Jimmy Folco was 25 years old –– robust, athletic, unable to imagine himself sick –– when he learned that he had diabetes. Though he knew he had a serious illness, he didn’t focus on it, and for more than a decade continued eating all the foods he loved.

Then in December Folco got a phone call from Darlene Arthurs, a nurse manager newly hired to work in his doctor’s office. She invited him to come in to talk, and when they met she laid out the facts. Unless he changed his ways, Folco’s type 1 diabetes could lead to kidney failure, heart disease, blindness and many other problems.

This wasn’t news to Jimmy Folco, but he took it differently this time. Arthurs referred him to a nutritionist and then called him weekly with encouragement and advice. Pretty soon he was testing his blood diligently, tracking every morsel he ate, and putting less food on his plate at mealtimes. He gave up his bedtime snack of lunch meats and instead took to munching rice cakes with peanut butter.

Rice cakes and peanut butter –– such a small, simple thing. Yet making that kind of change can have huge consequences for people with chronic illnesses like diabetes –– and for the health care system as a whole.

It is often said that 80 percent of health-care spending goes to the 20 percent of people with chronic illnesses. A recent study by the California-based Milken Institute estimated that just in Rhode Island, $1.2 billion was spent in 2003 on medical care for people with chronic illnesses. Diabetes alone, which has been diagnosed in an estimated 63,000 Rhode Islanders, cost roughly $600 million in medical care here in 2002, according to the state Health Department.

Given these numbers, many experts believe that untold suffering can be prevented, and incalculable sums of money saved, if people like Jimmy Folco can develop a taste for what’s good for them.

Folco was able to start down that path, thanks to a Rhode Island experiment that is being watched by health-care policy makers nationwide.

The project is trying to upend a primary care system that rewards doctors for running a treadmill of brief office visits and leaves no time to focus on long-term health.

Here’s the problem: Folco’s doctor, internist Francis X. Basile, gets paid per patient visit, as do most primary-care doctors. If Basile doesn’t see enough patients each day, his practice (the University Medicine Foundation, in Providence) doesn’t make enough money to pay the staff and keep the lights on. No matter how much Basile and Folco respect and admire each other – and they do – Basile’s influence on Folco was limited to an occasional15-minute visit.

Yet controlling diabetes involves discipline, organization and no small measure of sacrifice, day after day, over a lifetime. “I’d always say the right things to him,” Folco says of his visits with Basile. “Within a week’s time I’d disregard everything we talked about and just go back to being me.” When Folco was scheduled to return to Basile three months later, he’d often cancel the appointment, embarrassed to let his doctor down yet again.

Basile, for his part, had no time to call Folco, or any of his patients, to see how they were doing in between visits or to give them tips on what to eat (and arguably that’s not the best use of a physician’s skills). If Basile did not know what was going on with Folco, he knew even less about patients who hadn’t called for an appointment in years.

“All you get paid for is face time between doctor and patient and that’s not really what chronic care patients need,” said Christopher F. Koller, the state health insurance commissioner. “You get this disconnect where people want to do the right thing but the payment system is set up the wrong way.”

It’s well-documented that greater access to primary care improves health and also lowers costs, Koller says, but in Rhode Island only 5.9 percent of commercial insurance dollars are spent on primary care. That’s one percentage point less than in Massachusetts and about one fifth of the proportion spent in some European countries.

In 2005, Koller decided to start setting things right. He pulled together a work group of physician leaders, big employers and insurers, and together they crafted a two-year experiment called the Chronic Care Sustainability Initiative or CSI. The pilot project started last October.

Five medical practices signed on, involving 25 doctors and an estimated 28,000 patients. The practices agreed to transform themselves into what’s called a “patient-centered medical home” or “advanced medical home” – a place that patients go to first with any health complaint (instead of, say, the emergency room or a specialist), that coordinates their care among a team of providers (such as nurses, nutritionists and psychologists), and that tracks their care over time to make sure best practices are followed.

The medical home concept is being tried in different pilot projects around the country. “It is a very current, hot health-care policy approach that’s playing out in just about every state,” says Michael Bailit, a Massachusetts-based health-care consultant who is working with a similar project involving 32 practice sites and 149 physicians in Pennsylvania. “With the CSI, Rhode Island has been a step ahead of the rest of the states to date.”

Like Pennsylvania’s, Rhode Island’s effort is unusual because all the major payers, except the federal Medicare program, are participating. That is, health insurance companies and the state Medicaid program are kicking in money — $3 per patient per month, plus the salaries of one nurse manager at each practice, for a total of $1.2 million a year.

