9,
          "avg_star": 3.16
        },
        {
          "state": "MS",
          "total_facilities": 99,
          "davita": 11,
          "fresenius": 71,
          "chain_owned": 83,
          "independent": 16,
          "big2_pct": 82.8,
          "chain_pct": 83.8,
          "avg_star": 2.6
        },
        {
          "state": "MO",
          "total_facilities": 152,
          "davita": 57,
          "fresenius": 50,
          "chain_owned": 130,
          "independent": 22,
          "big2_pct": 70.4,
          "chain_pct": 85.5,
          "avg_star": 2.58
        },
        {
          "state": "MT",
          "total_facilities": 17,
          "davita": 1,
          "fresenius": 5,
          "chain_owned": 14,
          "independent": 3,
          "big2_pct": 35.3,
          "chain_pct": 82.4,
          "avg_star": 2.47
        },
        {
          "state": "NE",
          "total_facilities": 37,
          "davita": 14,
          "fresenius": 8,
          "chain_owned": 25,
          "independent": 12,
          "big2_pct": 59.5,
          "chain_pct": 67.6,
          "avg_star": 2.84
        },
        {
          "state": "NV",
          "total_facilities": 52,
          "davita": 28,
          "fresenius": 17,
          "chain_owned": 50,
          "independent": 2,
          "big2_pct": 86.5,
          "chain_pct": 96.2,
          "avg_star": 2.31
        },
        {
          "state": "NH",
          "total_facilities": 20,
          "davita": 3,
          "fresenius": 16,
          "chain_owned": 19,
          "independent": 1,
          "big2_pct": 95,
          "chain_pct": 95,
          "avg_star": 3.21
        },
        {
          "state": "NJ",
          "total_facilities": 192,
          "davita": 90,
          "fresenius": 77,
          "chain_owned": 181,
          "independent": 11,
          "big2_pct": 87,
          "chain_pct": 94.3,
          "avg_star": 3.57
        },
        {
          "state": "NM",
          "total_facilities": 60,
          "davita": 7,
          "fresenius": 26,
          "chain_owned": 55,
          "independent": 5,
          "big2_pct": 55,
          "chain_pct": 91.7,
          "avg_star": 2.55
        },
        {
          "state": "NY",
          "total_facilities": 347,
          "davita": 94,
          "fresenius": 74,
          "chain_owned": 235,
          "independent": 112,
          "big2_pct": 48.4,
          "chain_pct": 67.7,
          "avg_star": 3.09
        },
        {
          "state": "NC",
          "total_facilities": 255,
          "davita": 100,
          "fresenius": 127,
          "chain_owned": 253,
          "independent": 2,
          "big2_pct": 89,
          "chain_pct": 99.2,
          "avg_star": 3.17
        },
        {
          "state": "ND",
          "total_facilities": 16,
          "davita": 2,
          "fresenius": 0,
          "chain_owned": 4,
          "independent": 12,
          "big2_pct": 12.5,
          "chain_pct": 25,
          "avg_star": 2.43
        },
        {
          "state": "OH",
          "total_facilities": 314,
          "davita": 134,
          "fresenius": 106,
          "chain_owned": 298,
          "independent": 16,
          "big2_pct": 76.4,
          "chain_pct": 94.9,
          "avg_star": 2.49
        },
        {
          "state": "OK",
          "total_facilities": 83,
          "davita": 39,
          "fresenius": 31,
          "chain_owned": 76,
          "independent": 7,
          "big2_pct": 84.3,
          "chain_pct": 91.6,
          "avg_star": 2.48
        },
        {
          "state": "OR",
          "total_facilities": 69,
          "davita": 27,
          "fresenius": 33,
          "chain_owned": 69,
          "independent": 0,
          "big2_pct": 87,
          "chain_pct": 100,
          "avg_star": 2.72
        },
        {
          "state": "PA",
          "total_facilities": 305,
          "davita": 131,
          "fresenius": 106,
          "chain_owned": 290,
          "independent": 15,
          "big2_pct": 77.7,
          "chain_pct": 95.1,
          "avg_star": 3.07
        },
        {
          "state": "RI",
          "total_facilities": 16,
