The bulk of medical care system management in the United States does not ground decisions in use of available, high quality evidence. The previous chapters in this book demonstrate both that there sometimes is a rich scientific foundation in health care organization, delivery, and financing that could, if applied, lead to better outcomes, and that sometimes there is little or no evidence on effectiveness of interventions. However, we also observed that the bulk of health care management in the United States does not ground decisions in evidence, using it if available and taking uncertainty into account if not – instead “magical thinking” is often used to make choices.1 Ironically, management holds evidence in high esteem for decision-making by clinicians. In this chapter, we explore why management holds itself to a lower standard regarding its organizational, staffing, and planning choices, seeing experience, intuition, and opinions as good-enough evidence for decisions. We explore what needs to happen for this to change.