Over the last 20 years in Australia, outcomes have improved for patients with asthma. With the advent of inhaled corticosteroids and long-acting beta agonists, and improvements in management including implementation of the guided self-management plan system of care, the mortality rate for asthma has fallen by almost half. However, despite huge improvements, there remains a small but significant cohort of patients with inadequately controlled severe persistent asthma. This group of patients consumes a substantial proportion of public health resources. Patients who have poorly controlled asthma, despite receiving 'optimal' treatment, are the ones most likely to benefit from new therapies such as those that target IgE. This presentation provides an overview of severe asthma in terms of prevalence and morbidity, mortality, economic costs and then considers a way forward in terms of identifying patients in greatest need of novel treatment such as omalizumab.