Y ▁has ▁often ▁been ▁used ▁in ▁cost - ut ility ▁analysis ▁to ▁calculate ▁the ▁ratio ▁of ▁cost ▁to ▁Q AL Y s ▁saved ▁for ▁a ▁particular ▁health ▁care ▁inter vention . ▁By ▁ 2 0 0 8 ▁the ▁National ▁Institute ▁for ▁Health ▁and ▁Care ▁Ex cell ence ▁( N ICE ) ▁in ▁England ▁and ▁Wales , ▁for ▁example , ▁operated ▁with ▁a ▁threshold ▁range ▁of ▁£ 2 0 , 0 0 0 – 3 0 , 0 0 0 ▁per ▁quality - ad just ed ▁life ▁year ▁( Q AL Y ). ▁ ▁By ▁ 2 0 0 5 ▁doub ts ▁were ▁raised ▁about ▁the ▁use ▁of ▁economic ▁evalu ations ▁in ▁or phan ▁dru gs . ▁By ▁ 2 0 0 8 ▁most ▁of ▁the ▁or phan ▁dru gs ▁app ra ised ▁had ▁cost - effect iveness ▁th resh olds ▁" well ▁in ▁excess ▁of ▁the ▁' accept ed ' ▁level ▁and ▁would ▁not ▁be ▁re imb urs ed ▁according ▁to ▁conventional ▁criteria ." ▁As ▁early ▁as ▁ 2 0 0 5 ▁McC abe ▁et ▁al . ▁argued ▁that ▁r ar ity ▁should ▁not ▁have ▁a ▁prem ium ▁and ▁or phan ▁dru gs ▁should ▁be ▁treated ▁like ▁other ▁ph arma ce ut ical s ▁in ▁general . ▁Dr um mond ▁et ▁al . ▁argued ▁that ▁the ▁social ▁value ▁of ▁health ▁techn ologies ▁should ▁also ▁be ▁included ▁in ▁the ▁assess ment ▁along ▁with ▁the ▁estimation ▁of ▁the ▁increment al ▁cost - effect iveness ▁ratio . ▁ ▁Ab use ▁potential ▁ ▁The ▁very ▁large ▁in