Koller says it wasn’t hard to win the cooperation of the big insurers –– UnitedHealthcare of New England and Blue Cross & Blue Shield of Rhode Island. United is already testing medical home projects in other states and welcomed a pilot involving other insurers.

“This is the most exciting development in primary care that I’ve seen in my 25 years in health care,” says Dr. Neal Galinko, United’s chief medical officer. Galinko says he expects the project to end up saving enough money to offset the cost, through fewer hospitalizations, unnecessary tests and emergency room visits.

At Blue Cross, chief medical officer Gus Manocchia says his company hopes for savings but isn’t requiring them. The main goal, he says, is to improve the lives of both patients and doctors. “Patients feel left out. They don’t feel the doctor spends enough time with them,” he says. “Primary care doctors are disenchanted. They’re burned out.”

The participating doctors are focusing on three common, costly chronic illnesses – diabetes, depression and coronary artery disease. They are working to identify every patient who suffers from one of these conditions and refer them to their new nurse managers. The nurses reach out to those patients, steer them into services, coach them on keeping healthy, and keep track of their health.

“We are responsible for how these patients do,” says Dr. Christopher P. Campanile, a family doctor at one of the participating practices, Hillside Family and Community Medicine, in Pawtucket. “The doctor needs to transform from an old-world director to a new-world collegial player.”

Dr. Jeffrey Wilson of Family Health and Sports Medicine, in Cranston, says that a typical visit with a diabetic involves “back and forth that sometimes just is not real positive. … It’s not very fulfilling.” But when “doctor’s orders” are backed with help from nutritionists and nurse managers, the visit “becomes a much more meaningful and deeper exchange because the person feels that they’re part of the process.”

But will it work? Every practice can trot out a success story, but will there be enough? Will the improvements last? Will they actually save money?

Health policy experts agree that boosting primary care must be central to any health care reform, says Deborah Peikes, a senior health researcher with the New Jersey-based Mathematica Policy Research, a nonpartisan social-policy research firm. But how to make that happen remains an open question, she says. “There are lots of things that are common sense –– they should work,” Peikes said. “And they don’t work.”

The CSI project requires behavior change by both doctor and patient, always a tall order.

“A lot of physicians are kind of stuck in the way they do things. They’re comfortable seeing their 25 patients a day,” says Dr. Mark D. Jacobs, an internist with Coastal Medical whose Smithfield office is participating in the CSI project. Jacobs says, “I had to really untwist my two partners” to win their participation. “They thought it was going to be a lot of work for not a lot of money. There isn’t a lot of money on the table.”

The extra payments from the insurance companies average about $35,000 per doctor each year (plus the salaries of the nurse managers), when primary-care doctors are already among the lowest-paid physicians. The money helps fund the hours of meetings and extra efforts to screen and track patients. For example, the CSI practices are developing registries of patients with chronic illness and collecting objective measurements of their health. Still, Jacobs points out, even CSI participants remain trapped in the same reimbursement system –– getting paid by the visit, rather than by patient or by the outcomes of care.

Even so, at a recent meeting on CSI, Koller says, “It was the first time in ages that I saw primary care docs really excited about what they were doing. … This is what absolutely has to happen if we want to get health care reform.”

The project is now six months along. Koller says he will consider it a success if, at the end of the two years, everyone involved is still “at the table” and the insurers are willing to continue financing it.

There will also be an objective measure: The Harvard School of Public Health has been hired to evaluate the project.

As for Jimmy Folco, he gets objective measures too. The week before last, he had an appointment with Frank Basile. Folco was actually looking forward to it. Finally he had news that would make Basile happy. With Arthurs’ persistent coaching over three months, he’d lost 21 pounds, lowered his cholesterol and triglycerides, and brought his blood sugar within the normal range.

Arthurs, the nurse manager, thinks the extra attention she offers can convince people that their condition is worth working on. “I think it shows that we’re serious about what we’re trying to do,” she says. “And that they are valuable and that their needs are important.”

Folco, 37, of North Kingstown, says his wife and son are amazed at how he’s changed. “In the refrigerator today, I’ve got sliced green peppers, sliced red pepper and zucchini, and a fat-free dip. Almost daily I have some of that,” he says with enthusiasm. “Things like that I never looked forward to, but I do today.”

He doesn’t even miss his nightly plate of cold cuts. When bedtime approaches, Jimmy Folco finds himself craving one thing: rice cakes and peanut butter.

ffreyer@projo.com