To understand South Florida's healthcare gluttony, you have to look at the area's history and culture. There has been an abundance of hospitals and specialized physicians here, going back to the first days of Medicare, when the region was truly a retirement haven. Back then, the government health program paid for virtually anything.

Seniors no longer dominate areas like Miami Beach -- and Medicare has become much stricter about lengthy hospital stays -- but the large number of licensed beds and specialists remains. And therein lies part of the problem.

In most industries, having more choices means greater competition, which drives down cost. In healthcare, the reverse is true. Hospitals and medical offices compete for patients by buying state-of-the-art equipment. That machinery doesn't pay for itself unless it is used.

So the medical industry makes sure that equipment gets a workout.

Doctors tell the patient what he or she needs and then provide it, in effect dictating both supply and demand. Since a third party -- a private insurer or Medicare -- pays the bulk of the bill, patients rarely complain.

''Utilization goes up, even where it may not be necessarily needed,'' Ullmann said.

This is compounded by the high ratio of specialists -- seven out of every 10 doctors -- in the South Florida medical community. Cardiologists refer their patients to neurologists, who refer to gastroenterologists, who refer to urologists. Each performs a battery of tests.

Care provided by a specialist is usually far more expensive than treatment by a primary physician. A gastroenterologist sticking a camera in your intestine gets paid far more than the general practitioner listening to you gripe about your aches and pains.

In Europe, there are 70 primary care doctors for every 30 specialists -- a reversal of the United States ratio. That's one reason Europe spends half what the United Stats does on healthcare.

LEGAL PROTECTION

Tony Prieto, a primary care physician who heads the Broward County Medical Association, said cutting back on specialized tests will be difficult without legal reform. ''Doctors are ordering tests to protect their behinds,'' he said, ``because of the malpractice climate.''

Still another factor contributing to South Florida's unusually high healthcare costs: The region has more uninsured people than most urban areas. Almost one in three people under 65 in Miami-Dade lacks coverage. In Broward it's one in four. They tend to skip primary care and end up in emergency rooms -- where treatment is expensive -- and they usually leave without paying.

''Hospitals have to get those costs back somehow,'' Ullmann said. ``So they increase their rates for those who do have insurance, and do more in treating them.''

Then there is home healthcare. In Miami, it costs five times the national average, according to Dartmouth data. And durable medical equipment -- things like artificial limbs -- costs seven times the national average. Law enforcement officials have long identified both areas as filled with fraud.

''Fraud is a huge issue here,'' Ullmann said.

As reform moves along, all these high-cost areas will be targeted for reductions. If the feds succeed in reducing Medicare costs in South Florida to the national average -- admittedly a monumental task, experts say -- it could mean more than $4 billion removed from the local economy.

INDISCRIMINATE CUTS

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