Pamela Hyde was nominated by President Barack Obama and confirmed by the U.S. Senate in November 2009 as Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA). She leads SAMHSA's staff of approximately 550 public health professionals and manages a budget of approximately $3.5 billion with responsibility for improving the accountability, capacity, and effectiveness of the nation’s substance abuse prevention, addictions treatment, and mental health services delivery system.

Hyde comes to SAMHSA with more than 30 years experience in management and consulting for public healthcare and human services agencies. She has served as a state mental health director, state human services director, city housing and human services director, as well as CEO of a private non-profit managed behavioral healthcare firm. In 2003 she was appointed cabinet secretary of the New Mexico Human Services Department by Gov. Bill Richardson.

In this, her first published interview, Hyde answered our questions about the role of the agency in driving the integration of behavioral healthcare and primary care, delivering evidence-based practices to the field, supporting parity and healthcare reform legislation, and helping cash-strapped states and providers make the most of anticipated changes in funding for substance abuse and mental health services.

Q. As a former state official in New Mexico, what were your perceptions of SAMHSA’s work and where would you like to see it continued or changed with regard to states in the future?

A. With regard to states, I think that SAMHSA does a terrific job managing with the dollars they are provided by Congress and getting those dollars out to states and helping the states make the most of those dollars. I certainly expect that to continue. SAMHSA has a great track record in doing that and in getting great results from all of those dollars and grant programs. 

My hope is beyond the relationship with the states, we can have SAMHSA play a significant role in the amazing number of issues that are merging on the federal level—including healthcare reform and the commitment to prevention and wellness. As a leader in mental health and substance abuse issues, we can have a huge impact on healthcare costs—costs to communities and businesses. If we can help people understand how they can make a difference in those areas through strong prevention and other interventions, that would be a great role. That’s what we’re going to try to work on.

Q. Given your experience in the New Mexico Behavioral Health Collaborative, are you seeking more integration among the various agencies and providers that are delivering mental health and substance abuse services?

A. The short answer is yes, but I’m not the first person who’s bringing that to the fore. This administration is committed to cross-agency and cross-government collaborations. You can look in the many areas just within the HHS department and see the many places where behavioral health issues play out. Whether through Medicaid, Medicare, HRSA (Health Resources and Services Administration) and its work with the primary care workforce, or other places, behavioral health is involved. We want to work inside HHS to bring all of those together.

Across government, we also want to work outside HHS, through relationships to the Departments of Defense, Veterans’ Affairs, Education, and Justice. There are so many places where behavioral health issues are being dealt with and are impacting service delivery systems. I believe that my experience in New Mexico and other states is going to help me here. The commitment is high and the need is great.

Q. Do you plan to work out in the field, and in what ways, to encourage more integrated care models that combine primary healthcare services with behavioral health and substance abuse services?

A. That’s a great question. This will get played out in many ways. Here are a few examples: 

The behavioral health/primary care interface is where lots of SAMHSA people are working to make sure we’re getting SBIRTs (Screening-Brief Intervention-Referral to Treatment) provided. These are brief screening programs that providers can use in primary care settings to help identify people with mental health or substance abuse needs and get them referred quickly. 

Another example is the medical home approach, where we’re trying to get medical homes into primary care settings and community health centers and ensure that they take on the issue of mental health and substance abuse screening. And vice versa, people who receive specialty mental health and substance abuse care really need to be screened for health problems because we know that the co-occurrence of diabetes and chronic diseases is high. So there are lots of opportunities for that interface.

Q. Any more particulars on those programs—perhaps for primary care or emergency settings? 

A. As we work on all of these issues—there’s no either/or—it’s going to be a matter of integrating behavioral health issues into the healthcare arena and looking at where specialty care delivery systems can help identify people’s healthcare needs. We have a lot of people getting specialty mental health or substance abuse care and we forget to look at their diabetes or their heart disease, hypertension, or the issues that we know drive costs and drive morbidity in the wrong direction.

So, there’s not an either/or. We’re going to be looking at all of the programs in SAMHSA and across HHS and other agencies to keep those issues at the forefront.

