Asthma is a common disease for which morbidity and mortality have been increasing. This despite advances in the scientific understanding of asthma and in the pharmacologic armamentarium available to treat it. The dichotomy between knowledge and outcomes led us to review asthma from a systems perspective. We have presented data first to document failure in the current system of care and then to examine factors associated with improved outcomes. We found a disparity in outcome and costs when care given by experts was contrasted with care given by generalists. We conclude that "expert-based" care systems are superior from the perspective both of the patient and of the insurer; medical outcomes are better at lower overall cost. Managed care companies are in a unique position to identify asthmatics and to shift them from generalist to expert-based care when appropriate.