Health care in the United States is in a crisis. At present, rising costs account for 13% of the gross national product making health care the third largest industry in the country, and there is no end in sight as costs spiral out of control.1 For years we have been admonished as healthcare providers to control costs by improving productivity and flexibility, by adopting new appropriate technologies, and by using competitive market strategies to squeeze the fat out of the healthcare system. All of these innovations, it was assumed, would allow healthcare providers to continue to deliver high quality care while eventually cutting costs to the bone.2The promise of managed care as the big fix for US healthcare problems has not been realised. An analysis of managed care plan performance from 37 recently published peer reviewed studies reveals …