Q. What initiatives will you be undertaking to address the tremendous gap between the discovery of new information and the introduction of best practices related to that research in the field—currently about 12 years?  

A. Again, that’s a good question. We started having those conversations here on my sixth or seventh business day. What is it that we know here that we just aren’t getting out to the field in terms of information and data about what works, what doesn’t work, and what would work better? What’s impeding the uptake [in the field] of the things that would work better?

Of course, whenever you talk about evidence based practices, you have to know that when you’ve got a specific individual, you’ve still got to have an individual approach to treatment and care. But in terms of services and practices, how can we get the information out there and how do we get providers to take it up? And what kind of things are we doing within SAMHSA, and what kind of moneys do we control that we can utilize to get that information out and require those kinds of practices to be implemented? And then how can we track to ensure that what happens in the research arena really works when you put it on the ground?  And there are two different things there—between the efficacy of research and the effectiveness of practices on the ground, in the community.

We also have to look at ways to bring practice to research. We’ve got an awful lot of good practices out there that haven’t been researched formally to see if they can produce results beyond a particular program or community. So, we play a role both ways. It’s also important to mention the SAMHSA Web site, which offers the latest and best practices, all vetted before they are posted. 

Q. What sorts of things can SAMHSA do in a funding environment when state funding is down in 40 of 50 states? What do you do when providers are closing their doors or reducing their programs? How do you turn that around?

A. Let’s go back for a second to one of your earlier questions. Let’s look at collaborations. We can no longer afford to look just at the programs that SAMHSA funds or that states fund because so much of the funding for programs and services that work is going to come through other sectors. It’s going to come through Medicaid, through Medicare for older Americans, and increasingly through private health insurance given the parity bill and the regulations that are coming out for that.

So, we’re going to have to think differently about funding. When services and dollars are cut in one area, I think we’ll have to get more creative. SAMHSA is going to have to help states get more creative in how they view their influence around substance abuse and mental health services that are going to be paid for by others. [It even extends to] things like TANF (Temporary Assistance for Needy Families) dollars and other types of human services dollars that help people in different ways.

We’re trying to take the broadest look possible so that behavioral health concerns become integrated in a lot of ways and the effect of cuts to specialty programs can be mitigated.

Q. Are you considering some type of technical assistance program to help states to deal with issues that may arise due to parity and increased payments or coverage from private insurers?

A. I don’t think we have a specific program in mind. What we intend to do is what we’ve done as the parity regulations were developed: We want to be at the table, providing input. 

We want to help communities understand that, with parity and healthcare reforms, people may have greater access to care than they have had before. There will be people being covered who weren’t covered at all before. Hopefully, we can get behavioral health and substance abuse services delivered to them.

We’re going to keep this front and center at SAMHSA, because it’s not just with one program or grant, but with every one where we have to help people take advantage of the opportunities.

Q. What are your two or three priorities going forward?  What are the things you will most focus on?

A. We’re still sorting this out, but I can name a couple: What’s our ability to impact healthcare reform? That’s going to be huge. That’s an area where we’re going to paying a lot of attention.

The prevention area is another. We’ve got a good start there through partnerships with the ONDCP (Office of National Drug Control Policy), with healthcare, with the Surgeon General, we’re really looking at the prevention issue and how we can make an impact. If we can get set to drive metrics into the future, we’ll see the results [of prevention] over many years. We want to set up our country to reduce demand [for drugs and services], increase treatment, and to increase recovery for both substance abuse and mental health disorders.

There are a couple of other areas and we’re still developing initiatives, so perhaps we can talk about those later.

Q. In terms of mental health and substance abuse parity, can you provide an example of what you hope the impact will be?

A. This will depend on what the final bill is, but there are things in both bills that we are watching closely that we’ll have the ability to impact. Things like the medical home approach—both for specialty and primary care—the issue of the services are that are contained in the essential benefit plan—there’s language in there about behavioral health so we clearly want to be at that table talking about what that means. There are others—HIT (health information technology), the exchanges (health insurance exchanges), the processes that get set up, and many more. As we watch these bills, we want to make sure that we can play a role in keeping behavioral health at the table.