          "davita": 1,
          "fresenius": 4,
          "chain_owned": 14,
          "independent": 2,
          "big2_pct": 31.3,
          "chain_pct": 87.5,
          "avg_star": 3.88
        },
        {
          "state": "SC",
          "total_facilities": 152,
          "davita": 38,
          "fresenius": 76,
          "chain_owned": 152,
          "independent": 0,
          "big2_pct": 75,
          "chain_pct": 100,
          "avg_star": 2.86
        },
        {
          "state": "SD",
          "total_facilities": 26,
          "davita": 3,
          "fresenius": 1,
          "chain_owned": 11,
          "independent": 15,
          "big2_pct": 15.4,
          "chain_pct": 42.3,
          "avg_star": 3.8
        },
        {
          "state": "TN",
          "total_facilities": 191,
          "davita": 56,
          "fresenius": 82,
          "chain_owned": 184,
          "independent": 7,
          "big2_pct": 72.3,
          "chain_pct": 96.3,
          "avg_star": 2.58
        },
        {
          "state": "TX",
          "total_facilities": 748,
          "davita": 254,
          "fresenius": 276,
          "chain_owned": 709,
          "independent": 39,
          "big2_pct": 70.9,
          "chain_pct": 94.8,
          "avg_star": 2.87
        },
        {
          "state": "UT",
          "total_facilities": 54,
          "davita": 17,
          "fresenius": 16,
          "chain_owned": 44,
          "independent": 10,
          "big2_pct": 61.1,
          "chain_pct": 81.5,
          "avg_star": 3.3
        },
        {
          "state": "VT",
          "total_facilities": 8,
          "davita": 0,
          "fresenius": 1,
          "chain_owned": 1,
          "independent": 7,
          "big2_pct": 12.5,
          "chain_pct": 12.5,
          "avg_star": 2.29
        },
        {
          "state": "VA",
          "total_facilities": 208,
          "davita": 92,
          "fresenius": 75,
          "chain_owned": 198,
          "independent": 10,
          "big2_pct": 80.3,
          "chain_pct": 95.2,
          "avg_star": 2.95
        },
        {
          "state": "WA",
          "total_facilities": 114,
          "davita": 51,
          "fresenius": 29,
          "chain_owned": 111,
          "independent": 3,
          "big2_pct": 70.2,
          "chain_pct": 97.4,
          "avg_star": 3.06
        },
        {
          "state": "WV",
          "total_facilities": 41,
          "davita": 9,
          "fresenius": 30,
          "chain_owned": 39,
          "independent": 2,
          "big2_pct": 95.1,
          "chain_pct": 95.1,
          "avg_star": 1.87
        },
        {
          "state": "WI",
          "total_facilities": 123,
          "davita": 56,
          "fresenius": 43,
          "chain_owned": 110,
          "independent": 13,
          "big2_pct": 80.5,
          "chain_pct": 89.4,
          "avg_star": 2.81
        },
        {
          "state": "WY",
          "total_facilities": 10,
          "davita": 0,
          "fresenius": 1,
          "chain_owned": 5,
          "independent": 5,
          "big2_pct": 10,
          "chain_pct": 50,
          "avg_star": 2.9
        },
        {
          "state": "DC",
          "total_facilities": 19,
          "davita": 11,
          "fresenius": 6,
          "chain_owned": 19,
          "independent": 0,
          "big2_pct": 89.5,
          "chain_pct": 100,
          "avg_star": 3.07
        }
      ]
    }
  ],
  "limitations": [
    "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.",
    "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.",
    "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.",
    "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.",
    "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.",
    "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."
  ],
  "reproducible_sql": null,
  "license": "U.S. Government Works (17 U.S.C. §105)",
  "generated_by": "Fonteum — https://fonteum.com",
  "notes": "Aggregate, source-traced figures frozen to the as-of date above. Re-derive by running the published query against the named source file; no per-person records are included."
}